Journal of Pediatric Nursing (2015) xx, xxx–xxx
Maternal Underestimation of Child's Weight Status and Health Behaviors as Risk Factors for Overweight in Children1 Maite Vallejo ScD a , Beatriz A. Cortes-Rodríguez MSN b , Eloisa Colin-Ramirez PhD a,⁎ a
National Institute of Cardiology, Mexico City, Mexico National Institute of Social Security, Mexico City, Mexico
b
Received 10 December 2014; revised 19 February 2015; accepted 21 February 2015
Key words: Childhood obesity; Maternal perception; Overweight
Objectives To evaluate children's risk of being overweight associated with maternal underestimation of weight status and health behaviors. Results: One hundred forty mother–child dyads were included. Children whose weight status was underestimated by their mothers were at greater risks of being overweight compared to those whose weigh status was correctly perceived (adjusted OR 2.31, 95% CI 1.11–4.81). Less television viewing time was associated with a 63% reduced risk of being overweight (adjusted OR .37, 95% CI .17–.83). Conclusions: Maternal underestimation of weight status was common among overweight and normalweight children, and it was associated with an increased children's risk of being overweight. © 2015 Elsevier Inc. All rights reserved.
CHILDHOOD OBESITY IS considered to be a chronic and epidemic disease with a rising prevalence. In preschool children, the worldwide prevalence of overweight increased from 4.2% in 1990 to 6.7% in 2010. This same year, the number of overweight children under age 5 was estimated to be over 42 million, 35 million of these in developing countries (De Onis, Blossner, & Borghi, 2010). In Mexico, according to the National Health and Nutrition Survey 2012, 9.7% of preschool children are overweight or obese; this prevalence is slightly higher compared to 7.8% reported in 1988 for this same age population (Gutiérrez et al., 2012). It has been well established that parents are likely to misperceive the weight status of their overweight children (Parry, Netuveli, Parry, & Saxena, 2008), especially in children 2–6 years (Rietmeijer-Mentink, Paulis, van Middelkoop, 1 Authorship: MV. Conceived and designed the work that led to the submission and played an important role in interpreting the results. Revised the manuscript and approved the final version. BACR. Conceived and designed the work that led to the submission, acquired data, revised the manuscript, and approved the final version.ECR. Conceived and designed the work that led to the submission, analyzed data, interpreted results, drafted the manuscript, and approved the final version. ⁎ Corresponding author: Eloisa Colin-Ramirez, PhD. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.pedn.2015.02.009 0882-5963/© 2015 Elsevier Inc. All rights reserved.
Bindels, & van der Wouden, 2013), and this parental misperception of overweight might hinder early detection, preventive actions and management of overweight among children (Moore, Harris, & Bradlyn, 2012; Warschburger & Kröller, 2012). However, little is known about perception of weight status among parents of normal-weight children. Parental misperceptions of weight status of normal-weight children in any direction (underestimated or overestimated) might also misguide health-related parental behavior and impact children's weight status. The main objective of this cross-sectional study was to evaluate maternal perceptions of their child's weight status and the intention to modify family health behaviors among mothers of normal-weight and overweight children. Additionally, we explored the children's risk of being overweight associated with maternal underestimation of weight status and current implementation of health behaviors.
Material and Methods Study Population A cross-sectional study was conducted in a convenience sample of mothers and their children (2–6 years) attending a
2
M. Vallejo et al.
primary health care facility in Mexico City, from May to August 2010. Children with underweight, metabolic disorders, chronic pathologies affecting their nutritional status or currently receiving dietetic treatment for weight loss were excluded. Written informed consent was obtained from all participating mothers. The study was approved by the Institutional Health Research Ethics Board.
The series of sketches has seven body images for each age group, the middle image was developed to represent a child at the 50th BMI percentile categories; upper and lower sketches were not tied to particular BMI percentile categories (Eckstein et al., 2006). Therefore, answers were classified as follows: lighter than middle sketch (1–3), middle sketch (4), and heavier than middle sketches (5–7).
Body Mass Index Classification
Health Behavior Mothers were asked to answer 4 questions to assess the intention to modify family health behaviors related to diet, physical activity, and television viewing (response options: I already do this, I will try, I will not try) (Eckstein et al., 2006).
Body weight and height were collected from all children with shoes, and heavy outer clothing was removed. Body mass index (BMI) Z-scores were calculated and classified according to the World Health Organization age- and gender-specific growth standards. Z-scores are used to describe how far a measurement (in this case BMI) is from the median, which is the exact middle of a distribution, in terms of standard deviation (SD). Normal weight was defined as a Z-score between − 2 SD and 1 SD in both children aged 2–5 years and children above 5 years; possible risk of overweight, Z-score N 1 SD in children aged 2–5 years; overweight, Z-score N 2 SD in children aged 2–5 years and N 1 SD in children older than 5 years; and obesity, Z-score N 3 SD in children aged 2–5 years and N 2 SD in children older than 5 years (De Onis et al., 2007; WHO Multicentre Growth Reference Study Group, 2006; World Health Organization, 2008). Children with underweight defined as a Z-score b − 2 SD at screening were not included in this study. Children were divided into two study groups: 1) normalweight and 2) overweight children (children at possible risk of overweight, overweight or obesity).
Statistical Analysis Continuous variables were expressed as mean ± standard deviation, and categorical variables were presented as frequencies. For comparison of continuous variables between groups of weigh status, Student's t test was used, and for categorical variables, Pearson chi-square test or Fisher's exact test were employed. Logistic regression analysis using the enter method was performed to establish the independent contribution of maternal underestimation of weight status and health behaviors on children's risk of being overweight. Health behaviors with p b 0.05 in the bivariate analysis were included in the full model and tested along with maternal underestimation of children's weight status in presence of sex and age. A p value b 0.05 was considered statistically significant, and 95% confidence intervals (CIs) were calculated for adjusted odds ratios (OR). All analyses were performed with commercially available software (SPSS 22.0 for Windows, SPSS, Inc., Chicago, IL, USA).
Data Collection
Results Mothers were asked to complete a short questionnaire about perceptions and concerns about their child's weight status and health behavior intentions. Demographic data were also collected. Maternal Perception of Children's Weight Status It was assessed in two ways, first with verbal description and then with schematic body images. A 5-point scale was used for verbal description. Mothers were asked to classify their children's weight status as underweight, a little underweight, about the right weight, a little overweight, or overweight. Maternal perception of children's weight status was classified as: 1) correctly perceived when maternal perception matched real weight status, 2) underestimated when maternal perception of weight status was lighter than real weight status, and 3) overestimated when maternal perception was heavier than real body weight status. Maternal perception of children's weight status by using body images was assessed with the gender- and age-rangespecific sketches of body weight proposed by Eckstein et al.
Overall, 140 mother–child dyads were included, 65 in the normal-weight children group and 75 in the overweight children group. Demographic characteristics of mothers and children are shown in Table 1. There were no significant differences between groups either in children's age and sex or in mothers' age and education. Mean BMI Z-score for children in the normal-weight group was − .07 ± .52 SD, while Z-score in the overweight children group was 1.8 ± .25 SD, which indicates that BMI observed in the group of overweight children was 1.8 SD above the median BMI for the reference population. Maternal perceptions of the child's weight status using verbal descriptions and body images are presented in Table 2. Misclassification rate of children's body image was higher in the group of mothers of normal-weight children (72.3%) than among mothers of overweight children (57.3%). Importantly, only 3.1% of normal-weight children were classified as having a heavier body image, pointing out that underestimation was the most common misperception of
Weight Status Misperception and Childhood Obesity Table 1
3
Demographic characteristics of children and their mothers.
Child age, (months) Sex (male), % Mother age (years) Mother education, % Primary school Junior high school High school College
Normal weight (n = 65)
Overweight (n = 75)
⁎p value
46.1 ± 13.9 53.3 30.8 ± 7
49.5 ± 13.4 54.7 30.7 ± 5.6
.1 .9 .9
9.2 36.9 36.9 16.9
10.7 29.3 38.7 21.3
.8
Values are mean ± standard deviation for continuous variables and relative frequencies (percentages) for categorical variables. ⁎ Student's t test to compare groups was used for continuous variables; Pearson chi-square or Fisher's exact tests were used for categorical variable.
children's body image among mothers in both groups. Likewise, the percentage of maternal misclassification of weight status by verbal description in the normal-weight children group was 49.2%, where 41.5% were perceived by their mothers as having a degree of underweight. Similarly, weight status in the overweight children group was misclassified by verbal description in 61.3% of the cases; weight status in these children was underestimated by their mothers who perceived their child to have a normal weight or a degree of underweight (Table 2). When mothers were asked about their intentions to modify health behaviors related to diet, physical activity, and television viewing, there was a higher proportion of mothers in the normal-weight children group that reported already implementing all the evaluated health behaviors at home compared to mothers in the overweight children group; however, a statistically significant difference between groups was only seen for television viewing time (Table 3). Therefore, this was the only health behavior included in the logistic regression analysis. Logistic regression analysis showed that children whose weight status was underestimated by their mothers are at greater
Table 2 groups.
risks of being overweight compared to those whose weight status was correctly perceived by their mothers (adjusted OR 2.31, 95% CI 1.11–4.81), and this association was independent of child's television viewing time, sex and age. In contrast, children of mothers reporting that they were already limiting television viewing time were less likely to be overweight or obese (adjusted OR .37, 95% CI .17–.83), independent of maternal underestimation of weight status and child's sex and age.
Discussion Findings of this study in children aged 2–6 years and their mothers showed that maternal underestimation of child's weight status is common in either normal-weight and overweight children, and this misperception of weight status was associated with a greater risk of being overweight after adjustment for key variables. In this study, weight status was underestimated by verbal description in 61.3% of overweight children and 41.5% of normal-weight children. These results are in accordance with a recent meta-analysis of 51 studies (35,103 children aged 2–18 years) (Rietmeijer-Mentink et al.,
Maternal perceptions of child's weigh status and degree of maternal misperception according to verbal description by study
Verbal description Underweight/A little underweight About the right weight A little overweight/overweight Body image Lighter sketch (1–3) Middle sketch (4) Heavier sketch (5–7) Maternal misperception of children's weight status by verbal description Correctly perceived Underestimated Overestimated
Normal weight (n = 65)
Overweight (n = 75)
⁎p value
41.5 50.8 7.7
6.7 54.7 38.7
b .001
69.2 27.7 3.1
28 29.3 42.7
b .001
50.8 41.5 7.7
38.7 61.3 0
Values are relative frequencies (percentages). ⁎ Pearson chi-square or Fisher's exact tests were used for comparison between groups.
.008
4
M. Vallejo et al. Table 3
Proportion of mothers by study groups that are already implementing the studied health behaviors.
Statement During the next month… I I I I
intend to get 30 min of physical activity ≥ 5 days per week intend to buy less sugar- and fat-rich food such as candy, pizza, cookies, ice cream, etc. intend to limit the amount of juice and sweetened beverages that my child drinks. intend to limit my child's daily television viewing.
Normal weight (n = 65)
Overweight (n = 75)
⁎p value
35.4 33.8 33.8 47.7
28 24 20 24
.4 .2 .06 .003
Values are relative frequencies (percentages). ⁎ Pearson chi-square or Fisher's exact tests were used for comparison between groups.
2013) reporting that 62.4% of overweight children were incorrectly perceived as normal weight by their parents, and that misperception of overweight is higher in parents with children aged 2–6 years compared to parents of older children. Results of this present study extend the existing evidence base by demonstrating that maternal underestimation of weight status is common not only among overweight children, but also in normal-weight children, who are perceived as having underweight. Similar results have been previously observed in other studies including preschool-children from different cultural settings, suggesting that underestimation of children's weight status is a common observation across cultures (Eckstein et al., 2006; Killion, Hughes, Wendt, Pease, & Nicklas, 2006; Lara-García, Flores-Peña, Alatorre-Esquivel, Sosa-Briones, & Cerda-Flores, 2011). In this sense, it has been reported that mothers of preschool-aged children are more concerned about their children being underweight than overweight (Pagnini, Wilkenfeld, King, Booth, & Booth, 2007) and parental concerns about child's diet are focused on not eating enough food or having a fussy eating, whereas concerns about eating too much junk food are more likely to be given by parents of older children (Slater et al., 2009). It is likely that these concerns are strengthened by the underestimation of weight status among preschool-aged normal-weight children, often perceived as being underweight by their parents; this might affect parent's attitude towards child's feeding, inducing potentially overfeeding and therefore affecting child's weight status. However, the effects of parental underestimation of weight status on child's weight development have been contradictory. Kroke, Strathmann, and Günther (2006) conducted a longitudinal study in 253 children to investigate the relation between mothers' perception of their children's weight status at different ages and child's future weight. They observed that children whose weight was considered too low gained more weight until age 7, and those who were considered to be too heavy lost more weight as compared to the children whose weight was considered to be just right, supporting the hypothesis that parental misperceptions of overweight status constitute unfavorable conditions for preventive actions, probably due to the lack of awareness about child overweight and health risks associated with childhood overweight and obesity (GuevaraCruz, Serralde-Zuniga, Vazquez-Vela, Blancas, & Islas-Ortega, 2012; Moore et al., 2012; Warschburger & Kröller, 2012).
In contrast, a recent study based on longitudinal data from the KOALA Birth Cohort Study (Gerards et al., 2014) reported that accurate weight status perception at age 5 years was significantly associated with higher BMI in overweight children until the age of 9 years, corrected for actual BMIz (BMI standardized to a reference population) at age 5 years. Authors pointed out that parental awareness of child's overweight by itself does not guarantee subsequent weight management by the parents, suggesting that parents who recognize their child's overweight may not be able or willing to adequately manage the overweight. In this cross-sectional study, maternal underestimation of weight status was found to be associated with a more than 2-fold increased risk of being overweight compared to those children whose weight status was correctly perceived by their mothers (adjusted OR 2.31, 95% CI 1.11–4.81). In contrast; a 63% reduced risk of being overweight (adjusted OR .37, 95% CI .17–.83) was seen in children of mothers reporting that they were already limiting television viewing time, which implies a 2.7-fold increased risk of being overweight among children who were not yet viewing less television compared to those who were already doing so, independent of maternal underestimation of weight status and child's sex and age. These findings suggest that even though maternal underestimation of weight status is of relevance for the presence of overweight in preschool-aged children, health behaviors such as reducing television viewing time have a greater impact on the child's risk of being overweight even at such an early stage of life. The association between television viewing time and risk of overweight in preschool-aged children has been previously described. A longitudinal study in 8,234 children reported that the OR for obesity increased linearly as the number of hours of television viewing increased. For children reported to watch television for 4–8 hours per week at age 3 the adjusted OR for obesity at age 7 was 1.37 (1.02 to 1.83). For those reported to watch more than 8 hours per week the adjusted OR was 1.55 (1.13 to 2.12) (Reilly et al., 2005). More recently, an analysis of longitudinal data of 4724 children recruited at birth and 4340 recruited at age 4 showed a bidirectional relationship between television viewing habits and BMI. Child's dietary intake, television viewing habits and BMI were evaluated at three time points, separated by 2 years. Children who watched television were more likely to gain weight, and children who were heavier were also more likely to watch television. Interestingly, dietary intake mediated the BMI-television viewing relationship for the
Weight Status Misperception and Childhood Obesity older children, but not for the birth cohort (Fuller-Tyszkiewicz, Skouteris, Hardy, & Halse, 2012). Therefore, it is important that health care professionals make parents aware of actual weight status of their children during well child visits using anticipatory guidance, but also a great effort should be focused on encouraging parents of preschool-aged children to promote and adopt a family healthy lifestyle in order to prevent and manage overweight among these children. Results of this study are relevant for nursing practice due to the key role that nursing professionals have in the identification and prevention of childhood obesity through the development, implementation and evaluation of educational interventions aimed to identify, prevent and manage childhood obesity.
Study Limitations This study has three main limitations: first, the crosssectional nature of the study; second, the relative small sample size and therefore the likelihood of type II error in some of the estimates. Finally, the current number of hours of television viewing was not evaluated; however, regardless of the number of hours spent in this activity, less television viewing time was associated with a significant lower risk of being overweight in this study population.
Conclusions Maternal underestimation of weight status was a common finding among both overweight and normalweight children, and this misperception of weight status was associated with an increased children's risk of being overweight; however, less television viewing time showed a stronger association with children's risk of being overweight. Parents should be made aware of the actual weight status of their child during the well child visits, but more importantly, they need to be aware of the importance of promoting heath behaviors among their children and be willing to do so in order to prevent and properly manage the overweight in preschool aged-children. Further studies aimed to evaluate educational interventions to effectively modify family and child health behaviors and their longterm impact on children's weight status are needed.
Funding Sources None.
Conflict of Interest/Disclosures Authors declare no conflicts of interest.
5
References De Onis, M., Blossner, M., & Borghi, E. (2010). Global prevalence and trends of overweight and obesity among preschool children. The American Journal of Clinical Nutrition, 92, 1257–1264. De Onis, M., Onyango, A. W., Borghi, E., Siyam, A., Nishida, C., & Siekmann, J. (2007). Development of a WHO growth reference for school-aged children and adolescents. Bulletin of the World Health Organization, 85, 660–667. Eckstein, K. C., Mikhail, L. M., Ariza, A. J., Thomson, J. S., Millard, S. C., & Binns, H. J. (2006). Parents' perceptions of their child's weight and health. Pediatrics, 117, 681–690. Fuller-Tyszkiewicz, M., Skouteris, H., Hardy, L. L., & Halse, C. (2012). The associations between TV viewing, food intake, and BMI. A prospective analysis of data from the Longitudinal Study of Australian Children. Appetite, 59, 945–948. Gerards, S. M., Gubbels, J. S., Dagnelie, P. C., Kremers, S. P., Stafleu, A., de Vries, N. K., et al. (2014). Parental perception of child's weight status and subsequent BMIz change: The KOALA birth cohort study. BMC Public Health, 14, http:// dx.doi.org/10.1186/1471-2458-14-291. Guevara-Cruz, M., Serralde-Zuniga, A. E., Vazquez-Vela, M. E. F., Blancas, L., & Islas-Ortega, L. (2012). Association between maternal perceptions and actual nutritional status for children in a study group in Mexico. Nutrición Hospitalaria, 27, 209–212. Gutiérrez, J. P., Rivera-Dommarco, J., Shamah-Levy, T., VillalpandoHernández, S., Franco, A., Cuevas-Nasu, L., et al. (2012). Encuesta Nacional de Salud y Nutrición 2012. Resultados Nacionales Cuernavaca. México: Instituto Nacional de Salud Pública. Killion, L., Hughes, S. O., Wendt, J. C., Pease, D., & Nicklas, T. A. (2006). Minority mothers' perceptions of children's body size. International Journal of Pediatric Obesity, 1, 96–102. Kroke, A., Strathmann, S., & Günther, A. L. (2006). Maternal perceptions of her child's body weight in infancy and early childhood and their relation to body weight status at age 7. European Journal of Pediatrics, 165, 875–883. Lara-García, B., Flores-Peña, Y., Alatorre-Esquivel, M. A., Sosa-Briones, R., & Cerda-Flores, R. M. (2011). Percepción materna de sobrepeso-obesidad infantil y riesgos de salud en Nuevo Laredo, Tamaulipas, México. Salud Pública de México, 53, 258–263. Moore, L. C., Harris, C. V., & Bradlyn, A. S. (2012). Exploring the relationship between parental concern and the management of childhood obesity. Maternal and Child Health Journal, 16, 902–908. Pagnini, D. L., Wilkenfeld, R., King, L. A., Booth, M. L., & Booth, S. L. (2007). Mothers of pre-school children talk about childhood overweight and obesity: The weight of opinion study. Journal of Paediatrics and Child Health, 43, 806–810. Parry, L. L., Netuveli, G., Parry, J., & Saxena, S. (2008). A systematic review of parental perception of overweight status in children. The Journal of Ambulatory Care Management, 31, 253–268. Reilly, J. J., Armstrong, J., Dorosty, A. R., Emmett, P. M., Ness, A., Rogers, I., et al. (2005). Early life risk factors for obesity in childhood: Cohort study. BMJ, 330, 1357, http://dx.doi.org/10.1136/bmj.38470.670903.E0. Rietmeijer-Mentink, M., Paulis, W. D., van Middelkoop, M., Bindels, P. J., & van der Wouden, J. C. (2013). Difference between parental perception and actual weight status of children: A systematic review. Maternal & Child Nutrition, 9, 3–22. Slater, A., Bowen, J., Corsini, N., Gardner, C., Golley, R., & Noakes, M. (2009). Understanding parent concerns about children's diet, activity and weight status: An important step towards effective obesity prevention interventions. Public Health Nutrition, 13, 1221–1228. Warschburger, P., & Kröller, K. (2012). Childhood overweight and obesity: Maternal perceptions of the time for engaging in child weight management. BMC Public Health, 12, http://dx.doi.org/10.1186/1471-2458-12-295. WHO Multicentre Growth Reference Study Group (2006). WHO Child Growth Standards based on length/height, weight and age. Acta Paediatrica. Supplementum, 450, 76–85. World Health Organization (2008). Training course on child growth assessment. (Geneva).
Maternal Underestimation of Child's Weight Status and Health Behaviors as Risk Factors for Overweight in Children1 Maite Vallejo ScD a , Beatriz A. Cortes-Rodríguez MSN b , Eloisa Colin-Ramirez PhD a,⁎ a
National Institute of Cardiology, Mexico City, Mexico National Institute of Social Security, Mexico City, Mexico
b
Received 10 December 2014; revised 19 February 2015; accepted 21 February 2015
Key words: Childhood obesity; Maternal perception; Overweight
Objectives To evaluate children's risk of being overweight associated with maternal underestimation of weight status and health behaviors. Results: One hundred forty mother–child dyads were included. Children whose weight status was underestimated by their mothers were at greater risks of being overweight compared to those whose weigh status was correctly perceived (adjusted OR 2.31, 95% CI 1.11–4.81). Less television viewing time was associated with a 63% reduced risk of being overweight (adjusted OR .37, 95% CI .17–.83). Conclusions: Maternal underestimation of weight status was common among overweight and normalweight children, and it was associated with an increased children's risk of being overweight. © 2015 Elsevier Inc. All rights reserved.
CHILDHOOD OBESITY IS considered to be a chronic and epidemic disease with a rising prevalence. In preschool children, the worldwide prevalence of overweight increased from 4.2% in 1990 to 6.7% in 2010. This same year, the number of overweight children under age 5 was estimated to be over 42 million, 35 million of these in developing countries (De Onis, Blossner, & Borghi, 2010). In Mexico, according to the National Health and Nutrition Survey 2012, 9.7% of preschool children are overweight or obese; this prevalence is slightly higher compared to 7.8% reported in 1988 for this same age population (Gutiérrez et al., 2012). It has been well established that parents are likely to misperceive the weight status of their overweight children (Parry, Netuveli, Parry, & Saxena, 2008), especially in children 2–6 years (Rietmeijer-Mentink, Paulis, van Middelkoop, 1 Authorship: MV. Conceived and designed the work that led to the submission and played an important role in interpreting the results. Revised the manuscript and approved the final version. BACR. Conceived and designed the work that led to the submission, acquired data, revised the manuscript, and approved the final version.ECR. Conceived and designed the work that led to the submission, analyzed data, interpreted results, drafted the manuscript, and approved the final version. ⁎ Corresponding author: Eloisa Colin-Ramirez, PhD. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.pedn.2015.02.009 0882-5963/© 2015 Elsevier Inc. All rights reserved.
Bindels, & van der Wouden, 2013), and this parental misperception of overweight might hinder early detection, preventive actions and management of overweight among children (Moore, Harris, & Bradlyn, 2012; Warschburger & Kröller, 2012). However, little is known about perception of weight status among parents of normal-weight children. Parental misperceptions of weight status of normal-weight children in any direction (underestimated or overestimated) might also misguide health-related parental behavior and impact children's weight status. The main objective of this cross-sectional study was to evaluate maternal perceptions of their child's weight status and the intention to modify family health behaviors among mothers of normal-weight and overweight children. Additionally, we explored the children's risk of being overweight associated with maternal underestimation of weight status and current implementation of health behaviors.
Material and Methods Study Population A cross-sectional study was conducted in a convenience sample of mothers and their children (2–6 years) attending a
2
M. Vallejo et al.
primary health care facility in Mexico City, from May to August 2010. Children with underweight, metabolic disorders, chronic pathologies affecting their nutritional status or currently receiving dietetic treatment for weight loss were excluded. Written informed consent was obtained from all participating mothers. The study was approved by the Institutional Health Research Ethics Board.
The series of sketches has seven body images for each age group, the middle image was developed to represent a child at the 50th BMI percentile categories; upper and lower sketches were not tied to particular BMI percentile categories (Eckstein et al., 2006). Therefore, answers were classified as follows: lighter than middle sketch (1–3), middle sketch (4), and heavier than middle sketches (5–7).
Body Mass Index Classification
Health Behavior Mothers were asked to answer 4 questions to assess the intention to modify family health behaviors related to diet, physical activity, and television viewing (response options: I already do this, I will try, I will not try) (Eckstein et al., 2006).
Body weight and height were collected from all children with shoes, and heavy outer clothing was removed. Body mass index (BMI) Z-scores were calculated and classified according to the World Health Organization age- and gender-specific growth standards. Z-scores are used to describe how far a measurement (in this case BMI) is from the median, which is the exact middle of a distribution, in terms of standard deviation (SD). Normal weight was defined as a Z-score between − 2 SD and 1 SD in both children aged 2–5 years and children above 5 years; possible risk of overweight, Z-score N 1 SD in children aged 2–5 years; overweight, Z-score N 2 SD in children aged 2–5 years and N 1 SD in children older than 5 years; and obesity, Z-score N 3 SD in children aged 2–5 years and N 2 SD in children older than 5 years (De Onis et al., 2007; WHO Multicentre Growth Reference Study Group, 2006; World Health Organization, 2008). Children with underweight defined as a Z-score b − 2 SD at screening were not included in this study. Children were divided into two study groups: 1) normalweight and 2) overweight children (children at possible risk of overweight, overweight or obesity).
Statistical Analysis Continuous variables were expressed as mean ± standard deviation, and categorical variables were presented as frequencies. For comparison of continuous variables between groups of weigh status, Student's t test was used, and for categorical variables, Pearson chi-square test or Fisher's exact test were employed. Logistic regression analysis using the enter method was performed to establish the independent contribution of maternal underestimation of weight status and health behaviors on children's risk of being overweight. Health behaviors with p b 0.05 in the bivariate analysis were included in the full model and tested along with maternal underestimation of children's weight status in presence of sex and age. A p value b 0.05 was considered statistically significant, and 95% confidence intervals (CIs) were calculated for adjusted odds ratios (OR). All analyses were performed with commercially available software (SPSS 22.0 for Windows, SPSS, Inc., Chicago, IL, USA).
Data Collection
Results Mothers were asked to complete a short questionnaire about perceptions and concerns about their child's weight status and health behavior intentions. Demographic data were also collected. Maternal Perception of Children's Weight Status It was assessed in two ways, first with verbal description and then with schematic body images. A 5-point scale was used for verbal description. Mothers were asked to classify their children's weight status as underweight, a little underweight, about the right weight, a little overweight, or overweight. Maternal perception of children's weight status was classified as: 1) correctly perceived when maternal perception matched real weight status, 2) underestimated when maternal perception of weight status was lighter than real weight status, and 3) overestimated when maternal perception was heavier than real body weight status. Maternal perception of children's weight status by using body images was assessed with the gender- and age-rangespecific sketches of body weight proposed by Eckstein et al.
Overall, 140 mother–child dyads were included, 65 in the normal-weight children group and 75 in the overweight children group. Demographic characteristics of mothers and children are shown in Table 1. There were no significant differences between groups either in children's age and sex or in mothers' age and education. Mean BMI Z-score for children in the normal-weight group was − .07 ± .52 SD, while Z-score in the overweight children group was 1.8 ± .25 SD, which indicates that BMI observed in the group of overweight children was 1.8 SD above the median BMI for the reference population. Maternal perceptions of the child's weight status using verbal descriptions and body images are presented in Table 2. Misclassification rate of children's body image was higher in the group of mothers of normal-weight children (72.3%) than among mothers of overweight children (57.3%). Importantly, only 3.1% of normal-weight children were classified as having a heavier body image, pointing out that underestimation was the most common misperception of
Weight Status Misperception and Childhood Obesity Table 1
3
Demographic characteristics of children and their mothers.
Child age, (months) Sex (male), % Mother age (years) Mother education, % Primary school Junior high school High school College
Normal weight (n = 65)
Overweight (n = 75)
⁎p value
46.1 ± 13.9 53.3 30.8 ± 7
49.5 ± 13.4 54.7 30.7 ± 5.6
.1 .9 .9
9.2 36.9 36.9 16.9
10.7 29.3 38.7 21.3
.8
Values are mean ± standard deviation for continuous variables and relative frequencies (percentages) for categorical variables. ⁎ Student's t test to compare groups was used for continuous variables; Pearson chi-square or Fisher's exact tests were used for categorical variable.
children's body image among mothers in both groups. Likewise, the percentage of maternal misclassification of weight status by verbal description in the normal-weight children group was 49.2%, where 41.5% were perceived by their mothers as having a degree of underweight. Similarly, weight status in the overweight children group was misclassified by verbal description in 61.3% of the cases; weight status in these children was underestimated by their mothers who perceived their child to have a normal weight or a degree of underweight (Table 2). When mothers were asked about their intentions to modify health behaviors related to diet, physical activity, and television viewing, there was a higher proportion of mothers in the normal-weight children group that reported already implementing all the evaluated health behaviors at home compared to mothers in the overweight children group; however, a statistically significant difference between groups was only seen for television viewing time (Table 3). Therefore, this was the only health behavior included in the logistic regression analysis. Logistic regression analysis showed that children whose weight status was underestimated by their mothers are at greater
Table 2 groups.
risks of being overweight compared to those whose weight status was correctly perceived by their mothers (adjusted OR 2.31, 95% CI 1.11–4.81), and this association was independent of child's television viewing time, sex and age. In contrast, children of mothers reporting that they were already limiting television viewing time were less likely to be overweight or obese (adjusted OR .37, 95% CI .17–.83), independent of maternal underestimation of weight status and child's sex and age.
Discussion Findings of this study in children aged 2–6 years and their mothers showed that maternal underestimation of child's weight status is common in either normal-weight and overweight children, and this misperception of weight status was associated with a greater risk of being overweight after adjustment for key variables. In this study, weight status was underestimated by verbal description in 61.3% of overweight children and 41.5% of normal-weight children. These results are in accordance with a recent meta-analysis of 51 studies (35,103 children aged 2–18 years) (Rietmeijer-Mentink et al.,
Maternal perceptions of child's weigh status and degree of maternal misperception according to verbal description by study
Verbal description Underweight/A little underweight About the right weight A little overweight/overweight Body image Lighter sketch (1–3) Middle sketch (4) Heavier sketch (5–7) Maternal misperception of children's weight status by verbal description Correctly perceived Underestimated Overestimated
Normal weight (n = 65)
Overweight (n = 75)
⁎p value
41.5 50.8 7.7
6.7 54.7 38.7
b .001
69.2 27.7 3.1
28 29.3 42.7
b .001
50.8 41.5 7.7
38.7 61.3 0
Values are relative frequencies (percentages). ⁎ Pearson chi-square or Fisher's exact tests were used for comparison between groups.
.008
4
M. Vallejo et al. Table 3
Proportion of mothers by study groups that are already implementing the studied health behaviors.
Statement During the next month… I I I I
intend to get 30 min of physical activity ≥ 5 days per week intend to buy less sugar- and fat-rich food such as candy, pizza, cookies, ice cream, etc. intend to limit the amount of juice and sweetened beverages that my child drinks. intend to limit my child's daily television viewing.
Normal weight (n = 65)
Overweight (n = 75)
⁎p value
35.4 33.8 33.8 47.7
28 24 20 24
.4 .2 .06 .003
Values are relative frequencies (percentages). ⁎ Pearson chi-square or Fisher's exact tests were used for comparison between groups.
2013) reporting that 62.4% of overweight children were incorrectly perceived as normal weight by their parents, and that misperception of overweight is higher in parents with children aged 2–6 years compared to parents of older children. Results of this present study extend the existing evidence base by demonstrating that maternal underestimation of weight status is common not only among overweight children, but also in normal-weight children, who are perceived as having underweight. Similar results have been previously observed in other studies including preschool-children from different cultural settings, suggesting that underestimation of children's weight status is a common observation across cultures (Eckstein et al., 2006; Killion, Hughes, Wendt, Pease, & Nicklas, 2006; Lara-García, Flores-Peña, Alatorre-Esquivel, Sosa-Briones, & Cerda-Flores, 2011). In this sense, it has been reported that mothers of preschool-aged children are more concerned about their children being underweight than overweight (Pagnini, Wilkenfeld, King, Booth, & Booth, 2007) and parental concerns about child's diet are focused on not eating enough food or having a fussy eating, whereas concerns about eating too much junk food are more likely to be given by parents of older children (Slater et al., 2009). It is likely that these concerns are strengthened by the underestimation of weight status among preschool-aged normal-weight children, often perceived as being underweight by their parents; this might affect parent's attitude towards child's feeding, inducing potentially overfeeding and therefore affecting child's weight status. However, the effects of parental underestimation of weight status on child's weight development have been contradictory. Kroke, Strathmann, and Günther (2006) conducted a longitudinal study in 253 children to investigate the relation between mothers' perception of their children's weight status at different ages and child's future weight. They observed that children whose weight was considered too low gained more weight until age 7, and those who were considered to be too heavy lost more weight as compared to the children whose weight was considered to be just right, supporting the hypothesis that parental misperceptions of overweight status constitute unfavorable conditions for preventive actions, probably due to the lack of awareness about child overweight and health risks associated with childhood overweight and obesity (GuevaraCruz, Serralde-Zuniga, Vazquez-Vela, Blancas, & Islas-Ortega, 2012; Moore et al., 2012; Warschburger & Kröller, 2012).
In contrast, a recent study based on longitudinal data from the KOALA Birth Cohort Study (Gerards et al., 2014) reported that accurate weight status perception at age 5 years was significantly associated with higher BMI in overweight children until the age of 9 years, corrected for actual BMIz (BMI standardized to a reference population) at age 5 years. Authors pointed out that parental awareness of child's overweight by itself does not guarantee subsequent weight management by the parents, suggesting that parents who recognize their child's overweight may not be able or willing to adequately manage the overweight. In this cross-sectional study, maternal underestimation of weight status was found to be associated with a more than 2-fold increased risk of being overweight compared to those children whose weight status was correctly perceived by their mothers (adjusted OR 2.31, 95% CI 1.11–4.81). In contrast; a 63% reduced risk of being overweight (adjusted OR .37, 95% CI .17–.83) was seen in children of mothers reporting that they were already limiting television viewing time, which implies a 2.7-fold increased risk of being overweight among children who were not yet viewing less television compared to those who were already doing so, independent of maternal underestimation of weight status and child's sex and age. These findings suggest that even though maternal underestimation of weight status is of relevance for the presence of overweight in preschool-aged children, health behaviors such as reducing television viewing time have a greater impact on the child's risk of being overweight even at such an early stage of life. The association between television viewing time and risk of overweight in preschool-aged children has been previously described. A longitudinal study in 8,234 children reported that the OR for obesity increased linearly as the number of hours of television viewing increased. For children reported to watch television for 4–8 hours per week at age 3 the adjusted OR for obesity at age 7 was 1.37 (1.02 to 1.83). For those reported to watch more than 8 hours per week the adjusted OR was 1.55 (1.13 to 2.12) (Reilly et al., 2005). More recently, an analysis of longitudinal data of 4724 children recruited at birth and 4340 recruited at age 4 showed a bidirectional relationship between television viewing habits and BMI. Child's dietary intake, television viewing habits and BMI were evaluated at three time points, separated by 2 years. Children who watched television were more likely to gain weight, and children who were heavier were also more likely to watch television. Interestingly, dietary intake mediated the BMI-television viewing relationship for the
Weight Status Misperception and Childhood Obesity older children, but not for the birth cohort (Fuller-Tyszkiewicz, Skouteris, Hardy, & Halse, 2012). Therefore, it is important that health care professionals make parents aware of actual weight status of their children during well child visits using anticipatory guidance, but also a great effort should be focused on encouraging parents of preschool-aged children to promote and adopt a family healthy lifestyle in order to prevent and manage overweight among these children. Results of this study are relevant for nursing practice due to the key role that nursing professionals have in the identification and prevention of childhood obesity through the development, implementation and evaluation of educational interventions aimed to identify, prevent and manage childhood obesity.
Study Limitations This study has three main limitations: first, the crosssectional nature of the study; second, the relative small sample size and therefore the likelihood of type II error in some of the estimates. Finally, the current number of hours of television viewing was not evaluated; however, regardless of the number of hours spent in this activity, less television viewing time was associated with a significant lower risk of being overweight in this study population.
Conclusions Maternal underestimation of weight status was a common finding among both overweight and normalweight children, and this misperception of weight status was associated with an increased children's risk of being overweight; however, less television viewing time showed a stronger association with children's risk of being overweight. Parents should be made aware of the actual weight status of their child during the well child visits, but more importantly, they need to be aware of the importance of promoting heath behaviors among their children and be willing to do so in order to prevent and properly manage the overweight in preschool aged-children. Further studies aimed to evaluate educational interventions to effectively modify family and child health behaviors and their longterm impact on children's weight status are needed.
Funding Sources None.
Conflict of Interest/Disclosures Authors declare no conflicts of interest.
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