Mother's perception on child's weight status

Objectives: To examine the accuracy of mothers’ perceptions of their children’s weight status, factors associated with their perceptions and their plans for controlling their children’s weights.
Method: 482 overweight Kuwaiti preschool children and their mothers were selected from a sample of 2329 from the Kuwait Nutrition Surveillance System [KNSS] from September 2003 to June 2004. Heights and weights were measured for the children and their mothers to identify their weight status. Mothers were interviewed by a questionnaire to assess their perceptions and plans for their children’s weights.
Results: Mothers of overweight children (97%), male children (88.4%), and children without a family history of obesity (89%) showed significantly incorrect perception of their children’s weight. Interestingly, the age of the child, the mother’s education level, the mother’s working status and the mother’s Body Mass Index (BMI) did not significantly contribute to correct perception of weight status. However, two thirds of mothers had a plan to control their child’s weight. The child’s age, the BMI of mother and child, the family history of obesity, and a correct perception of a child’s weight by the mother were significantly associated with a plan for weight control.
Conclusion: A majority of Kuwaiti mothers were unable to correctly perceive their child’s weight status, especially for their male and overweight children. Two-thirds of the mothers had a plan to control their weight if the child becomes obese. The child’s age, the child and mother’s body weight, and the mother’s correct perception mainly affected the selection of the plan.

Key words: Kuwait, Mothers, Perception, Preschool children, Weight status

INTRODUCTION

Obesity is considered a global epidemic as it affects 27% of the children worldwide (1). According to a report by the Kuwait Nutrition Surveillance System [KNSS], in 2007 the prevalence of obesity in preschool children (

Early identification of obesity in childhood is important because it offers the best hope for preventing disease progression with its associated co-morbidities (3). Studies showed that obese children are more likely to remain obese as adults (4). It is also very difficult for obese adults to lose weight permanently (5); hence, starting intervention programs at its earliest stage in children is the most effective (6).

Cultural and psychosocial factors are the primary influences on eating behaviors of children. For children, the primary environment is the family in which these influences are demonstrated, and it is within the family context that eating behaviors are developed (7). Unlike adults, children are only partially responsible for their eating behaviors as they are fed and influenced in their food choices by their parents, especially when they are young (8), (9). Families differ in their beliefs, eating habits, and willingness or ability to engage in diet modification for improved health. Individual, familial, and cultural differences in the perception of appropriate body size and shape might also contribute to differences in perception of overweight as a health concern or as a sign that the child is healthy and well fed (10).

Significant differences were found between mothers’ perception of their children’s body size and the actual body size of the children. On average, mothers perceived their children to be thinner than their actual size (7). Maternal recognition of overweight is a necessary factor in affecting dietary and life style changes for children. While mothers are in an important position to prevent obesity in their children by shaping their early diet and activity patterns, several studies have reported variations in rates of maternal misperception of overweight status of their preschool children (11), (12), (13). Christoffel (14) has rightly pointed out the need for research into attitudes and behaviors of parents while Killion (7) identified mother’s perception of their child’s excess weight as an important area for research in prevention of obesity.

In Kuwait, the present study is the first attempt made in assessing a mother’s perception of her child’s weight status compared to the child’s actual (i.e., measured) weight. This preliminary investigation was conducted to:
– Assess the accuracy of Kuwaiti mothers’ perceptions of their preschool child’s weight status;
– Identify the factors associated with the accuracy of maternal perception; and
– Find out if the mothers have any plan to control their child’s weight.

METHODS

Kuwait is a small wealthy country with an area of 17,818 km2, located at the 30.27° N and 48.46° E. It is bordered by Iraq on the North and West, Saudi Arabia on the South and Arabian Gulf on the East. In 2006, the mid-year population of Kuwait was 3.05 million. Only a third of the total population is Kuwaiti citizens, with the majority of the remainder being foreign workers (15). This survey was conducted only among the Kuwaiti population as the majority of the foreign population are single, and working class males from Asia and Arab countries.

The discovery of oil in 1940s changed the living standards of Kuwait citizens dramatically with high standard of living, which includes free medical care, education, and other amenities together with increased income. As a result, food habits are changed from traditional to western foods with high energy density meals (16).

Kuwaiti society is quite homogenous with most citizens having similar living conditions. Food availability, purchasing power and accessibility, food security, and health care facilities are readily available and within reach of all Kuwaitis. The young children in Kuwaiti society are taken care by mothers, grandmothers and maids. In addition, maids who are of different nationalities, have influence on children’s eating habits. Fathers generally get involved with their children, especially sons, only when they reach adolescence. Food habits among the Kuwaiti children have been changed. In recent years from traditional foods to western fast foods. Furthermore, children in general are not involved in any kind of physical activity or sports. This is mainly due to the harsh weather and lack of proper public facilities, or both.

Design and Sample:
A sample of 2329 Kuwaiti pre-school children (3 to 6 years of age) (1114 males and 1215 females) and their mothers were taken from the on-going Kuwait Nutrition Surveillance System [KNSS] from September 2003 to June 2004. A subsample of 482 overweight and obese children were chosen to assess the mother’s perception of their overweight and obese children. These mothers were also targeted for intervention programs, including educating them to incorporate healthy eating habits, engaging their children in physical activities, and reducing the television viewing time.

The KNSS was started with World Health Organization (WHO) assistance in 1995. It is advised by the Center for Disease Control and Prevention (CDC) and is designed to be a sentinel sample of the Kuwaiti population. It is based on an estimated sample size for each population group recommended by CDC experts, and reflects the nutritional status of the population and monitors the trends. Annually, trained personnel collected data randomly from health clinics and schools of all six governorates that comprise the State of Kuwait. All students in the selected school and all the cases who had attended the clinic for immunization were included and their mothers answered the questionnaire. Approval from the Ministries of Education and Health, and informed written consent from the mothers were obtained, after explanation of the purpose of surveillance.

Height and Weight Status of the Children and their Mothers:
Children’s heights were measured without shoes to the nearest 0.1 cm using a SECA model 220 electronic stadiometer. Children’s weights were measured without shoes and in light clothing to the nearest 0.1 kg using a SECA 708 electronic weighing scale (SECA, Medical Scales and Measurement systems, Hamburg, Germany). Children are considered overweight if their BMI for age and gender are between 85th and < 95th percentiles and obese if the BMI is ≥ 95th percentile from the WHO growth charts (17). BMI for age was chosen because it is a worldwide accepted standard for screening overweight and obesity in children, and in early childhood it is correlated with fatness. The BMI (weight in kg / height in meter 2) of mothers was classified as underweight (<18.5), normal weight (≥18.5 to <25), overweight (≥25.0 to <30) and obese (≥30.0) (18).

Child and Maternal Characteristics:
Demographic information for the children and their mothers was obtained from the structured questionnaire used in the KNSS. Additional questions regarding a mother’s perception of her child’s weight status and her plan for her overweight children were added to the questionnaire. The questionnaire was pre-tested in a small group and the results of this pilot study were used to finalize the questionnaire. The final analysis was limited to 482 overweight and obese children and their mothers from the 2329 from the on-going KNSS sample.

Statistical Methods:
Statistical analyses were carried out using Statistical Package for Social Sciences, v16.0 (SPSS Inc., Chicago, USA). The level of statistical significance was set at 0.05. The chi square test was used to assess the association between qualitative variables. Multiple logistic regression was used to estimate the risk of different factors in the mother’s wrong perception after controlling confounding between them. The adjusted odds ratios and their 95% CI for associated factors were computed from the coefficients of the logistic regression model.

RESULTS

The mothers’ ages ranged from 21 to 53 years old (mean+/- SD = 34.1 +/- 6.0 years) with more than half of them (n=263; 54.6%) in the 30 to 39 years group. Children’s ages ranged from 36 to 68 months (mean +/- SD = 55+/- 9 months), with a male to female ratio of 1:1.23. About 58% of the children were obese and 31.7% had a family history of obesity. Of the 482 mothers, 37% had a high school education or less and about 38% were not working. The majority of mothers (50.6%) were obese and only 15.1% had a normal BMI.

Data on mother’s perception of her child’s weight status according to the child’s and the mother’s characteristics are shown in Table 1. Table 1 shows that over 401 mothers (83.2%) incorrectly perceived their children’s weight status. Male children (88.4%) were more incorrectly perceived than female (78.9%), p=0.006. There was a highly significant difference in mothers’ incorrect perception among obese children (73.1%) and overweight children (97%), p

Younger mothers perceived their children’s weight status more incorrectly than older mothers, p=0.023, but a mother’s education, working status, or BMI status did not show any association. Family history of obesity showed a very strong association with mother’s perception of their child’s weight status. Interestingly, 69.9% mothers of children with a positive family history of obesity perceived their child’s weight status incorrectly compared to 89.4% mothers of children without a family history of obesity.

Multivariate logistic regression analysis was used to adjust for confounding between the factors with mother’s perception (0 for correct and 1 for wrong) as the dependent variable, and child’s and mothers’ characteristics as independent variables. Child’s gender, BMI and family history of obesity were retained as significant factors (Table 2). As indicated previously, there was a significantly greater likelihood of mother’s wrong perception for male children (OR=2.17) compared to female children; overweight children (OR=11.39) compared to obese children; and children without family history of obesity (OR=2.99) compared to children with family history of obesity.

Two-thirds of mothers had a plan to reduce their child’s weight (Table 3), 29.5% of the mothers said they would reduce their children’s food intake, 25.5% would consult a dietitian, and 12.6% would increase their child’s activity. The child’s age and BMI showed a significant association (p=0.009, p=0.018 respectively) with mother’s choice of plan. As the child’s age increased, the mother’s plan was more likely to involve an increase in their child’s activity rather than a reduction in the child’s food intake. The mother’s BMI showed a significant association with a plan for reducing their child’s weight; mothers with normal BMI were more likely to have a plan, particularly consulting a dietitian.

A family history of obesity was significantly associated with having a plan to control child’s weight particularly by reducing food intake or increasing activities compared to those without family history.

Of the 81 mothers who accurately perceived their overweight children as overweight, 83% had a plan to control their child’s weight. Of these, 48.1% would chose to reduce their child’s food intake and 17.3 % to increase their child’s activities compared to 25.7% and 11.7% respectively of the 259 mothers who did not accurately perceive their child’s weight, p

DISCUSSION

Recognition of overweight and obesity in children by parents is important for early prevention and treatment. In this study, 73.1% mothers of obese children and 97% of overweight children incorrectly perceived their children’s weight status. These findings are consistent with previous studies in Australia (19) and in the United States (20) showing low rates of correct perceptions.

Campbell et al (19) have suggested that increased prevalence of overweight has normalized the condition in the public’s mind and contributed to mother’s inability to correctly perceive their own child’s weight status. Jain et al (21) provided qualitative evidence that low-income mothers viewed their child’s heaviness as a reflection of inherited build or an indicator of good health. This may also be true in the cultural context of the recently affluent Kuwaiti society, but further studies are needed.

Actual causes of a mother’s misperception were not measured in this study, but associations with some maternal and child characteristics support some potential etiologies. Logistic regression analysis showed that mothers are more than twice as likely to correctly classify overweight daughters than overweight sons, consistent with two studies (12), (22) that showed a relation between mother’s perception and sex of the child. This could reflect a mother’s concern about the negative body image of their large daughters while the large body size of the sons was seen as having physical advantage (19).

As expected, obesity in the child decreased the probability that a mother would incorrectly perceive her child’s weight. Although weighing between the 85th and < 95th percentile (overweight) is not considered to be health risk in 3- to 6-year olds (23, 24), the early identification of extra weight is important for prevention of obesity and avoidance of secondary complications such as hypertension and dyslipidaemia, which are associated with excess weight (23), (25).

Family history, or a possible genetic predisposition to obesity, was also a strong factor in the logistic regression analysis. Mothers of children with a positive family history of obesity were more likely to recognize their children as overweight compared to those without such a family history. They were also more likely to have a plan to reduce their child’s weight, most choosing to decrease their child’s food intake. This could reflect exposure to suffering of a family member to the medical or social morbidity of obesity.

Although most mothers described their children as being of normal weight, two-thirds of them were concerned enough to have plan for reducing their child’s weight. Their plan was mainly affected by the child’s age and the child’s and mother’s body weight. Mothers were more concerned about their younger children and their plan for these younger children involved the child’s food intake. Jain et al have shown that mothers believe that as their obese children get older, and more active, they will grow out of their obesity (22).

Mothers were more likely to have a plan for their obese children than for their overweight children, and their plan was reducing the children’s food intake. A mother’s weight has a significant effect on their plan; obese mothers were less likely to have a plan for controlling their child’s weight or to plan to consult a dietitian. What extent this reflects their own lack of concern for obesity or their own unsuccessful attempts to lose weight requires future study.

The fact that mothers who could identify their children as overweight were more likely to have a plan to reduce their child’s weight confirms the importance of mother’s perception in the prevention of their child‘s obesity. Therefore, targeting intervention programs to the mothers is recommended to help them correctly classify their children’s weight and take appropriate action before their children become obese.

One limitation of our study is the use of closed ended questions, which prevented us from assessing any attitudes, or knowledge deficits that would cause maternal misperceptions. The other limitations are not involving the fathers, not including information regarding psychosocial factors that may relate to mother’s perceptions and not using child figure silhouettes to identify their children’s body size.

For future studies we would like to select a sample with more information on the child such as birth weight, number of siblings, and the responsible person who feeds the child. We would also like to use a scale with child figure silhouettes and compare the silhouettes with the children’s actual body mass index. Targeting intervention programs to mothers is recommended to help them correctly classify their children’s weight and take appropriate actions before their children become obese.

CONCLUSION

Maternal perception of child’s body weight may have important behavioral impact and health implications. Accurate perception of risk is necessary as a first step for establishing behavioral modification goals for diet and physical activity for children’s health. These goals can be achieved by getting support and reinforcement from health care professionals and families as well as schools and the whole community. Lack of awareness of the normal weight status and the complications of obesity may be responsible for the incorrect perception of mothers.

ACKNOWLEDGEMENT

We thank all the children and their mothers who participated in this study. We acknowledge our gratitude to the data collectors of Kuwait Nutrition Surveillance System [KNSS] for their help.

REFERENCES

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2. Report of Kuwait Nutrition surveillance System (KNSS), 2007.

3. Moran R. Evaluation and treatment of childhood obesity. Am Fam Physician 1999;59(4):861-870.

4. Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;337:869-873.

5. Wadden TA. Treatment of obesity by moderate and severe caloric restriction: results of clinical research trails. Ann Intern Med 1993;119:688-693.

6. Bouchard C. Can obesity be prevented? Nutr Rev 1996;54:ss125-ss30.

7. Killion L, Hughes SO, Wendt JC, et al. Minority mothers’ perception of children’s body size. Int J of Pediatr Obes, Vol 1, issue 2, 2006, 96-102.

8. Dixon R, Adair V, O’Connor S. Parental influences on the dieting beliefs and behaviors of adolescents females in New Zealand. J Adolesc Health 1996;19:303-307.

9. Johnson SL, Birch LL. Parent’s and children’s adiposity and eating style. Pediatrics 1994;94:653-661.

10. Abood DA, Mason MA. Exploring racial differences in body dissatisfaction and eating attitudes and behaviors. Am J Health Stud 1997;13:119-127.

11. Baughcum AE, Chamberlin LA, Deeks CM, et al. Maternal perception of overweight preschool children. Pediatrics 2000;106:1380-1386.

12. Maynard ML, Galuska AD, Blanck MH, et al. Maternal perceptions of weight status of children. Pediatrics 2003;111:1226-1231.

13. Simonetta G, Macro G, Andrea F. Maternal perception of excess weight in children: A survey conducted by pediatricians in the province of Milan. Acta Paediatrica Taylor & Francis 2005;94:747-752.

14. Christoffel KK, Ariza A. The epidemiology of overweight in children: relevance for clinical care. Pediatrics 1998;101:103-105.

15. Health Kuwait, 2006, Ministry of Health, Kuwait, 2006.

16. Kuwait Nutrition Profile – Nutrition and Consumer Protection Division, FAO, 2006.

17. WHO Multicentre growth reference Study Group. WHO child growth standards: length/height-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development. Geneva; World Health Organization, 2006.

18. World Health Organization. The international classification of adult underweight, overweight and obesity according to body mass index, 2004.

19. Campbell M W-C, Williams J, Hampton A, et al. Maternal concern and perceptions of overweight in Australian preschool-aged children. Med J Aust 2006;184(6):274-277.

20. Hackie M, Bowels CL. Maternal perception of their overweight children. Public Health Nursing 2007;4(6):538-546.

21. Jain A, Chamberlin LA, Carter YP, et al. Why don’t low-income mothers worry about their preschoolers being overweight? Pediatrics 2001;107(5):1138-1146.

22. Jeffery AN, Voss LD, Metcalf BS et al. Parents’ awareness of overweight in themselves and their children: cross sectional study within a cohort (Early Bird 21). BMJ 2005;330: 23-24.

23. Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. Pediatrics 1998;102(3):e29.

24. Kuczmarski RJ, Flegal KM. Criteria for definition of overweight in transition: background and recommendations for the United States. Am J Clin Nutr 2000; 72:1074-1081.

25. Himes JH, Dietz WH. Guidelines for overweight in adolescent preventive services: recommendations from an expert committee. The expert committee on clinical guidelines for overweight in adolescent preventive services. Am J Clin Nutr 1994;59:307-316.

TABLES

Table 1: Mother’s perception of her child’s weight status according to characteristics of preschool children and their mothers.

Total

(N=482) Mother’s perception
p-value
Correct
81 (16.5%)
N (%) Wrong
401 (83.2%)
N (%)
Child’s gender
Male
Female
216 (44.8)
266 (55.2)
25 (11.6)
56 (21.1)
191 (88.4)
210 (78.9) 0.006a
Child’s age in years
3
4
5
99 (20.5)
220 (45.6)
163 (33.8)
22 (22.2)
32 (14.5)
27(16.6)
77 (77.8)
188 (85.5)
136 (83.4) 0.334b
Child’s BMI
Overweight
(85th -94th percentile)
Obese
(≥95th percentile)
203 (42.1)

279 (57.9)
16 (3.0)

75 (26.9)
197 (97.0)

204 (73.1) <0.001a
Age of mother (years)
<30
30-
≥40
123 (25.5)
263 (54.6)
96 (19.9)
16 (13.0)
41 (15.6)
24 (25.0)
107 (87.0)
222 (84.4)
72 (75.0)
Education of mother
Secondary or below
Above secondary
179 (37.1)
303 (62.9)
27 (15.1)
54 (17.8)
152 (84.9)
249 (82.2) 0.437a
Occupation of mother
Not working
Working
182 (37.8)
299 (62.2)
32 (17.6)
49 (16.4)
150 (82.4)
250 (83.6) 0.734a
Mother’s BMI
Normal
(18.5-24.9kg/m2)
Overweight
(25-29.9kg/m2)
Obese
(≥30kg/m2)
73 (15.1)

165 (34.3)

244 (50.6)
10 (13.7)

23 (13.9)

48 (19.7)
63 (86.3)

142 (86.1)

196 (80.3) 0.122b
Family history of obesity
No
Yes
329 (68.3)
153 (31.7)
35 (10.6)
46 (30.1)
294 (89.4)
107 (69.9) <0.001a
P-value is generated by achi-square test and bchi-square test for linear trend.

Table 2: Factors associated with mother’s wrong perception by multiple logistic regression analysis in the studied preschool children.

Variable Adjusted
Odds ratio 95% CI
p-value
Child’s gender
Male
Female (reference)
2.17
1.00
1.23 – 3.81
0.007
Child’s age in years
3 (reference)
4
5
1.00
1.55
1.32

0.78 – 3.07
0.64 – 2.72

0.213
0.453
Child’s BMI
Overweight
Obese (reference)
11.39
1.00
4.76 – 27.23 <0.001
Age of mother (years)
30-
≥40
1.0
1.06
0.64

0.52 – 2.13
0.29 – 1.41

0.878
0.266
Education of mother
Secondary or below
Above secondary (reference)
1.61
1.00
0.80-3.22
0.182
Occupation of mother
Not working
Working (reference)
0.83
1.00
0.41-1.65
0.588
Mother’s BMI
Normal (reference)
(18.5-24.9kg/m2)
Overweight
(25-29.9kg/m2)
Obese
(≥30kg/m2)
1.00

1.06

0.93

0.43 – 2.58

0.40 – 2.18

0.907

0.867
Family history of obesity
No (reference)
Yes
1.00
2.99

1.73 – 5.15 <0.001
CI = Confidence interval for odds ratio

Table 3: Mother’s plan according to characteristics of 482 preschool Kuwaiti children and their mothers.
Variable Mother’s Plan
Consult
Dietician
N (%)

123 (25.5) Reduce Food intake
N (%)

142 (29.5) Increase activities
N (%)

61 (12.6) No plan

N (%)

156 (32.4)
p-value
Child’s gender
Male
Female
48 (22.2)
75 (28.2)
63 (29.2)
79 (29.7)
29 (13.4)
32 (12.0)
76 (35.2)
80 (30.1) 0.420
Child’s age in years
3
4
5
29 (29.3)
61 (27.7)
33 (20.2)
40 (40.4)
62 (28.2)
40 (24.5)
7 (7.1)
28 (12.7)
26 (16.0)
23 (23.3)
69(31.4)
64 (39.3) 0.009
Child’s BMI
Overweight
Obese
56(27.6)
67 (24.0)
49 (24.1)
93 (33.3)
20 (9.9)
41 (14.7)
78 (38.4)
78 (28.0) 0.018
Age of mother (years)
<30
30-
≥40
29 (23.6)
69 (26.2)
25 (26.0)
28 (22.8)
90 (34.2)
24 (25.0)
22 (17.9)
30 (11.4)
9 (9.4)
44 (35.8)
74 (28.2)
38 (39.8) 0.061
Education of mother
Secondary or below
Above secondary
54 (30.2)
69 (22.8)
50 (27.9)
92 (30.4)
20 (27.9)
41 (13.5)
55 (30.7)
101 (33.3) 0.338
Occupation of mother
Not working
Working
45 (24.7)
78 (26.2)
60 (33.0)
82 (27.4)
19 (10.4)
42 (14.0)
58 (31.9)
97 (32.4) 0.488
Mother’s BMI
Normal (18.5-24.9kg/m2)
Overweight(25-29.9kg/m2)
Obese (≥30kg/m2)
26 (35.6)
51 (30.9)
46 (18.9)
19 (26.0)
42 (25.5)
81 (33.2)
14 (19.2)
16 (9.7)
31 (12.7)
14 (19.2)
56 (33.9)
86 (35.2) 0.003
Family history of obesity
No
Yes
84 (25.5)
39 (25.5)
88 (48.1)
54 (35.3)
38 (11.8)
23 (15.0)
119 (36.2)
37 (24.2) 0.042