Does maternal concern about children's weight affect children's body size perception at the age of 6.5?—A community-based study

Abstract

Objective

Though overweight is often established by school entry, not all mothers of such children report weight concerns. Enhancing concern might assist lifestyle change, but could lead to child body dissatisfaction. We investigated (i) perceived/desired body size and body dissatisfaction in mothers and their 6.5-year-old children, and (ii) the impact of earlier maternal concern about overweight on children's body mass index (BMI) status and body dissatisfaction.

Design

Prospective community study.

Setting

Melbourne, Australia.

Subjects

317 mother–child dyads.

Main exposures

Child and maternal BMI (kg m−2) at 4.0 and 6.5 years; maternal concern about child overweight at 4.0 years.

Outcome measures

Paired perceived and desired body size on 7-point figural rating scales self-reported by mothers and children, and reported by mothers regarding children; dissatisfaction (‘desired’ minus ‘perceived’) score.

Results

For all three actual BMI perceived size pairings (mother self-report, mother's report on child and child self-report), BMI correlated with perceived body size (r=0.82 (mother self-report); r=0.65 (mother reporting on child); r=0.22 (child self-report); all P<0.001). Similarly, all three dissatisfaction scores were greater with increasing BMI status. Children's own dissatisfaction scores correlated with their actual BMI, but were not related to mothers’ own body dissatisfaction scores or with mothers’ dissatisfaction with children's body size. Maternal concern about overweight at the age of 4 years was not associated with BMI change, or child body dissatisfaction by the age of 6.5. Most mothers of overweight and obese children (88 and 90%, respectively) regarded their child as the middle figure (that is, 4) or thinner.

Conclusions

Despite low rates of recognition of child overweight, maternal perceptions of the child's body correlated strongly with the child's actual BMI. Maternal concerns about child BMI did not appear to impact on child BMI change or child body dissatisfaction.

Introduction

Consistent with the global experience,1, 2, 3 overweight and obesity in Australian children have risen rapidly since 1985 and now affect approximately one-quarter of all primary school children.4 Although the epidemic is attracting substantial health, media and public attention, parent perceptions about the overweight status of their own children often seem to be inconsistent with the magnitude of public health concern. Assuming that addressing the childhood obesity epidemic requires at least some individual change, it is important to understand underlying perceptions at the individual level. However, there is also concern that focusing on a child's weight could foster the development of body image problems, mental health issues and disordered eating.5 The challenge is therefore to understand not only the problem of lack of recognition for individual children, but also how and when body image problems come about.

According to behavior change theories, such as the stages of change model,6 parents would need to recognize the issue of overweight in themselves or their own child to motivate the behavior change needed to achieve weight reduction. However, multiple reports (mainly studying mothers) have shown a striking picture of low rates of recognition; between 17–98% of parents do not recognize overweight in their overweight children.7, 8, 9, 10, 11 The wide range may be attributed to study differences on factors such as the obesity cut points used, child age and the method of questioning. Mothers are more accurate with older and heavier children,10 and better at estimating body size when pictorial or photographic figures, rather than the words ‘overweight’ and ‘obese,’ are used.7 Postulated reasons for this low recognition include the normalization of overweight, denial, a genuine lack of concern or a belief that childhood ‘puppy fat’ is healthy; however, the evidence about the reasons remains scant. Concluding that ‘the laypersons’ perception of average weight and the clinical definition of overweight are now in conflict,’ Jeffery reported 40% of overweight mothers and 45% of overweight fathers judged their own weight ‘about right’ and that a large proportion were unconcerned about their weight.

It is possible that parents are more concerned about their child's future than current weight status. In Campbell's recent study, while only 5% of mothers of overweight and obese children had concerns about current overweight in their 4-year-old children, three times as many (16%) were concerned that their child would later become overweight.12 Parents are more likely to be concerned about future overweight if their children are already overweight or they themselves are overweight.9 However, it is not yet clear whether parental concern about either current or future overweight actually influences weight change over time or subsequent body perception in young children.

Paradoxically, despite this under-recognition, negative body image and its associated problems are prevalent. Several studies indicate that children, from as young as 5, want body sizes thinner than they have.13, 14, 15 Truby and Paxton, using a sophisticated figural scale developed to represent actual body mass index (BMI), showed 48% of girls and 36% of boys of primary school age wanted to have a smaller body figure.14 One study found that 5-year-old girls with higher weight status had lower body self-esteem, especially when their parents were overtly concerned about their weight.16 As children mature, overweight and obesity become risk factors for disordered eating behavior. The 2002 US population-based ‘Project EAT’ showed that 76% of overweight teenage girls and 55% of overweight teenage boys reported unhealthy weight control behavior, such as skipping meals, smoking, fast food substitutes and eating very little food. More extreme behaviors, such as binge eating, vomiting, laxatives, diuretics and weight control pills were reported by one in five overweight girls.5

In this paper, we draw on data from an established community-based longitudinal cohort to report on (1) cross-sectional relationships between actual, perceived and desired body mass, as reported by mothers and their 6.5-year-old children; (2) longitudinal relationships between earlier maternal concern (at the age of 4 years) about child overweight and the child's own subsequent BMI gain, perceived and desired body mass and body satisfaction and (3) whether these relationships are influenced by factors such as the mother's own weight status, child's weight status, socioeconomic status and sex of the child.

Methods

Design and participants

Participants were all 6.5-year-old children in the PEAS (Parent Education and Support) Kids Growth Study, an established longitudinal community-based study.17 Between June 1998 and December 1999, all community-based well-child nurses in three local government areas (inner urban, suburban and semirural) in Melbourne, Australia, sequentially approached parents of first-born newborns, with 493 of the parents approached (70% response) ultimately recruited. The 402 still-contactable families were invited to participate in semiannual follow-ups between 4 and 6.5 years, of which 317 provided data for this paper. When children were between ages 4 and 6.5 years, parents completed written questionnaires and children were weighed and measured; at the age 6.5 years, the children themselves completed a questionnaire by interview and mothers were also weighed and measured. The study was approved by the Royal Children's Hospital Ethics in Human Research Committee, and parents provided written informed consent at both recruitment and 4 years.

Measures

Concern about child overweight (age 4 years)

Mothers responded on identical five-point scales to two statements (‘I am worried that my child will become overweight’ and ‘I am worried that my child is overweight right now’), which were then dichotomized into ‘not concerned’ (‘disagree a lot,’ ‘disagree a little’ or ‘no strong feelings’) vs ‘concerned’ (‘agree a lot’ or ‘agree a little’). Prevalence of responses by child sex, BMI and demographic categories have been reported previously elsewhere.12

Body perceptions (age 6.5 years)

To assess perceptions of body mass and satisfaction, we used Stunkard's18 and Collins’13 sex-specific figural rating scales, a series of seven line-drawings, numbered 1 (thin) to 7 (obese), depicting an adult (Stunkard) or child (Collins) with increasing levels of adiposity. Excellent reliability has been reported for the adult scale.18 For grades 1–3 children (mean age 8.0 years), Collins13 reported an overall correlation of 0.37 between the figural rating scale score and BMI, although it was stronger for older children. Similarly, using the Collins drawings arranged nonlinearly, Williamson and Delin14 have reported accurate identification of body size with Australian children as young as five. Regarding the adult female pictures, mothers were asked their perceived body size (‘Which picture looks most like you?’) and their desired body size (‘Which picture looks most like you want to look?’). Regarding the child sex-specific pictures, mothers were asked ‘Which picture looks most like your child?’ and ‘Which picture looks most like how you want your child to look?’ Children were asked ‘Which picture looks most like you?’ and ‘Which picture looks most like you want to look?’ by a trained interviewer who recorded the figure pointed to by the child.

‘Body dissatisfaction scores’ were calculated for three paired sets of ratings (mother self-report, mother report on child, child self-report) by subtracting the numerical rating of the perceived figure from that desired. Possible dissatisfaction scores were −6 to +6, with a positive score indicating a desire for a heavier body and a negative score a desire for a lighter body.

Anthropometry (ages 4 and 6.5 years)

Height and weight were recorded at both time points by trained research assistants according to the standardized protocol.19 Height was measured to the nearest 0.1 cm using an Invicta portable stadiometer and weight to the nearest 0.1 kg on digital scales, without shoes and wearing light clothing. BMI (kg m−2) was calculated at each time point. Child BMI was transformed to a z-score according to the UK 1990 Growth Reference20 and children were categorized as nonoverweight, overweight or obese using sex- and age-specific International Obesity Task Force (IOTF) cut points.21, 22 Maternal BMI was calculated from self-reported height and weight23 at the 4-year time point and direct measurement at the 6.5-year time point; BMI data for pregnant women were excluded. Mothers were categorized as nonoverweight (<25 kg m−2), overweight (25 to <30 kg m−2) and obese (30 kg m−2).

Demographic data

Socio-Economic Indexes for Areas (SEIFA) disadvantage index scores were assigned according to the family postcode of residence data at the age of 6.5 years and were analyzed by population-based quintiles. SEIFA values are standardized scores derived from the 2001 national population census data, which can be linked to geographic areas and summarize the social and economic conditions (national mean 1000, s.d. 100; higher values represent greater advantage).24

Statistical analyses

χ2 tests were used to compare children in the original birth cohort who were retained at the age of 6.5 years (n=317) to those who were not retained (n=176) on child sex and maternal age and education status at the birth of the child. Children in the cohort at 4 years (n=341) who were retained at 6.5 years (n=317) were further compared to those who were not retained (n=24) on child and maternal BMI status when the child was 4 years of age.

Box and whisker plots and Pearson's correlation coefficients were generated to summarize the relationship of actual BMI with each of perceived and desired body image for mother self-report, mother report on child and child self-report. For each of the three sets of dissatisfaction scores, Cuzick's nonparametric Wilcoxon-like test for trend was carried out to test for linear trend across the categories of the relevant BMI status variable.

Three multivariable linear regression models were fitted to estimate the strength of longitudinal associations between maternal concern about children's current and future overweight status at the age of 4 years and (a) change in child BMI z-score from the age of 4 to 6.5 years, (b) maternal body dissatisfaction score regarding the child at 6.5 years and (c) child dissatisfaction score at the age of 6.5 years. The following variables were added to each of the three models as covariates: maternal BMI status at the age of 4 years, child sex and SEIFA disadvantage index quintile. Child BMI z-score at the age of 4 years was added as a covariate for models (b) and (c), but not for model (a) because of the potential introduction of bias.25

Two multivariable linear regression models were fitted to estimate the strength of the association between child dissatisfaction score at the age of 6.5 years with (i) maternal dissatisfaction score regarding herself and (ii) maternal dissatisfaction score regarding the child. Both crude and adjusted (for maternal BMI status at the age of 6.5 years, child sex, SEIFA disadvantage index quintile and child BMI z-score at the age of 6.5 years) coefficients were calculated. Linear regression analysis assumptions were checked for all models and were found to be nonviolated. Ordinal and continuous covariates were tested for departure from linearity and are presented as linear effects where the test result was nonsignificant at the 5% level. All analyses were carried out using Stata version 9.0 software (Statacorp 2005, College Station, TX, USA).

Results

Characteristics of participants retained and lost through the study are shown in Table 1, highlighting that fewer of the retained than lost mothers were overweight or obese. For the 317 mother–child dyads contributing to these analyses, 97.5% of the mothers and 99.7% of the children completed the figural rating scales.

Table 1 Comparison of characteristics between those retained at the age of 6.5 years and (i) the total lost to follow up by the age of 6.5 years and (ii) the subset of those retained at the age of 4.5 years but lost by 6.5 years

Table 2 shows characteristics of the sample at the age of 4 and 6.5 years; it can be seen that the two most disadvantaged SEIFA quintiles were relatively underrepresented. Overall, there was little change between 4 and 6.5 years in the percentages of overweight and obese children. At the age of 6.5 years, 90% of mothers and 82% of children saw the child as being the ‘middle’ weight or thinner (4), even though 19.5% of children were classified as overweight or obese.

Table 2 Characteristics of the sample (n=317)

Relationship between body mass, body image and body dissatisfaction

Figure 1 shows the three pairs of perceived and desired body image ratings in relation to BMI: (a) mother self-report in relation to maternal BMI, (b) mother report on child in relation to the child's BMI z-score and (c) child self-report in relation to the child's BMI z-score. Maternal BMI correlated strongly with maternal perceived figural rating (r=0.82, P<0.001) and moderately with maternal desired figural rating (r=0.51, P<0.001); in other words, heavier mothers reported perceiving themselves as heavier, but also desiring heavier bodies, than thinner mothers. Nonetheless, a substantial proportion (42%) of the overweight and some (5%) of the obese women still regarded themselves as the middle figure (that is, 4) or less. Trends were similar but weaker when mothers reported on their children, with correlations between the child's BMI z-score and the perceived and desired figural ratings of 0.65 (P<0.001) and 0.37 (P<0.001), respectively. For the child self-report, the child's actual BMI z-score bore only weak relationships to either the child's perceived (r=0.22, P<0.001) or desired (r=0.10, P=0.08) figural rating. Virtually, all mothers of overweight and obese children (88 and 90%, respectively) perceived the child as best represented by the middle figure or thinner, in other words seeming to view them as considerably thinner than they actually were. Similar to their mothers, almost all overweight (83%) and obese (83%) children perceived that they were best represented by the middle figure or thinner. Overall, the desire to be heavier than the middle figure was expressed by very few mothers or children for themselves and by very few mothers for their children.

Figure 1
figure1

Body image and body mass index (BMI). Box-and-whisker plots depicting relationships between measured BMI and scores on (i) perceived and (ii) desired body size. Graphs depict (a) mother self-report in relation to maternal BMI, (b) mother report on child in relation to the child's BMI z-score and (c) child self-report in relation to the child's BMI z-score.

Table 3 shows the body dissatisfaction results according to the BMI status. For all three results (mother self-report, mother's report on child and child self-report), there was strong evidence (all P<0.001) of a linear relationship between increasingly negative dissatisfaction scores (that is, desire to be thinner) and increasing BMI status, with the strongest gradient in the mother self-report and smallest in the child self-report. These child self-report findings for BMI status contrast with the minimal correlation demonstrated in the figure between children's BMI z-score and their own perceived or desired body image, suggesting that the desire to be thinner was focused among those at the upper end of the BMI spectrum. Neither maternal dissatisfaction with maternal body size nor maternal dissatisfaction with the child's body size predicted the child's self-reported dissatisfaction score. The only predictor of child self-dissatisfaction was increasing child BMI z-score (β coefficient 0.41, 95% CI −0.57 to −0.26, P<0.001).

Table 3 Body dissatisfaction (mean (s.d.) by BMI status

Effect of earlier maternal concern on BMI change and body dissatisfaction

Table 4 shows the results of the three linear regression analyses investigating associations between early maternal concern (at 4 years of age) about current and/or future overweight, change in BMI z-score and body dissatisfaction outcomes at the age of 6.5 years. Change in child BMI z-score rose with high maternal BMI status (0.10 increase for each step from not overweight to overweight to obese) and being a female child (0.15), whereas fell by 0.07 for each quintile of increasing social advantage; it was not associated with either current or future concern about overweight at the age of 4 years. Mothers who were concerned about the child's current, but not future, overweight at 4 years were the most dissatisfied (that is, desired their child to be thinner than perceived) at the age of 6.5 years, but there was no evidence for an association between these concerns and children themselves having large dissatisfaction scores at the age of 6.5 years. The child's BMI z-score at the age of 4.0 years was the strongest predictor of both child and mother dissatisfaction with the child's body at the age of 6.5 years, but mother's own BMI status was not predictive. Both child and maternal ratings of dissatisfaction with the child's body were slightly higher for female children, but this reached statistical significance only for the maternal ratings of dissatisfaction with the child's body.

Table 4 Change in BMI z-score and dissatisfaction outcomes at the age of 6.5 years: results of the three linear regression models

Discussion

Although mothers were poor at recognizing overweight and obesity in their children at the age of 6.5 years (as at the age of 4 years in this same cohort12), on the whole, their ratings correctly ranked children along the BMI spectrum on a figural rating scale. Earlier maternal concern about the child being overweight was linked to subsequent maternal dissatisfaction with the child's body size. However, it appeared to have neither positive (reduction in BMI gain) nor negative (a greater desire by the child to be thinner) impacts, suggesting that mothers may not act on or impart their concerns to children of this age. It is also possible that this outcome may reflect a lack of knowledge about how to assist their children or a fear that they may damage their child's self-esteem by addressing the problem of overweight. The only predictor of children's self-reported body dissatisfaction was their own BMI.

Strengths of this study include the use of a longitudinal community cohort of generally healthy children with high interwave cohort retention. Rates of maternal overweight/obesity and child overweight reflected current Australian population rates using the conservative IOTF cut points, although obese children were underrepresented (3%, rather than the expected 5–6% at this age). This study is unusual in that we were able to compare and analyze body image data from mothers and young children simultaneously, and to explore longitudinal developments and influences on weight and body image.

One limitation is the mixed use of maternal self-report and measured BMI; the known tendency to underreport weight and overreport height may have inflated the estimate of the increase in maternal BMI demonstrated in Table 2. However, this would not have affected the cross-sectional analyses at the age of 6 years (Figure 1 and Table 3) for which measured BMI was used. For the longitudinal analyses, this may have slightly attenuated the small effect for maternal BMI status noted in Table 4, but we do not believe would have altered the other (negative) longitudinal findings. Our findings are also limited by the age of the children in our study, as young children are less accurate than older children on linear figural rating scales.13 Clearly, the relationship between body dissatisfaction in children and their mothers needs to be studied in older age groups. If different results were found, this could imply either greater understanding of the task at hand or changing predictors of body image with age. As children mature, their parents may be increasingly concerned about,11 and focused on, overweight, and this may lead to children developing views that reflect their parents’ beliefs about their body size and influence body image.

Consistent with the current literature,7, 8, 9, 10, 11 mothers tended to regard their heavier children as having smaller body sizes than the measured BMI would objectively suggest, even though there were strong correlations between BMI and maternal body image of self and child. Overall, larger women and mothers of larger children desired and perceived themselves or their children to be heavier compared with smaller women or mothers of smaller children. The finding that some heavier mothers or mothers of heavier children actually desired for themselves or their children to be comparatively heavier was concerning. Desire for a heavier body size in this situation may reflect a misguided judgment about what body mass is healthiest, or perhaps an acceptance of overweight as the normal state.

Body dissatisfaction was found in all three reporting scenarios—mother self-report, the mother's report on the child and child self-report. Interestingly, although children were poor at recognizing body size, they were increasingly dissatisfied with their bodies with increasing body mass. The lack of statistical evidence that child dissatisfaction was linked to maternal self-dissatisfaction, maternal dissatisfaction with the child's body size or earlier maternal concern about the child's weight status contrasts with Krahnstoever–Davison's conclusion that ‘parental concern about weight status is associated with negative self-evaluation in 5-year-old girls.’16 However, in Krahnstoever–Davison's study, low self-esteem was only found in girls whose fathers expressed ‘concern,’ and ‘concern’ was measured through a series of questions that included comments on concern about the girl eating too much or needing to diet, in addition to concern about overweight. Relationships between fathers’ views and how they relate to their young children's self-perceptions require further research, as do community and societal perceptions of overweight in young children.

Links between obesity, concern about overweight and body image could provide information about factors that may or may not motivate change when weight threatens health, and perhaps about the likelihood of creating mental health problems in a generation of increasingly heavy children. This is a complex issue involving multiple factors. Effectively moving overweight and obese children toward a healthier body size should ideally occur without increasing their body dissatisfaction or damaging their mental health. In suggesting that raising rates of maternal recognition of their young children's overweight and obesity would not necessarily damage their children's body image, this study offers some cause for optimism that this can be achieved in this age group. However, whether increasing such recognition would also progress readiness to change, and whether such progression would in fact alter BMI outcomes, remains to be tested. It will be important to ensure that the way in which this concern is expressed to children is carefully considered, and that parents with this concern have adequate community resources to assist them. Finally, as concern (even when appropriately held) was not linked to altered BMI trajectories, it is imperative that ongoing research focuses on developing ways of effectively translating maternal concern into improved BMI outcomes.

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Acknowledgements

This paper draws on data from a larger longitudinal study, the PEAS Kids Growth Study. RM worked on and MW supervised all phases of the work leading to this paper; MW founded the PEAS Study, and has been a Chief Investigator in all phases; LC conducted all statistical analyses and prepared the tables; JW was the Principal Investigator for the PEAS Kids Growth Study (4.0- to 6.5-year-old waves) and advised on the paper. RM, MW and LC co-wrote and JW edited the paper. We thank all the parents and children who took part in the study, and the research assistants who assisted with data collection. We also acknowledge the major role of Dr Michele Campbell (PhD student) in the 4.0- to -6.5-year-old wave of the PEAS Kids Growth Study.

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Correspondence to R Mitchell.

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Financial Disclosures:

The PEAS Kids Growth Study 4.0- to -6.5-year-old waves were funded by the Australian National Health and Medical Research Council (NHMRC Project Grant 284509) and the Murdoch Childrens Research Institute. Dr Wake's salary is part-funded by NHMRC Population Health Career Development Award no. 284556. There are no competing interests.

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Mitchell, R., Wake, M., Canterford, L. et al. Does maternal concern about children's weight affect children's body size perception at the age of 6.5?—A community-based study. Int J Obes 32, 1001–1007 (2008). https://doi.org/10.1038/ijo.2008.12

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Keywords

  • body mass index
  • body image
  • child
  • mothers
  • longitudinal studies

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