Maternal Perception of Weight Status and Health

Risks Associated With Obesity in Children

WHATS KNOWN ON THIS SUBJECT: One major barrier to living a
healthy lifestyle seems to be parents failure to recognize the
overweight or at-risk status of their child. Child gender and age
and parental sociodemographic inuences are discussed as possible
sources of underestimation.
WHAT THIS STUDY ADDS: Little is known about the perception of
unrelated childrens weight status. Therefore, we examined the
inability to identify the weight status of unrelated children as a
reason for parents failure to estimate their childs weight status.

abstract
OBJECTIVE: To examine factors associated with the maternal perception
of the weight status in related and unrelated children and to examine
whether associated health risks for childrens physical and mental health
are recognized.
PATIENTS AND METHODS: Two hundred nineteen mothers with children
between 3 and 6 years of age took part in this study. The participating
mothers were recruited from inpatient clinics and kindergartens. Parents
were presented with 9 silhouettes representing different age- and genderspecic BMI percentiles. Demographic and weight-related variables were
assessed with regard to their inuence on the accuracy of the maternal
weight estimation in general and for their own child.
RESULTS: Of the participating mothers, 64.5% identied the overweight
silhouettes of preschool-aged children correctly. However, only 48.8% of
the mothers identied the overweight silhouettes associated with an increased risk for physical health problems, and 38.7% identied the silhouettes associated with an increased mental health risk. Mothers with a
lower educational background were more likely to misclassify the overweight silhouettes and underestimate the associated health problems. For
their own child, only 40.3% of the mothers chose silhouettes that were in
agreement with the objective weight status of their child. This underestimation was associated with a higher maternal and child weight status but
not with a general inability to identify the weight status of children.
CONCLUSIONS: Identifying unrelated overweight silhouettes is inuenced
by maternal education level, whereas estimating their own childs weight
status is inuenced by the weight status of the mother and the child.
Hence, feedback on the childs risk to become overweight is necessary to
increase maternal risk awareness and willingness to take part in prevention programs. Pediatrics 2009;124:e60e68

e60

WARSCHBURGER and KROLLER

CONTRIBUTORS: Petra Warschburger, Prof Dr, and Katja Kroller,

DiplPsych
Department of Psychology, University of Potsdam, Potsdam,
Germany
KEY WORDS
maternal perception, obesity, preschool-aged children, risk
factors for overweight, perceived weight
www.pediatrics.org/cgi/doi/10.1542/peds.2008-1845
doi:10.1542/peds.2008-1845
Accepted for publication Feb 24, 2009
Address correspondence to Petra Warschburger, Prof Dr,
University of Potsdam, Department of Psychology, KarlLiebknecht-Strasse 24/25, 14476 Potsdam OT Golm, Germany.
E-mail: warschb@uni-potsdam.de
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.

ARTICLES

In Germany, 3% of the 3- to 6-year-old

children and even 6.4% of the 7- to 10year-old children are already obese.1
Given the physical and psychosocial
consequences of overweight and obesity as well as the high persistency into
adulthood,2 obesity prevention has
been regarded as a public health task
of high priority. Preschool age seems
to be a critical period for shaping attitudes and behaviors such as food preferences, eating behavior, and physical
activity. For children, parents are the
primary mediators of change; therefore, prevention efforts should involve
them.
An examination of the pediatric obesity
treatment and prevention literature
shows that many parents of overweight or at-risk children do not make
use of such opportunities.3,4 One major
barrier to living a healthy lifestyle or to
participate in prevention programs
seems to be parental failure to recognize the overweight or at-risk status of
their child and the associated health
problems.5,6 Research in this eld has
shown that misclassication of childs
weight status is common and includes
misclassication both to higher and
lower weight categories. Overall, 30%
to 72% of parents identify their childs
weight correctly.69 Parents of overweight children frequently do not identify their children as overweight but,
rather, misclassify them as at about
the right weight.6,912 Currently under
discussion as possible sources of underestimation are the childs gender
and age, social status, and parental
and child weight. Different studies
have produced different results: some
have found that maternal education
and low family income8,13 are related to
maternal underestimation of childs
weight, whereas others did not nd
such an association.9,14 The results for
child age and gender are less diverse.
A majority of the studies have found
that for younger children8,15,16 and
PEDIATRICS Volume 124, Number 1, July 2009

boys7,8,10,12,16 inaccurate weight status

estimations were more frequent. Interviews also revealed that parents
often described their childs overweight with positive attributes such
as solid, big-boned, or strong
and failed to see the associated health
risks.17,18 Independent from factors
that affect weight estimation, not
recognizing the childs overweight status or weight-related health problems
is associated with a stabilization of an
unhealthy lifestyle and unfavorable
weight development.19,20
So far, only 1 study has examined parents perception of unrelated children.
The results showed that nearly two
thirds of the parents (58%) were able
to identify the weight status of unrelated children correctly.8 This number
increased when mothers instead of fathers and families with more than 1
child were questioned. Furthermore, it
seems to be easier to classify the
weight status of unrelated, older, normal-weight and female children.
In summary, more is known about parents perception of their own childs
weight status than their general accuracy of perception of children. One reason for parents failure to estimate
their childs weight status correctly
might be an inability to identify the
weight status of children in general.
Therefore, we addressed this question
by using age- and gender-specic silhouettes. We explored the impact of
demographic and weight-related factors on the weight estimation of unrelated and related children as well as
the identication of childs overweight
as a health risk. In addition, we analyzed how demographic factors and
the general perceptional ability inuence the accuracy of identifying ones
own childs weight status. Our focus
was on overweight mothers, mothers
from lower social backgrounds, and
mothers of overweight children, be-

cause their children bear a higher risk

of becoming or staying overweight.

METHODS
Procedure
The participating mothers were recruited during February to August
2006 from 9 inpatient clinics specializing in child rehabilitation (46.6%) and
9 municipal kindergartens (53.4%).
All participating institutions received
written information about the scope
of the study. Mothers were asked to
participate if they had a preschoolaged child who was (1) between 3
and 6 years old and (2) the parents
were overweight themselves, came
from a low socioeconomic background,
or their child was already overweight.
Because the clinical sample received
medical counseling as part of their inpatient stay, the mothers were asked
to ll in the questionnaire within the
rst days after arrival at the clinic. This
study was approved by the University
of Potsdam institutional ethics committee and has therefore been performed in accordance with the ethical
standards of the 1964 Declaration of
Helsinki.
Measures
Demographic Aspects
Socioeconomic status was a composite measure of the familys net income
and maternal graduation level. Income
(composed of unemployment, housing,
child or sickness benets, pension,
work, or comparable earnings) was
calculated allowing for the number of
family members living from this
household income. On the basis of the
2005 German Report of Poorness and
Richness,21 we divided the mothers
into groups with an income below and
above the national poverty threshold
(60% of the equivalent income: mean:
1859.18 [SD: 358.21]). The graduation level equals the number of school
years the mother completed. Mothers
e61

with up to 9 years were classied as

low educated, whereas mothers with
at least 10 years of school were dened as average educated. In addition, mothers reported whether they
needed professional assistance for
emotional problems during the last 6
months (Did you enlist professional
assistance concerning psychological
problems within the last 6 months?).
Weight Status
Mothers reported their own height
and weight. Within the clinical subsample, children (n 139) were
weighed by means of a standard beam
scale (accurate to 100 g) (SECA 920
[SECA, Hamburg, Germany]) and measured with a calibrated stadiometer
(accurate to 1 cm) (SECA 220). According to national and international cutoff
points the existence of overweight for
mothers (BMI 25) was classied.22
For the childs weight status we used
the objective weight data of the clinical
sample. A standardized BMI (BMI-SDS)
based on age and gender was calculated23,24 and according to national guidelines (BMI percentile 90) the existence of overweight in the children
classied.23
Silhouettes
To measure the perception of weight
status mothers were presented a
panel of silhouettes. These were developed on the basis of childrens measures (height of body, spinal and symphysis, shoulder/head broadness,
intercristal and thorax diameters,
head circumference, as well as arm
length) collected during the longitudinal study of Jena.25 Four sets of gures
were developed representing different
age (exemplarily presented in Fig 1)
and gender groups. In each set, 2 silhouettes represented an underweight
child (3rd and 10th percentiles), the
next 3 sketches represented children
within the normal weight range (25th,
50th, and 75th percentiles), and the
e62

WARSCHBURGER and KROLLER

FIGURE 1
Silhouettes of 5- to 6-year-old children.

last 2 represented an overweight and

an obese child (90th and 97th percentiles).
The silhouettes were evaluated by 26
medical experts in childhood obesity
investigating whether they represent
the different weight groups accurately. Therefore, the silhouettes were
represented in random order, and the
experts were asked to arrange them in
the correct order and estimate the BMI
percentile presented. Overall, 86% to
91% of these experts were able to arrange the silhouettes in the correct order, with the highest accordance for
overweight silhouettes. There was perfect agreement for which gures represent underweight, normal, and overweight. The results did not differ
signicantly for the different age and
gender groups.
The mothers were instructed to
choose the age- and gender-relevant
set of silhouettes to answer the following questions: Which of the silhouettes do you think represent overweight children? (perception of

unrelated silhouettes) and Which silhouette best represents the weight

status of your child? (perception of
their own child). In addition, they were
questioned about their perception of
the risk for physical and mental health
problems associated with overweight
(eg, Which silhouettes do you think
have an increased risk for physical
health problems?). Because overweight is associated with a future excess body weight and weight-related
health problems,2,26 we dened silhouettes above the 90th percentile as representing a higher health risk. Mothers were able to check more than 1 of
the 7 silhouettes; the rst mark was
set as the lower bound.
Sample
A total of 219 mothers took part in this
study. Most of the participants were of
German nationality (94.5%) and lived
in a partnership (81.2%). The children
were between 3 and 6 years of age, and
58.1% were boys. Table 1 summarizes
the relevant demographic data.

ARTICLES

TABLE 1 Sample Description

Mothers (n 219)
Age, mean (SD) range, y
BMI-SDS (self-reported)
Mean (SD) range
Normal or underweight, n (%)
Overweight or obese, n (%)
Family income
Above poverty threshold (60% of the equivalent income), n (%)
Below poverty threshold (60% of the equivalent income), n (%)
Education
At least 10 y of school, n (%)
Up to 9 y of school, n (%)
Mental health
No professional help for emotional problems, n (%)
Enlisted help for emotional problems during the last 6 mo, n (%)

Children (n 219)
Age, mean (SD) range, y
BMI-SDS (measured, n 142), mean (SD) range
Normal or underweight, n (%)
Overweight, n (%)

Statistical Analyses

2 tests were used to evaluate whether

the groups differed in the frequency of
the chosen silhouettes and, hence, in
perception of body gures. Logistic regression analysis was applied to predict mothers who do not estimate their
childs body size accurately. To establish comparability, all metric scales
were transformed to range from 0 to
100. A higher score indicates a greater
presence of the factor. All analyses
were conducted by using SPSS 15.0
(SPSS Inc, Chicago, IL).

RESULTS
General Identication of
Overweight Silhouettes
Overall, 58.1% of the mothers identied the overweight silhouettes (90th
respectively 97th percentile) correctly.
In addition, we analyzed the inuence
of demographic aspects such as childrens age and gender, maternal and
child weight status, educational level,
and family income (see Table 2) on
their general ability to identify overweight silhouettes. Those mothers,
who identied the overweight silhouPEDIATRICS Volume 124, Number 1, July 2009

34.2 (5.4) 23 to 59
26.79 (6.29) 17.43 to 48.11
104 (48.2)
111 (51.7)
115 (66.5)
58 (33.5)
171 (81.0)
40 (19.0)
181 (83.8)
35 (16.2)
Girls (n 91)

Boys (n 126)

Total

4.6 (0.83) 3 to 6
0.22 (1.08) 1.82 to 3.12
42 (29.6)
9 (6.3)

4.7 (0.92) 3 to 6
0.31 (1.29) 6.75 to 3.61
73 (51.4)
18 (12.0)

4.6 (0.9) 3 to 6
0.28 (1.22) 6.75 to 3.61
115 (81.0)
27 (19.0)

ettes and those who did not, did not

differ with regard to their own or their
childs weight status, their mental
health status, or childs age or gender.
Mothers with a lower income less frequently identied the overweight silhouettes in comparison with mothers
with a higher income. The same observation was made with regard to the
maternal educational level: mothers
with an average educational background were more often able to identify the overweight silhouettes.
Awareness of Overweight-Related
Health Risks
Only 48.8% of the mothers indicated
that silhouettes above the 90th percentile carry a higher physical health risk,
and even fewer of them (38.7%)
thought that these carry an elevated
mental health risk. For the estimation
of the physical health risk, no gender,
weight, mental health, or incomerelated group differences were found
(see Table 3).
Those mothers who identied overweight silhouettes with a heightened
risk for mental health problems were

more often overweight or obese themselves (see Table 4). Furthermore,

there were signicantly more mothers
of older children who were aware of
the mental health risks related to overweight. With regard to the educational
background, we found that more mothers with a higher education correctly
perceived that the overweight silhouettes carry a risk for physical and mental health problems.
The fact that mothers failed to recognize an increased risk for physical and
mental health problems caused by
overweight seemed to be inuenced by
their general ability to classify silhouettes correctly. Mothers who did not
identify the unrelated overweight silhouettes were less frequently aware of
the health risk for these silhouettes
than mothers who identied the overweight silhouettes as such (see Table 3
respectively 4 and Fig 2).
Inuences on the Accuracy of
Identifying Ones Own Childs
Weight Status
When the mothers were asked to indicate the matching silhouette for
e63

TABLE 2 Demographic Inuences on the General Ability to Identify Overweight Silhouettes

Childs gender
Male
Female
Childs age
34 y
56 y
Childs weight status
Normal weight
Overweight
Maternal weight status
Normal weight
Overweight
Education
Average educated
Low educated
Family income
Average income
Low income
Maternal mental health
Average
Enlisted professional help
a
b

Correct

Incorrect

df

Odds Ratioa

73
52

53
37

0.01

.94

0.98 (0.571.70)

52
74

40
51

0.16

.69

0.90 (0.651.93)

61
17

53
10

0.79

.37

0.68 (0.291.61)

56
69

48
40

1.96

.16

0.68 (0.391.17)

112
12

62
23

10.93b

1b

.01b

3.46 (1.617.49)b

83
21

32
36

19.90b

1b

.01b

4.45 (2.268.74)b

104
20

77
13

0.11

.74

.88 (0.411.87)

The odds ratio is given for the probability of an incorrect perception considering the second parameter.
Signicant difference.

TABLE 3 Differences Between Mothers Who Identied Overweight and Obese Silhouettes as at Risk
for Physical Health Problems and Those Who Did Not
Childs gender
Male
Female
Childs age
34 y
56 y
Childs weight status
Normal weight
Overweight
Maternal weight status
Normal weight
Overweight
Education
Average educated
Low educated
Family income
Average income
Low income
Maternal mental health
Average
Enlisted professional help
Identication of overweight
Correct
Incorrect
a
b

Correct

Incorrect

df

Odds Ratioa

63
43

63
46

0.06

.81

1.07 (0.611.84)

38
68

54
57

3.64

.06

0.59 (0.982.92)

55
13

59
14

0.00

.99

1.00 (0.432.32)

50
55

54
54

1.12

.73

0.91 (0.531.56)

95
10

79
25

7.90b

1b

.01b

3.01 (1.366.64)b

64
24

51
33

2.80

.09

1.73 (0.913.28)

85
19

96
14

0.11

.74

.65 (0.311.38)

92
34

14
77

70.24b

1b

.01b

14.88 (7.4529.73)b

The odds ratio is given for the probability of an incorrect perception considering the second parameter.
Signicant difference.

their own child, 40.3% identied the

silhouette that was in agreement
with the individual percentile according to the objective weight data.
e64

WARSCHBURGER and KROLLER

Focusing on the group of overweight

children (n 19), we found that
78.9% of the mothers underestimated the weight of their child, that

is, chose normal-weight silhouettes

(75th BMI percentile).
To explore factors that predict mothers who are not able to identify their
own childs body size accurately, stepwise logistic regression analysis (enter method) was performed. In the
rst step we entered sociodemographic variables (childrens gender
and age, mothers education, mental
health status, and the family income)
followed by maternal and child weight
status. In the last step, the mothers
ability to identify overweight silhouettes and their awareness of weightrelated health risks were entered.
These aspects were assessed as dichotomous: the correct or incorrect
identication of unrelated overweight
silhouettes and the identication of
health risk associated with overweight
(see also Silhouettes above). Overall,
child and maternal overweight proved
to be signicant predictors for correctly identifying the maternal accuracy status in 68.5% of the cases. Overweight and obese mothers bore a
nearly 3-times-higher risk of not recognizing their own childs body size. Having an overweight or obese child increased that risk fourfold (see Table
5).

DISCUSSION
Little is known about the relationship
between mothers general ability to
identify overweight silhouettes and the
ability to classify their own childs
weight status correctly or about factors that inuence the ability to recognize overweight. According to our data,
nearly 40% of the mothers did not
recognize the overweight silhouettes.
In addition, more than half of the
mothers were unable to recognize
the increased health risk associated
with overweight or obesity. We did not
nd any differences in demographics,
weight factors, or mental health to explain that effect except for the social

ARTICLES

TABLE 4 Differences Between Mothers Who Identied Overweight and Obese Silhouettes as at Risk
for Mental Health Problems and Those Who Did Not
Childs gender
Male
Female
Childs age
34 y
56 y
Childs weight status
Normal weight
Overweight
Maternal weight status
Normal weight
Overweight
Education
Average educated
Low educated
Family income
Average income
Low income
Maternal mental health
Average
Enlisted professional help
Identication of overweight
Correct
Incorrect
a
b

Correct

Incorrect

df

Odds Ratioa

46
38

80
51

0.84

.36

28
56

64
69

4.61b

1b

.05b

0.54 (1.053.27)b

43
12

71
15

0.42

.52

0.76 (0.321.77)

33
49

71
60

3.93b

1b

.05b

0.57 (0.330.99)b

76
6

98
29

8.61b

1b

.01b

3.75 (1.489.49)b

49
23

66
34

0.80

.78

1.10 (0.582.09)

70
12

111
21

0.11

.74

1.10 (0.512.38)

69
57

15
76

32.63b

1b

.01b

6.13 (3.1811.81)b

The odds ratio is given for the probability of an incorrect perception considering the second parameter.
Signicant difference.

background of the mothers. For maternal weight status we found differences

in the identication of a higher risk for
mental health problems in overweight
or obese silhouettes. Here, overweight
mothers more often identied silhouettes with a high risk for mental health
problems than normal-weight or underweight mothers.
In general, nearly 60% of the mothers
underestimated the weight of their

child, and nearly 80% of the mothers of

overweight children did not recognize
the overweight of their child. These results are in accordance with those of
other studies.12,15 We did not nd any
differences in the rate of misclassication due to age or gender, neither of
the child nor of the mother. However,
other authors have found such an effect.7,8,12,15,16 One possible explanation
for the lack of inuence of age and gen-

der in our sample could be that we focused on a relatively homogenous

sample (3 6 years of age). The age
range in our sample may also explain
why we did not nd differences in the
maternal accuracy between sons and
daughters. With increasing age weight
status becomes more inuenced by
gender, whereas in preschool-aged
children gender does not inuence
maternal perception. Consistent with
this assumption, one can nd that
mothers of elementary schoolaged
children are more likely to comment
on their daughters than their sons
weight.27 The nding that mothers of
heavier children were more likely to
underestimate the weight of their child
is consistent with other research.6,911
Our results also suggest that the maternal weight status inuences the
perception of the childs weight, an effect controversially discussed in the
literature (pro8; no inuence11,13).
Moreover, we wanted to test the hypothesis of whether mothers misinterpreting the overweight status of their
own child is caused by a general inability to recognize overweight or obesity.
In agreement with Huang et al,8 we did
not nd any signicant association between identifying overweight silhouettes in general and correctly classifying ones own childs weight. Contrary
to the results of others,8,13 socioeco-

TABLE 5 Logistic Regression to Predict Mothers Who Mismatched Their Childs Silhouette
Girls
5- to 6-y-old children
Low education
Low family income
Low maternal mental health
Childs overweight
Mothers overweight
Incorrect identication of overweight silhouettes
Incorrect identication of physical risk
associated with overweight
Incorrect identication of mental risk associated
with overweight
Constant

SE

Wald

df

OR (95% CI)

0.07
0.37
0.23
0.01
0.84
1.42a
1.06a
1.07
0.54

0.47
0.46
0.59
0.52
0.61
0.65a
0.46a
0.60
0.59

0.02
0.65
0.15
0.00
1.89
4.73a
5.46a
3.19
0.83

1
1
1
1
1
1a
1a
1
1

.89
.42
.70
.99
.17
.03a
.02a
.07
.36

1.07 (0.422.71)
1.44 (0.593.53)
1.25 (0.403.97)
1.01 (0.362.80)
0.43 (0.131.43)
4.13 (1.1514.86)a
2.90 (1.197.07)a
2.92 (0.909.49)
0.58 (0.181.86)

0.48

0.58

0.69

.41

0.61 (0.201.93)

0.44

0.52

0.72

.40

0.64

OR indicates odds ratio; CI, condence interval.

a Signicant difference.

PEDIATRICS Volume 124, Number 1, July 2009

e65

70

incorrect identification of overweight silhouettes

correct identification of overweight silhouettes

60
50

6.45%

35.48%

40

6.91%

35.02%

31.8%

26.27%

Aware

Unaware

30
20
10

42.39%

15.67%

Aware

Unaware

of physical health risks

of mental health risks

FIGURE 2
Maternal awareness of health risks associated with overweight based on their general ability to
identify overweight silhouettes (percentages are given).

nomic status was not associated with

the classication of the mothers own
childs weight but with the identication of overweight in unrelated children. This may suggest different inuences. We believe that the mothers
perception of their own child is more
affected by emotional factors than a
universal misperception of overweight
children. The estimation of unrelated
children, on the other hand, is based
more on cognitive factors such as
knowledge about weight and body image, which are highly associated with
the educational status.5 This assumption is also supported by the nding
that overweight mothers indicated
more often that mental health problems are linked with overweight than
normal-weight mothers. This may be
because overweight and obese mothers experience weight-related emotional strain and, therefore, are more
likely to expect such a health risk for
overweight children, too.28 Because we
did not ask parents about their reasons, we can only speculate about the
different inuences for unrelated and

related children. Given that our sample

comprised only a small number of already overweight children and we
used a newly developed panel of silhouettes, conclusions should be
drawn with caution. Here, further validation is needed.

CONCLUSIONS
Our ndings indicate that mothers of
overweight children are generally able
to identify overweight in unrelated
children but seem to fail to recognize
the overweight status of their own
child. Furthermore, the underestimation of overweight was associated with
maternal educational status for unrelated children, whereas the correct
identication of their own childs
weight status was impaired in the
group of overweight mothers as well
as those with already overweight children. These ndings have relevant
practical implications for the prevention of pediatric obesity. Given the parental inuence on the feeding environment of the child,29 we have to
reach parents early to reduce the risk

that their child will become obese or

the childs weight status stabilizes at a
higher level. Families vary in their individual risk level determined by their
socioeconomic and weight status.
Therefore, we have to take into account these factors to develop effective prevention programs.30 The rst
step for parents is to recognize and
accept that their child is overweight
or, at least, threatened by overweight
and to recognize overweight in this
particular age group as a signicant
and severe health risk. Preceding results suggest that parents are more
aware of their childs weight when recalling their doctors concern and advice.15 Hence, strategies such as the
use of motivational interviewing
seem to be appropriate ways for pediatricians and dieticians to get in touch
with high-risk families and help them
to modify their behavior.31 It is important that health professionals not only
give feedback about the childs health
status but also support the parents in
changing their childs feeding environment.32

ACKNOWLEDGMENTS
This study was supported by Bundesministerium fur Bildung und Forschung/Deutsches Zentrum fur Luftund Raumfahrt Forderkenn-zeichen
GFELO 1054304 (to Prof Dr Warschburger).
Special thanks go to Dr Katrin Kromeyer-Hauschild (for supplying the
data to develop the silhouettes), Marcel Schonebeck, DiplDes (for outlining
the silhouettes), Sebastian Mohnke,
MSc (for assistance in conducting the
expert survey), and Maria Richter, DiplPsych (for helpful comments and
proofreading).

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WARSCHBURGER and KROLLER

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