Short research communication
Abdullah Al-Taiar,1 Nawal Alqaoud,2 Reem Sharaf-Alddin3 and Muge Akpinar-Elci1
1School of Community & Environmental Health, College of Health Sciences, Old Dominion University, Norfolk, Virginia, United Stated of America. (Correspondence to: A. Al-Taiar:
Abstract
Background: Mothers’ perceptions of their children’s weight remain mostly unknown in oil-rich countries of the Middle East.
Aims: To compare maternal perceptions of their children’s weight with actual body weight.
Methods: We used the Kuwait nutritional surveillance data for 5 consecutive years (2015-2019) (N = 5119), which were collected through face-to-face interviews with mothers of children aged 2-5 years attending vaccination centres.
Results: Of the 5119 mothers in the study, 163 (3.18%) and 332 (6.48%) had obese or overweight children, respectively. Among 4624 mothers who had normal weight children, 1350 (29.20%) perceived their children’s weight as below normal. Seventy-nine (48.47%) and 16 (9.82%) mothers of children with obesity thought their children had normal weight or were underweight, respectively.
Conclusion: Mothers in Kuwait often underestimate the weight of their children, including those children who have normal weight. This highlights the importance of addressing maternal misperceptions during visits to the primary healthcare centre.
Keywords: mothers, children, perception, body weight, overweight, obesity, Kuwait
Citation: Al-Taiar A; Alqaoud N; Sharaf-Alddin R; Akpinar-Elci M. Mothers’ perceptions of their children’s weight: opportunity for health promotion in Kuwait. East Mediterr Health J. 2022;28(12):904−908. https://doi.org/10.26719/emhj.22.095
Received: 28/06/21; accepted: 11/08/22
Copyright © Authors 2022; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction
Childhood obesity is a major public health problem with well-documented short- and long-term adverse health consequences (1–3). It is estimated that > 40 million children aged < 5 years are overweight or obese (4). Habitual food consumption and physical activity are the key modifiable factors that mitigate the risk of obesity, and are developed during early childhood (5). Unlike schoolchildren who are capable of making their own lifestyle choices, such as which foods they consume and their level of physical activity, mothers shape these habits completely in children aged < 5 years. This highlights the potential of modifying maternal perceptions of children’s weight in this age group to prevent obesity at an early age. However, studies that have attempted to link maternal perceptions of children’s weight to subsequent weight gain have shown controversial findings (6–9). This could be because most of those studies were conducted on schoolchildren, which is the age group over which parents have little control of their children’s diet or physical activity.
Little is known about maternal perceptions of children’s weight in oil-rich countries in the Middle East, such as Kuwait, although childhood obesity is a major public health problem (10,11). In this study, we assessed the perceptions of children’s weight status among mothers of children aged 2 to < 5 years and compared maternal perceptions with actual objectively measured body weight using data from the Kuwait Nutritional Surveillance System (KNSS).
Methods
KNSS data are collected by trained collectors who are employed on a long-term basis for this purpose, independently from the delivery of healthcare services (11,12). KNSS recruits children aged 2 to < 5 years from primary healthcare centres during vaccination and from kindergartens. However, for logistic reasons, we only conducted face-to-face interviews with mothers who attended healthcare centres for vaccination of their children. Every mother was invited to participate (2% refused) and provided written informed consent before the interview was initiated. To assess maternal perceptions of their children’s weight status, we asked mothers whether they thought their children’s weight was normal, below normal, or above normal.
The child's weight was measured digitally to the nearest 100 g, and their height was measured to the nearest 0.1 cm by trained data collectors in a standardized manner. Body mass index (BMI) was calculated by dividing weight in kilograms by squared height in metres. BMI-for-age z scores were calculated using STATA zanthro package release 14 [StataCorp., Cary, NC, United States of America (USA)]. Obesity was defined as BMI-for-age z score ≥ 3.0 SD and overweight as BMI-for-age z score ≥ 2.0 to < 3.0 SD, using the World Health Organization growth reference median (13). The ꭓ2 test was used to investigate any sex difference in maternal perceptions of children’s weight status. We did not collect data on maternal socioeconomic status or on factors associated with maternal perception. Data collectors for KNSS did not have access to children’s or mothers’ medical records; therefore, it was not possible to link the data to clinical notes written by nurses or clinicians. Although KNSS is a public health activity, all data collection procedures were approved by the Ethics Committee at the Kuwaiti Ministry of Health (approval No. 98:262/2015).
Results
During the study period (2015–2019), 5166 children were recruited and 51.57% were male. The mean (SD) age was 3.14 (0.84) years. The analysis comprised 5119 children (48 records were excluded: 21 with biologically implausible BMI, and 27 with missing maternal perceptions of children’s weight status). The prevalence of overweight/obesity was 9.66%.
Figure 1 shows the maternal perception of their children’s weight status according to actual body weight. Among 4624 mothers with a normal-weight child, 1350 [29.20%; 95% confidence interval (CI): 27.89–30.53%] perceived their children’s weight to be below normal. Among 163 mothers of children with obesity, 79 (48.47%; 95% CI: 40.58–56.41%) thought their children were normal weight, and 16 (9.82%; 95% CI: 5.72–15.45%) thought their children were underweight. Among 332 mothers with overweight children, 220 (66.27%; 95% CI: 60.90–71.34%) perceived their children to be normal weight, and 39 (11.75%; 95% CI: 8.49–15.71%) perceived them to be underweight. Maternal perceptions of weight of children who were obese (P = 0.554), overweight (P = 0.414), or normal weight (P = 0.103) did not differ significantly between boys and girls.
Discussion
The role of parents in preventing childhood obesity is recognized by several organizations, including the American Academy of Pediatrics (14), and interventions that aim to reduce childhood obesity are deemed to be successful when they involve parents (15,16). However, the involvement of parents in preventing childhood obesity requires that they are aware of the weight status of their children (17–19). Mothers shape habitual food consumption and physical activity of children aged < 5 years, which highlights the potential of modifying maternal perceptions of children’s weight status in this age group. This study documented maternal perceptions of weight status of children aged 2 to < 5 years and linked them to actual body weight. Using a large nationally representative sample, we demonstrated that almost one-third of mothers with normal-weight children perceived their children to be underweight, while most mothers with overweight or obese children thought their children were normal weight or underweight.
In our study, 29% of mothers with normal-weight children thought their children were underweight, which is higher than reported in high-income countries, such as Greece 16% (20), Netherlands 4% (6,21), and USA 1.3% (22). The majority of mothers of overweight/obese children perceived their children to be normal weight or underweight. This is consistent with a previous study of overweight children (average age 4.6 years) in Kuwait, where most mothers were unable to correctly identify their children as overweight (23). Many mothers of overweight or obese children perceived their children to be normal weight in several other countries (6,20–22,24). A systematic review of studies worldwide found that almost half of parents underestimated their children’s overweight or obesity status but only 14% underestimated normal weight (17). Several explanations have been suggested for the high percentage of parents underestimating the weight status of their overweight or obese children. First, media reports regarding childhood obesity usually show images of children with severe obesity, which may distort parental understanding of how overweight children may look (17,25). Second, parents may refuse to label their children as overweight or obese because this may feel stigmatizing in some settings (17,26). Third, qualitative research has shown that parents may genuinely feel that their children cannot be overweight or obese if they are physically active, have no obvious health issues, and are not mocked for their size (17,27).
Maternal perceptions of children’s weight status have been studied before (6,17,20,22,23); however, the emphasis has been on correcting misperceptions of mothers of overweight or obese children. Most children aged < 5 years have normal weight and correcting maternal misperceptions in this particular group would have the potential to reduce the risk of childhood obesity. Compared with Peru, Greece, USA (6,20,22), and globally (17), we found a higher proportion of mothers of normal-weight children who perceived their children’s weight to be below normal. These findings are essential to inform initiatives that combat childhood obesity in oil-rich countries in the Middle East, such as Kuwait, where childhood obesity has become a major health problem (10,11).
It is reported that mothers perceive the weight status of boys and girls differently (28) and this difference in perception increases with children’s age (7,22). Mothers are more likely to underestimate the weight status of their sons than daughters (20,22). We found no significant sex difference in the maternal perceptions of children’s body weight in Kuwait. This could be because we exclusively included children aged 2 to < 5 years, while most other studies included children older than 5 years.
Our study has several strengths, including large sample size, and objectively measured height and weight of children in a standardized manner by a trained team. Vaccination is compulsory, and the coverage is high in Kuwait, which makes our sample nationally representative. However, because of the lack of data on socioeconomic and other factors, we were unable to investigate factors associated with maternal perception of their children’s weight status.
In conclusion, maternal perception of children’s weight status affects parenting behaviour that aims to reduce children’s weight (29). We found that 29% of mothers of normal-weight children perceived their children to be underweight, and most mothers of overweight or obese children perceived their children to be normal weight or underweight. This highlights the importance of correcting maternal misperceptions of children’s weight, including normal weight children, to combat childhood obesity. Every primary healthcare encounter, including for vaccination, is an opportunity to reassure mothers of normal-weight children about their children’s weight.
Acknowledgement
We would like to thank Ms Faheema Alanezi and Mrs Monica Subhakaran for their efforts in supervising data collection and data entry at KNSS.
Funding: None
Competing interests: None declared.
Perceptions des mères concernant le poids de leurs enfants : une occasion à saisir pour promouvoir la santé au Koweït
Résumé
Contexte : Les perceptions des mères concernant le poids de leurs enfants restent pour la plupart inconnues dans les pays riches en pétrole du Moyen-Orient.
Objectifs : Comparer les perceptions maternelles du poids de leurs enfants avec le poids corporel réel.
Méthodes : Nous avons utilisé les données de surveillance nutritionnelle du Koweït pendant cinq années consécutives (2015-2019) (N = 5119), qui ont été recueillies lors d'entretiens en face à face avec des mères d'enfants âgés de deux à cinq ans consultant dans des centres de vaccination.
Résultats : Sur les 5119 mères participant à l'étude, 163 (3,18 %) et 332 (6,48 %) avaient des enfants obèses ou en surpoids respectivement. Sur les 4624 mères qui avaient des enfants de poids normal, 1350 (29,20 %) considéraient le poids de leurs enfants comme inférieur à la normale. Soixante-dix-neuf mères (48,47 %) et 16 mères (9,82 %) d'enfants obèses pensaient que leurs enfants avaient un poids normal ou étaient en déficit pondéral, respectivement.
Conclusion : Les mères au Koweït sous-estiment souvent le poids de leurs enfants, y compris ceux qui ont un poids normal. Cela souligne l'importance de lutter contre les perceptions erronées des mères lors de leurs visites au centre de soins de santé primaires.
تصورات الأمهات عن وزن أطفالهن: فرصة مُهدَرة لتعزيز الصحة في الكويت
عبد الله الطيار، نوال القعود، ريم شرف الدين، موج أكبينار-إلسي
الخلاصة
الخلفية: لا تزال تصورات الأمهات بشأن وزن أطفالهن غير معروفة على نطاق واسع في البلدان الغنية بالنفط في الشرق الأوسط.
الأهداف: هدفت هذه الدراسة الى مقارنة تصورات الأمهات عن وزن أطفالهن بالوزن الفعلي للجسم.
طرق البحث: استخدمنا بيانات الترصُّد التغذوي في الكويت التي جُمعَت لمدة 5 سنوات متتالية (2019-2015) (العدد= 5119)، من خلال مقابلات مباشرة أُجريت مع أمهات الأطفال الذين تتراوح أعمارهم بين سنتين و5 سنوات، ممن يتوجهون إلى مراكز التطعيم.
النتائج: من بين الأمهات اللائي شملتهن الدراسة وعددهن 5119، وُجِدَ أن 163 (3.18%) و332 (6.48%) طفلًا يعانون من السِّمنة أو زيادة الوزن، على التوالي. ومن بين الأمهات اللاتي لديهن أطفال يتمتعون بوزن طبيعي والبالغ عددهن 4624 أُمًّا، رأى 1350 (29.20%) أن وزن أطفالهن أقل من الطبيعي. وتعتقد تسع وسبعون أُمًّا (%48.47) و16 أُمًّا (9.82%) لأطفال مصابين بالسِّمنة أن أطفالهن يتمتعون بوزن طبيعي أو يعانون من نقص الوزن، على التوالي.
الاستنتاجات: تميل الأمهات في الكويت في الغالب إلى التقليل من وزن أطفالهن، حتى أولئك الذين يتمتعون بوزن طبيعي. ويسلط ذلك الضوء على أهمية تصحيح المفاهيم الخاطئة لدى الأمهات أثناء زياراتهن إلى مركز الرعاية الصحية الأولية.
References
1. Lobstein T, Jackson-Leach R, Moodie ML, Hall KD, Gortmaker SL, Swinburn BA, et al. Child and adolescent obesity: part of a bigger picture. Lancet. 2015 Jun 20;385(9986):2510–20. https://doi.org/10.1016/S0140-6736(14)61746-3 PMID:25703114
2. Kumar S, Kelly AS. Review of childhood obesity: from epidemiology, etiology, and comorbidities to clinical assessment and treatment. Mayo Clin Proc. 2017 Feb;92(2):251–65. https://doi.org/10.1016/j.mayocp.2016.09.017 PMID:28065514
3. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014 Aug 30;384(9945):766–81. https://doi.org/10.1016/S0140-6736(14)60460-8 PMID:24880830
4. Global nutrition report 2018. Shining a light to spur action on nutrition. Bristol: Development Initiatives; 2018 (https://reliefweb.int/attachments/9ab1b493-99fa-334b-b0d8-6a368d185011/2018_Global_Nutrition_Report.pdf, accessed 27 September 2022).
5. Porter RM, Tindall A, Gaffka BJ, Kirk S, Santos M, Abraham-Pratt I, et al. A review of modifiable risk factors for severe obesity in children ages 5 and under. Child Obes. 2018 Oct;14(7):468–76. https://doi.org/10.1089/chi.2017.0344 PMID:30156438
6. Gerards SM, Gubbels JS, Dagnelie PC, Kremers SP, Stafleu A, de Vries NK, et al. Parental perception of child’s weight status and subsequent BMIz change: the KOALA birth cohort study. BMC Public Health. 2014 Mar 31;14:291. https:/doi.org/10.1186/1471-2458-14-291 PMID:24678601
7. Jeffery AN, Metcalf BS, Hosking J, Mostazir MB, Voss LD, Wilkin TJ. Awareness of body weight by mothers and their children: repeated measures in a single cohort (EarlyBird 64). Child Care Health Dev. 2015 May;41(3):434–42. https://doi.org/10.1111/cch.12167 PMID:24912623
8. Robinson E, Sutin AR. Parental perception of weight status and weight gain across childhood. Pediatrics. 2016 May;137(5): e20153957. https://doi.org/10.1542/peds.2015-3957 PMID:27244811
9. Vrijkotte TGM, Varkevisser T, van Schalkwijk DB, Hartman MA. Maternal underestimation of child’s weight at pre-school age and weight development between age 5 and 12 years: the ABCD-Study. Int J Environ Res Public Health. 2020 Jul 18;17(14):5197. https://doi.org/10.3390/ijerph17145197 PMID:32708459
10. Di Cesare M, Sorić M, Bovet P, Miranda JJ, Bhutta Z, Stevens GA, et al. The epidemiological burden of obesity in childhood: a worldwide epidemic requiring urgent action. BMC Med. 2019 Nov 25;17(1):212. https://doi.org/10.1186/s12916-019-1449-8 PMID:31760948
11. Al-Taiar A, Alqaoud N, Ziyab AH, Alanezi F, Subhakaran M, Sharaf Alddin R, et al. Time trends of overweight and obesity among schoolchildren in Kuwait over a 13-year period (2007-2019): repeated cross-sectional study. Public Health Nutr. 2021 Nov;24(16):5318–28. https://doi.org/10.1017/S1368980021003177 PMID:34342262
12. Al-Taiar A, Alqaoud N, Hammoud MS, Alanezi F, Aldalmani N, Subhakaran M. WHO infant and young child feeding indicators in relation to anthropometric measurements. Public Health Nutr. 2020 Jul;23(10):1665–76. https://doi.org/10.1017/S1368980019004634 PMID:32285763
13. de Onis M, Lobstein T. Defining obesity risk status in the general childhood population: which cut-offs should we use? Int J Pediatr Obes. 2010 Dec;5(6):458–60. https://doi.org/10.3109/17477161003615583 PMID:20233144
14. Barlow SE, Bobra SR, Elliott MB, Brownson RC, Haire-Joshu D. Recognition of childhood overweight during health supervision visits: does BMI help pediatricians? Obesity (Silver Spring). 2007 Jan;15(1):225–32. https://doi.org/10.1038/oby.2007.535 PMID:17228051
15. Epstein LH, Myers MD, Raynor HA, Saelens BE. Treatment of pediatric obesity. Pediatrics. 1998 Mar;101(3 Pt 2):554–70. PMID:12224662
16. Magarey AM, Perry RA, Baur LA, Steinbeck KS, Sawyer M, Hills AP, et al. A parent-led family-focused treatment program for overweight children aged 5 to 9 years: the PEACH RCT. Pediatrics. 2011 Feb;127(2):214–22. https://doi.org/10.1542/peds.2009-1432 PMID:21262890
17. Lundahl A, Kidwell KM, Nelson TD. Parental underestimates of child weight: a meta-analysis. Pediatrics. 2014 Mar;133(3):e689–703. https://doi.org/10.1542/peds.2013-2690 PMID:24488736
18. Young PC, DeBry S, Jackson WD, Metos J, Joy E, Templeman M, et al. Improving the prevention, early recognition, and treatment of pediatric obesity by primary care physicians. Clin Pediatr (Phila). 2010 Oct;49(10):964–9. https://doi.org/10.1177/0009922810370056 PMID:20837628
19. Arcan C, Hannan PJ, Himes JH, Holy Rock B, Smyth M, Story M, et al. American Indian parents' assessment of and concern about their kindergarten child’s weight status, South Dakota, 2005-2006. Prev Chronic Dis. 2012;9:E56. PMID:22338596
20. Manios Y, Kondaki K, Kourlaba G, Vasilopoulou E, Grammatikaki E. Maternal perceptions of their child’s weight status: the GENESIS study. Public Health Nutr. 2009 Aug;12(8):1099–105. https://doi.org/10.1017/S1368980008004412 PMID:19105868
21. de Hoog ML, Stronks K, van Eijsden M, Gemke RJ, Vrijkotte TG. Ethnic differences in maternal underestimation of offspring’s weight: the ABCD study. Int J Obes (Lond). 2012 Jan;36(1):53–60. https://doi.org/10.1038/ijo.2011.199 PMID:22005721
22. Maynard LM, Galuska DA, Blanck HM, Serdula MK. Maternal perceptions of weight status of children. Pediatrics. 2003 May;111(5 Pt 2):1226–31. PMID:12728143
23. Al-Qaoud NM, Al-Shami E, Prakash P. Kuwaiti mothers’ perception of their preschool children's weight status. J Dev Behav Pediatr. 2010 Jul–Aug;31(6):505–10. https://doi.org/10.1097/DBP.0b013e3181e56dc7 PMID:20611037
24. Ruiter ELM, Saat J, Molleman GRM, Fransen GAJ, van der Velden K, van Jaarsveld CHM, et al. Parents’ underestimation of their child’s weight status. Moderating factors and change over time: a cross-sectional study. PLoS One. 2020 Jan 16;15(1):e0227761. https://doi.org/10.1371/journal.pone.0227761 PMID:31945129
25. Campbell MW, Williams J, Hampton A, Wake M. Maternal concern and perceptions of overweight in Australian preschool-aged children. Med J Aust. 2006 Mar 20;184(6):274–7. https://doi.org/10.5694/j.1326-5377.2006.tb00236.x PMID:16548831
26. Latner JD, Stunkard AJ, Wilson GT. Stigmatized students: age, sex, and ethnicity effects in the stigmatization of obesity. Obes Res. 2005 Jul;13(7):1226–31. https://doi.org/10.1038/oby.2005.145 PMID:16076992
27. Jain A, Sherman SN, Chamberlin LA, Carter Y, Powers SW, Whitaker RC. Why don’t low-income mothers worry about their preschoolers being overweight? Pediatrics. 2001 May;107(5):1138–46. https://doi.org/10.1542/peds.107.5.1138 PMID:11331699
28. Blanchet R, Kengneson CC, Bodnaruc AM, Gunter A, Giroux I. Factors influencing parents’ and children’s misperception of children’s weight status: a systematic review of current research. Curr Obes Rep. 2019 Dec;8(4):373–412. https://doi.org/10.1007/s13679-019-00361-1 PMID:31701349
29. Min J, Wang VH, Xue H, Mi J, Wang Y. Maternal perception of child overweight status and its association with weight-related parenting practices, their children’s health behaviours and weight change in China. Public Health Nutr. 2017 Aug;20(12):2096–103. https://doi.org/10.1017/S1368980017001033 PMID:28583222
