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Predictors of Maternal Perceptions of their Offspringand#8217;s Weight Status During Adolescence: Evidence from the Mater-University of Queensland Study of Pregnancy Cohort
ISSN: 2165-7904
Journal of Obesity & Weight Loss Therapy
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Predictors of Maternal Perceptions of their Offspring’s Weight Status During Adolescence: Evidence from the Mater-University of Queensland Study of Pregnancy Cohort

Abdullah A Mamun1*, Brett M McDermott2, Munim Mannan1, Michael J O’Callaghan3, Jake M Najman1 and Gail M Williams1
1School of Population Health, University of Queensland, Brisbane, Australia
2Kids in Mind Research: The Mater Centre for Service Research in Mental Health and Department of Psychiatry, University of Queensland, Brisbane, Australia
3Child Development and Rehabilitation Services, Mater Children’s Hospital, University of Queensland, Brisbane, Australia
Corresponding Author : Dr. Abdullah Al Mamun
Associate Professor, School of Population Health
Herston Rd, Herston, QLD 4006, Australia
Fax: +61(0)733655599
Tel: +61(0)733464689
Received April 30, 2012; Accepted May 22, 2012; Published May 24, 2012
Citation: Mamun AA, McDermott BM, O’Callaghan MJ, Najman JM, Williams GM (2012) Predictors of Maternal Perceptions of Their Offspring’s Weight Status: Evidence from a Birth Cohort Study. J Obes Wt Loss Ther 2:133. doi:10.4172/2165-7904.1000133
Copyright: © 2012 Mamun AA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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We examined the predictors of maternal perceptions on their adolescent offspring’s weight status. A mother-child linked analysis was carried out using 14 years follow-up data from a population-based prospective birth cohort of 3721 children (52% males) who born in Brisbane, Australia, between 1981 and 1983. Maternal perception of offspring weight was reported when the offspring were 14 years old and predictors were prospectively. We found that mothers perceived their adolescents’ sons were more underweight and less overweight than their daughters. The independent predictors of maternal perceptions of child overweight status were gender, maternal perceived child dissatisfaction of appearance, shape, size and weight, adolescent dieting to lose weight, their general health status, sports and maternal BMI. Mainly two factors- child health and dieting predict maternal perception of offspring underweight. This study found more child factors than family or maternal factors predict maternal perceptions of their offspring weight status. The finding that child factors are related to maternal perception should be helpful to clinicians as it suggests understanding adolescent and maternal perceptions of weight will best be achieved by a focus on current adolescent body image, dieting, behavioural problems, and parental weight status.

Perception; Adolescents; Body weight; Diet
The prevalence of overweight and obesity are at epidemic level [1] and to date most of the interventions or treatments have had limited long-term effectiveness [2,3]. There is a consistent argument that prevention of overweight and obesity should start from early life and intervention programs are more successful with parental involvement [4,5]. Therefore, parental recognition, especially mother, of their children’s weight status may be important to motivate help seeking behaviour and if appropriate facilitate intervention strategies early in life. Studies suggest that clinically defined weight categories (e.g. normal, overweight or obese) of children differ from the parental perceived weight of their children [6-8]. Recent studies, including in the United States, Australia and United Kingdom, have found that parents tend to underestimate the weight status of their overweight or obese child [9-16]. Parental weight status estimation was less accurate for younger children and for sons [14]. There was also a trend for under-estimation seen more often in mothers who themselves were heavier [14,17,18].
These studies consistently found that some parents perceived their offspring’s weight status to be different from observed weight. There is speculation that weight perception rather than measured weight status per se is causally related to depressive symptoms [19] because obese people experience weight-related stigma, which eventually could lead to the stances of distress and depression. Few studies, including our recent study [20], supported this hypothesis by finding stronger associations between overweight perception and depressive symptoms compared with actual overweight status and depressive symptoms [19-22]. Research is warranted to better understand factors predicting parental perceptions of their child’s weight status. If our intention is to promote early help seeking behaviour by parents, including increased parent motivation to change then knowing what predicts parental perceptions of their offspring weight status and reducing the gap between subjective and objective differences of overweight and obesity is crucial.
This study is an extension of a previous study [7], where we examined the extent of misclassifications and the possible predictors of the maternal misclassifications of their offspring weight status. Using the similar set of predictors and methodology, the aim of this study was to identify the predictors of maternal perceptions of their child’s weight status, using a cohort of Australian adolescents.
The study
The data used for this study were from the Mater-University of Queensland Study of Pregnancy and its Outcomes (MUSP). MUSP is a prospective study of 7223 mother-offspring pairs. Participant mothers received antenatal care at their First Clinic Visit (FCV) around 18 weeks of gestation at a major public hospital in Brisbane between 1981 and 1983 and delivered a live singleton child who was not adopted out before leaving hospital [23]. Both mother-offspring pairs have been followed-up prospectively with maternal questionnaires being administered when their children were 3-5 days, 6 months, 5 and 14 years. In addition, at the 5 and 14 year follow-up detailed physical, cognitive and developmental examinations of the children were undertaken and at 14 years the children completed a questionnaire with health, socio-demographic and lifestyle questions. Participants gave signed informed consent for their participation and that of their children. Full details of the study participants and measurements have been previously reported [23,24].
In this paper, we examined the predictors of maternal perceptions of child weight status. Data are restricted to the 3721 mother-offspring pairs for whom we had recorded maternal perceptions on their offspring weight at 14-years follow-up. Non-participants were more likely to be from families with low income at birth, to have mothers who smoked throughout their pregnancy and to have mothers and fathers with lower educational attainment [24,25].
Outcomes: The main outcome of interest of this study was maternal perception on their offspring’s overweight status. At 14 years followup, mothers were asked to complete the statement “Do you think your child is…” by giving 1 of 5 possible responses: “very underweight”, “slightly underweight”, “about the right weight”, “slightly overweight” or “very overweight”. In the analysis of maternal perception of child weight status, the 5 categories are collapsed into 3 categories because of small numbers of the two extreme categories. The mothers who answered very or slightly underweight were classified as believing that their child was underweight, and those who responded very or slightly overweight were classified as believing their child was overweight. Mothers answering at about the right weight were classified as believing their child was neither underweight nor overweight.
Predictors and confounders: The selection of potential factors at different follow-ups of the study were based on identification of studies examining self reporting bias for height, weight, BMI [26,27] and our previous study [7] where we identified predictors of maternal misclassifications of offspring overweight status. These factors are, at FCV, maternal age (three categories 13-19, 20-29 and 30 or more years), maternal educational attainment (did not complete secondary school, completed secondary school, completed further/ higher education) and parental racial origin (Caucasian, Asian and Aboriginal-Islander) were obtained from questionnaires at the FCV and obstetric records in the study. Maternal measured height and selfreported pre-pregnancy weight were obtained at the study initiation. A high degree of correlation was obtained between maternal estimate of her pre-pregnancy weight and her measured weight on the FCV (Pearson’s correlation coefficient = 0.95). We defined three BMI categories (normal, overweight and obese) for the mother based on the World Health Organization guidelines (1998) [28]. Factors from FCV to 14 years follow-up measured consistently were maternal depression (using Bedford and Fould’s [29]. Delusions Symptoms States Inventory, the experience of four or more symptoms was used to define those who were depressed). Combining all follow-ups, a composite indicator of maternal depression over 14 years of follow-up was generated with two categories: (1) not depressed at any follow-ups or (2) at least one episode of depression. A composite indicator of maternal tobacco consumption based on prospectively collected maternal smoking status (non-smokers or smoked at least one cigarette per day at each follow-up) was categorized as never smoked (reported non-smoker at each follow-up), smokers (consistently reported smoked at least one cigarettes at each follow-up) and otherwise ex-smokers.
A 5 and 14 years follow-up child behavioral problems were prospectively assessed from maternal reports of child behavior using Achenbach’s child behavior check list (CBCL) [30] at age 5 and 14. We refer to those with scores above one standard deviation (1SD) of the mean score as having behavioral problems. Based on this cut-off the CBCL was categorized into four mutually exclusive groups: (a) no behavioral problems (<1SD on the CBCL) at ages 5 and 14; (b) early remitter (>1SD percentile on the CBCL) at age 5 but normal at 14; (c) adolescent onset – normal at age 5 but had problems at 14 years and (d) persistent problems at ages 5 and 14 years. Change in gross-family income from ages 5 to 14 years: poor if income <=A$ 15548/year at 5 years follow-up and income <=$ 20799/year at 14 years follow-up; rich if income >26000/year at 5 years follow-up and >=$ 31149/year at 14 years follow-up, otherwise middle income.
At 14 years follow-up, mothers were asked how often their child was dissatisfied about their personal appearance, body shape, body size and weight, each having the response options “often”, “sometimes”, “rarely” and “never”. Combining the four items a composite indicator (standardized alpha coefficient = 0.92) was generated with the lower quintile of scores being used to indicate children most dissatisfied (i.e. low score indicates most dissatisfaction) with their appearance, shape, size and weight. Adolescent’s BMI (weight in kg/height in meter2) at the 14-year follow-up was calculated from the measured weight and height. In all assessments, the average of two measures of the participant’s weight, with the participant wearing light clothing, with a scale accurate to 0.2 kg was used. A portable stadiometer was used to measure height.
Adolescent’s were asked “How often do you go on a diet to lose weight?” with four options ‘most of the time’, ‘a few times a year’, ‘rarely’ or ‘never’. For the purpose of analysis, the first two categories are combined into one category to increase the frequencies in this group. Maternal and child self-reported general health status was categorized as excellent, good and fair/poor. Change in marital status (no change, 1 to 2 changes and 3 or more changes during last 7 years) was used to assess the family stability. The Parent-Adolescent Communication Scale [31] was used to assess mother-child communication at adolescence. Maternal report of the amount of time the child spent watching television (<1 hour per day, 1 to <3 hours per day, 3 to <5 hours per day and 5 or more hours per day), time spent on sports or exercise (4-7 days per week; 0-3 days per week), as well as the family attitude to having meals together (at least once a day, few times/once/ less than once a week) were considered as predictors.
Statistical Analysis
The associations of maternal perceptions with maternal, child and family characteristics are assessed using Chi-square tests. Those factors appeared statistically significant (p < 0.05) in bivariate analysis were included in the multivariable analysis. Multivariable associations were evaluated using multinomial logistic regression [32]. Finally, those factors remain statistically significant in the multivariable models were included in the final analyses (Table 1, Table 2). Statistical evidence for a difference in effect between males and females was assessed by computing a likelihood ratio test of the interaction with sex. As we found statistical evidence that the association for maternal perceptions of child weight status differ between the sexes (p<0.001) and the difference was substantial, results are presented for males and females separately. All analyses were undertaken using Stata version 10.0 (Stata inc., Texas).
Mothers perceived more boys than girls to be underweight (16.82% and 11.46%, respectively) and fewer boys than girls to be overweight (16.87% and 19.56%, respectively). The remaining children were described as ‘about the right weight’.
In the bivariate analyses, the following child, maternal and family factors were associated with maternal perceptions of child weight status for adolescent boys and girls. Child factors included dissatisfaction with personal appearance, dieting to lose weight, general health and behavioral problems and their involvement in sports. Maternal and family factors were maternal attitude to having family meals together, maternal health status, and maternal pre-pregnancy BMI and family communication problems. However, in the fully adjusted model, factors independently associated with maternal perception of child weight status were child dissatisfaction with their personal appearance, child health, and behavioral problems, dieting to lose weight, child sports and maternal BMI and for boys, TV watching (Table 1, Table 2). Maternal education, age, race, mental health, smoking status, change in marital status and family income were not associated with their perception of child’s weight status.
Mothers who perceived their boys were most dissatisfied with appearance, shape, size and weight, were three folds (AdjOR 3.14; 95% CI: 2.07, 4.77) more likely to be underweight and nearly five folds (AdjOR 4.92; 95% CI: 3.25, 7.44) more likely to be overweight compared to mothers who perceived their boys were least dissatisfied (fully adjusted model, Table 1). Similarly, mothers who perceived their girls were most dissatisfied were nearly 1.48 (95%CI: 0.99, 2.22) times more likely to be underweight and 3.54 (95% CI: 2.56, 4.91) times more likely to be overweight (Tables 2). Those boys who reported they dieted to lose weight were five to ten times more likely to be perceived as overweight by their mother compared to their counterparts. Girls were three to four times more likely to be perceived as overweight by their mothers if they reported that they went for dieting. Those girls had experienced behavioral problems at 14 years but not age 5 years, were two fold more likely to be perceived as overweight. Boys who spent at least one hour of watching TV everyday were perceived by their mothers as two to three folds more likely to be overweight.
In the additional analyses, we found adolescents measured BMI was significantly associated with maternal perceptions of their adolescents weight status. However, inclusion of this variable in the adjusted model did not substantially alter the associations we presented in tables 1 and 2 (results are not shown since the inclusion of adolescents BMI reduced the sample substantially).
In this mother-offspring link study in an Australian population, in relation to maternal perceptions of the child being overweight, we found five common factors (dissatisfaction, child health, diet, sports and maternal BMI) are in similar directions apart from dieting which is stronger in males and maternal overweight status which is stronger for females. Two factors TV watching and adolescent behavioral problems are associated differently. TV watching is positively associated with males but no association with females. Adolescent behavioral problems positively associated with females but no association with males. For maternal perception of the child been underweight two factors- child health and dieting are common. Early life, social, maternal mental health and maternal life style and other family factors considered in this analysis are not associated with maternal perceptions of their child overweight and underweight.
From a broader perspective, the predictors we found in this study are similar with our previous study where we identified six independent predictors (gender, child dissatisfaction, dieting to lose weight, general health status, maternal BMI and family meals) of maternal misclassifications of their offspring’s weight status [7]. Although these predictors are in similar direction in both studies, the strength of association (measured in odds ratios) is stronger for the predictors of maternal perceptions compared to maternal misclassifications. For example, the odds of child dissatisfaction ranges from 1.71 (AdjOR, Underweight) for females (Table 2) to 4.74 (AdjOR, Overweight) for males (Table 1), which was 1.35 for underestimation and 1.94 for overestimation, for male and female combined model in the previous study [7]. It is interesting child personal appearance dissatisfaction predictions both maternal underweight and overweight perception. Children voicing their dissatisfaction may place the issue “on the table”. This factor may be necessary for the mother to form a perception but not sufficient to influence direction, this is influenced by other factors such as engagement in sport. From an early intervention perspective there is a strong message that parents being attentive to children voicing body dissatisfaction, especially boys, will enable parents to form opinions about their child’s weight status. Similarly for other factors, except maternal BMI, the odds are two to three times higher than previous study. In addition, we also found three more factors such as child sports, child behavioural problems and problems with family communication are independent predictors of maternal perception of their child weight status.
Our predicting model of maternal perceptions of child weight status showed that the more mothers perceived their children are concerned about their physical appearance, shape, size and weight, and the more they dieted to lose weight. Consistent with the finding that the child-parent concordance for externalizing behaviors is higher than internalizing (e.g. anxiety and depression) symptoms [33], the behavior of dieting is well recognized by parents and creates the opportunity for the parent to make a clear perception about the child’s weight.
Maternal perception of social values for adolescent boys and girls are different. Involvement in sports is seen as healthy for both boys and girls. The perceived weight status associated with TV watching in boys may reflect a gender specific perception that boys are more expected to be outside playing sport. Girls may give up sports in adolescence and are perceived as more likely to be at home, where TV watching is considered normal.
Study limitations
The lost of follow-ups are considerable in this study. However, our results would be biased if the associations we have assessed were non-existent or in the opposite direction in non-participants, which is unlikely. We have compared our estimates of overweight or obese at age 14 to the Australian National Nutritional Survey (NNS) 1995 for similar age categories and the results are compatible. At age 14, the prevalence of overweight or obesity was 25% in MUSP and 23% in NNS. These small differences are likely to be explained by regional variations and this comparison does not suggest a major problem with selection due to loss of follow-up. A variety of modeling strategies have been used in MUSP studies in order to adjust for attrition, though use of these methods have not resulted in marked alteration of findings [34,35]. From our recent investigation, we found that the proportion lost to follow up in MUSP is consistent with that in other large lifecourse cohorts (e.g. the British 1946, 58 and 70 birth cohorts, and the Avon Longitudinal Study of Parents and Children). We also found broad similarities between our published findings and those of previous birth cohort studies (with shorter follow-ups) with lower attrition rates, providing some support that our findings were not biased by lost of follow up. We do not have information about father’s perception of offspring weight status, which could be different from mothers.
Implications of the findings
We found more child factors than family or maternal factors predict maternal perceptions of their offspring weight status. This study suggests that, irrespective of offspring observed BMI, maternal perception of child weight status depends on how mothers perceived their children appearance, shape, size and weight, adolescent dieting, their health status and maternal BMI status. This perceived weight is less affected by the maternal mental health, socio economic status and life style factors.
Consistent evidence suggest that primary prevention of childhood overweight and obesity, including promoting healthy nutrition and patterns of activity, is likely to be successful with parental involvement [4,5]. However, such support is less likely to occur if parents, particularly mothers, do not recognize or perceive their overweight children as overweight. The finding that child factors are related to maternal perception should be helpful to clinicians as it suggests understanding adolescent and maternal perceptions of weight will best be achieved by a focus on current adolescent body image (appearance, shape, size), dieting, behavioural problems, and parental weight status.
The core study was funded by the National Health and Medical Research Council (NHMRC) of Australia. AAM is supported by a Career Development Awards from the NHMRC (ID 519756). For the work in this paper AAM has a grant from the National Heart Foundation of Australia (ID G07B3135). The views expressed in the paper are those of the authors and not necessarily those of any funding body and no funding body influenced the way in which the data were analysed and presented.
We thank all participants in the study, the MUSP data collection team, and data manager, University of Queensland who has helped to manage the data for the MUSP.
Ethics approval: Written informed consent from the mothers was obtained at all data collection phases of the study. Ethics committees at the Mater Hospital and the University of Queensland approved each phase of the study.



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