Barba G

Baughcum AE

Braga PD

Campbell MW

Carolina Perim de Faria

Etelson D

Gualdi-Russo E

Hirschler DV

Jeffery AN

Mamun AA

Maria del Carmen Bisi Molina

Maynard LM

Mendoza JA

Montero P

Must A

Nagela Valadão Cade

Pilar Montero

Welch C

Cadernos de Saúde Pública

Crossref

Cad. Saúde Pública, Rio de Janeiro, 25(10):2285-2290, out, 2009
2285
Correspondence between children’s nutritional 
status and mothers’ perceptions: 
a population-based study
Correspondência entre o estado nutricional de 
crianças e a percepção materna: 
um estudo populacional
1 Centro de Ciências da 
Saúde, Universidade Federal 
do Espírito Santo, Vitória, 
Brasil.
2 Centro Biomédico, 
Universidade Federal do 
Espírito Santo, Vitória, Brasil.
3 Universidad Autónoma de 
Madrid, Madrid, España.
Correspondence
M. C. B. Molina
Centro de Ciências da Saúde, 
Universidade Federal do 
Espírito Santo.
Av. Marechal Campos 1468, 
Vitória, ES
29000-000, Brasil.
mdmolina@uol.com.br
Maria del Carmen Bisi Molina 1
Carolina Perim de Faria 2
Pilar Montero 3
Nagela Valadão Cade 2
Abstract
This study aimed to investigate the correspon-
dence between the nutritional status of children 
aged 7-10 years and their mothers’ perceptions 
of their children’s weight. A cross-sectional sur-
vey was conducted among 1,282 children. Weight 
and height were measured and classified accord-
ing to International Obesity Taskforce (IOTF) cri-
teria. Mothers’ perceptions were assessed based 
on four possible conditions. The Kappa test (k) 
was used to evaluate the correspondence between 
nutritional status and mothers’ perceptions and 
followed by regression analyses. The prevalence 
of overweight and underweight was 23.2% and 
5.7% respectively. Half of mothers reported that 
their children were “underweight”; 61.2% said 
that their children were “normal”; 11.8% said 
that their children were “above normal weight”; 
and 1.1% referred to their offspring as “very 
much above normal weight”. Highest and low-
est correspondence between nutritional status 
and mother´s perception were: underweight 
and much above normal weight, respectively 
(k = 0.217, p < 0.000). Gender and ethnicity 
showed significant association with the mother’s 
perception, even after controlling for other vari-
ables. Low correspondence levels between nutri-
tional status and mother’s perception were ob-
served, especially among obese children.
Nutritional Status; Body Image; Anthropometry
Introduction
A mother’s perception of her child’s nutritional 
status is fundamental in that it determines pat-
terns of care which define both in-house feeding 
practices and daily eating habits. This in turn af-
fects the child’s overall nutritional status. Often, 
once overweight is present, there is no corre-
spondence between measured nutritional status 
and the individual’s perception of their bodies 1. 
Although many previous studies have pointed 
that women overestimate their nutritional status, 
studies focusing on identifying the correspon-
dence levels among the “measured and quanti-
fied” body and the “perceived” body often use 
different approaches 2,3.
Studies have shown that parents often under-
estimate either their children’s obesity or over-
weight 4,5,6, and a range of factors underlie such 
misreading of their nutritional status. Younger 
and male children’s weight, for example, are 
less accurately perceived, while older and male 
children’s are better interpreted 7, especially by 
mothers with higher levels of education 8.
This study aims at both investigating the cor-
respondence between anthropometric evalua-
tions of 7-10 year old children and their mothers’ 
perceptions of their weight, and identifying the 
associated socio-demographic factors.
NOTA   RESEARCH NOTE
Molina MCB et al.2286
Cad. Saúde Pública, Rio de Janeiro, 25(10):2285-2290, out, 2009
Methods
A cross sectional quantitative design was chosen 
and data were collected and analyzed from a sam-
ple of 1,282 children aged 7-10, currently attend-
ing public and private schools in Vitória, Espírito 
Santo State, Brazil. The sample was planned to 
geographically cover the area of Vitória. In order 
to avoid interclass bias, conglomerate sampling 
was performed in two stages.
Anthropometric measurements were taken 
in each school by trained health personnel and 
performed using standardized procedures 9. Cri-
teria used to classify nutritional status followed 
Must et al. 10 and sociodemographic information 
was provided by parents or tutors. A multiple 
choice test was used to assess the mother’s per-
ception of her child’s nutritional status. In order 
to study the main factors associated with ma-
ternal perception the following variables were 
investigated: child’s sex and age, socioeconomic 
status, skin color (white vs. non white), type of 
school (public vs. private) and maternal level of 
schooling.
Variables were presented in percentages and 
the chi-square test was used to test for the hy-
pothesis of homogenic proportions. Kappa was 
used to evaluate the correspondence between 
the children’s nutritional status and maternal 
perception. Multivariate analysis was carried out 
through multinomial logistic regression proce-
dures, with maternal perception as the depen-
dent variable and normal weight as reference 
category. Significance level for variable inclusion 
in the model was established in 5% for any of the 
dependent variable categories.
Statistical analysis was performed using SPSS 
for Windows (SPSS Inc., Chicago, USA). Adjusted 
odds ratio (OR) and 95% confidence intervals 
(95%CI) were calculated for the variables remain-
ing in the multivariate model. Parents were fully 
informed of the study and signed a written con-
sent form. The present study was approved by the 
Research Ethics Committee of the Universidade 
Federal do Espírito Santo (UFES – nº. 089/06).
Results
Table 1 shows the distribution of sociodemo-
graphic and anthropometric variables. Males 
and females presented no significant differences 
for any of the studied variables, including nutri-
tional status. Skin color was positively associated 
with maternal education, socioeconomic status 
and type of school. Therefore, skin color was used 
as a socioeconomic status marker in the present 
study.
Maternal education was the only variable 
which presented a significant association with 
nutritional status (p < 0.000). After adjusting for 
other socioeconomic and health related variables, 
association with overweight was still present (re-
sults not shown in the tables). The prevalence of 
underweight was greater among children born 
to unschooled mothers or mothers with fewer 
than eight years of education. The proportion of 
overweight and obese children was larger among 
mothers who completed high school.
Table 2 shows a poor correspondence be-
tween children’s anthropometric classification 
and their mother’s perception (kappa = 0.217, 
p < 0.000). The greatest agreement rates were for 
underweight (72.6%) and normal weight children 
(68.3%). Better correspondence can be observed 
in underweight male children as compared to fe-
males (data not shown).
Statistically significant differences were 
found for maternal perception and gender, skin 
color and maternal level of schooling. Boys were 
perceived by their mothers as underweight more 
frequently than girls, the latter being perceived 
as overweight more often than boys. Non-white 
children were perceived as underweight in great-
er proportion than white children (results not 
shown on tables).
The analysis of adjusted data for maternal 
perception towards their children’s nutritional 
status (Table 3) demonstrated that the only pre-
dictive variables for which an association was 
maintained throughout were gender and skin 
color. We found that males have a 1.78 (95%CI: 
1.37-2.31; p < 0.000) greater chance of being seen 
as underweight than females; also, having white 
skin lessens the chance of being perceived as 
underweight (OR = 0.74; 95%CI: 0.56-0.99; p = 
0.04) and triples the chance of being perceived as 
obese (OR = 3.39; 95%CI: 1.13-10.21; p = 0.03).
Discussion
Most of the studies on this subject have been car-
ried out with teenagers and adults, individuals 
capable of choosing and defining their lifestyles. 
The lifestyles and eating habits of children, on the 
other hand, are strictly dependent on their moth-
ers or other adults both at home and at school. 
The quality and quantity of foods offered to chil-
dren do not solely depend on consensual choices, 
as they are directly influenced by socioeconomic 
conditions 11 and the perception mothers have of 
their children’s nutritional status 12.
In this study, the correspondence between 
nutritional status and maternal perception was 
found to be low, especially among overweight 
CHILDREN’S NUTRITIONAL STATE AND MATERNAL PERCEPTION 2287
Cad. Saúde Pública, Rio de Janeiro, 25(10):2285-2290, out, 2009
Table 1
Sample distribution according to nutritional status and sociodemographic variables. Vitória, Espírito Santo State, Brazil, 2007.
 Variable Gender Skin color
   Male Female p value White Non-white p value
   n (%) n (%)  n (%) n (%)
 Skin color     
  White 176 (42.0) 243 (58.0) 0.920  
  Non-white 347 (41.7) 485 (58.3)   
 Maternal education (years)     
  ≤ 3 129 (24.7) 200 (27.3) 0.750 60 (14.5) 269 (31.9) 0.000
  4-10 106 (20.3) 145 (19.8)  64 (15.5) 187 (22.2)
  11-14 189 (36.1) 267 (36.5)  144 (34.9) 312 (37.1)
  ≥ 15 99 (18.9) 120 (16.4)  145 (35.1) 74 (8.8)
 Socioeconomic class     
  A + B 113 (43.1) 149 (56.9) 0.854 69 (19.2) 193 (25.3) 0.002
  C 162 (41.1) 232 (58.9)  152 (42.3) 242 (31.7)
  D + E 199 (42.6) 268 (57.4)  138 (38.4) 329 (43.1)
 Type of school     
  Public 446 (42.0) 615 (58.0) 0.911 277 (66.1) 784 (90.8) 0.000
  Private 92 (41.6) 129 (58.4)  142 (33.9) 79 (9.2)
 Age (years)     
  7 103 (40.9) 149 (59.1) 0.183 74 (17.7) 178 (20.6) 0.565
  8 139 (38.7) 220 (61.3)  125 (29.8) 234 (27.1)
  9 150 (41.7) 210 (58.3)  117 (27.9) 243 (28.2)
  10 146 (46.9) 165 (53.1)  103 (24.6) 208 (24.1)
 Nutritional status     
  Underweight 32 (43.8) 41 (56.0) 0.828 17 (4.1) 56 (6.5) 0.216
  Normal 383 (42.0) 528 (58.0)  305 (72.8) 606 (70.2)
  Overweight 72 (39.3) 111 (60.7)  64 (15.3) 119 (13.8)
  Obese 51 (44.0) 64 (55.7)  33 (7.9) 82 (9.5)
Table 2
Correspondence between nutritional status of 7-10 year old children and their mothers’ perceptions of their weight. Vitória, 
Espírito Santo State, Brazil, 2007.
 Child’s nutritional status Mother’s perception of child’s nutritional status
   Underweight Normal Overweight Obese
   n (%) n (%) n (%) n (%)
 Underweight 53 (72.6) 19 (26.0)  1 (1.4)  0 (0.0) 
 Normal 271 (30.0) 616 (68.3) 15 (1.7) 0 (0.0)
 Overweight 4 (2.2) 116 (63.7) 60 (33.0) 2 (1.1)
 Obese 0 (0.0) 28 (24.3) 75 (65.2) 12 (10.4)
Kappa = 0.217, p < 0.000.
and obese children. Similar low results were found 
in a study undertaken with Australian preschool 
children 13. In general, mothers more frequent-
ly perceive their children as underweight 6,14; 
even though significant differences were ob-
served when these perceptions were associated 
with sociocultural factors and gender 8,15. These 
are the variables which our study found to best 
account for the mismatch between maternal per-
ception and nutritional status. It should be noted 
Molina MCB et al.2288
Cad. Saúde Pública, Rio de Janeiro, 25(10):2285-2290, out, 2009
that skin color was used as a socioeconomic sta-
tus marker.
In our sample, we observed that non-white 
children were born to women who consistently 
had lower schooling and income. Our results 
point to the fact that mothers with higher school-
ing and income seem to be able to identify more 
accurately their children’s health concerns, both 
physical and psychological (such as obesity and 
low body image), than low schooling and income 
level mothers. Similar results were found in a 
study performed in the United States 15.
Also, mothers with higher educational levels 
have more access to information and can af-
ford the tools to fight their children’s overweight, 
while mothers of lower socioeconomic status 
and schooling are often less aware of preventive 
actions and less equipped to implement treat-
ment if necessary.
Mothers tend to perceive their children as 
thinner than they really are, and this is especially 
true for males. This can be related to a gender is-
sue difference in which girls are led to pursue and 
value thinness more than boys. Although there 
is no significant difference in the proportion of 
different weight categories in this study, previous 
population studies undertaken with adults have 
shown a decrease in the proportion of overweight 
among women of higher socioeconomic status. 
On the other hand, men are growing heavier in all 
socioeconomic classes 16. Actually, for this sam-
ple, self-reported body mass index (BMI) values 
for fathers were found to be higher than those 
for mothers; the former were associated with ex-
cessive body weight of their children, which may 
indicate that gender influences maternal percep-
tion and concerns about the daughters’ health 
and nutritional status. 
Final considerations
Maternal concerns about their children’s body 
image differ from sons to daughters, and this 
may bring about gender-related risk factors: in-
crease of overweight and obesity in boys during 
their growth period from childhood into adult-
hood, eating disorders (anorexia, bulimia) in 
girls triggered by low body image. Although the 
correspondence between nutritional status and 
maternal perception of the children’s body im-
age was low in this study, it may ultimately de-
pend on socioeconomic status and the children’s 
gender.
Table 3
Factors associated with mother’s perception of their child’s nutritional status: adjusted odds ratio (OR) with respective confi dence 
intervals (95%CI). Vitória, Espírito Santo State, Brazil, 2007.
 Mother’s  β coefficient p value OR 95%CI
 perception/Variable    Lowest Highest
 Underweight     
  Gender     
   Male/Female 0.574 0.000 1.78 * 1.368 2.305
  Skin color     
   White/Non white -0.297 0.040 0.74 * 0.559 0.987
 Overweight     
  Gender     
   Male/Female -0.180 0.334 0.83 0.579 1.204
  Skin color     
   White/Non white -0.190 0.323 0.83 0.567 1.205
 Obesity     
  Gender     
   Male/Female 0.166 0.761 1.18 0.405 3.445
  Skin color     
   White/Non white 1.221 0.030 3.39 * 1.125 10.215
* p value ≤ 0.000.
CHILDREN’S NUTRITIONAL STATE AND MATERNAL PERCEPTION 2289
Cad. Saúde Pública, Rio de Janeiro, 25(10):2285-2290, out, 2009
Resumo
Para investigar a correspondência entre classificação 
antropométrica de crianças e percepção de peso re-
ferida por suas mães, foi realizado estudo com 1.282 
crianças (7-10 anos). Utilizou-se o critério recomenda-
do pela International Obesity Task Force (IOTF) para 
avaliação antropométrica e a percepção foi aferida por 
meio de pergunta objetiva. Teste de kappa foi usado 
para avaliação da correspondência. A percepção ma-
terna foi associada a fatores sócio-demográficos, utili-
zando-se modelo de regressão logística multinominal 
(α = 0,05). A prevalência de excesso de peso e baixo pe-
so foi de 23,2% e 5,7%, respectivamente. Vinte e cinco 
vírgula oito por cento das mães disseram que seus fi-
lhos estão “abaixo do peso”, 61,2% disseram que seus 
filhos estão “normais”, 11,8% disseram que seus filhos 
estão “acima do peso” e 1,1% “muito acima do peso”. 
Baixo peso e muito acima do peso obtiveram a maior 
e a menor correspondência, respectivamente (kappa = 
0,217, p < 0,000). Gênero e cor da pele mostraram as-
sociação significativa com percepção materna, mesmo 
após ajuste por outras variáveis. Observou-se baixa 
correspondência entre classificação antropométrica e 
percepção materna, especialmente entre crianças clas-
sificadas como obesas.
Estado Nutricional; Imagem Corporal; Antropometria
Contributors
M. C. B. Molina was responsible for data analysis, article 
conception and write up. C. P. Faria participated in the 
write up and analysis of the article. P. Montero partici-
pated in the conception and revision of the article and 
data analysis. N. V. Cade revised the manuscript. 
Acknowledgments
The study received financial support from the Fundo de 
Apoio à Ciência e à Tecnologia de Vitória (FACITEC).
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Submitted on 13/Nov/2008
Final version resubmitted on 19/Jul/2009
Approved on 29/Jul/2009


Correspondence between children's nutritional status and mothers' perceptions: a population-based study

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Correspondence between children's nutritional status and mothers' perceptions: a population-based study

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