minority mothers' perceptions of children's body size

ORIGINAL ARTICLE

Minority mothers’ perceptions of children’s body size

LORRAINE KILLION1, SHERYL O. HUGHES2, JANICE C. WENDT3, DALE PEASE3

& THERESA A. NICKLAS2

1Houston Baptist University, Department of Education and Kinesiology, Houston, Texas, USA, 2Baylor College of Medicine,

Children’s Nutrition Research Center, Department of Pediatrics, Houston, Texas, USA, 3University of Houston, Department

of Health & Human Performance, Houston, Texas, USA

AbstractObjective. To investigate African-American and Hispanic mothers’ perceptions of their children’s body size using a scale withchild figure silhouettes and compare those perceptions with their children’s actual body mass index. Methods. A set of childfigure silhouettes was developed depicting 4 and 5 year-old African-American and Hispanic children. Body mass index wassystematically estimated for each child figure on the set of silhouettes. Minority mothers with children enrolled in ten HeadStart centers (n�/192) were interviewed using the silhouettes, and height and weight measurements were taken on theirchildren. Head Start, a comprehensive child development program that serves children aged 3 to 5 years old, was chosenbecause of the large percentage of minorities, the low-income status of the families, and the age of the children. Results .Significant differences were found between mothers’ perceptions of their children’s body size and the actual body size of thechildren. On average, mothers perceived their children to be thinner than their actual size. Furthermore, of those motherswith children at risk for overweight or overweight, two-thirds were either satisfied with their children’s existing body size orwanted their children to be heavier. However, half of the mothers of children above the 95th percentile for BMI wanted theirchildren to be thinner. Conclusions. These data suggest that minority mothers’ perceptions of their children’s body size maynot be consistently biased in one direction. Despite the possible social norm for a larger body size among low-incomeminorities, some mothers of overweight minority children do perceive their children to be too heavy when they reach acertain size.

Key words: Preschoolers, overweight, measurement, silhouettes, ethnic minorities, BMI, perceptions of body size, Head Start,

body satisfaction, parental socialization

Introduction

The prevalence of adult and pediatric obesity has

increased dramatically in the past two decades (1).

Women tend to be more at risk for being obese, with

low-income minority women facing the greatest risk

(2). Furthermore, overweight among preschoolers

has increased, and is more prominent in minority

children (3,4). Numerous studies have implicated

genetic and social factors as predictors of children’s

weight with positive associations existing between

parental weight and that of their offspring (5,6). The

specific contributions of parental socialization fac-

tors on children’s weight are still unclear.

Parental perceptions of their own weight and

their children’s weight have been investigated as

potential socialization factors on children’s weight.

It is possible that parents’ attitudes and beliefs

concerning eating, weight, and body size directly

influence (either through modeling or direct trans-

mission) their children’s eating behaviors, body

size and weight (7). Parental perceptions among

European-American parents have shown that par-

ents and their 5 year-old children share similar

weight concerns, for example, they both desire

thinner body sizes (8). However, cultural differ-

ences may exist between perceptions of the major-

ity of the European-American population and

those of minorities (e.g., African-American and

Hispanic) regarding ideal weights for their chil-

dren.

Correspondence: Sheryl O. Hughes, PhD, Baylor College of Medicine, Children’s Nutrition Research Center, Department of Pediatrics, 1100 Bates Avenue,

Houston, Texas 77030-2600, USA. Fax: 1 713 798 7130. E-mail: [email protected]

International Journal of Pediatric Obesity. 2006; 1(2): 96�102

(Received 5 December 2005; accepted 12 March 2006)

ISSN Print 1747-7166 ISSN Online 1747-7174 # 2006 Taylor & Francis

DOI: 10.1080/17477160600684286

Recent studies have found that many minority

parents underestimate the weight of their children

(13,14). However, the measurement of these weight

perceptions has been somewhat simplistic, resulting

in a possible misunderstanding of the construct and/

or measurement error. A more comprehensive way

to measure cultural perceptions of weight among

minority parents may be through the use of scales

with child figure silhouettes. These scales provide

contour figures ranging in size from very under-

weight to very overweight and have typically been

used by individuals to assess their own body size

(15).

The purpose of our study was to investigate

minority mothers’ misperceptions of their children’s

body size. Scales with child figure silhouettes depict-

ing 4 and 5 year-old African-American and Hispanic

children were developed specifically for this study

and estimated body mass index (BMI) was calcu-

lated for each of the child figures. These scales were

used to investigate minority mothers’ perceptions of

their children’s body size, determine mothers’ satis-

faction with the size of their children, and investigate

how these factors were related to the children’s

actual BMI.

We hypothesized that mothers in this study would

perceive their children to be thinner than their actual

body size. Furthermore, based on the possible

existence of a cultural norm for a larger body size

among minorities, we wanted to explore differences

in mothers’ satisfaction with their children’s body

size as a function of their children’s weight status. We

also wanted to examine perceptions of mothers who

had normal weight children and those with children

whose weight was above normal.

Methods

Participants

Participants were part of a larger study to investigate

parental feeding practices of African-American and

Hispanic preschool children in Head Start (16). A

total of 231 parents were recruited from ten Head

Start centers located in a suburban area in Southeast

Texas. Head Start is a comprehensive child devel-

opment program that serves children aged 3 to

5 years old and their families. The program is

child-focused with the overall goal of increasing the

school readiness of young children from low-income

families. The population of Head Start is large with

more than 900 000 children. More than 40% of the

children living in poverty in the United States during

the first 5 years of life will participate in Head Start.

In the present study, fathers, grandparents, and

pregnant mothers were excluded from the study

resulting in 192 non-pregnant mothers of Head Start

children. Only mothers were included in this study

because of evidence showing that mothers are

influential in shaping children’s early eating habits,

which may affect weight status (17). Of the mothers

in this study, 42% were African-American (n�/81)

and 58% were Hispanic (n�/111). Mean age of the

mothers was 29.9 years old (SD�/6.6). Of the

children, 43% were African-American and 57%

were Hispanic with a gender breakdown of 45%

boys and 55% girls. The children ranged from 3 to

5 years-of-age with 18% 3 year-olds, 51% 4 year-

olds, and 31% 5 year-olds. Mean age of the children

was 4.2 (SD�/0.07). Specific details regarding the

socio-demographic characteristics of the sample are

provided elsewhere (16).

Procedures

Participants were recruited at the Head Start centers

prior to picking up their children and with phone

calls to the home. The general consent form

procedure was for the participants to take the

consent form home. Participants were then sched-

uled to complete questionnaires. When participants

came to the Head Start centers to complete the

questionnaires, project staff went over the consent

form in detail and answered questions. At that time,

a staff member explained the purpose of the study,

confidentiality was assured, and consent forms were

signed.

Data collection took place after hours at the Head

Start centers from 2:30 p.m. to 5:30 p.m. Partici-

pants were selected one at a time to be interviewed in

a separate area to ensure privacy. Interviews were

conducted in Spanish or English based on the

mothers’ preference. Height and weight measure-

ments were obtained on the mothers and children.

The study was reviewed and approved by the

Internal Review Board at Baylor College of Medicine

prior to data collection and conforms to the provi-

sions of the Declaration of Helsinki in 1995.

Measurements

Body mass index

Body mass index (BMI; weight (kg)/height2 (m))

was assessed following procedures described by

Lohman, Roche, & Martorell (18). Participants

were asked to remove their shoes and any heavy

clothing before being weighed and measured.

Height and weight measurements were obtained by

trained staff, measured in duplicate, and recorded in

centimeters (height) and kilograms (weight) to the

nearest tenth of a point. Age- and gender-specific

Mothers’ perceptions of children’s body size 97

BMI scores were calculated for children using the

CDC standard criteria (19). Children were classified

as normal weight (BMIB/85th percentile), at risk for

overweight (BMI]/85th percentile), and overweight

(BMI]/95th percentile). Mothers were classified

using gender-specific CDC criteria as normal weight

(BMI5/24.9), overweight (BMI]/25) or obese

(BMI]/30).

Mothers’ perceptions of their children’s body size

Mothers’ perception of their children’s body size was

assessed by figure silhouettes of 4 and 5 year-old

children. These rating scales consisted of line draw-

ings of children’s bodies designed to be age and

ethnic appropriate. Mothers were shown cards con-

taining seven figures which corresponded to the

gender and ethnicity of their children. They were

asked to view the card and indicate which of the

seven figures most closely resembled the current size

of their children and the ideal size or which child

figure they would like their children to look like. The

mothers’ responses were recorded on a separate

scoring sheet by the staff member. The child figures

were developed based on input from Head Start

parents through cognitive interviews. Multiple itera-

tions of the child figures were culled resulting in

ethnically age-appropriate silhouettes for use with

African-American and Hispanic mothers.

Development of the silhouettes

During the development phase, cognitive interviews

with three sets of African-American & Hispanic

parents with children from another Head Start

center were conducted to ensure that: 1) the pictures

depicted 4 to 5 year-old children, 2) the facial

features and hair were ethnically appropriate, and,

3) the scaling represented thinnest to heaviest. First,

the age appropriateness of the child figures was

addressed. Twenty parents were asked to estimate

the age of the children through the following

question: ‘‘Approximately what age does the child

on the card represent?’’ Based on parental feedback,

the faces and physiques of the child figures were

adjusted to better reflect 4 and 5 year-old children.

Second, cultural sensitivity of the child figures was

addressed. Twenty different parents were asked two

questions: ‘‘Are the facial features (hair, nose, eyes,

etc.) appropriate to the culture of the child shown on

the card?’’ and ‘‘Is there anything offensive to the

culture that needs to be changed?’’ Based on parents’

suggestions, facial features and hairstyles were ad-

justed. Third, 25 parents were asked questions

regarding the sequencing of the child figures. Each

parent was given a set of seven cards (gender and

ethnic specific) arranged randomly in the packet

with each card containing one child figure. Parents

were asked to remove the cards and arrange them on

the sheet provided. Parents were given the following

instructions: ‘‘Please remove the cards from the

packet and arrange them on the sheet in a progres-

sion with the first card representing the thinnest

child and the last card representing the heaviest

child’’. With a 92% agreement, parents concurred

with the arrangement of child figures from thinnest

to heaviest. The families used in the development of

the child silhouettes were different from those who

took part in the study.

Estimation of BMI for each child figure

One limitation to the use of scales with child

silhouettes is that figures usually do not estimate

the weight of the figure they represent (15). As part

of the validation process in developing these figures,

two methods were used to estimate BMI for each

child figure in the set of seven figures. Two separate

experts in the field of body composition and young

children’s growth and development were used to

estimate the BMI for each child figure. The first

expert, a pediatric nutritional scientist, subjectively

assigned BMI values for each child figure using

the Center for Disease Control’s (CDC) BMI age-

and gender-specific data for 4 and 5 year-old

children (personal communication with N. Butte).

The second expert, a body composition scientist,

used a different approach by utilizing a volume of

cylinders method (personal communication with

K. Ellis). This procedure consisted of measuring

the arms, legs, and trunk of each child figure, and

forming one cylinder by adding each part together

to form the total volume. This procedure is similar to

the BOMAD model used in Health Physics to

calculate radiation doses (20). BMI for each child

figure was then determined by applying the volume

to the CDC age-and gender-specific growth charts

for 4 and 5 year-old children. To make certain that

the calculations by the two experts were similar, a

Pearson’s correlation was conducted showing the

two ratings to be highly correlated (r�/0.96; pB/

0.001). The authors decided to use the mathema-

tical calculations for the estimates of BMI for each

child figure because of their relative objectivity.

Final four sets of gender and ethnic specific silhouettes

The final sets of silhouettes consisted of four lami-

nated cards (based on gender and ethnicity) depicting

seven figures of 4 and 5 year-old children. The four

sets were as follows: 1) seven male African-American

children, 2) seven female African-American children,

98 L. Killion et al.

3) seven male Hispanic children, and 4) seven female

Hispanic children. The four sets were developed on a

single template of seven child figures with only the

skin color, facial features, and hair changing (to

reflect gender and ethnicity) across the four sets.

The difference in size between each of the seven

figures was synchronized to an incremental 7/16 inch

(0.0625) scaling metric added to the waistline of each

child figure, with the middle child figure as the anchor

figure . Therefore, only the torso changed across the

seven figures, with the height and clothing held

constant.

A ‘G’ to ‘A’ code was assigned to each child figure

so parents could identify the chosen figure during

data collection. Reverse coding was done so that

sequencing from thinnest to heaviest was less pro-

nounced. BMI scores based on the volume of

cylinders method were assigned to each of the seven

child figures. Scores were not placed on the cards

but were used for data analysis only (See Figure 1).

Mothers’ satisfaction with their children’s body size

Mothers’ satisfaction with their children’s body size

or the extent to which mothers wanted their children

to be different from the existing size was determined

by calculating the difference between their current

and ideal perception of their children’s body size

using the silhouettes. By subtracting the ideal from

the current, possible dissatisfaction scores ranged

from �/6 to �/6. Positive scores indicated that

mothers were not satisfied with their children’s size

and wanted their children to be thinner. A score of

zero indicated satisfaction. Negative scores indicated

that mothers were not satisfied with their children’s

size and wanted their children to be heavier. In the

past, scores based on this type of rating scale have

been interpreted as a continuous measure (8).

However, researchers need to be very cautious in

this type of interpretation since both ends of the

scale indicate that mothers are not satisfied with

their children’s size. Therefore, in the present study,

we categorized mothers based on their desire to have

their children be heavier (negative scores), their

desire to have their children be thinner (positive

scores), and their desire for no change indicating

satisfaction with their children’s size (scores of zero).

For ease of interpretation of analyses, negative scores

were recoded as 2, positive scores were recoded as 1,

and scores of 0 remained the same.

Statistical Analysis

Data were analyzed using the Statistical Package for

the Social Sciences (SPSS 10.0; Prentice Hall,

Upper Saddle River, New Jersey). Descriptive sta-

tistics were generated for all variables in the study.

Pearson correlation was used to evaluate the associa-

tion between mother and child BMI. A t-test was

used to compare mothers’ perceptions of their

children’s existing body size relative to the actual

body size of the children. Chi-square statistics were

used to evaluate mothers’ perceptions of their

children’s body size as a function of the children’s

weight status. Statistical significance was defined as

pB/0.05.

Results

Body mass index of mother and child

The mean BMI for the mothers was 29.9 (SD�/6.8)

with 32% categorized as overweight and 44%

categorized as obese. The mean BMI for the

children was 16.7 (SD�/1.8). Thirty-four percent

of the children were above the 85th percentile with

16% at risk for overweight and 18% overweight.

Figure 1. Child figure silhouettes for Hispanic boys. Letters under each figure were assigned for parents’ ease in identifying the chosen

figure during data collection. Note: The numbers under each figure represent the estimated BMI for each child figure and are not shown to

the parents on the child figure cards.


Overall, mothers’ BMI was significantly correlated

with child BMI (r�/0.20; pB/0.01).

Mothers’ perceptions of their children’s body size and

actual body size of their children

Significant differences were found between mothers’

perception of their children’s existing body size and

the actual body size of their children. Mothers

perceived BMI (mean�/15.0; SD�/0.66) of their

children were less than the actual BMI (mean�/

16.7; SD�/1.84) of their children (t�/15.77; pB/

0.0001). Therefore, on average, mothers perceived

their children to be thinner than their actual size.

Differences in mothers’ perceptions as a function of

children’s weight status

The significant chi-square analysis, x2�/7.13, p�/

0.008, suggests that there were differences in

mothers’ perceptions of their children’s body size

by the weight status of the children. Differences in

mothers’ perceptions of their children’s size categor-

ized by children’s weight status are presented in

Table I. Within the normal weight category, about

half of the mothers (50%) were satisfied with their

children’s body size, about half (48%) wanted their

children to be heavier, and 2% wanted their children

to be thinner. Within the at risk for overweight

category, 58% of the mothers were satisfied with

their children’s body size, 26% wanted their children

to be heavier, and 16% wanted their children to be

thinner. Within the overweight category, about half

(49%) were satisfied with their children’s body size,

2% wanted their children to be heavier, and about

half (49%) wanted their children to be thinner.

Significant differences were found on satisfaction

and preference for thinness for mothers of children at

risk for overweight versus those whose children were

overweight. Mothers of children at risk for over-

weight were more likely to be satisfied with their

children’s body size compared to mothers of children

who were overweight (x2 �/4.91; pB/0.05).

Discussion

The purpose of this study was to use scales with

ethnic-specific child silhouettes to examine minority

mothers’ perceptions of their children’s body size; to

determine mothers’ satisfaction with the size of their

children, and to see how those factors relate to their

children’s actual BMI. The findings of this study

confirmed our hypothesis in that, in general, minor-

ity mothers perceived their children to be thinner

than their actual size. This finding supports results

from previous studies showing that minority parents

consistently underestimate the weight of their chil-

dren. In a previous study, 79% of mothers with

Table I. Differences in mothers’ perception as a function of weight status.

Mothers’ Perceptions of Children

Weight Status Satisfied 0 Wants thinner 1 Wants heavier 2 Total

Normal

n 63 3 60 126

n% within weight status 50% 2% 48% 100%

% within perception 64% 12% 87% 66%

% of total 33% 2% 31% 66%

At Risk for Overweight

n 18 5 8 31

% within weight status 58% 16% 26% 100%


% of total 9% 3% 4% 16%

Overweight

n 17 17 1 35



% of total 8% 8% 2% 18%

Total

n 98 25 69 192



% of total 51% 13% 36% 100%

Note. ‘‘Satisfied’’ denotes that the mother is satisfied with her child’s weight. ‘‘Wants thinner’’ denotes that the mother wants her child to be

thinner. ‘‘Wants heavier’’ denotes that the mother wants her child to be heavier. The significant chi-square analysis, x2�/7.13, p�/0.008,

suggests that there were differences in mothers’ perceptions of their children’s body size by the weight status of the children.


overweight preschool children failed to perceive

those children as overweight, with misclassification

greater among less educated mothers (13). In

another study of low-income parents of obese

children (mostly Hispanic), 35% did not believe

their obese child was overweight and 53% did not try

to control what their children ate (14).

The second objective of this study was to deter-

mine whether mothers with children at risk for

overweight or overweight were satisfied with the

weight of their overweight children. Of those

mothers with children at or above the 85th percen-

tile, 66% were satisfied with their children’s size or

wanted their children to be heavier. The fact that

essentially two-thirds of mothers with children who

were at risk for overweight or overweight were

satisfied or wanted their overweight children to be

heavier may be indicative of a social norm for a larger

body size among low-income African-Americans and

Hispanics.

The idea that some of these mothers may have a

distorted view of their children is not a novel idea.

Social psychologists have explored the construct of

‘positive illusions’ in many studies. Taylor (21)

argues that the normal person construes information

in a manner that promotes illusions or mispercep-

tions about the self and others. Normal human

perception is marked not by accuracy but by positive

self-enhancing illusions. Taylor believes that these

illusions are adaptive and promote well-being (21).

Furthermore, other researchers have argued that

because of the great importance of the concept of

the ‘good family’ or the idea of what constitutes a

‘good parent’ to both individuals and society, parents

may be unwilling or unable to provide truthful

accounts of their perceptions (22). This may be

especially true with low-income minorities because

of cultural and/or socio-economic differences.

Although misperceptions or illusions regarding the

weight status of their children may benefit mothers’

well-being in the short-term, these misperceptions

could have long-term consequences for children’s

health in these populations.

The concept that mothers believe that a larger

body size means a healthier child has been explored

in some studies with minorities. Sherry et al. (23)

found that low-income African-Americans generally

believed that their children would outgrow their

overweight as they got older and having a high

weight in childhood was healthy. Because of these

beliefs, parents may be satisfied with heavier children

and/or want their children to be larger.

An unexpected finding in this study was that half

of mothers with children at or above the 95th

percentile for BMI actually wanted their children

to be thinner. This may be indicative of a shift in

perception among some mothers of very overweight

children. These data suggest that despite the possible

social norm for a larger body size among low-income

minorities, some mothers of very overweight minor-

ity children do perceive their children to be too heavy

and want them to be thinner when they reach a

certain size.

The significant correlation between the BMI of

mothers and their children in this study supports

previous studies showing the heritability of weight

status. Strauss and Knight (24) found that maternal

obesity was the most significant predictor of child-

hood obesity compared with a range of factors

relating to the home environment. Furthermore,

there is other evidence showing that children with

overweight or obese parents have a higher chance of

becoming overweight or obese themselves (25�27).

Limitations to the study and suggestions for future

research

The current study was limited to low income

African-American and Hispanic mothers and their

children and, therefore, can only be generalized to

those populations. Misperception of children’s

weight has been found in other studies with nearly

one third of mothers across all ethnic groups

reporting their overweight children as ‘about the

right weight’ (28). Future studies should take a more

comprehensive approach to better understand the

social norms for a thinner or heavier body size

among specific socio-economic and ethnic groups.

Implications

Many studies have suggested obesity is a socio-

cultural problem. Given that this is true, mothers’

perceptions of their children’s size could have an

impact on their feeding behavior with young chil-

dren, their motivation to obtain information on

healthy eating and nutrition for the family, and their

encouragement for their children to be more physi-

cally active. Since some mothers of overweight

minority children do perceive their children to be

too heavy when they get to a certain size, it is

important to understand why some parents perceive

their children as overweight whereas others do not.

By better understanding the etiology of cultural

perceptions regarding body size, we will be able to

enhance parental understanding of what overweight

means and what is a desired body size for healthy

children. However, to raise parents’ awareness of

overweight at this time may be somewhat premature

because we currently do not have effective over-

weight intervention programs in the community.


Acknowledgements

This research was supported by funds from the

United States Department of Agriculture, Environ-

mental Influences on Children’s Food Consumption

Grant No. 2001-35200-10659. Partial support was

received from Dairy Management Inc. This work is a

publication of the United States Department of

Agriculture (USDA/ARS) Children’s Nutrition Re-

search Center, Department of Pediatrics, Baylor

College of Medicine, Houston, Texas, and has

been funded in part with federal funds from the

USDA/ARS under Cooperative Agreement No. 58-

6250-6001. The contents of this publication do not

necessarily reflect the views or policies of the USDA,

nor does mention of trade names, commercial

products, or organizations imply endorsement from

the U.S. government.

The authors wish to thank Sandra Lopez and

Janet Bonner, who were instrumental in the devel-

opment of the questionnaire, and for their help in

data collection. We also thank Pamelia Harris for

help in preparing the manuscript. We extend a

special thanks to Nancy Butte and Ken Ellis for

their help in estimating the BMI of each of the child

silhouette figures.

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