Influence of behavior and maternal perception on their children’s eating and nutritional status

Abstract

Mothers carry a major responsibility for nutrition and feeding behavior during childhood. The present study aimed to analyze the maternal attitude and perception of the mealtimes and nutritional status of their children. A non-probabilistic sample of 116 mothers and their respective children who go to the Basic Health Units of the City of Sao Paulo, were invited to respond to a Parent Mealtime Action Scale (PMAS) and the Child Feeding Questionnaire (CFQ). The age, income, education and nutritional status of mothers and their children were assessed, and the associations between these characteristics and the PMAS and CFQ scores were examined using linear regression. The correlations between PMAS and CFQ were analyzed by the Spearman test and the nutritional status correlations between mothers and their children, by the Pearson's chi-square. It was found that 71.5% of the mothers and 57.7% of the children were either overweight or obese. The most common positive maternal attitudes according to the PMAS were: daily offer of fruits and vegetables, limits on sweets, and positive persuasion. The negative attitudes were sweet-eating role models, use of rewards and providing many food options. Among the CFQ factors, the most frequent were: perceived responsibility toward their children's food intake, monitoring by mothers of healthy food consumption, junk food restrictions, and exerting pressure to eat. There was a moderate correlation between the nutritional status of the mother and child. It was concluded that the attitudes and perceptions of mothers regarding their children's nutrition vary according to their own nutritional status, as well as the child's.

Full text

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Inuence of behavior and maternal perception on
their children’s eating and nutritional status#
Inuência do comportamento e percepção materna sobre a
alimentação e estado nutricional dos lhos
Kathleen Jellmayer*
Aline de Piano Ganen**
Marle Alvarenga***
Resumo
As mães exercem grande responsabilidade sobre alimentação e comportamento alimentar durante a infância. O
presente estudo objetivou analisar as atitudes e percepção materna sobre a alimentação e estado nutricional da criança.
Selecionou-se uma amostra não probabilística de 116 mães e respectivos filhos, que frequentam Unidades Básicas
de Saúde da Prefeitura de São Paulo. Aplicou-se a Escala de Comportamento dos Pais durante a Refeição (ECPDR)
e o Questionário de Alimentação da Criança (QAC) para as mães. Avaliou-se a idade, renda, escolaridade e estado
nutricional das mães e filhos e associações entre estas características e os escores da ECPDR e QAC por meio de
regressão linear. Analisaram-se correlações entre a ECPDR e QAC pelo teste de Spearman e entre estado nutricional
das mães e filhos pelo Qui quadrado de Pearson. Verificou-se que 71,5% das mães e 57,7% dos filhos apresentaram
excesso de peso. As atitudes maternas positivas mais presentes segundo ECPDR foram: disponibilidade diária de frutas
e hortaliças, limite de guloseimas e persuasão positiva; e as negativas: modelo de guloseima, uso de recompensas
e oferecimento de muitas opções alimentares. Pelo QAC, os mais presentes: responsabilidade percebida quanto à
alimentação da criança, monitoramento exercido sobre o consumo de alimentos saudáveis, restrição de alimentos não
saudáveis e pressão para comer. Houve correlação moderada entre estado nutricional da mãe e do filho. Concluiu-se
que as atitudes e percepções maternas relacionadas à alimentação dos filhos variam em função de seu próprio estado
nutricional e o da criança.
Palavras-chave: Comportamento alimentar; estado nutricional; criança.
Abstract
Keywords: Feeding behavior; nutritional status; child.
Mothers carry a major responsibility for nutrition and feeding behavior during childhood. The present study aimed to
analyze the maternal attitude and perception of the mealtimes and nutritional status of their children. A non-probabilistic
sample of 116 mothers and their respective children who go to the Basic Health Units of the City of Sao Paulo, were
invited to respond to a Parent Mealtime Action Scale (PMAS) and the Child Feeding Questionnaire (CFQ). The age,
income, education and nutritional status of mothers and their children were assessed, and the associations between
these characteristics and the PMAS and CFQ scores were examined using linear regression. The correlations between
PMAS and CFQ were analyzed by the Spearman test and the nutritional status correlations between mothers and their
children, by the Pearson’s chi-square. It was found that 71.5% of the mothers and 57.7% of the children were either
overweight or obese. The most common positive maternal attitudes according to the PMAS were: daily offer of fruits
and vegetables, limits on sweets, and positive persuasion. The negative attitudes were sweet-eating role models, use of
rewards and providing many food options. Among the CFQ factors, the most frequent were: perceived responsibility
toward their children’s food intake, monitoring by mothers of healthy food consumption, junk food restrictions, and
exerting pressure to eat. There was a moderate correlation between the nutritional status of the mother and child. It was
concluded that the attitudes and perceptions of mothers regarding their children’s nutrition vary according to their own
nutritional status, as well as the child’s.
* Centro Universitário São Camilo, Sao Paulo - SP, Brazil.
** Centro Universitário São Camilo, Sao Paulo - SP, Brazil. E-mail: aline.depiano@gmail.com
*** School of Public Health - University of Sao Paulo. Sao Paulo-SP; Brazil.
#This manuscript is the result of the Master’s Dissertation of the student Kathleen Jellmayer, titled Behavior of mothers and maternal
perception concerning their children’s diet, 2016, Centro Universitário São Camilo.
The authors declare no conflicts of interest.
DOI: 10.15343/0104-7809.20174102180193
Artigo Original • Original Paper
O Mundo da Saúde, São Paulo - 2017;41(2):180-193

181
Inuence of behavior and maternal perception on their children’s eating and nutritional status
INTRODUCTION
Childhood obesity has been producing
alarming indices, worldwide. According to
the World Health Commission (WHO), it is
estimated in 2014, 41 million children under 5
years of age were affected by excess weight.
The prevalence of obesity in school-age children
and adolescents has remained at a plateau in
critical regions around the world, however, in
absolute numbers, there is a higher incidence of
overweight in children living in low- and middle-
income countries, than those in high-income
countries.1 The latest data from the 2008-2009
Family Budget Survey (FBS) showed that 33.5%
of children between five and nine years old
were overweight, 16.6% of boys and 11.8% of
girls were obese.2
During childhood, the family has a great
responsibility not only in supplying the types
of food, but also in the formation of nutritional
behavior and, consequently, of the nutritional
status of the child; thus, designating the parents
with the role of being their first nutritional
educators.3 In this context, cultural factors and
psychosocial aspects of the family influence the
child’s feeding experiences from the moment of
birth, initiating the learning process.4 Among the
sociocultural factors, the influence of the media
on food behavior and satisfaction with the body
image of adults and children is highlighted.5
These means of communication can have an
impact on food consumption by influencing
decision-making in the acquisition of certain
foods, as well as the internalization of specific
values in relation to the appearance, idealized
model of beauty.6
Parents influence children’s eating behavior
in a variety of ways: they actively make food
choices for the family (food and beverage
selection); they serve as role models for food
choices and how to eat; and they are also
models of eating practices to reinforce the
development of habits and behaviors.7
Recent research conducted in Australia on
healthy eating and body image with parents of
children aged 1 to 6 years found that parents
described healthy eating of children with variety
and balance by limiting certain foods such as
sugar, salt and processed food. They were
O Mundo da Saúde, São Paulo - 2017;41(2):180-193
well informed about nutrition and had access
to healthy food, expressing a desire for more
practical information on how to avoid negative
body image and promote healthy eating.8
The mother is the one who most frequently
cares for her children and can contribute to
healthy eating standards or unregulated intake,
which could lead to obesity, eating disorders
(ED), and nutritional deficiencies. In some
cases, this can happen when, even in a well-
intentioned way, mothers with forceful attitudes
impose food practices that do not give children
the opportunity to control their own food
intake, as well as their choices.9
Cross-sectional studies have sought to
identify the parental and familiar functioning
characteristics that could occur before the
onset of ED. Among the results are inadequate
parenting pressures, overprotective parents’
behavior / high concern, parental indifference,
family discord, lack of parental care, and greater
adversity, all distinguish patients with ED
from those in normal psychiatric conditions.10
Therefore, research suggests that the family
environment, responsible for influencing the
eating behavior of children and adolescents,
may also be a risk factor for the development
of ED.
It is emphasized that knowing the role
of the mother and / or the responsible ones
can be fundamental for interventions that are
more adjusted to the necessary changes of the
feeding behavior of the child in the familiar
context, since they are the ones that more
frequently take care of the children’s diet. The
present study aimed to analyze the influence of
behavior and maternal perception on feeding
and on the nutritional status of their children.
MATERIALS AND METHODS
Study Design
This cross-sectional study was carried out in
two Basic Health Units (UBS) of the Technical
Supervision of Health in Mooca / Aricanduva,
belonging to the Southeast Regional
Management of the City Health Department -
City Hall of the City of Sao Paulo.

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After the approval of the project by the
ethics committee of the São Camilo University
Center (Proposal No. 48/2015) and the
Municipal Health Department of the City of São
Paulo (Proposal No. 1.239.197), the free and
informed consent form was delivered to those
responsible.
Sample
Non-probabilistic sample, of convenience,
composed by mothers and their respective
children attending the UBS’s in question. A
total of 232 people participated, including 116
mothers and 116 children. Mothers were invited
to participate, provided they met the inclusion
and exclusion criteria below:
Inclusion criteria:
- Mothers with children of both sexes
between 6 and 10 years of age.
The choice of the age group was justified
because it was included in the age group
indicated in the validation studies of the scales
used in this research. In addition, the school
phase was chosen because it is considered an
important period for the formation of eating
habits, with a significant risk of developing
obesity.
- Child accompanying the mother in the
appointment at the selected UBS’s, to evaluate
the nutritional status.
Exclusion Criteria:
- Mothers who are illiterate or incapable of
responding to research instruments; children
with significant allergies or food restrictions, and
chronic health problems affecting food, such
as: multiple food allergies; metabolic or genetic
disorders; anatomical or mechanical problems
of the upper respiratory tract or the acquired or
congenital gastrointestinal tract, and defects in
the larynx, trachea, and esophagus that partially
or totally incapacitate oral feeding.
All the mothers who agreed to participate
received information about the study according
to the Informed Consent Form (ICF). In the case
of mothers with more than one child in the age
range of the study, she was asked for her to
choose one for participation.
Study variables and data collection
Demographic variables
Through the application of the demographic
data questionnaire, demographic variables
were represented by age (mother and child);
sex (mother and child); education; civil status;
maternal work; and child’s gender.
Nutritional status
The weight (W) and height (H) of mothers
and children were measured according to the
WHO technical standards11 adopted by the
Ministry of Health12, in which children were
weighed in minimal clothes and mothers
in light clothing, both without shoes, in an
anthropometric mechanic adult Welmy® scale
with a capacity of 150 kg and divisions of 100g,
with an anthropometric ruler with a scale of 2.00
meters, used for the measurement of height; all
measurements were taken by the researcher.
The Body Mass Index (BMI) was calculated
following to the formula - BMI = weight/height².
For the children, the Z-score of the BMI / Age
indicated for boys and girls from 5 to 19 years13
was calculated, and subsequent classification of
the nutritional condition.
Socioeconomic Situation
The evaluation of the socioeconomic
situation was performed using the Brazilian
Economic Classification Criteria (CCEB) – 2015
update - established by the Brazilian Association
of Research Companies (ABEP), which
identifies the consumption potential of Brazilian
households, classifying the population into six
socioeconomic strata A, B1, B2, C1, C2 and DE.
The CCEB is based on the possession of assets,
attaching to each item a number of points,
which must be added together and the resulting
value identified in the criterion, according to its
cut points, the socioeconomic classification of
the family.14 A simplified questionnaire model
was suggested for CCEB application.
Evaluation of Mothers’ Behavior for Feeding
Children
The Escala de Comportamento dos Pais
durante a Refeição (ECPDR) is the Portuguese
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183
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version of the Parent Mealtime Action Scale
(PAMS), recently developed and validated for
a US population by Hendy et al.15 In Brazil, the
version was translated and validated by Petty et
al.16, in a study with parents or official caregivers
of children aged 6 to 10 years, enrolled in
schools in the city of São Paulo. The original
scale had a reliability (Cronbach’s Alpha) of
0.62 - varying between 0.42 and 0.81 among
the 9 domains15; and the validation work found
Cronbach’s Alpha of 0.61 - ranging from 0.47 to
0.81 between domains.16
The questions were answered according
to the frequency of practice of each behavior
(1-never, 2-sometimes, 3-always). The responses
were organized, and to obtain the result of
each of the 9 behaviors evaluated, the average
of the items that composed each domain was
calculated. The frequency of each action was
obtained by the average of all responses in each
subgroup.
There is no classification system with
respective cut-off points to diagnose the score
found. According to Petty et al.16, in their
studies for instrument validation and use in the
Brazilian population, they have identified an
interpretation for the various domains based on
the opinions of several authors of studies using
these domains.
Assessment of Child Feed Perception
The Questionário de Alimentação da
Criança (QAC) is the translated and validated
Child Feeding Questionnaire for the Portuguese
language, developed by Birch et al.17, and
is considered an appropriate instrument for
research with parents of children with normal
development. The scale was translated and had
its reliability evaluated in Brazil by Miranda da
Cruz.18
The original scale had a reliability (Cronbach’s
Alpha) of 0.70 to 0.92 among the 7 factors17;
The work of Miranda da Cruz18 did not evaluate
the reliability of the application in the Brazilian
sample.
This instrument has 31 questions and
tests seven factors: four that assess parents’
perceptions and concerns and the control of
infant feeding practices, and three factors that
assess parental attitudes and practices on the
control of infant feeding.
Questions were answered according to the
intensity of perceptions and attitudes for each
of the questions of each factor; there are always
five options of answers with corresponding
points from 1 to 5. The arithmetic mean of the
points of each factor’s questions was calculated
to determine the factors, and the higher the
mean reached the greater the presence of the
factor was in the feeding attitudes and practices
of the parents.
Statistical Analysis
The data were processed in Stata software,
version 13.0. The level of significance was 5%.
The description of the general characteristics
of the sample was presented through the
distribution of simple, average frequencies,
and their respective standard deviations. In the
absence of normality of the continuous variables,
medians and their respective interquartile
intervals (IQ25-75) were used. The descriptions of
maternal perceptions and attitudes, measured
by the ECPDR and QAC scores, were performed
by presenting the medians (IQ25-75) of the total
score and each subscale that compose the
scores.
Box-type charts were presented to illustrate
the median distribution of ECPDR and QAC
subclass values (IQ25-75) as a function of the
child’s nutritional status. For the verification of
statistical differences between the scores of
each subclass, the Kruskal Wallis test and the
Mann-Whitney test were used.
The investigation to see if the general
scores of maternal attitudes and perceptions,
as well as their subscales, differed according to
characteristics of the child and the mother, was
performed by means of linear regression. Due
to the lack of normality of the QAC score, their
values were transformed into a square root unit,
since they offered better adjustment.
The association between maternal and
child nutritional status was evaluated through
Pearson’s Chi-Square test. The Spearman
correlation test was also used to investigate
the relationship between the maternal BMI
and the child’s BMI (in z-score units). The
correlation between the total ECPDR score
and the QAC was investigated, as well as the
Inuence of behavior and maternal perception on their children’s eating and nutritional status

184
RESULTS
116 pairs of mothers and children
participated in this study, the characteristics of
which are described in table 1.
A majority of the children were older than
8 years [8 ± 1.5 standard deviations (SD)], had
at least one sibling, ate meals in the presence
of the mother and were overweight, where the
BMI / Age average was 1.4 (1.6). Regarding
maternal characteristics, the majority were of
a social class equal or inferior to C1, were 30
years old or more, with median age = 38 years,
and interquartile range (IQ25-75) = 32-43 years,
had a partner and were overweight or obese,
where the median BMI was 28.4 kg/m2 (IQ25-
75 = 24.6-32.9 kg/m2). Half of them worked
and studied until high school.
The variables related to dietary attitudes are
presented in Tables 2 and 3.
The Cronbach’s Alpha in this sample for
QAC was 0.88 (ranging from 0.60 to 0.86), and
for ECPDR 0.66 (ranging from 0.28 to 0.86).
Observing the medians of the total ECPDR
score and its subscales, it was noted that the
highest medians were obtained for the domains:
daily availability of fruits and vegetables, limit
of treats and positive persuasion - all indicative
of positive maternal attitudes. The smallest
medians were found in the following domains:
treat types, use of rewards, and offering of many
food options - all related to negative attitudes.
The medians obtained in the QAC
subclasses indicated that the most present
factors in the mothers evaluated were the
perceived responsibility for the child’s diet, the
mother’s monitoring of healthy food intake, the
restriction of unhealthy foods, and the pressure
to eat. The least present factor was the mother’s
perception of the child’s weight.
Table1 – Descriptive characteristics of the study population. City of Sao Paulo, 2016.
Variables n (%)
Child Characteristics
Gender
Masculine 63 (54,3)
Feminine 53 (45,7)
Age group of the child
<8 years 45 (38,8)
8-10 years 71 (61,2)
Only Child?
Yes 32 (27,6)
No 84 (72,4)
Eats with mother?
Yes 89 (76,7)
No 27 (23,3)
Child’s Nutritional Status (BMIz)
Eutrophia 49 (42,3)
to be continued...
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correlation between each subclass of the QAC
with the ECPDR subclasses, using the Spearman
correlation test. The reliability of both scales
was assessed using Cronbach’s Alpha.
Inuence of behavior and maternal perception on their children’s eating and nutritional status

185
Overweight 23 (19,8)
Obesity 44 (37,9)
Maternal Characteristics
Socioeconomic Leve
A or B 28 (24,1)
C, D or E 88 (75,9)
Mother works?
Yes 59 (50,9)
No 57 (49,1)
Marital Status
With partner 94 (81,0)
Without partner 22 (19,0)
Maternal Education*
Elementary School 41(35,6)
High School 57 (49,6)
Higher Education 17 (14,8)
Maternal Age
<30 years 19 (16,4)
30|-40 years 49 (42,2)
≥40 years 48 (41,4)
Mother’s Nutritional State (BMI)
Underweight 2 (1,7)
Eutrophia 31 (26,7)
Overweight 39 (33,6)
Obese 44 (37,9)
BMI = Mother’s Body Mass Index
BMIz = Z-score of the child’s BMI
* The sample’s n for the maternal education variable was of 115 due to the failure by one volunteer to fill out the
question.
...continuation - Table 1
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Table 2 – Descriptive measures of the values obtained in the Scale of Parental Behavior During
Mealtimes (ECPDR) and their domains. City of Sao Paulo, 2016.
Variable Median IQ 25-75 Min-Max
ECPDR 68 64-71 49-79
1 – Availability of fruits and vegetables 2,7 2,3-3,0 1,3-3,0
2 – Model of treat consumption 1,7 1,7-2,0 1,0-2,7
to be continued...
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186
Table 3 – Descriptive measures of the values obtained in the Child Feeding Questionnaire (QAC) and
its factors. City of Sao Paulo, 2016.
Variable Median IQ 25-75 Min-Max
QAC 108 99-114 68-134
1 – Responsibility perceived by the mother
concerning the child’s diet
4,3 3,7-5,0 1,3-5,0
2 – Mother’s perception of her own body weight 3,3 3,0-3,5 2,0-4,3
3 – Mother’s perception of her child’s weight 2,5 2,0-2,7 1,5-4,2
4 – Mother’s concern with child’s weight 3,5 2,3-4,7 1,0-5,0
5 – Restriction of unhealthy food 3,8 3,1-4,3 1,1-5,0
6 – Pressure for child to eat 3,8 3,0-4,5 1,0-5,0
7 – Mother’s monitoring of child’s consumption of
unhealthy food
4,3 3,8-5,0 1,0-5,0
Answer options vary from 1 to 5; being that the greater the value is, the greater the evaluated attitude or
perception’s intensity is.
Scores on the QAC and ECPDR scales were
compared according to the nutritional status
of the children to assess whether the mothers’
perceptions and attitudes varied accordingly.
Figures 1 and 2 illustrate these variations.
Figure 1 illustrates the distribution of medians
and IQ25-75 of ECPDR subscales, according to the
child’s nutritional status. It was found that the
mothers of eutrophic children had significantly
higher median values for domains D3 “use of
rewards” and D9 “insistence on eating” when
compared to the mothers of obese children.
Figure 2 illustrates the distribution of the
medians and IQ25-75 of the QAC subscales
according to the child’s nutritional status.
Regarding factors related to maternal perception
(F1 to F4), it was observed that mothers of obese
children had a lower perceived responsiveness
to infant feeding (F1), greater perception of
their own body weight (F2), perception of the
child’s body weight (F3), and concern about
the child’s weight (F4) when compared to the
mothers of eutrophic children. We also verified
that mothers of overweight children had a
lower perception of the child’s body weight (F3)
compared to the mothers of obese children, and
a greater concern about the child’s weight (F4)
when compared to the mothers of eutrophic
children. In addition, the pressure to eat was
significantly higher among mothers of eutrophic
children than those of overweight children.
The variation in the QAC and ECPDR scores
according to the BMI Z-score of the children, as
well as the characteristics of the mothers, was
evaluated by linear regression. There was no
difference in relation to age groups, education,
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...continuation - Table 2
3 – Use of rewards 1,5 1,3-2,0 1,0-2,5
4 – Many food options 1,8 1,5-2,0 1,0-3,0
5 – Fat reduction 2,3 1,7-2,0 1,0-3,0
6 – Special meals 2,3 2,0-2,5 1,5-3,0
7 – Treat limits 3,0 2,3-3,0 1,0-3,0
8 – Positive persuasion 2,8 2,4-3,0 1,0-3,0
9 – Insistence on eating 2,0 1,7-2,7 1,0-3,0
Answer options: 1 (never), 2(sometimes), and 3 (always).
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187
marital status, work and socioeconomic status
of the mother (data not shown). It is noteworthy
that obese and overweight mothers presented a
significantly lower ECPDR score than eutrophic
mothers, in the order of B-2.58 (IC95% -5.06;
-0.10) units of ECPDR for obese mothers and
B-2.72 units of ECPDR for overweight mothers
(95% CI -5.28; -0.18).
Statistically significant differences were also
observed only for the child’s BMI, where each
unit of increase in the child’s BMI increased the
QAC score in B -0.08 units (95% CI 0.01; 0.15).
An inverse behavior was observed for ECPDR,
with a reduction of B-0.69 units (95% CI -1.30;
-0.07) in the score with each increase of one
unit of the child’s BMI.
There was a positive correlation between the
nutritional status of the mother and the child.
When categorically evaluated, the association
between the nutritional status of the mother
and the child was observed, that is, in obese
mothers, the frequency of obese children is
about twice as high (PR = 2.2) when compared
to the group of non-obese mothers (p <0.0001).
The Cronbach’s Alpha in this sample, for
QAC, was 0.88 (ranging from 0.60 to 0.86);
and for ECPDR, it was 0.66 (ranging from 0.28
to 0.86). There was a convergence between
total QAC and ECPDR scores (Spearman’s
rho 0.3802; p <0.0001). An exploration of the
correlation between the ECPDR domains and
the QAC factors was also performed - since the
scale scores are not unidirectional.
Table 4 presents the correlation coefficients
between the QAC and ECPDR subclasses,
as well as explores the correlation of these
subclasses with the mother’s BMI and the child’s
BMI (z score).
Figure 1 – Box Plot of subscales (domains) of the Parental Behavior During Mealtimes Scale (ECPDR),
according to the child’s nutritional status. City of Sao Paulo, 2016.
D1 = Availability of Fruits and Vegetables (FV); D2 = model of treat consumption; D3 = use of rewards;
D4 = many food options; D5 = fat reduction; D6 = special meals; D7 = treat limits; D9 = insistence on
eating. The response options vary from 1 (never), 2 (sometimes) and 3 (always), therefore, the higher the
score of the response options, the greater the presence of the evaluated domain. Statistically significant
differences (p <0.05) were found for: D3 (Eutrophia X Obesity) and D9 (Eutrophia X Obesity).
O Mundo da Saúde, São Paulo - 2017;41(2):180-193
Eutrophia Overweight Obesity
Answer options
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188
Figure 2 – Box Plot of subscales (factors) of the Child Feeding Questionnaire (QAC), according to the
child’s nutritional status. City of Sao Paulo, 2016.
F1 = responsibility perceived by the mother regarding the child’s diet; F2 = mother’s perception of her
own body weight; F3 = mother’s perception of the child’s weight; F4 = mother’s concern about the
child’s weight; F5 = restriction of unhealthy foods; F6 = pressure for the child to eat; F7 = Mother’s
monitoring of child’s consumption of unhealthy. Response options range from 1 to 5, the higher the
score of the response options, the greater the presence of the factor. Statistically significant differences
(p <0.05) were found for: F1 (Eutrophia X Obesity); F2 (Eutrophia X Obesity); F3 (Eutrophia X Obesity
and Overweight X Obesity); F4 (Eutrophia X Overweight and Eutrophia X Obesity); F6 (Eutrophia X
Overweight and Eutrophia X Obesity).
The data show that between the subclasses
of QAC and ECPDR there are positive
correlations between “perceived responsibility
by the mother” (F1) with “availability of fruits
and vegetables” (D1), “treat limits” (D7) and
“positive persuasion” (D8); between “concern
about the child’s weight” (F4) and “fat
reduction” (D5); between “food restriction”
(F5) and “use of rewards” (D3), “many food
options” (D4), “limit for goodies” (D7) and
“positive persuasion” (D8); between “pressure
to eat” (F6) and “use of rewards” (D3), “positive
persuasion” (D8) and “insistence on eating”
(D9); and between “monitoring” (F7) and “FV
availability” (D1), “fat reduction” (D5), “treat
limits” (D7), “positive persuasion” (D8), and
“insistence on eating” (D9).
Negative correlations were observed between
“responsibility perceived by the mother” (F1)
and “the model of treat consumption” (D2);
between “perception of child’s weight” (F3)
and “use of rewards” (D3) and “insistence on
eating” (D9); and between “monitoring” (F7)
and “model of treat consumption” (D2). In
general, the correlations observed among the
subclasses of the scores were weak (r <0.4),
with the exception of “pressure to eat” (F6) with
“insistence on eating” (D9); “Monitoring” (F7)
with “FV availability” (D1); “Monitoring” (F7)
with “fat reduction” (D5) and “monitoring” (F7)
with “treat limits “ (D7) (r≥0,4).
The mother’s BMI was positively correlated
with the “perception of her own body weight”
(F2) and negatively correlated with “use of
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Eutrophia Overweight Obesity
Answer options
Inuence of behavior and maternal perception on their children’s eating and nutritional status

189
rewards” (D3). The BMI of the child had a
positive and weak correlation with “perception
of her own body weight” (F2), a moderate
correlation with “perception of child’s weight”
(F3) and “concern about child’s weight” (F4),
and a negative and weak correlation with
“perceived responsibility of the mother” (F1),
“pressure to eat” (F6) and “monitoring” (F7). In
the analysis of ECPDR subscales with the child’s
BMI, all significant correlations identified with
“FV availability” (D1), “rewards use” (D3), “treat
limits” (D7) and “insistence on eating” (D9)
were negative and weak (r <0.4).
Maternal BMI was significantly correlated
with the child’s BMI, with moderate strength (r
= 0.44). The association between the presence
of maternal obesity and obesity of the child was
also explored, finding a positive association (p
= 0.000), with a childhood obesity frequency
of 25% among non-obese mothers and 58%
among obese mothers (data not presented in
Tables).
The rate of prevalence of childhood obesity
with obese mothers is twice as high as that
among non-obese mothers (RP = 2.2; IC95%:
1.2-4.0).
ECPDR F1 F2 F3 F4 F5 F6 F7 Mother’s
BMI
Child’s
BMI
D1 0,26* -0,03 -0,03 -0,07 0,05 0,01 0,40* -0,08 -0,20*
D2 -0,22* 0,09 0,08 0,06 -0,04 0,05 -0,21* 0,14 0,13
D3 -0,04 -0,08 -0,33* -0,11 0,38* 0,30* 0,03 -0,29* -0,35*
D4 -0,15 -0,02 0,12 0,07 0,18* 0,00 -0,08 -0,02 0,04
D5 0,07 -0,01 -0,01 0,25* 0,16 -0,02 0,44* 0,05 0,16
D6 -0,10 -0,04 -0,13 -0,09 -0,12 -0,14 -0,02 -0,09 -0,09
D7 0,32* -0,12 -0,05 0,10 0,22* 0,03 0,54* -0,10 -0,19*
D8 0,22* 0,02 -0,07 0,08 0,30* 0,27* 0,28* 0,05 0,02
D9 0,12 0,003 -0,20* -0,09 0,15 0,51* 0,20* -0,15 -0,22*
Mother’s
BMI
-0,002 0,54* 0,18 0,11 -0,02 -0,11 -0,02 --- --
Child’s
BMI
-0,24* 0,25* 0,40* 0,55* 0,07 -0,28* -0,07 0,44* --
*p<0,05
F1 = responsibility perceived by the mother regarding the child’s diet; F2 = mother’s perception of her own
body weight; F3 = mother’s perception of the child’s weight; F4 = mother’s concern about the child’s weight;
F5 = restriction of unhealthy foods; F6 = pressure for the child to eat; F7 = mother’s monitoring of the child’s
consumption of unhealthy foods. D1 = availability of FV; D2 = model of treat consumption; D3 = use of rewards;
D4 = many food options; D5 = fat reduction; D6 = special meals; D7 = treat limits; D9 = insistence on eating.
Table 4 – Correlation between all the domains (D1 to D9) of the Parental Behavior during Mealtimes
Scale (ECPDR) and the Child Feeding Questionnaire (QAC) factors (F1 to F7) and Body Mass Index
(BMI) of mother and child. City of Sao Paulo, 2016.
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190
DISCUSSION
This study evaluated 116 pairs of mothers
and their children to investigate the mother’s
behavior during meals and her perception
about the child’s diet. Validated questionnaires
were used for this evaluation, and although they
have been used previously in national studies,
this is the first time that the two - ECPDR and
QAC - are used together.
In the sample studied, it was identified that
most of the mothers were of a lower class,
middle aged (over 30 years), and half worked
and had a partner. Such a profile is compatible
with the population of UBS users, the place
where they were invited to participate in the
study. A very expressive number of overweight
and obese mothers (more than 70%) were
observed, showing a value above that found in
the last Family Budget Survey (FBS) 2008-20092
for the Brazilian female population that is 48%
overweight and 16.9 % obese. Therefore, the
frequency of obesity in the present study was
more than doubled (37.9%).
The majority of mothers were of a C, D, or E
socioeconomic class, and this may be related to
the nutritional profile presented when the study
points to an increase in excess weight among
the less favored classes.19
When analyzing the results found for
the ECPDR - which evaluates the behavioral
dimensions used by the parents at mealtime
- the data showed that the most frequent
attitudes were the “availability of fruits and
vegetables” (FV), the “treat limits” and “positive
persuasion”; which are behaviors that can be
considered positive.
Petty et al.16 observed that parents who
provided FV to their children and consumed
FV rarely prepared differentiated meals for their
children. This same study found that 70% of the
children had meals with at least one parent or
caregiver. This presence may imply motivation
and reward through positive attitudes such as
verbal praise - which may be associated with
increased intake of FV and less use of soft drinks
and treats.
In the present study, the majority of the
mothers answered that the children eat the
meals next to them, showing a positive aspect,
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provided that maternal attitudes are adequate.
The less frequent attitudes pointed out by the
mothers were: “model of treat consumption”,
“use of rewards”, and “many food options”
- which are all negative. Benton20 noted that
using food as a reward for the ingestion of
other foods is common practice in families,
but such a strategy actually leads to a decrease
in preference for the target food. Thus, these
mothers seem to somehow “know” that the use
of reward is not appropriate; or just do not do
it anyway.
When analyzing the domains of ECPDR
according to the nutritional status of the child,
it was found that the “use of rewards” and
the “insistence on eating” were higher for the
mothers of eutrophic children, compared to
the mothers of obese children. This finding
evidences the influence of maternal attitudes
on the nutritional status of their children. It is
hypothesized that, because they are overweight,
mothers do not use rewards as strategies to
increase food consumption, since there is no
need. In addition, it was found that the mothers
of children with higher BMI values, even though
they showed greater concern about their
children’s weight, also showed less monitoring
of meals, less control with the ingestion of
sweets, less availability of fruits and vegetables,
and less responsibility perceived with feeding
of their children in relation to eutrophic
children; contributing to the maintenance and
/ or worsening of nutritional status. That is, it is
presumed that it is not clear to these mothers the
need to follow, control and even modify their
children’s meals, even if they are overweight.
These findings reflect the importance of
awareness through nutritional education so that
concern about the child’s weight may actually
lead to changes in the family’s eating behavior.
According to the results obtained in the
QAC, the most frequent responses were:
“perceived responsibility” for feeding the child,
and “monitoring” the consumption of unhealthy
foods, followed by “restriction” of unhealthy
foods and “pressure to eat”. The less present
factors were the “mother’s perception of the
child’s weight,” “the mother’s perception of
her own body weight,” and “mother’s concern
about her child’s weight.”
Miranda da Cruz18 also identified the
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191
O Mundo da Saúde, São Paulo - 2017;41(2):180-193
“perception of responsibility” regarding the
child’s diet as the most frequent factor, and
among the less frequent factors, “concern
about child’s weight”, “pressure to eat” and
“monitoring” the consumption of non-healthy
food. In turn, Lorenzato21 pointed out the
“perception of responsibility”, “concern about
child’s weight”, “restriction”, and “monitoring”
as the most frequent factors; and the “mother’s
perception of the child’s weight,” and the
“mother’s perception of her own body weight”
as the less frequent factors.
The QAC was analyzed according to the
child’s nutritional status. It was found that the
“perceived responsibility to child’s feeding” was
higher in mothers of eutrophic children. On the
other hand, “perception of her own weight”
was higher in mothers of obese children, and
the “perception and concern about the child’s
weight” was higher in mothers of overweight
and obese children.
Lorenzato21, corroborating the results of
our research, found a positive correlation
between the BMI variables of the children and
the perception and concern of the children’s
weight. However, in the same study the
perceived responsibility also correlated with the
child’s BMI, in contrast to our finding.
When it comes to body perception, it is
known that parents often do not properly
perceive that their children are overweight.
Camargo22 found in five of eight articles studied
in his review that there is no proper perception
of parents regarding the overweight and obesity
of their children. Boa-Sorte (2007)23 also stated
that the inadequate perception of children’s
weight is more frequent in cases where they are
obese. Diverging from the latter author, in the
present study, the perception was higher for the
mothers of obese children - who also said they
were more concerned about their children’s
weight. The question is whether this perception
and concern are reflected in better attitudes
and behaviors.
It was verified that mothers of eutrophic
children reported greater perception of their
body weight, as well as the correlation between
BMI of mothers and children. Miranda da Cruz18
did not identify a positive correlation between
the BMIs of the children and their mothers, a
fact that may be due to a significantly different
sample, that is, families of high income social
classes (A or B) and a higher level of education
- differently of our research. Other studies,
however, point to a correlation between the
nutritional status of the children and their
parents.24, 25
The correlation analysis of ECPDR domains
and QAC factors with the BMI of the mothers
and their children showed that the higher the
BMI of the mother, the greater the “perception
of her own weight” and the smaller the use of
“rewards”. This suggests that, because of their
own nutritional status and body perception,
these overweight mothers may be more
concerned about their children’s weight gain as
well, thus, avoiding the use of rewards during
meals; since this feature is usually considered
a strategy in an attempt to increase general
consumption or increase consumption of a
particular food type.
In addition, there was a positive correlation
between the child’s BMI and the mother’s
perception of her own body weight, and
perception and concern about the child’s
weight. In contrast, the child’s BMI correlated
negatively with the pressure to eat, perceived
responsibility by the mother, monitoring,
availability of FV, use of rewards, treat limits, and
insistence on eating. These findings reinforce
the influence of maternal attitudes, such as less
monitoring, treat limits, and availability of fruits
and vegetables in the diagnosis of the nutritional
status of the child, reflected weight gain and the
development of obesity.
According to the literature, the lack of or
lesser maternal perception of the responsibility
of feeding their children may imply a
commitment to monitoring meals, inadequate
dietary practices, which may lead to worsening
of the nutritional status of overweight children
and adolescents, as well as impair the treatment
of these ones.22
As a limitation of the study, we can refer to
the unsuccessful intake and feeding frequency
of the mother-child binomial to estimate the
dietary intake and quality of the diet. However,
this was the first work that jointly applied QAC
and ECPDR, a convergence analysis between
these scales, is of great interest. In the case of
total scores, there was a weak correlation; and
in the subscales, it could be observed that the
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192
CONCLUSION
Overweightness and obesity were prevalent
in the study population. Overweight mothers
also had overweight children. These showed
concern about the nutritional status of the
child, but the concern detected was not enough
for these mothers to monitor their children’s
nutrition and to motivate food changes, such
as controlling the consumption of treats and
increasing the consumption of their children’s
fruits and vegetables. In addition, it was verified
that the perception of responsibility for feeding
the child was higher among mothers of eutrophic
children than among obese mothers. These
findings indicate the maternal influence on their
children’s diet - which could be reflected in the
nutritional state of the mothers themselves. In
this way, the importance of nutritional education
for the promotion of healthy habits and,
consequently, for the prevention and treatment
of obesity in childhood is emphasized.
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Recebido em maio de 2016.
Aprovado em junho de 2017.
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Inuence of behavior and maternal perception on their children’s eating and nutritional status