Yonago Acta medica 1997;40:137–145

Mothers’ Body Perception Biased to Obesity and its Effects on Nursing
Behaviors
Noriko Yakura, Tsunakiyo Kasagi and Kaori Hiroe*
Department of Nursing, Tottori University, Institute of Medical Care Technology and*Division of Nursing, University Hospital, Tottori University, Yonago 683, Japan
Many women who have dieted in adolescence seem to become mothers without correcting
their obesity-biased perceptions of the body. This study estimated the number of suchmothers and analyzed the problems in their nursing: 1496 mothers to 790 babies aged
4 months and 706 children aged 18 months completed questionnaires addressing
mothers’ images of their own and their children’s body, mothers’ behaviors to reducechildren’s weight, their behavior patterns and mothers’ experiences to reduce theirown weight. The level of obesity was calculated with the body mass index (BMI) (weightin kilograms divided by height in meters squared) from the measurements of children’s andmothers’ body weight and height. Body image was distorted most in mothers for themselves, and then for babies and children: 23.2% and 58.2% of nonobese babies (BMI:
18 and 19, respectively) and 23.2% of nonobese children (BMI: 17) were regarded asobese. Mothers’ objective evaluation by referring to the percentile values was less frequent than expected, and subjective evaluation such as “compared with other children”
was noted. Weight reducing was practiced in 7.7% of nonobese babies and 17.2% of nonobese
children. The high percentage level was due to mothers’ body shape evaluation biased
to obesity and worry about children’s possible future obesity. In 10.5% of the babies
and 11.8% of the children, the mothers took extreme dieting measures that could inhibit
normal growth of children, such as diluting the concentration of breast milk or formula,
reducing the frequency and amount of feeding, etc. Health participants should makeyoung mothers understand the difference of fatness in nursing babies from adolescentobesity through health guidance given individually to mothers on any occasion.
Furthermore, considering the effects of mass media, health participants should actively
offer related information in printed matter familiar to mothers.
Key words: body shape evaluation; weight-reducing behavior; mothers; nursing babies; wish to bethinner

It is likely for young girls between preadolescent and adolescent periods to have self-imagesof body shape biased to obesity, which sometimes cause dieting behaviors as we observed in
our previous studies (Ishitobi et al., 1991;
Yakura et al., 1991, 1993). The distorted selfimage of body shape drives many girls to want
to be thinner and to excessive dieting practices,and not a few girls execute extreme measures(Ishitobi et al., 1991; Yakura et al., 1991, 1993).
Because we have estimated that there are girls
Abbreviation: BMI, body mass index

who become mothers without correcting biased
body images, the present study aimed to clarify
how many mothers hold the biased perception,and how they nurse their babies.

Subjects and Methods
Municipal physical checkups are set up in Japan
to examine and support growth and development of baby children. Between April 1993 andMarch 1994, Yonago City in Tottori Prefecture137

N. Yakura et al.

Table 1. Contents of the questionnaire on
body shape addressed for mother subjects
who nurse babies
FOR CHILDREN
1) Age:months old
Sex: (male or female)
Birth order: (1st or later)
2) Do you think your child is(fat, normal or thin)?
3) Which reason(s) helped you judge your childas in 2)?
a) Indicated by medical or nursing specialistsb) Indicated by family members or friendsc) Judged from the percentile values printed in
the official maternity passbookd) Judged from the standard body weight in agematched childrene) Compared with other childrenf) Vaguely inclined to judge sog) Other4) Are you worry about whether your child will
be overweight in the future?
(yes or no)5) Have you ever inhibited your child’s appetite,even if the child had a good appetite?
(frequently, sometimes or hardly)
6) Which of the following, if any, have you carried out in order to control your child’s weight?
a) Reduced the amount of breast milk or formulab) Reduced the frequency of feeding breast milkor formulac) Diluted the density of breast milk or formulad) Gave no snackse) Changed the snack menuf) Reduced the amount and frequency of baby
foodg) Changed the baby’s food menuh) Exercised the child
FOR MOTHERS
7) Have you have dieted?
(yes or no)8) Do you regard your own body as(fat, normal or thin)?
9) Weight:
Height:kg
cm

carried out physical checkups for 706 babies
aged 4 months and 790 children aged 18
months. In total, the subjects involved werethese children and their mothers reaching 1496.
We mailed questionnaires to mothers whosechildren were scheduled to receive the physicalcheckups during fiscal 1993. The completed
questionnares were collected on the days of thecheckup. The collection rate was 85.3% for thebabies and 82.3% for the children.
The questionnaire (Table 1) contained
mothers’ images of their children’s body shape,
mothers’ behaviors to reduce children’s weight
when they regard their children as obese, contents of mothers’ behaviors, mothers’ bodyweight and height, mothers’ self-image of body
shape, and mothers’ experiences in reducing
their own weight. Children’s body weight andheight were measured during the physicalcheckup.
The level of obesity for the mothers andchildren was determined by body mass index(BMI) (weight/height2 expressed in kg and m)(W/H2): the babies, children and mothers were
determined to be obese when the BMI was 20
and over, 18 and over and 25 and over, respectively (Kamioka and Imamura, 1992; Ministryof Health and Welfare, 1994).
The data were analyzed with Student’s t-test
and chi-squared test at 5% level of significance.

Results

Mothers’ body shape evaluation

BMI distribution classified by body shapeevaluation
The mothers were requested to assess theirown and their children’s bodies as fat, normal
or thin. The assessed subjects were classified
into 9 groups of mothers, babies and children byfat, normal or thin body images. Table 2 shows
comparison of BMI values (mean ± SD) among
the 9 groups: the BMI of mothers, babies andchildren was highest in the fat-image groups,
respectively, followed by normal-image groups
and thin-image groups. As seen in the table, themean BMI was significantly correlated with138

Mothers’ body image and effects on nursing

Table 2. BMI values in groups classified by body shape evaluation by mothers
BMI value
Normal-image subject

Fat-image subject

Thin-image subject

Mother [1390]

23.4 ± 2.5 [478]←**→ 20.1 ± 1.3 [767] ←**→ 17.9 ± 1.0 [145]Baby†[ 699]

19.0 ± 1.3 [199]**←**→ 17.3 ± 1.3 [459] ←**→ 16.2 ± 1.2 [ 41]Child‡[ 780]

17.2 ± 1.2 [ 91]**←**→ 16.0 ± 1.0 [567] ←**→ 15.1 ± 1.2 [122]**Mean ± SD.
[ ], number of subjects.
† 4 months old; ‡18 months old.
** P < 0.01

mother’s body shape evaluation. However, ineach fat-image group of mothers, babies andchildren, the mean BMI was lower than thestandard body weight, respectively (Table 2).

(%)

(%)

20

30

Mothers with fat
image [478]Babies with and withoutmother’s fat image

Mothers with and without fat image

Fat body image
The subjects were classified by the BMI
distribution, and further divided by mothers’
evaluation of self-perceived obesity, respectively (Figs. 1–3). Mothers regarded themselves as fat from a BMI of 17 (Fig. 1): whenthe BMI was 22 and over, the rate of mothers
who regarded themselves as fat suddenly increased: 28.6% of nonobese mothers with a
BMI of 24 or less regarded themselves as obese.

The babies (Fig. 2) were regarded as obese froma BMI of 16, and the rate of fat-image babies
was as high as 58.2% when the babies’ BMI
was 19: 21.8% of nonobese babies, whose BMI
was 19 or less, were regarded as fat. Concerning the children (Fig. 3), fat image was heldfrom a BMI level of 15. At a BMI of 17, 23.2%of the children were regarded as obese. As awhole, 8.4% of nonobese children with a BMI of
17 or less were judged to be fat. The mothers’
body shape evalution was biased toward fatness
mostly for themselves, then for the babies and forthe children, with significant differences (P <0.0001) between the mother group and either ofthe baby or child groups.

15

Mothers without
fat image [912]
10

5

0
15

17

19

21

23

25

27

25

Babies with fat
image [199]20

Babies without fat
image [500]

15

10

5

0

29 (kg/m2)

13

BMI
Fig. 1. BMI distribution in mothers classified bytheir body image as obese or not: BMI ≥ 25 isdetermined to be obese. [ ], number of subjects.

15

17

19

21

2
23 (kg/m )BMI
Fig. 2. BMI distribution in 4-month-old babies
classified by mothers’ body image as obese or not:
BMI ≥ 20 is determined to be obese. [ ], number ofsubjects.

139

N. Yakura et al.

The rate of fat-image subjects evaluated by
the mothers was compared by the order of birthfor nonobese children. There was no differencein the babies; however, in the children, 10.0%of the first children were regarded as obese, as
well as 6.9% of the second or later children: therate was significantly higher for the firstchildren (P < 0.05).

Criteria for body shape evaluation
Mothers were requested in the questionnaire
to mark any of the following 7 criteria forthinking their children obese (Table 3), and themarked items were compared between groupsof the babies and children: i) indicated by
medical or nursing specia1ists, ii) indicated by(%)

Children with and withoutmother’s fat image

40

Children with fat
image [91]Children without
fat image [689]

30

20

10

0
11

13

15

17

19

21

23 (kg/m2)

BMI
Fig. 3. BMI distribution in 18-month-old childrenclassified by mothers’ body image as obese or not:
BMI ≥ 18 is determined to be obese. [ ], number ofsubjects.

family members or friends, iii) judged from thepercentile values printed in the official maternity passbook, iv) judged from the standard
body weight in age-matched children, v) compared with other children, vi) vaguely inclined
to judge so and vii) other reason(s). The babies
were judged overweight most frequently by thepercentile values (39.7%), followed by thestandard weight (25.2%) and comparison withother children (22.0%). The children were mostfrequently judged overweight by comparison
with other babies (37.3%), followed by thepercentile value (33.6%) and by vague inclination to judge so (19.6%).

Mothers’ behaviors to reduce children’s
weightWeight-reducing practice rate classified by
the BMIAmong the 698 babies, mothers practiced
weight-reducing for those with a BMI from 15
to 21, and the number of dieting babies was 62(8.8%). Dieting was practiced most frequently
at a BMI of 19 (16.4%), but differences in BMIs
were not significant. As a whole, 54 of 620
nonobese babies (8.7%) with a BMI of 19 orless were involved in weight-reducing behavior
by their mothers (Fig. 4).
Among the 781 children, dieting waspracticed throughout all levels of the BMI, andthe number totaled up to 158 with a mean
practice rate of 20.2%. The practice rate
showed a tendency to put children on a diet as a
BMI increased, but there were no significant

Table 3. Criteria for mothers’ deciding their children overweight
Criteria

Children aged
4 months
18 months
[686]
[759]

Indicated by medical or nuring specialists
Indicated by family members or friends
Judged from the percentile values printed in the official maternity passbook
Judged from the standard body weight in age-matchd children
Compared with other children
Vaguely inclined to judge so
Others
*P < 0.05, **P < 0.01: 4-month-old babies versus 18-month-old children.

140

13.7**
18.7*
39.7*
25.2*
22.0
16.6
1.6

7.0
14.1
33.6
20.7
37.3**
19.6
1.4

Mothers’ body image and effects on nursing

(%)

(%)
40

Nondiet babies[636]

Diet and nondiet children

Diet and nondiet babies

30

Diet babies [62]2010Nondiet children[623]
Diet children [158]

30

20

10

0

0
14

15

16

17

18

19

20

21

(kg/m2)

22

13

14

15

16

17

18

19

20

(kg/m2)

BMI

BMI

Fig. 4. BMI distribution and 4-month-old babies
treated and not treated with weight-reducing
behaviors by mothers. [ ], number of subjects.

Fig. 5. BMI distribution and 18-month-old children
treated and not treated with weight-reduced
behaviors by mothers. [ ], number of subjects.

differences in BMI distribution. As seen in Fig.
5, weight-reducing behavior was practiced in
134 of the 713 nonobese children (18.8%) witha BMI of 17 or less.

Weight-reducing practice rate with andwithout mothers’ experience of dieting
In nonobese children, the practice rate ofweight reducing was compared to mothers’
experiences of dieting: 11.5% (24/209) in 4month-old babies whose mothers had dieted;
7.4% (30/407) in 4-month-old babies whose
mothers had not dieted; 21.8% (53/243) in 18month-old children whose mothers had dieted;and 17.3% (80/463) in 18-month-old children
whose mothers had not dieted. Both in thebabies and children, the practice rate was higher
for those whose mothers had dieted, but without
significant differences.

Weight-reducing practice rate classified bybody shape evaluation
The practice rate of weight reducing wasanalyzed in nonobese subjects classified bymothers’ body image into fat, normal or thin. In
each of the mother, baby and child groups, thepractice rate was highest in fat-image subjects,
followed by normal-image subjects and by thinimage subjects (Fig. 6).
12.6%

Nonobesemothers

28.7%
48.5%

8.6%
19.6%

Nonobesechildren

36.7%

2.4%

NonobesebabiesThin image

5.9%

Normal image
19.1%

0

10

20

Fat image30

4050 (%)

Weight-reducing practice rate

Fig. 6. The practice rate of weight reducing in nonobese mothers, babies and children classified by body
image held by mothers.

141

Weight-reducing practice rate

N. Yakura et al.

(%)

respectively. The rate was significantly higher
in the worried groups, respectively (Fig. 7).
In addition, we analyzed relations between
the weight-reducing practice rate and sexual
differences or birth order of children, butobserved no significant differences.

P < 0.001

40
32.6%

WorriedNonworried30

P < 0.005
20

10

17.0%

17.0%

Means to prevent children’s obesity
The mothers were requested to mark in thequestionnaire any of 8 items they carried out for
preventing future obesity in their children(Table 1). In analyzing the data of nonobese
children, mothers were most frequently careful
for their children to have active exercise of the
body (22.7% of the babies and 38.6% of thechildren). Other behaviors noticed in several
percentages each were reducing the amount ofbreast milk or formula, reducing the frequencyof breast milk or formula feeding, and diluting
the density of breast milk or formula. Noted
behaviors other than exercise were, in decreasingorder, changing the menu of snacks (32.7%),
changing the menu of baby food (18.9%), giving no snacks (8.3%) and reducing the amountand frequency of baby food (0.6%) (Fig. 8).
The mothers taking such extreme dieting measures as reducing the amount and frequency ofbaby food, giving no snacks, diluting formula,
reducing the frequency of breast milk or formu-

7.4%

0

4-month-oldbabies18-month-old
childrenChildren with and without mother’sworry about future obesity

Fig. 7. Comparison of the weight-reducing practicerate in nonobese children whose mothers worried
about children’s future overweight and not.

Weight-reducing practice rate with and without mothers’ concern about children’s futureobesity
We compared the weight-reducing practicerate between nonobese children whose mothers
worried about their children’s possible futureobesity and those who did not worry. The
practice rate in worried and nonworried groups
was 17.0% and 7.4% for the babies, respectively, and (28) 32.6% and 17.0% for the children,

18.9%

Menu of baby food changed

0%
0.6%
0%

Amount and frequency of baby food reduced

32.7%

Menu of snacks changed

0%
8.3%

No snacks given

0%
38.6%

Active exercise of the body given

22.7%
5.2%
5.7%

Density of breast milk or formula diluted
Frequency of breast milk or formula feeding reduced

2.1%
2.8%

Amount of breast milk or formula reduced

3.4%
3.5%

18-month-old children [781]4-month-old babies [698]

0

10

20

30

40

(%)

Pattern and ratio of weight-reducing behaviors
Fig. 8. The pattern and ratio of weight-reducing behaviors practiced by mothers compared between nonobese
children aged 4 and 18 months. [ ], number of subjects.

142Mothers’ body image and effects on nursing

la feeding reached l0.5% for the babies and11.8% for the children.

Discussion

Body shape evaluation
A considerable number of mothers have a
distorted self-image that their body is fat. The
level of impact of being obese is not so severe
as in adolescent girls, but about 25% of nonobese mothers seem to hold the obesity-biased
body image, as reported by us (Ishitobi et al.,
1991; Yakura et al., 1991, 1993) and others(Aoyama, 1978; Matsuura et al., 1988; Tanaka
et al., 1988; Furukawa et al., 1993). The
obesity-biased body image is held not only by
young girls, but by females covering a wide
range of age (Nakai et al., 1983; Furukawa,1993). What lies in the background of a prevalence of such distorted perceptions? Ladies’
fashion journals are clear evidence that being
thin is a requirement for beauty accepted today.
Based on the recognition that obesity is a factor
related to adult disease, people have widely
favored dieting or jogging for health. Definitely, there are dominant social cultures which
praise a slender body shape and in which ahuman coping pattern toward that direction isalready formed.
Once when the “fat-cells theory” was advocated for fear of obesity during infancy, baby
obesity was regarded as a disorder to be inhibited, and even health guidance for children’s
fatness was widely given. Even toy dolls thathave acquired long-maintaining wide popularity among babies and young girls have slenderbody shapes. There is also the fact that there isincreasing social pressure on women to be thin.
Such a social background is related to abiased evaluation of body shape by mothers of
their children, as observed in the present study.
To our knowledge, this is the first report on
mothers’ perception of the body biased to obesity and its effects on nursing behavior, and norelevant reports are available from literature.
However, we expected the presence of suchmothers from the results of the series of ourprevious studies: the observed ratio of suchmothers was 22.0% for 4-month-old babies and8.4% for 18-month-old children. Comparisonof these data clearly show that maternal tendency toward the biased perception was moremarked in mothers of 4-month-old babies.
These mothers have little knowledge that theirbaby has a physiologically normal body shapeat this stage of development, when body weightgain is large and rapid. It is noteworthy that themothers showed a strong tendency to regard thebabies’ normal shape as obese.
By the way, it is reasonable to presume thatmothers’ experience of nursing affects the appropriate evaluation of the baby’s body shape. The
present results show, however, that mothers’
nursing experience was reflected in body shapeevaluation only for 18-month-old children but
not for 4-month-old babies. As noted above,
weight gain is quite remarkable during thisstage of growth. So, it is likely that mothers
have a false impression.
As for our questionnaire addressing thecriteria for body evaluation of children, manymothers marked reasons without any scientificbasis such as “compared with other children”
and “vaguely inclined to judge so.” Besides,
some mothers showed a tendency not to refer tothe percentile values written in the official
maternity passbook. These facts suggest that
health participants should give more guidanceon good occasions for mothers to heighten theirrecognition of the percentile values.
Pressure on adult women to drive themselves
to be slender is never irrelevant to children’s
growth. This fact also indicates that the pressure could be a disturbance also for children inhaving correct body images of themselves.

Weight-reducing behaviors
We analyzed the relation between the practicerate of weight reducing and mothers’ body
shape evaluation, and observed that the rate wasdecreased in the order of fat-image, normalimage and thin-image subjects in each of themother, child and baby groups, respectively.
However, the relation between the practice rate
and body image in the babies was reversed with143

N. Yakura et al.

that in the children. That is, the practice rate
was considerably lower in the babies whose
mothers were more inclined to have fat images,
while the practice rate was considerably higher
in the children whose mothers were less inclined to have fat images. This reverse phenomenon may be attributed to our method of data collection, in which mothers’ preventive behaviors
such as “gave active exercise of the body” or“changed the menu of snacks or baby food”
were counted as a pattern of dieting behaviors.
We should pay attention to the existence ofmothers who practice extreme dieting measuresfor nursing babies, as mentioned above. In thepresent study, we found a group of mothers who
greatly worried about their children’s futureobesity, and the worry seems to be hidden in the
background of their behaviors. Today, young
mothers generally live in two-generation families and are under nursing environments separated from experienced helpers to nurse babies.
We think that their hidden fear of children’s
obesity may drive them to act so. In 1990, theMinistry of Health and Welfare, Japan, published tabulated data on physical growth in nursing
babies, but the mean body weight among thedata was lower than that published in l980. Thisbody weight decrease seems to be relevant to
the problems discussed in the present article.
It is well known that obesity is a factor significantly related to chronic disease, and what isrequired for good health is to achieve andmaintain a healthy body weight throughout thelife-cycle. We have no objection to preparing
from infancy against future obesity; however,
we should also inform mothers of the fact that
dieting measures injurious to health are often
practiced, irrespective of children’s will or trueneeds.
It is desirable that on the occasion of babies’
physical checkups at health centers, healthparticipants should make young mothers understand that fatness in nursing babies differs fromadolescent obesity (Imamura, 1987). Furthermore, detailed health guidance should be given
individually to mothers on such occasions, so as
to make them assess children’s shape properly.
In addition, because these problems have been
deeply related to the attitude of mass media(Nishizono, 1989; Baba, 1990; Furukawa,1993), health participants should actively offer
related information not only to medical journals, but also to lady’s home journals or everyday TV programs young mothers like to watch.
In the present study, we observed that not a few
mothers recognized normally growing healthy
round bodies of their children as obese. Suchmothers felt some misgivings about future overweight of their children, and in excessive cases,
mothers practiced weight reducing for theirchildren. What was hidden in the backgroundof their behaviors was difficult personal experiences, a flood of one-sided information fromthe mass media, or isolated nursing environments separated from experienced helpers. We
infant health professionals should not emphasize any aspect of a phenomenon in treating
health problems of infants more than obesity.
Acknowledgments: The authors would like to express their profound gratitude to Prof. K. Ohno,
Dept. of Neurobiology, School of Life Sciences, andProf. K. Takeshita, Div. of Child Neurology, Inst. of
Neurological Sciences, Faculty of Medicine, Tottori
University, for their guidance, reading and criticism
of this study.
Parts of this article were presented at the 41st
and 42nd Meetings of the Japan Pediatric Health
Association held in Mito, 1994 and Nagasaki, 1995,
respectively.
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(Received August 18, Accepted September 24, 1997)

145