Warschburger and Kröller BMC Public Health 2012, 12:295 http://www.biomedcentral.com/1471-2458/12/295 weight status, or only at a higher weight status. Within this context we further investigated parental risk perception as well as their dissatisfaction with their child’s weight. Half of mothers correctly identified the overweight sil- houettes as well as related health risks, but 16 - 20% of mothers only identified overweight and its associated health risks with silhouettes corresponding to BMIs in the 97th percentile. These results are in agreement with other studies’ reports of low parental risk perceptions of children’s weight status [e.g. 6, 11]. The associated phys- ical and mental health problems were correctly classified more often by mothers with higher educational attain- ment and already-overweight children. Maternal educa- tion as a factor influencing the ability to recognize overweight-related health problems was previously shown in our own [12] and other studies [summarized in 11]. The child’s overweight status has so far only been examined as a factor increasing maternal tendencies to misclassify overweight in her own child [9,10], but there were no associations in this study between the child’s weight and maternal misclassification of unrelated sil- houettes [12]. Therefore, for mothers of overweight chil- dren it may be easier to apply knowledge about the obesity-related health risks to unrelated children rather than their own. Further studies that focus on this ques- tion are needed. Concerning maternal dissatisfaction with her own child’s silhouette, our results are in line with the work of Laraway and colleagues [21]. More mothers preferred a slightly thicker than a thinner silhouette for their child, and the desire for a thinner silhouette increased with the child’s overweight status. This desire seems to make sense, since we did not explicitly focus on already- overweight children, and therefore most children were in the normal weight range. Mother’s own overweight status and the age of the child were associated with a maternal preference for a thinner silhouette. In our opinion these results can be interpreted as possible out- come of more experience with obesity in both cases. Even though there is a higher prevalence of overweight in older children [1], the child’s weight status is not the underlying factor in this relation between the child’s age and maternal preference for thinner silhouettes. How- ever, overweight mothers could be more aware of having an overweight child due to their own experiences with overweight. This view is supported by the observation that overweight mothers reported more concern about their child’s future weight status independent of the child’s current weight status [26]. Half of the mothers see the need for action only on overweight silhouettes (90th percentile). In addition, 20% of mothers are convinced that there is no need for pre- vention until the child’s BMI exceeds the 97th percentile, i.e. when he or she is already obese. Taken together, Page 6 of 8 these results emphasize the fact that the vast majority of parents do not share basic ideas of health promotion or primary prevention with health professionals, whose standards state that prevention should start early and be- fore the child suffers from a weight problem. This obser- vation is consistent with the low participation rates often reported in prevention studies [27]. The only significant factor to predict this late parental engagement in pre- ventive efforts (at the 97th percentile) was maternal in- ability to identify physical health risks with overweight and obese silhouettes. This finding underscores the ap- proach of common health-related psychological theories (e.g. the Health Action Process Approach of Schwarzer or the Theory of Reasoned Action of Ajzen; see [28]) which stress the relevance of risk perception as a neces- sary basis for the construction of an intention to change behavior. Current empirical research reveals that paren- tal identification of overweight, as well as parents’ beliefs that overweight constitutes a health problem, are highly significant influences [18,29] in prevention and interven- tion. Since most mothers underestimate the health risks associated with overweight, there is an urgent need to sensitize parents to the health risks related to childhood obesity. Maternal commitment to preventive activities at the 75th weight percentile, on the other hand, is predicted by having a boy and by the identification of overweight at the 75th percentile. Previous work has already reported the importance of early parental identification of over- weight, as well as the identification of related health risks, as relevant factors affecting parental readiness for prevention activities with respect to maternal risk per- ception [summarizing 11]. Our finding that mothers see an earlier need for action for boys is unexpected. Since we controlled for several factors, this result could not be explained simply by the higher weight status of the boys, or by age differences. There are only a few studies that find significant sex differences regarding parental risk perception and these show the opposite results with re- spect to gender (in summary [11]). In addition, we did not examine maternal perceptions of preventive activ- ities for their own child, but in general for children in this age group. Therefore, we would not have expected any associations with the gender of the participant’s own child. We are not aware of any study using a similar ap- proach to bring our results in line with other research. Further investigations are needed to explore the influ- ence of the child’s gender on maternal risk perception. Our study has several limitations. We used a cross- sectional design, which does not allow us to draw causal conclusions. Further prospective research is therefore required to confirm the effects of the child’s age, as well as maternal ability to recognize overweight and related health risks in unrelated children. Another limitation is