Background
Rates of obesity among children ages zero to five have increased dramatically all over the world [
1]. This is concerning as the first year of a child’s life can make a significant impact on his/her long-term health [
2]. Specifically, rapid increases in weight during the first 6 months have been associated with increased risk for obesity at ages 5 and 10 years [
3]. Unfortunately, overweight and obesity has a negative impact on a child’s physical and psychological health as well as overall quality of life [
4]. For example, research studies have found cardiometabolic risk factors and development of atherosclerosis in obese preschoolers, once thought to only present in adulthood [
5,
6]. In addition to these concerning findings, being obese as a child increases one’s risk of adult obesity, which is associated with a variety of chronic health conditions. The obesity epidemic has had severe economic impact for countries all over the world ($73.8 billion in US, $10.9 billion in Germany) [
7]. Greater efforts are needed to prevent and treat infants (<12 months of age) who are at-risk for being overweight or obese (defined as having a weight-for-length (WFL) z-score greater than two standard deviation above the World Health Organizations (WHO) standards) [
4,
7].
Reducing the prevalence of overweight and obesity rates is no small task as a multitude of factors influence a child’s weight status such as genetic/biological, behavioral, and environmental factors as well as an individual’s culture and socioeconomic status [
4]. One of the recommended strategies to combat childhood obesity by the WHO is to “provide guidance on, and support for, healthy diet, sleep and physical activity in early childhood to ensure children grow appropriately and develop healthy habits” [4, pg. 26]. Within a child’s first year (i.e., infancy), parents play an obvious role in supporting and developing healthy habits. However, there is evidence that many parents fail to identify their infant as being overweight or obese because they prefer “chubbier” infants and health professionals (i.e., pediatricians) who parents look to for advice may also not acknowledge children’s overweight or obesity status [
8‐
19].
Parental preference for larger infants
Several studies have found parents prefer fatter infants, especially those parents whose infants are heavier [
14,
16]. For example, a survey conducted by Laraway and colleagues [
14] found that almost a quarter of parents of 6–27 month olds preferred their infant’s weight to be in the highest quartile on the WFL growth chart. This may be due to parent’s belief that higher percentiles equate to superior standings (i.e., academic achievement scores) [
14]. Redsell and colleagues [
16] found similar results in their qualitative study of parents of infants in the United Kingdom. However, the theme of a preference for heavier infants was only found in parents who were overweight or obese themselves. Additionally, parents’ perceptions were influenced by cultural or individual preferences such as what friends and family thought and advice received from previous generations (e.g., grandparents).
Conversely, parents may not recognize their infant is overweight. Jimenez-Cruz and colleagues [
13] found that 83% of mothers from Mexico with 5 to 24-month olds who were overweight or obese underestimated their infant’s weight. Thus, parents may need guidance on recognizing overweight and obese infants and guidance on why and how to promote healthy behaviors as preventative efforts against childhood obesity beginning in infancy [
16]. Additional in-depth exploration is needed to better understand parental perceptions of infants’ weight (normal weight, overweight) and how these perceptions may impact promotion of healthy behaviors [
14].
Fostering healthy habits
Parents are especially important targets for promoting healthy behaviors as they play a vital role in helping their children foster healthy habits from an early age [
4,
20,
21]. Research in this area has primarily focused on the influence of parental attitudes in the development of children’s eating practices [
13,
14,
21‐
26]. Another critical habit that parents begin to influence during infancy is the adoption of healthy physical activity practices. In general, it is recognized that parents play a critical role in their infant’s motor development as they make decisions on how much an infant is held, the time spent in restrictive devices (i.e., carriers, car seats, swings), the time given for play on their stomach, and infant physical activity in general [
27]. To promote infants’ health and motor development it is recommended that infants take part in daily developmentally appropriate activities (e.g., rolling, crawling) in open and safe play areas in which infants have the ability to take part in free movement with appropriate toys (e.g., rattles, balls). Additionally, guidelines suggest promoting parent-infant interaction and limiting time spent in restrictive devices (e.g., swings, car seats) [
28]. Understanding these perceptions is important as research has shown that a child’s movement and development of gross and fine motor skills is critical for muscle strengthening and participation in physical activity later in life [
29,
30]. However, research has found that few parents view physical activity as a top priority for infants and few are concerned about practices that may limit their infant or young child’s activity, such as stroller use [
16,
31,
32].
Interestingly, studies have found parents perceive high infant activity levels as problematic due to concerns of inappropriate behaviors in certain situations, discipline concerns, or the physical demands of having to chase a child around [
32‐
34]. A negative view of activity in infancy may lead to parents wishing their infant were less active which could increase the promotion of more sedentary activities. For example, Thompson and colleagues [
34] determined infants of low-income African American mothers’ who were perceived as being more active had higher odds of TV viewing. More research is needed with different socio-economic classes and in younger samples to gain a fuller picture of mothers’ perceptions of infants’ physical activity. Additionally, few studies have fully explored mothers’ of both normal weight and overweight infants’ perception of physical activity or mothers’ awareness of physical activity guidelines [
13,
16,
32].
Physicians’ recognition of obesity in infants
Within the United States, pediatricians serve as the cornerstone of children’s healthcare. While little research has examined pediatrician’s discussion of weight specifically with the parents of infants, several studies have found that often pediatricians do not acknowledge older children’s weight or are uncomfortable discussing with parents that a child is overweight or obese [
8,
10,
12]. This is concerning as the American Academy of Pediatrics recommends pediatricians see children 14 times prior to their fifth birthday, providing ample opportunities to discuss weight concerns with parents [
35]. The lack of acknowledgement from pediatric physicians may also contribute to parents’ lack of concern about their child’s weight [
11]. However, more research is needed regarding parent’s perception of pediatrician’s acknowledgement of weight, especially in the first year.
One theory that has been utilized in health behavior studies is the Social Cognitive Theory [
36]. The Social Cognitive Theory posits that behavior can be explained based on the interaction between personal cognitive factors (self-efficacy, collective efficacy, outcome expectations, knowledge), socioenvironmental factors (observational learning, normative beliefs, social support, opportunities and barriers), and behavioral factors (behavioral skills, intentions, reinforcement). A better understanding of these concepts in relation to parents perceptions of infant weight and physical activity could help inform the development of interventions designed to improve infant health.
Therefore, the central research question was: How do mothers’ of normal weight infants (NWI) and overweight infants (OWI) perceive their infant’s weight and physical activity? The sub-questions are as follows: What beliefs of the mother influence these perceptions? What external factors influence these perceptions? These findings are needed to increase our understanding of parents’ current knowledge and use of physical activity-related practices in infancy. This information may be useful for developing strategies to enable parents to engage with their infants in physical activities, especially those at-risk for obesity.
Discussion
This study aimed to understand how mothers of NWI and OWI perceive their infant’s weight and physical activity. A general theme was mothers’ perceptions of infant weight. Although most thought infants could be overweight, primarily due to overfeeding and/or using formula, no caregivers included their own infant in this description. Many thought that breastfed infants could not be overweight. This could be a normative belief of their society, a majority of whom exclusively breastfed their infants for six months or longer, which may be leading women to associate formula feeding as a negative behavior thus leading to negative health outcomes such as obesity. Interestingly, there is evidence that breastfeeding is associated with a lower prevalence of obesity later in life and has been promoted as an obesity prevention strategy [
44]. However, more information regarding parental overfeeding and its link to infant weight for both breast and formula fed infants is needed [
26]. Breastfeeding alone does not completely buffer an overweight child from long-term risk of obesity. Since knowledge is a precursor to health behavior change, making parents aware of other risk factors during infancy such as rapid increases in weight could be important for obesity prevention efforts [
36,
45]. Additionally, future research could explore the social norms and beliefs regarding weight in breastfeeding mothers.
Relatedly a person’s cultural norms and beliefs (normative beliefs) can also greatly influence what is perceived to be socially acceptable, thus impacting mothers parenting practices [
36]. Specifically, other researchers have found family members, especially grandparents, can have a large influence on an infant’s feeding practices [
46,
47]. As such, family members or comments by others about infants could also influence parents’ perception of their infant’s weight. Yet regardless of infant size, few mothers viewed these comments about the size of their infant as negative. For those mothers who had heard comments that their child was “big”, this may reflect a similar finding from other studies that mothers prefer “fatter” infants and/or this is the cultural norm of how one talks about infants [
14,
16]. Redsell and colleagues [
16] only found a preference for larger infants from parents who were overweight themselves. Overall, in this study, comments from others did not appear to be a factor in parents’ perceptions of their infants’ weight.
Our findings appear to be consistent with previous research in that pediatricians may not be having conversations regarding infant weight [
8,
10,
12]. Only one mother could recall her pediatrician addressing her infant’s weight and after learning of a family history of large size the pediatrician recanted their concern. As 11 of the infants in this study were overweight it is noteworthy that so few pediatricians had addressed this subject with parents. Future research should assess pediatricians’ recollection of discussing weight with parents of infants as well as to determine what pediatricians take in to consideration when deciding to discuss concerns about weight and how to promote healthy eating and physical activity habits during infancy.
In regards to mothers’ behavior, their interview responses reflected their awareness of some general physical activity guidelines but few reported engaging in behaviors to promote physical activity such as interacting with their child in physical activities. This is concerning as this is a key aspect of the physical activity recommendations and a critical need of healthy early development [
48]. The lack of discussion of interacting with their infant may be a result of mothers’ perceptions that infants are naturally active and are not in need of maternal guidance and interaction [
32,
49] or due to the views of some mothers in our study and others who thought the activity levels of infants was due to personality characteristics [
50,
51]. The lack of reported interaction could also be due to mother’s lack of self-efficacy for promoting infants’ activity. Evidence suggests that many young children do not achieve recommended levels of physical activity [
52,
53]. Future research studies could examine parent’s self-efficacy for interacting with their and providing physical activity for their infants. Regardless, efforts to increase parents’ knowledge of the importance of physical activity and to enhance their self-efficacy for engaging in physical activities with infants is warranted [
32]. Offering low or no-cost infant/parent play classes at a hospital or community center for parents to obtain knowledge and mastery experiences could be a viable strategy to verbally encourage mothers to interact during this play time. Relatedly, parents and other caregivers (e.g., family members, childcare providers) should be made aware of the potential negative impact of infant sedentary behaviors (i.e., sitting in restrictive devices, watching television). While research is still needed to examine the impact of these behaviors in infancy, given the impact sedentary behaviors has had on older populations the public health and healthcare community should not wait for evidence to mount and be proactive in their promotion of healthy physical behaviors in infancy.
Interestingly, mothers discussed playing outside or organized classes such as sports as future physical activity promotion efforts. Outdoor play offers numerous benefits to health including motor development and mental health [
54,
55]. Further, participation in organized sport could provide opportunities to increase behavioral skills for life-long participation in physical activity and participation is associated with a lower body mass index (BMI) [
56,
57]. The role of weight in the early development of these healthy physical activity habits is not fully understood. Some research suggests adiposity (e.g., central adiposity, skinfold assessments) is associated with delays in the achievement of motor milestones in infancy (e.g., rolling over, sitting up, walking) which could deter future participation in general physical activity and sport; however, more research is needed [
58].
Regardless of the type of physical activity, it is important to note that all mothers intended to promote physical activity. These opportunities provide avenues for mastery experiences and observational learning with peers and family members, which could lead to improved physical activity. Further the promotion of these activities could provide instrumental (i.e., taking child to sport practice) or emotional (i.e., verbally encouragement) support which is also linked to improved physical activity levels [
36,
59,
60]. It is important to note that while not specifically asked, these mothers did appear to have access to opportunities for their child to be physically active based on their own physical activities. Lack of access to appropriate physical activity environments due to issues such as lack of safety, sidewalks or open space has been a consistent barrier to physical activity found in the literature [
61]. Increased opportunities for activity through avenues such as a safe environment or access to a park are important to the development of healthy behaviors [
36,
61]. More research is needed to explore if parents have taken these factors into consideration when considering future physical activity promotion efforts.
Despite the fact that over half of mothers were currently active for four or more days/week, few mothers mentioned the importance of role modeling and none discussed actually participating in physical activity with their infants as a way of role modeling. Role modeling can provide infants and young children opportunities to learn from their mothers how to be physically active which can also lead to later increases in their own self-efficacy for physical activity [
36]. Several studies report the important influence parental activity and support for physical activity can have on children’s activity levels [
32,
62‐
64]. Specifically, Hnatiuk and colleages [
65] found that the amount of time an infant spent being physically active with their mother at 9-months of age predicted physical activity levels at 19-months of age. As some mothers in this study mentioned they purposefully were active alone as a “release”, encouraging mothers to spend additional time with their infants being active may be important for infants to observe and learn about physical activity to establish long-term physical activity habits.
Additionally, multiple mothers reported that the potential positive impact of their family and/or siblings could have to promote the infant’s future physical activity. When families are physically active together this could promote collective efficacy for physical activity which could lead to improved physical activity levels for the entire family. Further, this could contribute to a child’s normative beliefs about physical activity early on, believing that physical activity is a socially acceptable behavior [
36]. Previous findings show older siblings activity is positively associated with the younger siblings [
66,
67]. However, if physical activity is limited just to siblings, parents may believe physical activity is a natural inclination of all children [
32]. Thus, parents might not see the value of older siblings’ role-modeling positive physical activity behaviors.
Importantly, collective efficacy may not be limited to families. A previous research study found an association between time spent with children of the same age at 4-months of age and physical activity at 19-months of age [
65]. Future physical activity promotion efforts should focus on the importance of family-based approaches and play groups with respect to both role modeling and engaging in physical activity opportunities together. Further research should also examine the impact of mother/infant active play groups on infant and early childhood physical activity.
Strengths and limitations
This study is strengthened by exploring the perceptions of mothers of both NWI and OWI about infant obesity and physical activity. However, due to the sample characteristics (e.g., participants resided in the Midwest, included only mothers, most exclusively breastfed for six months or longer, and reported middle to high-income levels), the findings may not be readily generalizable to other populations. Future research studies should explore these topics in different regions, with both mothers and fathers, with a variety of different feeding strategies, and broader socioeconomic characteristics. Other limitations included the classification of infants as overweight if they were deemed to be overweight at any of the three appointments and the study design in which interviews only occurred at the third visit. Future research should explore differences in parents’ perception of OWI and NWI based on consistency of classifications at all time points with a larger sample size in order to provide a more systematic comparison to examine differences. A further limitation is the length of the interview (average length 22 min). Given that infants were with mothers during the interviews and they had taken part in additional measures for the overall study, the research team determined that a shortened interview guide could still provide detailed information and lessen participant burden. An additional limitation is that the findings were analyzed by researchers involved in the study, which could have biased the findings. While the researchers took part in validation strategies including reviewing the findings with an external researcher, including an external researcher in the preliminary analysis could have further strengthened the findings. Finally, it is important to note that societal view of childhood obesity and concern about obesity prevention beginning in infancy and the importance of physical activity are relatively recent targets of concern in early childhood. Thus, the pediatricians’ role in providing information to parents regarding infant obesity and physical activity and the sources of information available to parents on these topics are both changing, offering rich opportunities for further research.
Conclusions
Overall, this study shows that most mothers thought infants could be overweight, primarily due to overfeeding and/or using formula, yet did not identify their own infant as overweight. In addition, mothers thought infants could be active but rarely mentioned their own interaction with infants as a part of promoting physical activity with their child. Efforts are needed to inform mothers about the dangers of overfeeding with both breast and formula fed infants as well as the importance of being active with their infants. Without prompting, mothers discussed several topics related to key factors of Social Cognitive Theory that could lead to long-term healthy physical activity habits for infants such as family social support and collective efficacy for activity. However, issues such as normative beliefs regarding ability of breastfed infants to be overweight and mothers’ potential lack of self-efficacy for promoting infant activity could deter infant physical activity promotion efforts. Interventions grounded in Social Cognitive Theory, could lead to improved infant health. For example, interventions tailored towards increasing parents’ knowledge of risks associated with infant obesity and the importance of infant physical activity as well as ensuring equitable opportunities for infants and families to take part in physical activity could help to alter societal norms and expectations as well as enhance mothers’ self-efficacy regarding engaging in activity with their infants. To best understand the influence of physical activity promotion and interaction between mothers and infants on physical activity, motor skill development, and obesity, a larger-scale study is needed. Additionally, future research studies should examine the influence of fathers as well as cultural and ethnic beliefs about obesity on infant weight and physical activity behaviors.
Acknowledgements
We would like to thank all of the mothers for their participation in this study.