1. family and parenting
2. children

Public Health 123 (2009) 738–742
Contents lists available at ScienceDirect
Public Health
journal homepage: www.elsevierhealth.com/journals/pubh
Original Research
Diet quality of preschool children and maternal perceptions/misperceptions:
The GENESIS study
G. Kourlaba a, K. Kondaki a, E. Grammatikaki a, E. Roma-Giannikou b, Y. Manios a, *
a
b
Department of Nutrition and Dietetics, Harokopio University of Athens, 70 El. Venizelou Ave, 17671 Kallithea, Greece
First Department of Paediatrics, Athens University, Ag. Sophia Children Hospital, Thivon & Levadias, Athens, Greece
a r t i c l e i n f o
s u m m a r y
Article history:
Received 12 December 2008
Received in revised form
23 September 2009
Accepted 4 October 2009
Objectives: To quantify maternal perceptions regarding the quality of their child’s diet, and to identify
factors associated with misperceptions.
Study design: A representative sample of 2287 children aged 2–5 years from a cross-sectional study
(GENESIS study) was used.
Methods: Maternal perceptions of the quality of their child’s diet, child’s and mother’s anthropometric
characteristics, and other characteristics (i.e. socio-demographic and lifestyle) were recorded. The actual
quality of each child’s diet was estimated using the Healthy Eating Index (HEI) score.
Results: Based on the HEI score, 18.3% of participants had a ‘poor’ diet, 81.5% had a diet which ‘needs
improvement’ and only 0.2% had a ‘good’ diet. Almost 83% of mothers overestimated the quality of their
child’s diet. The overestimation rate was 86% among mothers who declared that they choose their child’s
food based on what they consider to be healthy, and 72% among those who reported that other factors
play the predominant role in food choices for their child (P < 0.001). Moreover, total energy intake as
well as the intake of fruits, grains, vegetables, meat and milk was significantly higher among children
whose mothers overestimated the quality of their diet.
Conclusion: The vast majority of mothers overestimate the quality of their child’s diet. Given that maternal
perceptions regarding the quality of their child’s diet are likely to be one of the predominant factors
determining the child’s food intake, health professionals should make mothers aware of the existence of
particular dietary recommendations that their children should meet in order to eat a healthy diet.
Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Keywords:
HEI score
Greece
Mothers
Young children
Overestimation
Introduction
Physical growth, cognitive and emotional development, and
nutrition-related diseases (e.g. deficiencies and toxicities) in
children are strongly related to nutrition during infancy.1,2 Moreover, ‘poor’ diets (i.e. diets not consistent with specific dietary
recommendations) among children in developed countries during
the last decades3–9 have resulted in increased prevalence of risk
factors for chronic diseases, such as obesity, high blood pressure
and cholesterol levels in children.10–13 Unhealthy dietary habits or
lifestyle patterns originating in early life may continue into adulthood, increasing the risk for the development of chronic diseases
(e.g. cardiovascular disease, hypertension, cancer etc.) in adult
life. Taking this into account, together with the fact that
childhood obesity usually persists in adulthood,14,15 the identification of young children with an unhealthy diet is of critical
* Corresponding author. Tel.: þ30 210 9549156; fax: þ30 210 9549141.
E-mail address: [email protected] (Y. Manios).
importance. If a ‘poor’ diet is recognized early in life, several health
problems are likely to be prevented through the appropriate
amendments to dietary habits.
It is a well-documented fact that family members exert
substantial influence on the development of eating behaviours16–18
and physical activity patterns19,20 of preschool- and school-aged
children. In that context, parental involvement is important for the
successful outcome of childhood obesity preventive actions.21–23
However, for active parental engagement in such actions, parents
need to be able to recognize if their children have a poor diet, and
be aware of potential health consequences. If parents cannot
recognize that their children have a ‘poor’ diet, they will not make
efforts to change their children’s dietary habits.
Although several studies have proposed that parents affect their
children’s eating habits18,24–26 and that these habits are related to
the development of chronic diseases, to the authors’ knowledge, no
studies to date have examined maternal misperceptions regarding
the quality of their child’s diet. Therefore, the present study aimed
to evaluate maternal overestimation of the quality of their child’s
diet in a sample of Greek children aged 2–5 years. For this purpose,
0033-3506/$ – see front matter Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.puhe.2009.10.005
G. Kourlaba et al. / Public Health 123 (2009) 738–742
maternal perception was compared with the actual quality of each
child’s diet as estimated based on the Healthy Eating Index (HEI);27
this has been found to be valid in such a population.28 In addition,
factors that may be associated with maternal misperception were
also investigated.
Methods
Sampling
The design and rationale of the GENESIS study have been
described previously.7 In brief, between April 2003 and July 2004,
2518 children (aged 1–5 years) were enrolled in the study from
a representative sample of randomly selected public and private
nurseries and day-care centres within municipalities in five
counties of Greece. Complete data became available for 2374
children. Two thousand two hundred and eighty-seven children
were included in the present work (those aged 2 years), since HEI
has been proposed for people above 2 years of age. Parental
perception of the quality of their child’s diet was recorded for 1859
children. Among those, records in which the interview respondent
was not the mother of the child participant were excluded
(n ¼ 100). Approval to conduct the study was granted by the Ethical
Committee of Harokopio University of Athens and by all municipalities invited to participate in the study.
Dietary assessment
739
10 components. The first five components measure the degree of
compliance of people’s diets with the USDA’s food guide pyramid
recommendations for grains (bread, cereals, rice and pasta), vegetables, fruits, dairy (milk, yogurt and cheese) and meat (meat,
poultry, fish, dried beans, eggs and nuts), as expressed in servings/
day. The next four components of the HEI assess the degree of
adherence to recommended dietary guidelines for Americans
regarding several nutrients (total fat, saturated fat, cholesterol and
sodium intakes). The final component examines the variety of foods
in a person’s diet. Scores between 0 and 10 were assigned to all
components. More details regarding the scores assigned to each
component are presented elsewhere.27 Based on the categorization
proposed by Kennedy et al.,27 an HEI score over 80 implies a ‘good’
diet, a score between 50 and 80 indicates that a diet ‘needs
improvement’ and a score below 50 indicates a ‘poor’ diet.
Data obtained from mothers and maternal perceptions about their
children’s diets
A structured interview was conducted to collect information
regarding maternal perceptions about their child’s appetite and the
quality of their diet. In particular, mothers were asked to characterize their child’s appetite choosing one of the following answers:
‘excellent’, ‘very good’, ‘good/normal’, ‘bad’ or ‘very bad’. In addition, in order to assess maternal perceptions of the quality of their
child’s diet, mothers were asked to answer the question ‘How
would you characterize your child’s diet?’ by choosing one of the
following five responses: ‘very good/healthy’, ‘good/healthy’, ‘not as
good’, ‘little good’ or ‘no good’. These responses were divided into
three groups as follows: ‘very good/good/healthy’, ‘not as good’
(i.e. ‘needs improvement’) and ‘little good/no good’ (i.e. ‘poor’) in
order to make these comparable with categories obtained for the
total HEI score indicating the actual quality of the child’s diet.
Maternal overestimation errors regarding the quality of their
child’s diet occurred when children who actually had a ‘poor’ diet or
a diet that ‘needs improvement’ were perceived by their mothers as
having a ‘very good/good/healthy’ diet. Moreover, this error
occurred when children who actually had a ‘poor’ diet were
considered by their mothers to have a diet that ‘needs improvement’. Furthermore, mothers were asked to declare the factor that
plays the predominant role when choosing their child’s food
(i.e. healthy, child’s preference, price, advertised on television, etc.).
Finally, mothers were asked to report how aware they are of what
their child consumes during a whole day (i.e. very well, well, so and
so, little or very little).
Dietary intake data were obtained for two consecutive weekdays and one weekend day using weighed food records (during
nursery hours) and 24-h recall or food diaries (outside nurseries).
During the two weekdays and while the child was at nursery,
a team member (i.e. a dietician) weighed and recorded all foods
consumed by each child. Information on food consumed outside
the nursery for these specific weekdays was obtained during
a prearranged meeting with the parent/guardian the following
morning, using the 24-h recall method. During these two morning
interviews, parents/guardians were familiarized with portion sizes
and the relevant procedures required to successfully complete
a food record at home on the forthcoming weekend day, preferably
Sunday. Parents/guardians were advised to return the food diaries
to the nurseries on Monday mornings, where a team member
received and checked the records for potential errors. Food intake
data were analysed using the Nutritionist V diet analysis software
Version 2.1 (First Databank, San Bruno, CA, USA), which was
amended extensively to include traditional Greek foods and
recipes, as described in food composition tables and composition of
Greek cooked food and dishes.29,30 Furthermore, the databank was
updated with nutritional information of chemically analysed
commercial food items widely consumed by infants and
preschoolers in Greece. The ratio of reported energy intake (EI) and
predicted basal metabolic rate (BMR) was used to check for underreporting. Schofield equations were used to estimate BMR,31 taking
gender, age and body weight into account. Therefore, children with
EI:BMR ratios lower than the calculated cut-off values (0.96 or 1.03
depending on the subjects’ physical activity levels, age and
gender)32–34 were excluded from further analysis. More information regarding dietary intake assessment is presented elsewhere.7
Anthropometric data (i.e. body weight and height) of children
were obtained using standard procedures at all study sites.7 Body
mass index (BMI) was calculated as the ratio of weight (kg) with
height squared (m2). The US Centers for Disease Control and
Prevention age- and sex-specific growth charts and relative cut-off
points were used for the definition of overweight.35 Specifically, for
children over 24 months of age, the BMI-for-age chart was used to
classify children 85th and <95th percentile as ‘at risk of overweight’ and those 95th percentile as ‘overweight’.
The Healthy Eating Index36
Physical activity assessment
The HEI has been proposed by the US Department of Agriculture’s (USDA) Center for Nutrition Policy and Promotion as
a useful tool to assess the dietary status of Americans aged over
2 years.27 This index is the sum of individual scores assigned to
Children’s physical activity was assessed using a valid, structured questionnaire, answered by parents during scheduled interviews at the nurseries.7 Emphasis was placed on light to vigorous
physical activity (L-VPA) with intensity higher than 4 metabolic
Anthropometric measurements
740
G. Kourlaba et al. / Public Health 123 (2009) 738–742
equivalents. More information on the type of activities comprising
L-VPA is presented elsewhere.7
Table 1
Sociodemographic and lifestyle characteristics by the actual quality of children’s
diets: the GENESIS study (n ¼ 1759).
Statistical analysis
The Shapiro-Wilks test was used to evaluate the normality of
continuous variables [i.e. HEI total score, total energy (in kcal) and
food intakes (in servings/day)]. Continuous variables are summarized as mean standard deviation, and categorical variables are
presented as relative (%) frequencies. Frequency analyses were
conducted to determine the percentages of mothers who considered that their children had ‘very good/healthy’, ‘good/healthy’, ‘not
as good’, ‘little good’ and ‘no good’ diets. The associations between
maternal overestimation and categorical variables (i.e. gender, child
physical inactivity, maternal employment status, place of residence
and age of child) were evaluated using Chi-squared test without
correction for continuity. Student’s t-test and Mann-Whitney test
were used to evaluate the association between maternal overestimation and continuous variables when they were distributed
normally or skewed, respectively. Finally, stepwise backward
logistic regression analysis was performed in order to determine
the factors independently associated with maternal overestimation
of the quality of their child’s diet. Variables found to be significantly
associated with maternal overestimation from the aforementioned
analyses were used as independent variables in the initial logistic
regression model (i.e. fruit, vegetable, milk, meat and grain intake,
and total EI).
A probability value of 5% was considered to be statistically
significant. All statistical calculations were performed using
Statistical Package for the Social Sciences Version 14.0 (SPSS Inc,
Chicago, IL, USA).
Results
Based on the HEI score, 18.3% of preschoolers had a ‘poor’ diet,
81.5% had a diet which ‘needs improvement’ and only 0.2% had
a ‘good’ diet. However, 80% of mothers considered that their child’s
diet was ‘good/very good/healthy’, 17% characterized it as ‘not as
good/needs improvement’ and only 3% of mothers considered it as
‘poor/little or no good’. Combining this information, it was
extracted that 82.5% of mothers overestimate the quality of their
child’s diet (Table 1).
Table 2 shows several sociodemographic characteristics of
participants by the actual quality of the child’s diet based on the HEI
score. Children with a ‘poor’ diet were more likely to be younger
and less likely to be active. Table 3 presents the maternal perceptions regarding the quality of their child’s diet (i.e. correct
perception and overestimation) based on several sociodemographic characteristics. No statistically significant associations were
observed.
The vast majority of mothers reported that the most important
determinant when choosing their child’s food is what they consider
to be healthy (78%). However, these mothers were more likely to
overestimate the quality of their child’s diet (overestimation rate:
86%) compared with mothers who reported that they choose their
child’s food based on different factors (72%, P < 0.001). On the
contrary, only 17.6% of mothers answered that the most important
determinant when choosing which foods to give to their child is
their child’s preference. These mothers seem to be more aware that
their children have an unhealthy diet, since the percentage of
overestimation was lower compared with that observed among
mothers who reported that they choose their child’s food based on
other factors (68% vs 85%, P < 0.001). Moreover, maternal perceptions regarding their child’s appetite (i.e. bad/very bad, normal,
good/very good) were found to be significantly correlated with
‘Poor’ diet
(HEI score < 51)
Diet which ‘needs
improvement’
or ‘good’ diet
(HEI score 51)
Gender
Male
Female
50%
50%
52%
48%
0.661
Age (years)
2–3
4–5
77%
23%
66%
34%
0.001
Child’s BMI status
Normal weight
At risk of being overweight
Overweight
68%
19%
13%
65%
19%
16%
0.349
Child’s physical activity status
<3 h/week
89%
3 h/week
11%
82%
18%
0.007
Maternal educational status
<9 years
9–12 years
>12 years
15%
31%
54%
11%
32%
57%
0.190
Maternal employment status
Unemployed
36%
Employed
63%
24%
76%
<0.001
Maternal BMI status
Normal
Overweight/obese
72%
28%
0.072
78%
22%
P-value
HEI, Healthy Eating Index; BMI, body mass index.
maternal overestimation of the quality of their child’s diet. In
particular, it was found that mothers considering that their child
has a ‘normal’ or ‘good/very good’ appetite were more likely to have
false impressions about their child’s diet (88% and 90%, respectively) compared with mothers characterizing their child’s appetite
as ‘bad/very bad’ (65%, P < 0.001).
In addition, a significant association was observed between food
intake and total EI and maternal overestimation of the quality of
their child’s diet (Table 4). In particular, total EI and the intake of
fruits, grains, vegetables, meat and milk were significantly higher
among children whose mothers overestimated the quality of their
diet.
Stepwise logistic regression analysis revealed that the intake of
vegetables, meat and milk, as well as maternal perceptions about
their child’s appetite and maternal food choices based on what
their child likes to eat, remained significantly correlated with
maternal overestimation of the quality of their child’s diet.
Discussion
To the best of the authors’ knowledge, this is the first study to
evaluate maternal misperception regarding the quality of their
child’s diet. The importance of correct maternal recognition of
a child’s poor diet is increased due to the fact that parents, especially mothers, are the principal regulators of young children’s
eating behaviours since they provide them with food.18,24,26
Moreover, it has been documented that an unhealthy diet in
childhood is associated with the development of childhood obesity.
Therefore, mothers with the capability to identify children with
a poor diet could contribute to obesity prevention efforts.
Unfortunately, the current results found that the vast majority of
preschoolers actually have a ‘poor’ diet or a diet that ‘needs
improvement’, while approximately 80% of mothers considered
G. Kourlaba et al. / Public Health 123 (2009) 738–742
Table 2
Maternal overestimation of the quality of their child’s diet by several sociodemographic and lifestyle characteristics: the GENESIS study (n ¼ 1759).
Correct perception
about the quality
of child’s diet
Overestimation
of the quality of
child’s diet
P-value
Gender
Male
Female
19%
22%
81%
78%
0.193
Age (years)
2–3
4–5
20%
21%
80%
79%
0.876
21%
20%
79%
80%
0.354
17%
83%
Child’s BMI status
Normal weight
At risk of being
overweight
Overweight
Child’s physical activity status
<3 h/week
21%
3 h/week
19%
79%
81%
0.600
Maternal educational status
<9 years
21%
9–12 years
20%
>12 years
20%
79%
80%
80%
0.890
Maternal employment status
Unemployed
19%
Employed
21%
81%
79%
0.322
Maternal BMI status
Normal
Overweight/obese
22%
78%
0.363
20%
80%
BMI, body mass index.
that their child’s diet was ‘very good/good/healthy’. This means that
mothers overestimate the quality of their child’s diet. This is
extremely worrying, since mothers who do not perceive that their
preschoolers follow an unhealthy diet will not make the appropriate amendments to improve their child’s dietary habits; this
results in increased risk for the development of nutrition-related
diseases.
The present study found that mothers who declared that they
choose healthy foods for their children were more likely to overestimate the quality of their diet. This suggests that although
mothers believe that they provide their children with healthy food,
their children may not have a healthy diet. This could be attributed
to the fact that mothers are not aware which foods are healthy, or
they are unaware of the appropriate quantities for children. In
addition, mothers reporting that their food choices for their children are based on the child’s preferences seem to perceive that
their children’s diet is poor, since the overestimation rate for these
Table 3
Food and total energy intake by maternal perception regarding the quality of their
child’s diet: the GENESIS study (n ¼ 1759).
Energy (kcal/day)
Grains (servings/day)
Vegetables (servings/day)a
Fruit (servings/day)a
Milk (servings/day)
Meat (servings/day)a
Correct perception
about the quality
of child’s diet
Overestimation of
the quality of
child’s diet
P-value
1390 274
2.78 1.30
0 (0–0.5)
1 (0.58–1.67)
2.91 1.27
1 (0.60–1.51)
1444 290
2.93 1.31
0.33 (0–0.67)
1 (0.67–2.0)
3.18 1.33
1.2 (0.6–1.6)
0.017
0.033
<0.001
0.050
0.002
0.003
Data are presented as mean standard deviation and Student’s t-test was used.
a
Data are presented as median (interquartile range) and the Mann–Whitney test
was used.
741
Table 4
Factors independently associated with maternal overestimation about the quality of
their child’s diet. Results from logistic regression: the GENESIS study (n ¼ 1759).
Vegetable intake (servings/day)
Milk intake (servings/day)
Meat intake (servings/day)
Most important factor for mothers
when choosing their child’s food
Other
Child’s preference
Mother’s perception regarding their
child’s appetite
Bad/very bad
Normal
Good/very good
Grain intake (servings/day)
Total energy intake (kcal)
Fruit intake (servings/day)
Most important factor for mothers
when choosing their child’s food
Other
To be healthy
OR
95% CI
1.33
1.24
1.34
1.00–1.89
1.07–1.45
1.06–1.70
P-value
1.00
0.63
–
0.33–1.00
–
1.00
5.30
6.65
1.06
1.00
1.11
–
3.78–7.41
4.33–10.22
0.92–1.22
0.99–1.01
0.95–1.30
–
<0.001
<0.001
0.430
0.150
0.190
1.00
1.70
–
0.96–3.02
–
0.050
0.005
0.013
0.045
0.071
OR, odds ratio; CI, confidence interval.
mothers is lower than the overall figure and that for mothers who
choose their child’s food based on other factors. However, the
overestimation rate in the former group is still extremely high, with
more than two out of three mothers overestimating the quality of
their child’s diet. In addition, the results indicate that mothers who
believe that their children have a good appetite are more likely to
overestimate the quality of their child’s diet. This may imply that
mothers who consider that their child has a good appetite cannot
perceive that they do not eat healthy food.
Finally, higher consumption of meat, vegetables, fruits and milk
was observed by children with mothers who overestimated the
quality of their child’s diet. This implies that mothers are aware of
the necessity for these foods in their child’s diet. However, they
seem to ignore the fact that children should meet specific recommendations for the intake of all foods and micro- and macronutrients in order to have a healthy diet.
In conclusion, this study found that the vast majority of mothers
perceive that their child’s diet is ‘healthy/very good/good’ while it is
actually ‘poor’ or ‘needs improvement’. This extremely high rate of
maternal overestimation may indicate that mothers are not aware
of the particular dietary recommendations that their children
should meet in order to have a healthy diet. However, family
members, particularly mothers, are the main determinants of
children’s dietary habits. Therefore, while mothers continue to
misperceive their children’s diet as ‘good/healthy’, they will not
make any efforts to help their children to adopt a healthier, more
balanced diet. As a consequence, the risk for the development of
chronic diseases will increase. All of these factors highlight the
need for the development and implementation of policies and
programmes to raise parental awareness of the poor quality of
young children’s diets, and the adverse effects of a poor diet on
child health and development.
Acknowledgements
The authors wish to thank Evdokia Oikonomou, Vivian Detopoulou, Anastasia Anastasiadou, Christine Kortsalioudaki, Elina
Ioannou, Margarita Bartsota, Manolis Birbilis, Elina Dimitropoulou,
Nikoleta Vidra, Theodoros Athanasoulis, Pari Christofidou, Lilia
Charila, Sofia Tzitzirika and Christos Vassilopoulos for their
contribution to the completion of the study.
742
G. Kourlaba et al. / Public Health 123 (2009) 738–742
Ethical approval
Ethical Committee of Harokopio University of Athens and all
municipalities invited to participate in the study.
Funding
The GENESIS study was supported with a Research Grant from
Friesland Foods Hellas.
Competing interests
YM works as a part-time scientific consultant for Friesland
Foods Hellas. None of the other authors had any personal or
financial conflict of interest. The study sponsor had no interference
in the study design data collection or writing of the manuscript.
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