Obesity has become the most prevalent nutritional disease worldwide, particularly in developing countries, where it has reached alarming numbers that multiply the medical, psychological, social and economic repercussions to face in the years to come [1–3]. Child obesity represents a special issue to focus on, since evidence points towards more premature development of obesity comorbidities formerly considered as adult diseases, such as type 2 diabetes and metabolic syndrome [4, 5]. Nowadays, Mexico is one of the countries with the highest prevalence of child obesity worldwide. Data from the National Health and Nutrition Survey 2012 [6], showed a combined prevalence of children overweight and obesity of 26%, strikingly contrasted to 18.4% assessed in 1999. This increase may not be solely explained by genetic factors or population redistribution derived from migration phenomena, but also because of environmental factors linked to major changes in the quality of life, more prone to energy homeostasis imbalance and fat accumulation [7–10].

In Mexico, in the last few years, strategies designed to prevent child obesity have been carried out by using mass communication media as diffusing platform, parallel to diverse particular interventions, which mainly promote healthy nutrition and physical activity [11–14]. However, the success of these interventions is limited by the individual motivational status, which is in turn influenced by nutritional status self-perception and the attitude around obesity within each family [15, 16].

On the other hand, underestimation of weight status is a common tendency, particularly in populations with high obesity prevalence. In Mexico, the erroneous but popular belief that a “chubby” child is synonymous of healthy child still prevails among medium and low income families, in which overprotective mothers commonly minimize or do not recognize the consequences of overweight and obesity. Under this perspective, children may receive distinct messages that may generate confusion and jeopardize the probability of success of any preventive intervention. Therefore, it is possible that actions or activities performed by children to prevent overweight/obesity are determined by how they perceive the impact of obesity on the physical, social or economic well-being throughout life. Currently, strategies against child obesity do not include actual perception that schoolchildren have about it. To address this need we evaluated, for the first time to our knowledge, the perception of Mexican children about the association between quality of life and obesity. Furthermore, we hypothesized that children body weight status could be a confounding variable in their responses.

In this study we have shown that about a third of Mexican school children do not consider that obesity can adversely affect the quality of life in adulthood, which seems to be influenced by their age and their perception their mothers’ body weight status. Numerous studies have been carried out to determine factors associated with the development of obesity in children, however, to our knowledge this is the first study that focuses on the child obesity problem from their own perspective, and related to their notion on obesity consequences. At scholar age, children may not be aware of the implications of being an obese person, considering the problem outside their reality. Nevertheless, it is possible to postulate that at this stage of acquisition of values and behaviors children begin to judge adult’s lives, and to associate the results of these judgments with the nutritional status, reflected by their physical appearance. To address this question, we conducted this survey, which aim was to explore two main aspects. The first one was the perception of obesity as a disease or a condition that predisposes to increased morbidity and early mortality, while the second aspect was the perception of obesity as a limiting factor for satisfying healthy/good lives as assessed through major aspects for this particular age, such as sport and social skills. For this purpose, we designed and validated the ObI-Q, a multiple-choice questionnaire of 8 items that enabled us to examine how children perceived the relationship between obesity and adult quality of life. For the validation and reliability process of the questionnaire, we carried out the various stages suggested by Streiner and Norman [21, 22]. Thus, before its application to the study population, the questionnaire was found to have both content and construct validity, and internal consistency. In addition, we conducted a pilot study to determine that the children understood the wording of the items and their answers. The ObI-Q differs from other instruments as the Youth Quality-of-Life-Weight module (YQOL-W) [23] or the Pediatric Quality of Life Inventory (PedsQL) [24], which are targeted to preadolescent and adolescent population. Besides, these instruments were designed to assess the current quality of life of individuals, so the questions are limited to situations experienced leaving out the possibility of a projection of the future of the circumstances as well as the opinion of the individual beyond himself.

Overall results showed a perception ranging from indifference to a clear view of obesity as a problem. Most children (~65%) perceived that obesity is a negative condition related to sickness and premature die. Notably, children with overweight and obesity were more aware of these complications (Table 2). This coincides with the findings of previous studies with adolescent populations, in which an inverse relationship between weight status and health-related quality of life was detected [25], and Jalali-Farahani S, Chin YS, Amiri P, Mohd Taib MN: Body mass index (BMI)-for-age and health-related quality of life (HRQOL) among high school students in Tehran. Child Care Health Dev 2013. doi:10.1111/cch.12103, forthcoming]. Our results show that the negative perception of obesity probably originates from an early life stage, and most children are aware of the consequences of obesity in relation to health, especially those who experience it in their own person and/or through the close mother figure. However, there was still a large proportion not sensitized about it, thus, it will be important to explore the factors that influence the formation of this view and direct it properly as a support for preventive strategies, as previously suggested [26].

Regarding the children perception of obesity on physical activity and success, it was clear that most children have realized that obesity creates limitations on physical performance, which has been shown to be functionally accurate, independent of gender, ethnicity, and age [27].

On the other hand, the cluster analysis show that the views of children of school age about the adverse consequences of obesity are not associated with neither actual nutritional status nor self-perception of it. This circumstance is probably determined by the perception of body shape, which is developed during adolescence [28].

In contrast with this negative perception, the results showed that the emotional area was not perceived as affected as the physical. In this regard, previous results from different analyzes of the psychological and depressive symptoms relative to the weight are contradictory [29–32], however, there is substantial heterogeneity between ethnicities and age groups of these studies that may explain these differences. In the particular case of Mexican population, we can argue that overweight and obesity have become very common conditions, to the extent that affected individuals are not excluded from the circles of daily living, and emotional development is not conditioned by their weight, which is positively perceived by children. This idea is reinforced by our own results, which show that obese children perceive their mothers mostly as overweight, opening the possibility that these children build their perception around the mother figure, traditionally protective and loving. This set of circumstances may skew the child perception towards a positive opinion about obesity and overweight, as has been recently demonstrated in a Mexican-American population [33]. Such observation has social and psychological connotations that do not concern this study, but needs to be further analyzed. In the meantime, the emotional aspect should continue to be considered invariably in the design of intervention strategies against obesity, since it represents a key element of their success.

Despite the strengths of this study, we recognize its limitations. For reasons of feasibility, measuring the parents’ body weight status was not performed, so we considered children perception. In addition, we surveyed only urban children where the problem of obesity is very high; therefore, it may be necessary to explore this phenomenon in populations of different socioeconomic status, as well as in rural environment. It may also be appropriate to analyze the evolution of this perception over time.

This study provides an overview of children’s perception on obesity and its consequences. Because the high proportion of schoolchildren who do not view obesity as an adverse consequence to the quality of life, then the results of this study could be used as part of strategies for the prevention of overweight and obesity.