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Pediatric Weight Management

PWM: Family Influences (2006)

Trombini E, Baldaro B, Bertaccini R, Mattei C, Montebarocci O, Rossi N. Maternal attitudes and attachment styles in mothers of obese children. Percept Mot Skills. 2003 Oct;97(2):613-20. PubMed ID: 14620250
Study Design:
Case-control study
C - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To differentiate mothers of obese and normal weight children by self-reported attachment styles and educational attitudes.

Inclusion Criteria:

Mothers of obese and normal weight children aged 5 to 18 years.

Exclusion Criteria:
None stated
Description of Study Protocol:


Mothers were contacted at the primary school attended by their children.


Mothers were administered an Attachment Style Questionnaire (self-evaluation questionnaire classifying internal attachment) and the Parental Attitude Research Instrument (self-evaluation questionnaire about opinions and attitudes of mothers toward their educational task and family life). The Parental Attitude Research Instrument measures, among other things, “Fostering Dependency” which measures hyperprotective & possessive attitudes.

Statistical Analysis

Multivariate analysis (for repeated measures), chi-square tests, and post hoc Tukey test
Data Collection Summary:

Dependent Variables


Independent Variables

Parental attitude


Description of Actual Data Sample:


Initial N: 110 (30 obese, 80 non-obese)

Attrition (final N): 110 (30 obese, 80 non-obese)

Age: 5 to 18 years

Location: Italy


Summary of Results:

Mothers of obese children had significantly higher mean scores than control group mothers on several subcales of the Parental Attitude Research Instrument.


33.3% of mothers of obese children and 62.5% of mothers of normal weight children showed a Secure Attachment Style, whereas the percentages for Insecure Attachment Styles (Dismissing, Preoccupied, and Fearful) were 66.6% and 38.5%, respectively (chi-square=8.85, p<0.05).

Insecurity in attachment relationships with one’s parent encourages these mothers in relational and educational attitudes with their children that tend to maintain the maternal figure as an inexorable reference point to avoid the anxiety of separation as the children become more autonomous.

Significant correlations found between scores on subscales of the Attachment Style Questionnaire and the Parental Attitude Research Instrument that differentiate the 2 groups of mothers support the hypothesis that maternal attitudes of the mothers of obese children are mediated by Insecure Internal Working Models.

Author Conclusion:

These data indicate that obese children’s mothers tend to make the family their exclusive center of interest. They also tend to dedicate themselves to their children with possessiveness and hyperprotection. They seem to have an insistent requirement of idealization of their own role as a parent and reward expectations that confirm the efficiency of the care they provide their children. Consequently, these findings suggest that in addition to dietetic treatment, it may be important to include a psychological intervention, which involves the mother and aims to modify the relational dynamics between the mother and her obese child.

Funding Source:
University/Hospital: University of Bologna
Reviewer Comments:


  • Exclusive reliance on self-report.
  • Small sample size.
  • No definition of obese.
  • Current or previous attachment styles not indicated.

Other Comments:

  • No known control variables (ie. there was no controlling for dietary intake, energy intake, physical activity/inactivity, parental BMI, etc.).
  • Analyses not separated by gender.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? No
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? ???
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) ???
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) ???
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? ???
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) No
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? ???
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) ???
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? ???
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? N/A
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? ???
  7.1. Were primary and secondary endpoints described and relevant to the question? No
  7.2. Were nutrition measures appropriate to question and outcomes of concern? N/A
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? ???
  7.6. Were other factors accounted for (measured) that could affect outcomes? No
  7.7. Were the measurements conducted consistently across groups? ???
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? ???
  8.1. Were statistical analyses adequately described and the results reported appropriately? ???
  8.2. Were correct statistical tests used and assumptions of test not violated? ???
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? No
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes