Parental perception of overweight in 3–5 y olds

Article (PDF Available)inInternational Journal of Obesity 29(4):353-5 · May 2005with91 Reads
DOI: 10.1038/sj.ijo.0802889 · Source: PubMed
Abstract
To assess the accuracy of parents' perceptions of their 3 to 5 y old children's weight status in a large UK sample. Parental perception and concern about child weight, demographic variables, and children's height and weight were obtained for 564 parent-child dyads. Only 1.9% of parents of overweight children and 17.1% of parents of obese children described their child as overweight. The odds of parents perceiving the child as overweight were increased for overweight (2.7; 95% CI 0.4, 16.5) and obese (28.5; 7.1, 115.4) compared with normal weight children, but were not associated with parental weight or with any demographic factors. Although few parents perceived their overweight children as overweight, more (66.2%) expressed concern about their overweight child becoming overweight in the future. Odds of concern were progressively higher for overweight (2.5; 1.6, 3.9) and obese children (4.6; 2.2, 9.7), and were also higher for parents who were themselves overweight (1.9; 1.2, 2.9) or obese (2.5; 1.3, 4.8). These findings suggest that parents of 3-5 y olds show poor awareness of their child's current weight status. Reframing discussions in terms of preventing future overweight may be an effective way to engage parents.
PEDIATRIC HIGHLIGHT
Parental perceptions of overweight in 3–5 y olds
S Carnell
1
, C Edwards
1
, H Croker
1
, D Boniface
1
and J Wardle
1
*
1
Cancer Research UK Health Behaviour Unit, Department of Epidemiology and Public Health, University College London,
London, UK
OBJECTIVE: To assess the accuracy of parents’ perceptions of their 3 to 5 y old children’s weight status in a large UK sample.
METHOD: Parental perception and concern about child weight, demographic variables, and children’s height and weight were
obtained for 564 parent–child dyads.
RESULTS: Only 1.9% of parents of overweight children and 17.1% of parents of obese children described their child as
overweight. The odds of parents perceiving the child as overweight were increased for overweight (2.7; 95% CI 0.4, 16.5) and
obese (28.5; 7.1, 115.4) compared with normal weight children, but were not associated with parental weight or with any
demographic factors. Although few parents perceived their overweight children as overweight, more (66.2%) expressed
concern about their overweight child becoming overweight in the future. Odds of concern were progressively higher for
overweight (2.5; 1.6, 3.9) and obese children (4.6; 2.2, 9.7), and were also higher for parents who were themselves overweight
(1.9; 1.2, 2.9) or obese (2.5; 1.3, 4.8).
CONCLUSION: These findings suggest that parents of 3–5 y olds show poor awareness of their child’s current weight status.
Reframing discussions in terms of preventing future overweight may be an effective way to engage parents.
International Journal of Obesity (2005) 29, 353355. doi:10.1038/sj.ijo.0802889
Keywords: childhood obesity, maternal perceptions, parents, preschool, perceived weight
Introduction
Parents who do not recognise the weight status of
their overweight children may be less likely to provide
them with support to achieve a healthy weight. Recent
population and cohort studies in the US and Australia
have demonstrated underestimation of weight
1
and weight
status
2
among parents whose children were overweight
or obese. Others have shown very low levels of concern
about their child’s weight status.
3,4
Results from a
large sample of mothers of 3–5 y olds in the US suggest
that awareness of weight problems may be particularly
low for this child age group.
5
The present study aimed
to explore the generalisability of this finding to a socio-
economically diverse sample of parents of 3–5 y olds in the
UK. We also assessed concern about the child becoming
overweight in the future, as a more subtle index of parental
awareness.
Subjects and methods
In all, 16 state-funded primary schools with nursery and
reception classes (3–5 y) in outer London were recruited to
represent a range of socioeconomic backgrounds. Socio-
economic deprivation was operationalised by the proportion
of pupils in each school who were eligible for free school
meals (a government benefit given to lower income
families). A total of 1082 3–5 y olds were present on the
days of data collection. Trained researchers weighed and
measured the children in class after removing shoes and any
outside clothing (eg coats). A questionnaire was distributed
to parents assessing attitudes towards their child’s weight
and eating, basic demographic information, and their own
weight and height. Measures of parental feeding styles were
also included and will be discussed in future work. Two
rounds of reminder questionnaires were sent to increase
response rates.
Parents’ appraisal of their child’s weight was assessed
with the question: ‘How would you describe your
child’s weight at the moment? (very underweight, under-
weight, normal, overweight or very overweight)’, and
concern about future weight with: ‘How concerned are you
about your child becoming overweight in the future?
(unconcerned, a little concerned, concerned, fairly con-
cerned, very concerned)’.
Received 24 June 2004; revised 9 October 2004; accepted 4 November
2004
*Correspondence: Professor J Wardle, Cancer Research UK Health
Behaviour Unit, Department of Epidemiology and Public Health,
University College London, Gower Street, London WC1E 6BT, UK.
E-mail: j.wardle@ucl.ac.uk
International Journal of Obesity (2005) 29, 353355
&
2005 Nature Publishing Group All rights reserved 0307-0565/05
$
30.00
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We calculated body mass index (BMI) using weight (kg)/
height (m)
2
. Children’s weight and height centiles were
based on 1990 UK reference curves.
6
International Obesity
TaskForce cutoffs were used to generate weight status
categories.
7
Ethical approval was obtained from the Joint
University College London/University College London
Hospital Ethics Committee.
Results
Overall, parental response rate was 52% (n ¼ 564), but varied
from 16 to 80%, with lower rates in schools with higher
proportions of pupils receiving free school meals and for
whom English was not the first language. Average parental
age was 34.9 y, 94.5% of respondents were mothers, 72.7%
were white, and 10.5% had no educational qualifications.
Table 1 gives child and parent characteristics together with
data on weight perceptions and concern by child weight
status category. In total, 501 parents gave their own weights
and heights, which put 26.9% in the overweight category
and an additional 8.8% in the obese category. In line with
current UK population data,
8
18.4% of children were over-
weight and an additional 7.3% obese. There were no
differences in height and weight between children whose
parents returned (M ¼ 16.6, s.d. 1.88) or did not return
(M ¼ 16.5, s.d. 2.03) the questionnaire (t ¼1.36, df 1080,
P ¼ 0.18).
Only 1.9% (2/104) of parents with overweight children
and 17.1% (7/41) of those with obese children described
their child as overweight. No parent described their child as
‘very overweight’. Logistic regression showed that the odds
of the child being perceived as overweight were higher for
overweight (2.7; 95% CI 0.5, 16.5) and obese (28.6; 7.1,
115.4) children compared with normal weight children.
Perception of overweight was not associated with the child’s
age or sex, or with the parent’s age, weight status, educa-
tional level, or ethnicity. Adjustment for these demographic
factors did not change the results.
Almost two thirds (62.5%) of parents with overweight
children and three quarters (75.6%) of those with obese
children, compared with 40.1% of parents with normal
weight children, expressed concern about their child
becoming overweight in the future. The odds of parents
being concerned were higher in overweight (2.5; 1.6–3.9)
and obese children (4.6; 2.2–9.7). Additionally, odds were
higher for parents who were overweight (1.9; 1.2–2.9) or
obese (2.5; 1.3–4.9) themselves. There were no significant
associations with other demographic factors, and adjust-
ment for these factors did not affect the results.
Discussion
Although 145 children were classified as overweight or obese
using the IOTF reference data, only nine (6%) of their
parents described them as ‘overweight’ and none described
them as ‘very overweight’. Odds of classification as over-
weight were increased for heavier children, but the over-
whelming majority of parents of overweight or obese
children (94%) did not classify them correctly. Misclassifica-
tion was markedly higher than in two large surveys in the
US.
2,5
One source of this discrepancy might be our use of
IOTF cutoff points, which assign a greater proportion of
children to the overweight group than some other methods,
thus increasing the likelihood of misclassification by
mothers. However, using the same cutoff point as other
studies did not significantly increase accuracy in perception:
only 9% (8/85) of mothers with children over the 95th
percentile for BMI classified them as overweight, compared
Table 1 Child and parent characteristics by child weight status (IOTF criteria)
a
Child weight status
Normal weight (n ¼ 419) Overweight (n ¼ 104) Obese (n ¼ 41)
Child
Age (y) 4.4 (4.3–4.4) 4.3 (4.2–4.5) 4.4 (4.3–4.6)
BMI (kg/m
2
) 15.8 (15.7–15.9) 18.1 (18.0–18.2) 21.2 (20.5–21.9)
BMI centile 53.5 (51.1–55.8) 93.9 (93.3–94.6) 99.6 (99.4–99.7)
Weight (kg) 17.7 (17.5–17.9) 20.9 (20.4–21.4) 25.7 (24.2–27.2)
Weight centile 56.0 (53.5–58.5) 89.7 (87.2–92.2) 98.5 (97.6–99.4)
Height (cm) 105.7 (105.2–106.3) 107.2 (106.0–108.5) 109.8 (107.7–111.9)
Height centile 55.6 (52.9–58.4) 68.4 (63.3–73.5) 76.3 (69.5–83.1)
Parent
Age (y)
b
35.0 (34.5–35.6) 34.5 (33.4–35.6) 34.9 (32.9–36.9)
BMI (kg/m
2
)
b
23.7 (23.3–24.1) 26.4 (25.6–27.3) 26.3 (24.5–28.1)
% white 74.3 (69.7–78.5) 72.6 (62.8–80.9) 56.4 (39.6–72.2)
% no educational qualifications 9.5 (6.8–12.7) 14.7 (8.5–23.1) 10.3 (2.9–24.2)
% perceiving child as overweight 0.7 (0.1–2.1) 1.9 (0.2–6.8) 17.1 (7.2–32.1)
% concerned child will become overweight 40.1 (35.4–45.0) 62.5 (52.5–71.8) 75.6 (59.7–87.6)
a
Values are mean (95% CI) for child and parent age and anthropometrics, and percentages (95% CI) for frequency data.
b
Age data were missing in 13 cases and
parent BMI in 63 cases. Means use data from the remaining parents.
Parental perceptions of overweight
S Carnell et al
354
International Journal of Obesity
with 67% in Maynard et al’s
2
sample and 29% in Baughcum
et al’s
5
sample. Another explanation for our lower rates
might be differences in samples. Maynard et al assessed
mothers with children of a much wider age range (2–11 y),
and Baughcum et al recruited over half of their families from
paediatric clinics participating in WICFa program that
supplies supplemental food and nutrition counselling to
low-income women and their children. Each of these
samples might be expected to display higher awareness than
parents of 3–5 y olds drawn from community primary
schools.
There are some limitations to our study design. The
generalisability of our results is limited by the response rate
to the parental questionnaire, but the similarity in children’s
BMI between respondents and nonrespondents makes it
unlikely that there was a response bias related to the child’s
weight. Even if the parents of overweight children among
the nonresponders were better aware of their children’s
weight status, the results would still represent considerable
lack of awareness overall. Our sample was more ethnically
diverse and more educated than UK population averages, but
nevertheless broadly representative of the urban areas from
which we recruited.
Notwithstanding the limitations, the results indicate a
notable lack of awareness in UK parents of overweight 3–5 y
olds about their children’s weight status. This appears to be
equally evident across all levels of parental education,
ethnicity and weight, and for both male and female
children. The finding may reflect a general shift in parents’
perceptions of what constitutes a ‘normal weight’ child,
following recent population increases in the prevalence of
overweight. Alternatively, parents may hold distorted per-
ceptions unique to their child, while still being capable of
recognising overweight in other children. It is also possible
that parents are privately aware of their child’s weight
problem, but reluctant to acknowledge it, particularly within
the context of a parental feeding survey.
The lack of awareness may be particularly evident for 3–5 y
olds because the prevailing health message to mothers of
young children is to encourage growth and keep pace with
centile charts. Results from a qualitative study of low-income
mothers in the US suggest that heaviness may be viewed as a
reflection of inherited build, or even as an indicator of good
health. Mothers may put greater emphasis on other factors
such as physical activity and social participation, when
deciding if their child is overweight.
9
While the extent of parents’ failure to categorise their
children’s weight according to medically defined definitions
of overweight is noteworthy, it may be unreasonable to
expect lay definitions to coincide with those of health
professionals. The lack of awareness is only important to the
extent that it affects parents’ engagement with weight
control for their children. Despite describing their children
as normal weight, two thirds of parents of overweight/obese
children expressed concern about their child becoming
overweight in the future. It is possible that a normative
tendency to choose the mid-point of a scale inflated scores
on the unipolar concern scale relative to the bipolar
perceived weight scale. However, there was little evidence
for this, with over half of parents indicating they were
‘unconcerned’ about their child becoming overweightFthe
lowest possible score on the scale.
Data on parental height and weight were self-report only
and therefore will underestimate BMI. However, the ordering
of BMI within the distribution is likely to be approximately
correct, and logistic regression demonstrated that concern
was more likely if parents were heavier themselves. This
indicates some awareness of a potential or current weight
problem, particularly among overweight parents. It suggests
that reframing discussions of weight in terms of preventing
future overweight rather than tackling current overweight
might be a way to engage parents while avoiding the stigma
of parental blame. Alternatively, greater use of school- and
community-wide interventions would eliminate the need to
raise the potentially sensitive issue of a particular child’s
weight, and would have the added advantage of promoting
healthy eating and exercise patterns in currently normal
weight children who may go on to become overweight.
Acknowledgements
The research was funded by the Medical Research Council
and Cancer Research UK.
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Parental perceptions of overweight
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International Journal of Obesity
    • "Similar to the Akinbami and Ogden study that showed larger differences between obesity estimates based on parent-reported versus interviewer-measured height and weight for Black and Mexican-American children than nonHispanic White children [4] , we found larger differences for Blacks, Latinos, and Asians than for nonHispanic Whites in prevalence of obesity, but not overweight/obesity, based on parent-reported and EHR data. Despite this overestimation of BMI from height and weight reports, a majority of our parents did not recognize that their child was overweight, consistent with the findings of other studies21222324. We found that this misperception was greater for younger than older children, but did not appear to differ by race or ethnicity . "
    [Show abstract] [Hide abstract] ABSTRACT: There is conflicting evidence about the accuracy of estimates of childhood obesity based on parent-reported data. We assessed accuracy of child height, weight, and overweight/obesity classification in a pediatric clinic population based on parent data to learn whether accuracy differs by child age and race/ethnicity. Parents of patients ages 3-12 (n = 1,119) completed a waiting room questionnaire that asked about their child's height and weight. Child's height and weight was then measured and entered into the electronic health record (EHR) by clinic staff. The child's EHR and questionnaire data were subsequently linked. Accuracy of parent-reported height, weight, overweight/obesity classification, and parent perception of child's weight status were assessed using EHR data as the gold standard. Statistics were calculated for the full sample, two age groups (3-5, 6-12), and four racial/ethnic groups (nonHispanic White, Black, Latino, Asian). A parent-reported height was available for 59.1% of the children, weight for 75.6%, and weight classification for 53.0%. Data availability differed by race/ethnicity but not age group. Parent-reported height was accurate for 49.2% of children and weight for 58.2%. Latino children were less likely than nonHispanic Whites to have accurate height and weight data, and weight data were less accurate for 6-12 year than 3-5 year olds. Concordance of parent- and EHR-based classifications of the child as overweight/obese and obese was approximately 80% for all subgroups, with kappa statistics indicating moderate agreement. Parent-reported data significantly overestimated prevalence of overweight/obesity (50.2% vs. 35.2%) and obesity (32.1% vs. 19.4%) in the full sample and across all age and racial/ethnic subgroups. However, the percentages of parents who perceived their child to be overweight or very overweight greatly underestimated actual prevalence of overweight/obesity and obesity. Missing data did not bias parent-based overweight/obesity estimates and was not associated with child's EHR weight classification or parental perception of child's weight. While the majority of parents of overweight or obese children tend to be unaware that their child is overweight, use of parent-reported height and weight data for young children and pre-teens will likely result in overestimates of prevalence of youth overweight and obesity.
    Full-text · Article · Dec 2015
    • "Parents of younger children tend to underestimate the degree of overweight and have less concern about their child's weight relative to parents of older children [3]. In one study, only 1.9% and 17.1% of overweight and obese children, respectively, perceived their child as overweight [7]. Similarly, mothers of young children incorrectly perceived their overweight or obese children to be " about the right weight " 93.6% and 77.5% of the time, respectively [8]. "
    [Show abstract] [Hide abstract] ABSTRACT: Perception of weight by parents of obese children may be associated with willingness to engage in behavior change. The relationship between parents’ perception of their child’s weight and their health beliefs and practices is poorly understood, especially among the Hispanic population which experiences disparities in childhood obesity. This study sought to explore the relationship between perceptions of weight and health beliefs and practices in a Hispanic population. Methods. A cross-sectional, mixed-methods approach was used with semistructured interviews conducted with parent-child (2–5 years old) dyads in a primarily Hispanic, low-income population. Parents were queried on their perceptions of their child’s health, health practices, activities, behaviors, and beliefs. A grounded theory approach was used to analyze participants’ discussion of health practices and behaviors. Results. Forty parent-child dyads completed the interview. Most (58%) of the parents of overweight and obese children misclassified their child’s weight status. The qualitative analysis showed that accurate perception of weight was associated with internal motivation and more concrete ideas of what healthy meant for their child. Conclusions. The qualitative data suggest there may be populations at different stages of readiness for change among parents of overweight and obese children, incorporating this understanding should be considered for interventions.
    Full-text · Article · Sep 2015
    • "Parental assessment of their child's weight status a) questionnaire item: 'How would you describe your child's weight at the moment?' (underweight, healthy weight, overweight, very overweight) [39]. b) visual analogue scale which consists of a 10 cm line with ends labelled 'extremely underweight' and 'extremely overweight'. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Parents typically do not recognise their child’s weight status accurately according to clinical criteria, and thus may not take appropriate action if their child is overweight. We developed a novel visual intervention designed to improve parental perceptions of child weight status according to clinical criteria for children aged 4–5 and 10–11 years. The Map Me intervention comprises age- and sex-specific body image scales of known body mass index and supporting information about the health risks of childhood overweight. Design This cluster randomised trial will test the effectiveness of the Map Me intervention. Primary schools will be randomised to: paper-based Map Me; web-based Map Me; no information (control). Parents of reception (4–5 years) and year 6 (10–11 years) children attending the schools will be recruited. The study will work with the National Child Measurement Programme which measures the height and weight of these year groups and provides feedback to parents about their child’s weight status. Before receiving the feedback, parents will complete a questionnaire which includes assessment of their perception of their child’s weight status and knowledge of the health consequences of childhood overweight. The control group will provide pre-intervention data with assessment soon after recruitment; the intervention groups will provide post-intervention data after access to Map Me for one month. The study will subsequently obtain the child height and weight measurements from the National Child Measurement Programme. Families will be followed-up by the study team at 12 months. The primary outcome is any difference in accuracy in parental perception of child weight status between pre-intervention and post-intervention at one month. The secondary outcomes include differences in parent knowledge, intention to change lifestyle behaviours and/or seek advice or support, perceived control, action planning, coping planning, and child weight status at 12 month follow-up. Discussion The Map Me tool has potential to make a positive impact on children’s health at a population level by introducing it into current intervention programmes to improve accuracy of parental perception of child’s weight status. This trial will inform the action of researchers, educators, health professionals and policy makers. Trial registration Current Controlled Trials ISRCTN91136472. Registered 3 May 2013
    Full-text · Article · Jun 2015
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