Are parents aware that their children are overweight or obese?

Abstract

OBJECTIVE

To compare children’s actual weight status with their parents’ perceptions of their weight status.

DESIGN

Cross-sectional study, including a self-administered questionnaire.

SETTING

Seven elementary schools in Middlesex-London, Ont.

PARTICIPANTS

A convenience sample of pupils in grades 4 to 6 and their parents. Of the 770 child-parent pairs targeted, 355 pairs participated in the study.

MAIN OUTCOME MEASURES

Children’s weight, height, and body mass index (BMI). Parents’ perceptions of their children’s weight status, family demographics, and parents’ self-reported body weight and height. The United States Centers for Disease Control’s BMI-for-age references were used to define children’s weight status (underweight, overweight, or obese).

RESULTS

Response rate was 46%. Children’s actual weight status (ie, 29.9% overweight or obese and 1.4% underweight) was different from their parents’ perceptions of their weight status (ie, 18.3% overweight or obese and 17.2% slightly underweight or underweight). Factors suchas children’s sex and ethnicity and mothers’ weight influenced parents’ ability to recognize their children’s weight status. Parents’ misperceptions of their children’s weight status seemed to be unrelated to their levelsof education, their family income, or their children’s ages.

CONCLUSION

A large proportion of parents did not recognize that their children were overweight or obese. Effective public health strategies to increase parents’ awareness of their children’s weight status could be the first key steps in an effort to prevent childhood obesity.

Pediatric obesity has been identified as a growing problem in Canada and many countries worldwide.^1–5 The importance of this emerging trend is the connection between pediatric obesity, type 2 diabetes, hyperlipidemia, hypertension, and adult obesity.^6–9 Given the risk of development of severe health consequences and the heavy burden on the health care system, effective prevention targeting children and their parents is the key to combating this health problem.¹⁰

Making parents aware that obesity is a health problem might be the first step in promoting a healthy lifestyle and a healthy body weight among school-aged children. Although there is no direct evidence that increasing parents’ awareness of children’s weight problems would prevent overweight and obesity in children, there is evidence that parents’ awareness and monitoring can prevent risky behaviour among children and adolescents.¹¹

Parents who do not recognize weight problems in their children are less likely to take steps to change their children’s unhealthy lifestyles and to prevent obesity. Studies from other countries have shown that parents are neither concerned about nor sensitive to their children’s overweight or obese status.^12–16 Little on childhood obesity has been reported in a Canadian context. As part of a multi-pronged study, this paper reports on parents’ awareness of their children’s overweight and obese status.

METHODS

This cross-sectional study targeted a convenience sample of children from 7 elementary schools located in diverse socioeconomic areas in the city of London and the County of Middlesex in Ontario. A desirable sample size of 384 subjects was calculated using a statistical formula for descriptive studies with dichotomous variables with a margin of error of 5% (95% confidence level).¹⁷

Participants were recruited through public health nurses in the schools who approached school principals and asked them whether they would volunteer to participate. Seven of 13 schools consented. All children in grades 4 to 6 and their parents were invited to participate in the study. Data were collected between 2001 and 2003.

The study was approved by the Brescia University College Research Ethics Board for Studies Involving Human Subjects. Written consent was obtained from parents before data collection.

Children’s weight and height were measured by trained personnel using standardized procedures.¹⁸ The age- and sex-specific body mass index references from the United States Centers for Disease Control were used to classify children’s weight status.¹⁹

Body mass index criteria²⁰

Underweight	<5th percentile
Normal weight	5th-85th percentile
Overweight	85th–95th percentile
Obese	>95th percentile

A self-administered questionnaire for parents was sent home with the children and returned by them to classroom teachers. Two questions that specifically asked parents about their perceptions of their children’s weight status were adopted and modified from Baughcum et al.²¹ The first question was “Compared with other children the same age, do you feel your child is underweight, slightly underweight, about the right weight, overweight, or obese?” The second question, “How much are you concerned about your child becoming overweight?” had 5 answer options: unconcerned, a little concerned, concerned, fairly concerned, and very concerned. The questionnaire also asked about socioeconomic status (parents’ education levels, employment, family structure, and family income) and parents’ self-reported body weight and height. The questionnaire was pilot-tested on 15 parents of school-aged children for readability and clarity. Due to funding constraints, its reliability and validity were not tested.

Data were analyzed using SPSS 13.0 for Windows. Measured rates and parents’ perceived rates of overweight and obesity were recorded. Because only a relatively small number of parents perceived their children as being slightly underweight or underweight, we combined these 2 categories into “underweight.” The rate at which parents wrongly classified their children’s weight status was calculated and presented with percentages and 95% confidence intervals by measured weight category. Logistic regression analysis was done to determine the influence of socioeconomic status, parents’ own overweight or obese status, and children’s sex on parents’ ability to accurately identify their children’s weight status.¹⁷

RESULTS

Study sample

Of the 770 pairs of children and parents targeted, 487 children and 406 parents participated. We had complete data on 355 pairs. Mothers filled out 87% of the questionnaires. Table 1 shows study subjects’ characteristics.

Table 1.

Characteristics of study subjects (N = 355^*)

DEMOGRAPHIC PROFILE	N	%
Children’s age (y)
• 9	124	34.9
• 10	115	32.4
• 11	102	28.7
• 12	14	3.9
Children’s sex
• Boys	198	55.8
• Girls	157	44.2
Family structure
• Two-parent families	302	85.1
• Single-parent families	53	14.9
Parents’ education levels
• Mothers’ education at university or above	244	68.7
• Fathers’ education at university or above	217	61.1
Annual family income
• <$23 000	16	4.5
• $23 001–$38 999	39	11.0
• >$39 000	281	79.2
• Missing value	19	5.4
Race or ethnicity
• White	301	84.8
• Non-white	54	15.2
Parents’ weight status
• Overweight mothers (BMI ≥ 25)	93	31
• Overweight fathers (BMI ≥ 25)	205	69.7
Parents’ concerns about children’s weights
• A little concerned	89	25.3
• Concerned to very concerned	81	22.8

^*N does not always equal 355 owing to missing data.

Parents’ perceptions and children’s actual weight categories

Figure 1 shows that children’s actual weight categories were statistically different from parents’ perceptions of them. Parents were more likely to perceive their children as being underweight than as being obese. Figure 2 shows that 22% of parents wrongly classified their normal-weight children as underweight, 63% considered their overweight children as normal weight, and 63% perceived their obese children as overweight. Parents tended to underestimate their children’s weight. About 26% of parents of overweight children and 15% of parents of obese children were not concerned about their children’s weight.

Figure 1.

Children’s weight categories by measured BMI and parents’ perceptions

Figure 2. Parents’ misclassification rate by measured weight categories.

X-axis is the children’s actual measured weight status. Y-axis is the parents’ misconception of their children’s weight status. For example, 22% of normal-weight children were perceived as underweight by their parents, 63% of overweight children were perceived as about the right weight by their parents, and 63% of obese children were perceived as overweight by their parents.

Factors associated with parents’ misperceptions of children’s weight status

In total, 62% of parents accurately classified their children’s weight. Logistic regression analysis showed that children’s sex, race and ethnicity, and mothers’ overweight status were associated with parents’ inability to categorize their children’s weight status accurately (Table 2). Parents were more likely to have incorrect perceptions of their boys’ weight than their girls’ weight. More white parents than non-white parents were able to identify their children’s weight categories accurately. Overweight mothers tended to be less aware of their children’s overweight status than normal-weight mothers were. Parents’ misperceptions of their children’s weight status were not associated with parents’ education levels, family income, or children’s age.

Table 2.

Predictors of parents’ accuracy in identifying children’s weight classification^*

FACTORS	N	ODDS RATIO	95% CONFIDENCE INTERVAL	P
Children’s sex				<.05
• Girls	157	1.73	1.02–2.85
• Boys	198	1.00	reference
Children’s race or ethnicity				<.05
• White	301	2.09	1.02–2.69
• Non-white	54	1.00	reference
Mothers’ weight status				<.05
• Normal weight (BMI < 25)	200	1.60	0.95–2.69†
• Overweight or obese (BMI ≥ 25)	89	1.00

BMI—body mass index.

^*Logistic regression model using backward stepwise method (Wald test). Dependent variable: accuracy of parents’ ability to classify children’s weight categories. Independent variables: children’s sex, age, and race; mother’s and father’s education levels; family income, mother’s weight status, and respondent’s relationship to the child (ie, mother, father, or other).

^†Confidence intervals are based on the Wald test.

DISCUSSION

This study confirms that a sample of Canadian parents did not recognize their children’s overweight or obese status. Parents were overly concerned about children being underweight, but not about them being overweight. Overall, 38% of parents were not able to identity their children’s weight categories accurately.

Studies have shown that pediatric obesity is prevalent in North America and many other countries.^22–24This study confirmed that many parents did not even recognize that their children were overweight and, as shown in other studies, tended to be unconcerned about the issue.^{13,14,21,25–27} Parents did not perceive their children as being overweight, as long as “they are active and have a healthy diet and good appetite.”²⁵ Qualitative research has indicated that parents, especially those from low-income families, describe overweight children as “solid” or “thick” rather than fat.²⁵

Although the reasons why parents misperceive their children’s weight status are not fully understood, we found that 3 factors were associated with their misperceptions. First, in line with the literature,^13,21,26 parents were less likely to think their boys were overweight than to think their girls were overweight. This could be because parents pay more attention to girls’ body image than to boys’ body image. Societal norms about the ideal weight for boys and girls might also have a role. One study showed that boys themselves tended to select substantially larger body-size silhouettes than girls did when choosing an ideal adult body size.²⁸

Second, the likelihood of misclassifying weight status seemed to be higher among non-white parents than among white parents in our study, although this influence of race or ethnicity was not detected by other researchers.^21,26 A qualitative study showed that Latin-American women considered thinness more worrisome than fatness in children²⁹ and preferred their children to be plumper.³⁰ The limited sample size in our study did not allow comparisons among various non-white ethnic groups. Further study with a larger and more diverse sample might help identify which specific ethnic groups are more likely to misperceive their children’s weight status.

Third, our study further confirms that overweight mothers were less aware of their children’s excess weight problems than normal-weight mothers were.²¹ Low parental education levels and low family income have been found to increase the odds of misperceiving weight problems, although results of studies are conflicting on this point.^12,21,25,26 In our study, education and income levels were not associated with parents’ accuracy in identifying their children’s weight status.

Since the health-related behaviour of school-aged children remains largely under the influence and control of their parents,^31,32 it is unlikely we can effectively address the increasing childhood obesity epidemic without parents’ awareness and understanding of its health consequences. From a public health standpoint, we need a mass media campaign to help the community at large to recognize this major public health problem. Efforts should be made to reach non-white and overweight parents specifically. The campaign should also draw parents’ attention to boys’ excess weight issues.

In Canada’s universal primary health care system,^33–35 family physicians and community pediatricians are the front-line health professionals seeing overweight children on a day-to-day basis. Health care professionals should be made aware of the potentially higher odds of misperceptions of their children’s weight status among non-white or overweight parents, as well as parents’ insensitivity to their sons’ weight problems. Plourde³⁶ recently recommended that Canadian physicians assess children’s and parents’ “stage of change” when counseling obese children. Effective but inoffensive strategies should be developed in primary health care settings to help parents recognize their children’s weight problems. Parents’ awareness and active involvement is key to family-oriented lifestyle changes, an essential step in pediatric weight management. In addition, education is needed for parents who perceive their normal-weight children as underweight, as their misperceptions could lead to overfeeding these children.

Limitations

This study surveyed a convenience sample of children in 7 elementary schools in just the Middlesex-London area, which might limit the generalizability of its results. Second, as all children in grades 4 to 6 were studied, there might be cluster effects on the outcome measures. Third, although 62% of children and 52% of parents participated in the study, we had complete data on only 46% of parent-child pairs. The provincial privacy protection act would not allow us access to socioeconomic information on nonrespondents, so we were unable to determine whether there were differences between respondents and nonrespondents. There might have been a self-selection bias that would further undermine the generalizability of the study findings. Nonetheless, our results suggest that, as in other countries, Canadian parents are unconcerned about their school-aged children being overweight or obese.^12–16

Conclusion

This study highlights the need for future research to explore effective strategies for helping busy physicians increase parents’ awareness of their children’s overweight and obese status and promote a healthy body weight for all children. Increasing parents’ awareness of their children’s weight problems is the first step in preventing pediatric obesity.

EDITOR’S KEY POINTS

• Helping parents to recognize their children’s weight status and to be aware that overweight and obesity are health problems could be the first step in promoting a healthy lifestyle and a healthy body weight among school-aged children.

• Studies from other countries have shown that parents are unconcerned and even unaware that their children are overweight or obese.

• This study confirms that a sample of Canadian parents did not recognize their children were overweight or obese: 22% of parents wrongly classified their normal-weight children as being underweight; 63% considered their overweight children as normal weight; and 63% perceived that their obese children were overweight.

POINTS DE REPÈRE DU RÉDACTEUR

• Un premier pas dans la promotion d’un mode de vie sain et d’un poids de santé chez les enfants d’âge scolaire pourrait être d’apprendre aux parents à bien évaluer la condition pondérale de leurs enfants et à prendre conscience que le surpoids et l’obésité constituent des problèmes de santé.

• Des études dans d’autres pays ont montré que les parents se préoccupent peu que leurs enfants souffrent de surpoids ou d’obésité ou l’ignorent.

• Cette étude confirme qu’un échantillon de parents canadiens ne reconnaissaient pas que leurs enfants souffraient de surpoids ou d’obésité: 22% d’entre eux croyaient à tort que leurs enfants de poids normal étaient trop maigres; 63% jugeaient que leurs enfants avec surpoids avaient un poids normal; et 63% que leurs enfants obèses avaient un simple surpoids.