Abstract
Objective
Recent public health and media attention on child obesity may have altered accuracy of self-perception of obesity and associated weight control behaviors in children and adolescents. Thus, we examined whether accuracy of weight perceptions were associated with weight loss behaviors.
Study design
We examined children 8–15 year olds in the National Health and Nutrition Examination Survey (2005–2010) who reported themselves as: “overweight/too fat,” “about right,” or “underweight/too thin.” Children reported on efforts to lose weight and engagement in specific weight control behaviors, including how frequently he/she had “been on a diet, starved, cut back on eating, skipped meals, or exercised” to lose weight. We categorized obesity based on measured BMI, and determined accuracy of weight perceptions. We used chi-squared tests to examine age- and sex-based differences in accuracy of perceptions and relationship to weight loss behaviors.
Results
Girls and older children more accurately perceived weight status. Both girls and boys of all ages who perceived themselves as overweight were more likely to engage in weight loss behaviors. Children who were overweight engaged in more weight loss behaviors than healthy weight children perceiving themselves as overweight. Among children who reported themselves as “about right,” overweight children engaged in more weight loss behaviors than healthy weight children but less so than those who accurately perceived being overweight.
Conclusions
The perception of being overweight and actual overweight status are both strongly associated with weight loss behaviors. These findings have important implications for counseling patients who may have inaccurate weight perceptions.
Keywords: weight perceptions, obesity, weight control behaviors, sex differences
Introduction
Prior reports have called attention to adolescents’ perception of themselves as overweight when they are healthy weight.1,2 As the prevalence of overweight and obesity among US children and adolescents has almost tripled over the past three decades, concern about weight has shifted towards obesity. Mass media and public health efforts have focused more on the obesity epidemic, and the importance of recognizing and addressing it. Recognition of obesity may be a necessary, though not sufficient step in addressing childhood and adolescent obesity, as weight perception may be an important predictor of weight control behaviors.3,4
It would seem that the recent public focus on obesity might mean that more overweight children and adolescents are able to recognize themselves as overweight or obese, and as a result, may be making dietary and physical activity changes. While some recent studies have, indeed, found that children and adolescents are able to recognize obesity in themselves,2,4 other studies have shown that many adolescents still do not accurately perceive their overweight or obese status.5,6 However, many of the prior studies have used self-reported height and weight to classify weight status and accuracy of weight perceptions, which generally underestimates actual weight status.7–10
Perception of being overweight has been shown to promote both healthy and unhealthy weight control behaviors, for both healthy weight and overweight/obese adolescents, and inaccurate perception of being overweight in healthy weight adolescents result in unnecessary weight control behaviors.2,11,12 However, correct perceptions among overweight children appear to be associated with attempts to lose weight or with weight control activities like exercising to lose weight.4,13,14 Prior work has revealed that girls are more likely to overestimate their weight, and that overweight/obese girls are more accurate in weight perception than overweight/obese boys.15 Racial differences also exist for accuracy of weight perception with African Americans being less likely to overestimate their weight compared to whites and Asian Americans being more likely to underestimate their weight versus whites.15 To date, most studies have focused on adolescents, and none has examined a recent, nationally representative sample of both children and adolescents to examine the relationships between weight perceptions and weight control behaviors using objectively measured height and weight.
The goal of this study was to examine how children and adolescents perceive their weight status, compared to their actual measured weight status. Additionally, we aimed to examine how these perceptions are associated with weight loss efforts and behaviors. We stratified the sample by sex and age groups to determine if there are differences in accuracy of perception and weight loss behaviors in boys versus girls and in younger children versus adolescents.
Methods
Data
We examined data from the National Health and Nutrition Examination Survey (NHANES), 2005–2010. NHANES is a cross-sectional, stratified, multistage probability sample of the United States’ population. It consists of a detailed questionnaire, physical examination, and laboratory analyses.
Beginning in 2005–2006 and continuing through the study period, a “weight history” component was included for children aged 8–15 years. In this computer-assisted questionnaire, children responded to questions about how they perceived their current weight, what efforts they were making to manage their weight, and about specific weight-management behaviors. We included all children and adolescents (N=4355) who completed the weight history component from 2005–2010.
Measures
Obesity
Height and weight were measured as part of the NHANES physical examination component.16 Height and weight were recorded at standardized mobile examination centers with a digital scale and wall-mounted stadio-meter with socks and lightweight examination gowns. Weight was measured to the nearest 0.1 kilogram and height was measured to the nearest millimeter. We calculated body mass index (BMI) percentiles according to current Center for Disease Control and Prevention growth charts.17,18 We classified children using standard definitions: underweight, <5th percentile; healthy weight, ≥5th to <85th percentile; overweight, ≥85th to <95th percentile; and obese, ≥95th percentile.18
Weight perceptions
Children were asked, “Do you consider yourself now to be…?” Available responses were “fat or overweight,” “about the right weight,” and “too thin.” In order to compare weight perceptions to actual weight, we collapsed the two highest weight categories (≥85th percentile representing overweight and obesity) into a single category. We then identified children as having over-reported (i.e. reported that they were overweight when actual BMI was at a healthy weight), correctly reported, or underreported (i.e. reported that they were about right when their measured weight was >85th percentile).
Weight-control behaviors
Children were asked to report what they were currently trying to do about their weight: lose weight, gain weight, maintain their weight, or nothing. Children were asked how often they had tried to lose weight in the past year: never, sometimes, or often. Those reporting that they “sometimes or often” attempted to lose weight were then asked how frequently they had engaged in the following behaviors to lose weight: been on a diet, starved, cut back on eating, skipped meals, and exercised.
Demographics
We categorized children as non-Hispanic white, non-Hispanic black, Hispanic, or “other race.” Income was calculated based on reported household income as a percentage of the federal poverty level. We separated boys and girls in all analyses. Finally, we stratified participants into two age groups: ages 8–11 years and ages 12–15 years since we were interested in whether there are differences by age groups in accuracy of weight perception and in associated weight loss behaviors.
Statistical analyses
We examined weight perceptions and accuracy of perceptions by measured BMI category using cross-tabs and tested for differences using an adjusted Wald test. We then examined differences in reported behaviors by measured weight, perceived weight, and accuracy of weight perceptions. All analyses were statistically weighted and adjusted for the complex survey design of NHANES and performed using Stata 12.0 (College Station, TX). This study was exempted from human subjects review by the University of North Carolina Office of Human Research Ethics IRB Review Board (IRB #12-2164).
Results
Sample Characteristics
Each of the age groups had similar number of boys and girls (1118 vs. 1050 girls and 1096 vs. 1091 boys for 8–11 year olds and 12–15 year olds respectively). The age groups were similar by race/ethnicity and had approximately 55–60% Non-Hispanic Whites, 13–15% Non-Hispanic Blacks, and 18–21% Hispanics (Table 1). There were no significant differences by sex for either age groups. There were no sex differences in measured BMI or for weight perceptions and accuracy of weight perception for younger children. However, there were differences by sex for perceived weight category and accuracy of weight perception for older children. Older overweight boys were less likely than older overweight girls to perceive themselves as overweight. Older boys were also less likely than older girls to correctly perceive their weight status.
Table 1.
Descriptive statistics by age and sex1
| N=4355 | Ages 8–11 (n=2214) | Ages 12–15 (n=2141) | ||||
|---|---|---|---|---|---|---|
| Girls | Boys | p | Girls | Boys | p | |
| n | 1118 | 1096 | 1050 | 1091 | ||
| Race/Ethnicity | ||||||
| Non-Hispanic White | 55.2 | 58.7 | 0.519 | 59.8 | 59.9 | 0.572 |
| Non-Hispanic Black | 15.0 | 13.2 | 14.7 | 13.3 | ||
| Hispanic | 20.7 | 19.6 | 18.6 | 18.4 | ||
| Other | 9.1 | 8.6 | 7.0 | 8.5 | ||
| Income | ||||||
| <100% Federal Poverty Level (FPL) | 23.5 | 20.6 | 0.093 | 19.3 | 20.8 | 0.206 |
| 100–199% FPL | 24.3 | 21.9 | 22.1 | 20.3 | ||
| 200–299% FPL | 14.0 | 18.1 | 19.0 | 14.6 | ||
| 300–399% FPL | 15.1 | 11.9 | 11.7 | 13.4 | ||
| 400–499% FPL | 9.5 | 11.5 | 8.9 | 12.2 | ||
| >500% FPL | 13.7 | 16.1 | 19.0 | 18.8 | ||
| Measured Weight Status | ||||||
| Overweight/obese (>85th percentile) | 34.8 | 36.6 | 0.750 | 36.7 | 32.9 | 0.260 |
| Healthy Weight (5–85th percentile) | 62.1 | 60.7 | 60.3 | 62.5 | ||
| Underweight (<5th percentile) | 3.1 | 2.7 | 3.1 | 4.6 | ||
| Perceived Weight Status | ||||||
| Overweight | 16.1 | 14.7 | 0.535 | 24.5 | 15.3 | <0.0001 |
| About Right | 77.3 | 77.5 | 70.1 | 75.5 | ||
| Underweight | 6.6 | 7.8 | 5.4 | 9.2 | ||
| Accuracy of Perception | ||||||
| Underestimates | 25.3 | 30.1 | 0.124 | 20.1 | 25.7 | 0.027 |
| Correct | 71.4 | 66.1 | 74.2 | 70.8 | ||
| Overestimates | 3.4 | 3.8 | 5.7 | 3.5 | ||
| Currently trying to do about weight: | ||||||
| Lose | 31.7 | 30.7 | <0.0001 | 40.3 | 25.6 | <0.0001 |
| Gain | 7.0 | 13.9 | 5.0 | 18.9 | ||
| Stay the same | 27.7 | 27.2 | 26.3 | 24.5 | ||
| Nothing | 33.6 | 28.1 | 28.4 | 31.0 | ||
| How often tried to lose weight: | ||||||
| Never | 49.5 | 48.0 | 0.562 | 47.7 | 62.5 | <0.0001 |
| Sometimes | 41.5 | 41.6 | 41.9 | 29.7 | ||
| A lot | 9.0 | 10.4 | 10.3 | 7.7 | ||
| How often been on a diet to lose weight: | ||||||
| Never | 59.3 | 57.9 | 0.799 | 48.9 | 58.7 | 0.054 |
| Sometimes | 35.8 | 36.3 | 45.3 | 37.4 | ||
| A lot | 5.0 | 5.8 | 5.8 | 3.9 | ||
| How often starved to lose weight: | ||||||
| Never | 83.6 | 75.6 | 0.001 | 83.4 | 87.1 | 0.089 |
| Sometimes | 14.3 | 22.8 | 14.1 | 12.4 | ||
| A lot | 2.1 | 1.6 | 2.5 | 0.5 | ||
| How often cut back on eating to lose weight: | ||||||
| Never | 36.5 | 24.8 | 0.001 | 18.6 | 28.6 | 0.028 |
| Sometimes | 55.9 | 65.8 | 66.3 | 58.6 | ||
| A lot | 7.7 | 9.4 | 15.1 | 12.8 | ||
| How often skipped meals to lose weight: | ||||||
| Never | 72.1 | 57.2 | <0.0001 | 64.5 | 69.8 | 0.391 |
| Sometimes | 24.6 | 34.9 | 30.3 | 25.9 | ||
| A lot | 3.3 | 7.9 | 5.2 | 4.4 | ||
| How often exercised to lose weight: | ||||||
| Never | 59.3 | 57.9 | 0.799 | 48.9 | 58.7 | 0.054 |
| Sometimes | 35.8 | 36.3 | 45.3 | 37.4 | ||
| A lot | 5.0 | 5.8 | 5.8 | 3.9 | ||
Significance test of difference between boys and girls.
Some sex differences were also noted in reported current weight change behaviors with younger boys more likely to report trying to gain weight. Among older adolescents, more girls were trying to lose weight while boys were trying to gain weight.
Weight Perceptions and Accuracy of Perceptions
Weight perceptions were significantly related to actual weight status in both sexes at all ages (Table 2). Younger children were less likely to recognize that they were overweight than older children. Among 8 to 11 year olds, 41% of overweight girls and 35% of overweight boys believed he/she were overweight. Among 12 to 15 year olds, 54% of overweight girls reported their weight as overweight while only 41% of overweight boys reported their weight correctly. Additionally, few healthy weight children reported that they were “overweight,” and no underweight children reported they were “overweight.”
Table 2.
Weight perceptions and accuracy of perceptions by measured weight.1
| BMI Percentile | Girls | Boys | ||||||
|---|---|---|---|---|---|---|---|---|
| >85th | 5th–85th | <5th | p | >85th | 5th–85th | <5th | p | |
| Perceived Weight | ||||||||
| Ages 8–11 | ||||||||
| Overweight | 41.1 | 2.8 | 0.0 | <0.0001 | 34.5 | 3.5 | 0.0 | <0.0001 |
| About right | 57.8 | 89.5 | 51.6 | 63.9 | 86.4 | 62.7 | ||
| Underweight | 1.1 | 7.6 | 48.4 | 1.6 | 10.2 | 37.3 | ||
| Ages 12–15 | ||||||||
| Overweight | 54.0 | 7.7 | 0.0 | <0.0001 | 41.1 | 2.8 | 0.0 | <0.0001 |
| About right | 45.6 | 86.9 | 33.9 | 58.8 | 87.1 | 37.5 | ||
| Underweight | 0.3 | 5.4 | 66.1 | 0.1 | 10.1 | 62.5 | ||
| Accuracy of Perception | ||||||||
| Ages 8–11 | ||||||||
| Underestimates | 58.9 | 7.6 | 0.0 | <0.0001 | 65.5 | 10.2 | 0.0 | <0.0001 |
| Correct | 41.1 | 89.5 | 48.4 | 34.5 | 86.4 | 37.3 | ||
| Overestimates | 0.0 | 2.8 | 51.6 | 0.0 | 3.5 | 62.7 | ||
| Ages 12–15 | ||||||||
| Underestimates | 46.0 | 5.4 | 0.0 | <0.0001 | 58.9 | 10.1 | 0.0 | <0.0001 |
| Correct | 54.0 | 86.9 | 66.1 | 41.1 | 87.1 | 62.5 | ||
| Overestimates | 0.0 | 7.7 | 33.9 | 0.0 | 2.8 | 37.5 | ||
Adjusted Wald test of difference between weight status classifications.
In terms of race/ethnicity, there were only differences in accuracy of perception for girls 8–11 years old and boys 12–15 years old with Non-Hispanic black and Hispanic participants were more likely to underestimate their weight status (Table 3). 32% of Non-Hispanic blacks and 30% Hispanics 8–11 year old girls underestimated their weight status as healthy weight when they were actually overweight/obese while 22% of Non-Hispanic whites did also. For 9–15 year old boys, 31% of Non-Hispanic blacks, 31% Hispanics, and 39% other race underestimated their weight status while 21% of Non-Hispanic whites did also.
Table 3.
| Underestimates Weight Status (%) | Correct (%) | Overestimates Weight Status (%) | p | |
|---|---|---|---|---|
| Girls | ||||
| Ages 8–11 | ||||
| Non-Hispanic White | 21.8 | 75.5 | 2.8 | 0.046 |
| Non-Hispanic Black | 32.3 | 63.8 | 3.9 | |
| Hispanic | 30.4 | 66.8 | 2.7 | |
| Other race | 23.0 | 69.5 | 7.4 | |
| Ages 9–15 | ||||
| Non-Hispanic White | 18.4 | 75.9 | 5.7 | 0.27 |
| Non-Hispanic Black | 25.0 | 72.2 | 2.7 | |
| Hispanic | 22.7 | 71.3 | 6.0 | |
| Other race | 17.7 | 71.6 | 10.7 | |
| Boys | ||||
| Ages 8–11 | ||||
| Non-Hispanic White | 28.3 | 67.6 | 4.1 | 0.16 |
| Non-Hispanic Black | 36.0 | 62.2 | 1.8 | |
| Hispanic | 34.7 | 60.1 | 5.2 | |
| Other race | 23.4 | 74.9 | 1.7 | |
| Ages 9–15 | ||||
| Non-Hispanic White | 21.2 | 74.6 | 4.1 | 0.01 |
| Non-Hispanic Black | 30.6 | 68.1 | 1.3 | |
| Hispanic | 30.5 | 66.2 | 3.3 | |
| Other race | 39.1 | 58.3 | 2.6 | |
Adjusted Wald test of difference between groups (accuracy of weight perception).
“Underestimates “weight status is defined as perception of being healthy weight when actually overweight/obese; “Overestimates” weight status is defined as perception of being overweight/obese when actually healthy weight.
Weight Loss Behaviors by Accuracy of Weight Perception
Interesting sex-based patterns of actual weight and perceived weight were seen in relationship to weight management behaviors (Table 4). For girls and younger boys, children who correctly perceived themselves as overweight were more likely to be attempting weight loss than those who believed they were overweight but were actually healthy weight. There were more children who were overweight but reported themselves as “about right” attempting to lose weight than healthy weight children, but less than overweight children who perceived themselves as overweight.
Table 4.
Percent reporting weight loss behaviors by accuracy of weight perception1
| Girls | Boys | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||
| Perceived Overweight | Perceived Healthy Weight | Perceived Overweight | Perceived Healthy Weight | |||||||
|
| ||||||||||
| Accurate | Inaccurate | Accurate | Inaccurate | p | Accurate | Inaccurate | Accurate | Inaccurate | p | |
| Currently trying to do about weight: | ||||||||||
| Ages 8–11 | ||||||||||
| Lose | 80.1 | 63.3 | 14.9 | 49.5 | <0.0001 | 90.0 | 72.0 | 8.8 | 54.0 | <0.0001 |
| Gain | 0 | 0 | 6.5 | 1.0 | 0 | 2. | 16.4 | 1.1 | ||
| Stay the same | 5.0 | 14.3 | 36.1 | 25.3 | 5.8 | 4.3 | 35.5 | 25.8 | ||
| Nothing | 14.9 | 22.4 | 42.5 | 24.2 | 4.3 | 21.6 | 39.3 | 19.1 | ||
| Ages 12–15 | ||||||||||
| Lose | 88.4 | 67.9 | 19.3 | 56.3 | <0.0001 | 73.2 | 79.3 | 9.6 | 46.9 | <0.0001 |
| Gain | 0 | 0 | 2.1 | 0 | 0.3 | 0 | 17.4 | 4.9 | ||
| Stay the same | 3.6 | 3.1 | 39.8 | 23.9 | 8.4 | 0 | 33.1 | 23.8 | ||
| Nothing | 8.0 | 29.0 | 38.8 | 19.8 | 18.2 | 20.7 | 39.9 | 24.5 | ||
| How often tried to lose weight: | ||||||||||
| Ages 8–11 | ||||||||||
| Never | 8.5 | 7.5 | 64.7 | 33.2 | <0.0001 | 5.9 | 31.9 | 64.7 | 24.5 | <0.0001 |
| Sometimes | 64.9 | 71.9 | 32.7 | 51.6 | 62.3 | 59.1 | 32.6 | 56.6 | ||
| A lot | 26.6 | 20.6 | 2.6 | 15.2 | 31.9 | 9.0 | 2.7 | 18.9 | ||
| Ages 12–15 | ||||||||||
| Never | 11.6 | 8.8 | 63.5 | 35.1 | <0.0001 | 17.1 | 23.9 | 76.1 | 40.8 | <0.0001 |
| Sometimes | 62.7 | 54.4 | 33.4 | 54.2 | 58.4 | 45.7 | 21.5 | 46.0 | ||
| A lot | 25.7 | 36.9 | 3.2 | 10.8 | 24.4 | 30.4 | 2.4 | 13.2 | ||
| How often been on a diet to lose weight: | ||||||||||
| Ages 8–11 | ||||||||||
| Never | 38.1 | 37.0 | 73.1 | 58.3 | <0.0001 | 47.4 | 34.4 | 73.0 | 48.9 | <0.0001 |
| Sometimes | 54.1 | 50.8 | 24.2 | 37.2 | 40.4 | 62.5 | 25.3 | 45.0 | ||
| A lot | 7.8 | 12.2 | 2.7 | 4.6 | 12.2 | 3.1 | 1.7 | 6.1 | ||
| Ages 12–15 | ||||||||||
| Never | 31.0 | 48.9 | 63.5 | 49.5 | 0.003 | 42.4 | 63.0 | 70.2 | 59.9 | 0.016 |
| Sometimes | 62.2 | 45.1 | 33.2 | 42.0 | 51.2 | 37.0 | 29.0 | 34.6 | ||
| A lot | 6.8 | 6.1 | 2.2 | 8.5 | 6.4 | 0 | 0.8 | 5.5 | ||
| How often starved to lose weight: | ||||||||||
| Ages 8–11 | ||||||||||
| Never | 80.6 | 92.7 | 86.2 | 81.9 | 0.741 | 64.8 | 32.6 | 76.7 | 75.8 | 0.182 |
| Sometimes | 17.4 | 7.3 | 11.8 | 15.6 | 35.2 | 56.3 | 20.6 | 22.2 | ||
| A lot | 2.0 | 0 | 2.0 | 2.6 | 0.0 | 11.1 | 2.7 | 2.0 | ||
| Ages 12–15 | ||||||||||
| Never | 81.5 | 77.8 | 88.9 | 79.5 | 0.232 | 84.5 | 83.8 | 90.9 | 85.8 | 0.749 |
| Sometimes | 14.6 | 22.3 | 8.6 | 19.8 | 14.9 | 16.2 | 8.2 | 14.2 | ||
| A lot | 3.9 | 0 | 2.5 | 0.6 | 0.6 | 0 | 0.9 | 0 | ||
| Ages 8–11 | ||||||||||
| How often cut back on eating to lose weight: | ||||||||||
| Never | 18.7 | 25.3 | 54.1 | 23.8 | <0.0001 | 13.4 | 10.0 | 34.7 | 20.5 | 0.002 |
| Sometimes | 68.6 | 55.9 | 42.4 | 68.5 | 77.4 | 78.6 | 58.9 | 69.0 | ||
| A lot | 12.8 | 18.8 | 3.5 | 7.8 | 9.2 | 11.4 | 6.5 | 10.4 | ||
| Ages 12–15 | ||||||||||
| Never | 10.3 | 26.9 | 22.8 | 18.9 | 0.007 | 15.9 | 24.5 | 40.3 | 25.2 | 0.005 |
| Sometimes | 66.0 | 51.3 | 71.1 | 65.7 | 59.8 | 61.2 | 55.8 | 62.6 | ||
| A lot | 23.7 | 21.7 | 6.2 | 15.5 | 24.3 | 14.2 | 3.9 | 12.2 | ||
| How often skipped meals to lose weight: | ||||||||||
| Ages 8–11 | ||||||||||
| Never | 64.9 | 95.3 | 77.9 | 68.7 | 0.040 | 52.5 | 35.4 | 66.9 | 52.5 | 0.039 |
| Sometimes | 29.1 | 4.7 | 19.9 | 28.8 | 37.7 | 61.5 | 28.9 | 36.2 | ||
| A lot | 6.0 | 0 | 2.3 | 2.5 | 9.8 | 3.1 | 4.2 | 11.3 | ||
| Ages 12–15 | ||||||||||
| Never | 57.7 | 64.0 | 71.1 | 65.8 | 0.226 | 52.0 | 83.8 | 82.2 | 70.8 | <0.0001 |
| Sometimes | 33.4 | 36.0 | 25.8 | 29.2 | 39.6 | 2.0 | 17.1 | 25.6 | ||
| A lot | 8.9 | 0 | 3.1 | 5.1 | 8.5 | 14.2 | 0.7 | 3.5 | ||
| How often exercised to lose weight: | ||||||||||
| Ages 8–11 | ||||||||||
| Never | 38.1 | 37.0 | 73.1 | 58.3 | <0.0001 | 47.4 | 34.4 | 73.0 | 49.0 | <0.0001 |
| Sometimes | 54.1 | 50.8 | 24.2 | 37.2 | 40.4 | 62.5 | 25.3 | 45.0 | ||
| A lot | 7.8 | 12.2 | 2.7 | 4.6 | 12.2 | 3.1 | 1.7 | 6.1 | ||
| Ages 12–15 | ||||||||||
| Never | 31.0 | 48.9 | 63.5 | 49.5 | 0.003 | 42.4 | 63.0 | 70.2 | 59.9 | 0.016 |
| Sometimes | 62.2 | 45.1 | 33.2 | 42.0 | 51.2 | 37.0 | 29.0 | 34.6 | ||
| A lot | 6.8 | 6.1 | 3.2 | 8.5 | 6.4 | 0 | 0.8 | 5.5 | ||
Adjusted Wald test of difference between groups (accuracy of weight perceptions).
Overweight girls and boys of all ages who correctly perceived themselves as overweight were more likely to report trying to lose weight “sometimes” or “a lot” compared to those who consider themselves “about right” but were actually overweight.
Of those who perceived themselves as overweight, they were more likely to be trying to lose weight when their weight status was actually overweight. Finally, many of those who perceive themselves as healthy weight but were actually overweight were trying to lose weight. These patterns remained similar for all types of weight control behaviors, with actual weight and perception of weight being both important factors: those who were actually overweight reported more weight control behaviors, and those who perceived themselves as overweight were even more likely to report these behaviors.
Discussion
Boys vs. Girls
Similar to findings in prior studies, it appears that girls are better able to recognize obesity than boys.3,5,6,15 However, 46% of older girls and 59% of older boys who are overweight are still unable to recognize themselves as such. Previous reports using recent data have shown better congruency between obesity and self-perception.4,19 One possible reason for the differences in our data is that children were only given three options “overweight, about right, or underweight.” Other surveys allow children to report “very overweight or slightly overweight” which children may be more comfortable in reporting than a singular “fat or overweight” category used in the survey design of NHANES.
Younger Children vs. Older Children and Adolescents
Our study adds to prior work by examining younger children and the differences in younger versus older children in accuracy of weight perception and weight loss intentions and behaviors in a large, nationally representative cohort using objective measurements of height and weight. Accurate perception of obesity is better in older children than younger children. This is not surprising, as older children may have had more exposure to messages about obesity. However, there were minimal differences in weight control behaviors by age based on weight perception, although younger children were not more likely to engage in unhealthy weight control behaviors such as starving to lose weight when they perceived themselves as overweight. This indicates that younger children who correctly identify themselves as overweight are capable of making efforts to manage their weight, and attempt to do so using healthy methods such as exercising to lose weight. We are unable to determine how children interpreted “cut back on eating to lose weight” vs. “been on a diet to lose weight” though percentages of children reporting each of these differ. Further research should explore whether there are differences in how children perceive dieting and cutting back on eating as weight control behaviors.
Self-perception and Weight loss behaviors
Although perception of weight is strongly associated with behaviors, it also appears that messages about dieting may be influencing all children, not just those who recognize themselves as overweight (and report themselves as such). Even among children who report themselves as “about right,” 19–28% report currently trying to lose weight and engaging in weight control behaviors such as dieting or cutting back on eating to lose weight. We are unable to determine in this study the extent to which these behaviors in healthy weight children are extreme or unhealthy due to the survey design of NHANES.
Our study confirms that self-perception of overweight or obesity, whether accurate or not, is associated with weight loss behaviors in both girls and boys. Recognition of obesity results in a 20–30 percent increase in the prevalence of weight loss efforts. Our study also demonstrates an important association between actual obesity and perception of obesity. Boys and girls of all ages who report their weight as “about right” are far more likely to be attempting weight loss when they are overweight/obese by objective measures, compared to those who are healthy weight. Accurate self-perception that he/she is overweight/obese is associated with greater weight loss effort. However, weight loss intentions in those who do not accurately report themselves as overweight/obese may suggest that even those who may be unwilling to report himself/herself as overweight do recognize that they are not healthy weight. A possible explanation for this may be the limited number of response options. If they had been given more options, such as “slightly overweight,” some overweight children may have been more willing to report other than “about right.”
Additionally, overweight children and adolescents of both sexes with correct weight status perception were more likely to be engaged in weight loss behaviors such as cutting back on eating and exercising to lose weight. Younger boys who incorrectly perceive themselves as overweight are more likely than boys with accurate weight perception to have engaged in unhealthy behaviors such skipping meals to lose weight. However, for adolescent boys, this reverses, with boys who are actually overweight more likely to report skipping meals—a pattern similar to that seen for younger girls. As unhealthy weight control behaviors including skipping meals and restrictive eating habits are predictive of weight gain over time,20,21 it may be important to improve accuracy of weight perception in both children and adolescents so that disordered eating and future weight gain are circumvented.
Limitations
There are several limitations to our study. First, the analysis included cross-sectional data so causality cannot be inferred from our results. Additionally, as mentioned above, nuances about weight perception may not be evident since the participants were asked to choose from only three choices when describing their weight status. Lastly, we are unable to know whether “cutting back on eating to lose weight” was unhealthy restriction/disordered eating or healthy portion control due to the survey design.
Though there are limitations, our study has several strengths. Most studies examining weight perceptions and weight control behaviors have been completed in mainly adolescents and do not provide a comparison between younger children and adolescents. Our study also used measured weight and height to classify accuracy of weight perceptions, which is often not available in large surveys. Finally, the study used recent nationally representative data, which is important since perceptions could be changing in light of recent public health efforts to stem the tide of obesity.
Conclusions
The implications of these findings are important when caring for children and adolescents, as self-perception of overweight/obesity is strongly associated with weight loss behaviors. Both children and adolescents who recognize their obesity report efforts to lose weight. Interventions to influence accuracy of weight perceptions and to assess weight perceptions as part of routine well child care or obesity programs may help to increase and promote weight control behaviors like increased physical activity or healthy portion control. Future research should examine in greater detail whether weight control efforts such as dieting and exercising are actually implemented by children and adolescents in healthy ways.
What’s New.
We provide recent, nationally representative information on accuracy of weight perceptions in both US children and adolescents and examine associated weight control behaviors, providing comparison between children and adolescents by sex, which could better tailor interventions and counseling efforts.
Acknowledgments
Funding: Dr. Chung was supported by a NRSA Primary Care Research Fellowship training grant (T32 HP14001). Dr. Skinner is supported by a NIH BIRWCH (K12 HD001441). Dr. Perrin was supported by a NIH career development award (5K23 HD051817) during part of this project. Drs. Skinner and Perrin and Chung were supported in part by a CTSA grant to UNC-Chapel Hill (UL1RR025747). Special thanks to UNC NRSA Fellows for providing edits and comments during initial drafts of the manuscript and to the Scientific Collaborative for Overweight and Obesity Prevention and Treatment who provided feedback in early formative work.
Abbreviations
- BMI
Body Mass Index
- NHANES
National Health and Nutrition Examination Survey
Footnotes
Disclosure Statement: Authors have no conflicts of interest/financial disclosures.
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