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. 2012 Oct 1;9(1):3–22. doi: 10.1111/j.1740-8709.2012.00462.x

Difference between parental perception and actual weight status of children: a systematic review

Marloes Rietmeijer‐Mentink 1, Winifred D Paulis 1,✉, Marienke van Middelkoop 1, Patrick JE Bindels 1, Johannes C van der Wouden 1,2
PMCID: PMC6860751  PMID: 23020552

Abstract

An increasing number of children worldwide are overweight, and the first step in treating obesity is to identify overweight. However, do parents recognise overweight in their child and which factors influence parental perception? The aim of the present review is to systematically study differences between parental perception and the actual weight status of children. Medline, EMbase, CINAHL and PsychINFO were searched. After screening 2497 abstracts and 106 full texts, two reviewers independently scored the methodological quality of 51 articles (covering 35 103 children), which fulfilled the inclusion criteria. The primary outcome parameters were sensitivity and specificity of parental perception for actual weight status of their child. The methodological quality of the studies ranged from poor to excellent. Pooled results showed that according to objective criteria 11 530 children were overweight; of these, 7191 (62.4%) were incorrectly perceived as having normal weight by their parents. The misperception of overweight children is higher in parents with children aged 2–6 years compared with parents of older children. Sensitivity (correct perception of overweight) of the studies ranged from 0.04 to 0.89, while specificity (correct perception of normal weight) ranged from 0.86 to 1.00. There were no significant differences in sensitivity or specificity for different cut‐off points for overweight, or between newer and older studies. Therefore we can conclude that parents are likely to misperceive the weight status of their overweight child, especially in children aged 2–6 years. Because appropriate treatment starts with the correct perception of overweight, health care professionals should be aware of the frequent parental misperception of the overweight status of their children.

Keywords: child, overweight, parent, perception

Introduction

Worldwide, an increasing number of children are overweight. (Haug et al. 2009) For example, in preschool children, the worldwide prevalence of overweight increased from 4.2% in 1990 to 6.7% in 2010. (de Onis et al. 2010).

Obesity in adults is related to metabolic disorders such as impaired glucose tolerance, diabetes, dyslipidaemia, cardiovascular diseases and certain types of cancer. (WHO 2006, 2012) Overweight and obesity in childhood can lead to diabetes and cardiovascular diseases at a younger age. (Freedman et al. 2009; Yeste & Carrascosa 2011; WHO 2012) Overweight that begins before 8 years of age and persists into adulthood is associated with a mean body mass index (BMI) of 41 in adulthood, as compared with 35 for adult‐onset obesity. (Freedman et al. 2001; Dietz & Robinson 2005) Therefore, the high proportion of overweight in children is alarming.

Although prevention of childhood overweight is the most desirable scenario (WHO 2012), because prevention of childhood obesity has not yet been very successful (Waters et al. 2011), the treatment of obesity remains an important item. The first step in treating obesity is to identify overweight. (Wofford 2008; Young et al. 2010) This applies to health care professionals and to parents, who often initiate treatment. Parents' concerns about their child's health depend on their awareness of their child's overweight and, consequently, whether they are willing to take action against overweight. (Wake et al. 2002; Soto & White 2010; Moore et al. 2012) Therefore, the perception of overweight of parents is an important initial step. However, previous reviews show that ≥50% of parents fail to accurately perceive the overweight of their child. (Parry et al. 2008; Doolen et al. 2009; Towns & D'Auria 2009). These reviews included studies published up to August 2007. Since then, in the wake of considerable focus on the prevention and treatment of overweight in children, it is unclear whether there has been an improvement in parental perception.

However, because studies often use different BMI cut‐off criteria to define overweight, this can influence the data and might contribute to the parental misperception that was that is found in other studies. Also, societal factors (e.g. child's age and gender of parent that filled out questionnaires) might influence parents' perception of overweight. It is therefore important to study factors that might influence differences between parental perception and actual weight status of children. This might reveal possible subgroups that need more attention by health care professionals to help them become aware about their child's weight status. Therefore, this systematic review investigates differences between parental perception and the actual weight status of children and explores possible determinants for these differences.

Key messages

  • 63.4% of the parents of overweight children fail to recognise overweight of their child.

  • 86% of the parents of children aged 2–6 years fail to recognise overweight of their child.

  • Although different studies used different cut‐off points for the definition of overweight, the misperception of overweight seems to be universal.

  • There are no significant differences in sensitivity of parental perception between the studies included in earlier reviews and the more recent studies.

  • Health care professionals should be aware of the frequent parental misperception of the overweight status of their children.

Materials and Methods

Study selection

The inclusion criteria for this review were the study investigated the perception of parents/caregivers, the children were aged 2–18 years and the outcome was the difference between measured weight status (classified by BMI) and weight status as observed by parents on the child level. Exclusion criteria were Diagnostic and Statistical Manual of Mental Disorders (DSM) classified eating disorders, medical conditions affecting the weight (e.g. Down syndrome, Prader Willi syndrome) and qualitative studies.

Data sources and search strategy

The PubMed, EMbase, CINAHL and PsychINFO databases were searched up to January 2011. Search terms were combined into four groups: child, body weight, parent and perception. Articles identified by the search strategy contained at least one term from each group. The search terms were adapted to the different databases to facilitate a comprehensive search (for details on search strings, see Appendix 1). In addition, the reference lists of the retrieved articles were reviewed for promising titles, in order to recover articles not included in the major databases. There were no restrictions regarding date of publication (prior to January 2011) or language. Two reviewers (MR, WP) independently selected citations based on titles and abstracts, or on retrieved articles. Full articles were obtained for those citations thought to fulfill the inclusion criteria. Eligibility was independently assessed by the same two reviewers. Any discrepancies were resolved through discussion.

Quality assessment

Because there was no existing quality assessment tool for the observational and cross‐sectional studies, a quality assessment tool for diagnostic studies based on the Cochrane criteria (Reitsma et al. 2009) was selected and adapted for our purpose (Table 1). The methodological quality of articles using a verbal description of the perception of the weight status was based on six items and categorised into poor quality (0–2 items scored positive), moderate quality (3–4 items positive), good quality (5 items positive) and excellent quality (6 items positive). The quality of articles using image scales was based on seven items (good quality = 5–6 items positive; excellent quality = 7 items positive).

Table 1.

Results of the quality assessment

Selection bias Blinding Method and data collection Non‐responders
Inclusion did not take place based on weight Characteristics were described, representative sample Parent did not know weight status before answering Type of equipment mentioned, all children same equipment In case of image scale a validated scale was used Description of weight status classification was mentioned Non‐responders were mentioned
Verbal description
Abbott et al. 2010 + + + + n.a. + +
Al‐Qaoud et al. 2010 ‐ ‐ ‐ + n.a. + +
Anderson et al. 2005 + + + _ n.a. + +
Baughcum et al. 2000 + ? ? + n.a. + +
Boa‐Sorte et al. 2007 + + + + n.a. + +
Boutelle et al. 2004 + + ? ‐ n.a. + +
Bracho & Ramos 2007 + + ? ? n.a. + +
Carnell et al. 2005 + ? ? – n.a. + +
Crawford et al. 2006 + + ? – n.a. + +
De La et al. 2009 + + ? + n.a. + +
Eckstein et al. 2006 + + ? – – + +
Flowers 2008 + ? ? – n.a. + +
Garret 2009 + + ? – n.a. + +
Goodman et al. 2000 + ? ? – n.a. + +
Gray et al. 2007 + – ? + n.a. + +
Hackie & Bowles 2007 – – ? – n.a. + +
Harnack et al. 2009 + + ? + n.a. + +
Hearst et al. 2011 + + ? + n.a. + +
Hernandez et al. 2010 + + ? – – + +
Hirschler et al. 2006 + + ? – n.a. + +
Hirschler et al. 2008 + + ? – n.a. + +
Huang et al. 2007 + + ? – n.a + +
Hudson et al. 2009 + + ? + n.a. + +
Jackson et al. 1990 + + + + n.a. + +
Jansen & Brug 2006 + + ? + n.a. + +
Jeffery et al. 2005 + + + ‐ n.a. + +
Juliusson et al. 2011 + + ? + n.a. + +
Kasemsup & Reicks 2006 + ? ? – n.a. + +
Kroke et al. 2006 + + ? – n.a. + +
Lampard et al. 2008 ‐ – – + n.a. + +
Lazzeri et al. 2006 + + ? – n.a. + +
Mamum et al. 2008 + + ? – n.a. + +
Manios et al. 2009 + + ? + n.a. + +
Mathieu et al. 2010 + + ? – n.a. + +
May et al. 2007 + + ? ? n.a. + +
Maynard et al. 2003 + + ? – n.a. + +
Molina Mdel et al. 2009 + + ? – n.a. + +
Myers & Vargas 2000 – – ? – n.a. + +
Neumark et al. 2008 – – ? – n.a. + +
Perrin et al. 2010 + + ? + n.a. + +
Rudolph et al. 2010 ‐ – – – n.a. + ?
Skelton et al. 2006 + ? ? – n.a. + ?
Tschamler et al. 2010 + + ? – n.a. + +
Valdes et al. 2009 + + ? – n.a. + +
Vuorela et al. 2010 + + ? – n.a. + +
Wald et al. 2007 + + ? – n.a. + ?
Young et al. 2010 ‐ – ? – n.a. + +
Ratio +/‐/? (%) 85/15/0 70/17/13 11/6/83 32/64/4 n.a. 100/0/0 94/0/6
Image scales
Beatty 2009 + + ? – ? – +
Eckstein et al. 2006 + + ? – – + +
Hernandez et al. 2010 + + ? – – + +
Reifsnider et al. 2006 + + + + – + +
Warschburger & Kroller 2009 – – ? + + + –
Zonana‐Nacach & Conde‐Gaxiola 2010 + + + – – + +
Ratio +/‐/? (%) 87/13/0 87/13/0 25/0/75 38/62/0 25/62/13 87/13/0 87/13/0
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+ = yes; – = no; ? = unclear; n.a., not applicable.

Data extraction

Study characteristics were extracted by the same two reviewers and included country; setting; number of children included; male‐to‐female ratio; age of children; type of caregiver (mother, father, other) who provided the data; and details on which classification for overweight was used (Table 2).

Table 2.

Characteristics of the included studies

Author, year of publication Country Setting No. of participants suitable for this analysis (n) Male (%) Range of age, or mean (years) Caregiver Definition of weight status
Verbal descriptions*
Abbott et al. 2010, § Australia school §§ 2148 49 5–12 n.a. IOTF Cole19
Al‐Qaoud et al. 2010, ‡ Kuwait sample Kuwait Nutrition Surveillance System study 482 45 3–6 mother WHO †††
Anderson et al. 2005 USA sample Head Start program 82 45 3–5 55% female, 45% male CDC ‡‡‡
Baughcum et al. 2000, § USA health care facility ¶¶ 304 n.a. 2–5 mother BMI >90th overweight
Boa‐Sorte et al. 2007, § Brazil school 827 46 6–19 mother CDC
Boutelle et al. 2004, § USA school 742 53 Mean 14.6 91% mother CDC
Bracho & Ramos 2007, § Chili school + health care facility 270 51 2–6 mother WHO
Carnell et al. 2005, UK school 564 n.a. 3–5 94.5% mother; 5.5% other IOTF Cole
Crawford et al. 2006, ‡ Australia school 1116 48*** 5–6 and 10–12 84.4% female, 15.6% male IOTF Cole
De La et al. 2009, ** USA school 576 49 5–12 n.a. WHO
Eckstein et al. 2006, § USA health care facility 223 42 2–17 n.a. CDC
Flowers 2008, USA health care facility 57 49 8–12 n.a. WHO
Garret 2009, § USA health care facility 120 53 2–5 92% mothers, 8% fathers BMI >95th overweight
Goodman et al. 2000, ‡ USA sample National Longitudinal Study of Adolescent Health 564 51 Teens n.a. BMI >95th obese
Gray et al. 2007, USA school 169 n.a Second‐grade students 90% mothers, 6.5% father, 2.5% grandmother, 1% other CDC
Hackie & Bowles 2007, ‡ USA health care facility 38 53 2–5 mother BMI >95th overweight
Harnack et al. 2009, ** USA school 593 54 2–5 90.5% mother, 9,5% father CDC
Hearst et al. 2011, ‡ USA sample Aetiology Childhood Obesity study 358 48 Mean 14 80% female WHO
Hernandez et al. 2010, § USA health care facility 49 57*** 2–5 n.a. WHO
Hirschler et al. 2006, ‡ Argentina School 321 50 2–6 mother CDC
Hirschler et al. 2008, Argentina School 620 48 5–13 mother WHO
Huang et al. 2007, ‡ USA health care facility 429 45*** 0–18 87% female, 13% male CDC
Hudson et al. 2009, USA sample Head Start program 96 45 3–5 75% mother, 25% father or mother CDC
Jackson et al. 1990, § USA School 107 51 3–6 mother BMI >90th overweight
Jansen & Brug 2006, ‡ The Netherlands sample Rotterdam Youth Health Monitor study 524 50 9–11 75% mothers, 15% fathers, 10% other IOTF Cole
Jeffery et al. 2005, ‡ UK sample Early Bird Study 272 56 Mean 7.4 can be mother or father BMI >91th overweight, BMI >98th obese
Juliusson et al. 2011, †† Norway Sample Bergen Growth study 3770 51 2–19 n.a. IOTF Cole
Kasemsup & Reicks 2006, ‡ USA School 80 n.a. 3–5 mother BMI >95th overweight
Kroke et al. 2006, ‡ Germany sample Dortmund Nutritional and Anthropometric Longitudinally Designed study 253 49 6 Months to 4 years mother CDC
Lampard et al. 2008, Australia health care facility + school 329 n.a. 6–13 n.a. IOTF Cole
Lazzeri et al. 2006, ‡ Italy School 2835 51*** 8–9 mother IOTF Cole
Mamum et al. 2008, § Australia sample Mater‐University Study of Pregnancy 2650 52 14 mother IOTF Cole
Manios et al. 2009, ** Greece sample Growth, Exercise and Nutrition Epidemiological Study in preschoolers 1759 54 2–5 mother CDC
Mathieu et al. 2010, § Canada birth cohort follow‐up 1128 48 Mean 6.2 can be mother or father WHO
May et al. 2007, ‡ USA previous research 228 49*** 2–5 mother CDC
Maynard et al. 2003, § USA sample Third National Health and Nutrition Examination Survey 5500 50 2–11 mother CDC
Molina Mdel et al. 2009, ** Brazil School 1272 42 7–10 mother Must et al. 23,24
Myers & Vargas 2000, ‡ USA health care facility 200 n.a. 2–5 can be mother or father BMI >90th overweight
Neumark et al. 2008 † USA school + sample Project EAT study 307 48 Mean 14.4 92% mother WHO
Perrin et al. 2010, ‡ USA health care facility 96 50*** 4–12 92.2% female WHO
Rudolph et al. 2010, ‡ Germany health care facility 150 54*** 7–17 can be mother or father WHO
Skelton et al. 2006, ‡ USA fair 37 n.a. 4–20 can be mother or father CDC
Tschamler et al. 2010, ‡ USA health care facility 193 50 1–9 89% mother, 11% father CDC
Valdes et al. 2009, ‡ USA health care facility 141 50*** 2–18 can be mother or father BMI >75th (at risk for) overweight, BMI >95th obese
Vuorela et al. 2010, ‡ Finland school 606 50 5 and 11 can be mother or father IOTF Cole
Wald et al. 2007, ‡ USA health care facility 612 55 3–12 can be mother or father CDC
Young et al. 2010, ‡ USA health care facility 111 43 5–11 n.a. BMI >95th overweight
Image scales ‡‡
Beatty 2009, ** USA health care facility 130 45 8–11 mother unknown
Eckstein et al. 2006, § , USA health care facility 223 42 3–17 78% mother CDC
Hernandez et al. 2010, § USA health care facility 150 57 2–5 n.a. WHO
Reifsnider et al. 2006, ‡ USA health care facility 25 64 3 mother WHO
Warschburger & Kroller 2009 Germany health care facility + child care 141 58*** 3–6 mother IOTF Cole
Zonana‐Nacach & Conde‐Gaxiola 2010 Mexico health care facility 525 48 2–13 mother WHO
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*Parents were asked to describe their child with words like ‘very underweight, underweight, about right, overweight, very overweight’. †Did parents recognise overweight? ‡Did parents recognise normal weight and overweight? §Did parents recognise underweight, normal weight and overweight? Did parents recognise normal weight, a little overweight and very overweight? **Did parents recognise underweight, normal weight, a little overweight and very overweight? ††Did parents recognise very underweight, a little underweight, normal weight, a little overweight and very overweight? ‡‡Parents were asked to compare their child with different images and say which most resembles their child. §§Selection of participants took place at school. ¶¶Selection of participants took place at well child visits or outpatient clinics. ***percentage male in original sample. †††weight status by WHO: BMI >85th overweight, BMI >95th obese. ‡‡‡weight status by CDC: >85th overweight, BMI >95th obese. BMI, body mass index; CDC, Centre for Disease Control and Prevention; IOTF, International Obesity Task Force; n.a., not available.

Data extracted included true positives (actual overweight, perceived overweight); false positives (actual normal weight, perceived overweight); true negatives (actual normal weight, perceived normal weight); and false negatives (actual overweight, perceived normal weight). In some studies, not all participants were suitable for analyses. For example, at two different moments (T1 and T2) parents were asked to give their perception about their child's weight status, but only at T2 were the child's weight and height measured. In this case, only data of T2 were extracted. In most studies (n = 47), parents were asked to choose the best verbal description for their child's weight status (e.g. underweight, normal weight, overweight). In some studies (n = 6), from a series of images, parents had to choose the one that best represented their child.

Authors were contacted when insufficient data were provided.

Definition of overweight

A variety of definitions are applied to indentify overweight in children (Table 2; Appendix 2 ). The cut‐off points for BMI used to classify overweight by the International Obesity Task Force (IOTF) are adopted from Cole et al. (2000). These centile curves for children and adolescents aged 2–17 years are similar to the widely used cut‐off points of a BMI of 25 kg m−2 (overweight) and 30 kg m−2 (obesity) for adults from age 18 years onwards.

The cut‐off points that the World Health Organisation (WHO) applies are BMI >85% on their centiles for overweight and BMI >95% for obesity. On their centiles, until 2010, the Centre for Disease Control and Prevention (CDC) defined BMI >85% as at risk of overweight and BMI >95% as overweight. After 2010, they changed the definition to BMI >85% as overweight and BMI >95% as obesity. (Ogden & Flegal 2010) From studies that referred to CDC centiles, measured BMI >85% are included as actual overweight. When articles used definitions other than those described above, this is indicated in the tables.

Definition of sensitivity and specificity

Sensitivity was defined as the correct perception of overweight (true positives/all overweight children). Specificity was defined as correct perception of normal weight (true negatives/ all normal weight children).

Subgroup analyses

Three subgroup analyses were defined to further explore differences in perception and actual weight status. The first analysis compared studies that included only young children (≤6 years) vs. studies that included older children, or a broader age range. The second subgroup analysis compared studies with different cut‐off points used for the definition of overweight (IOTF, WHO BMI >85% and CDC BMI >85%). The third subgroup analysis compared relatively older studies (included in the reviews published up to 2007) with more recent studies.

Statistical analysis

For studies using verbal descriptions for recognition of both normal weight and overweight, plots for sensitivity and specificity (including 95% confidence intervals and a summary ROC curve) were constructed using RevMan software version 5.1, (Rigshospitalet, Copenhagen, Denmark). (Cochrane 2011) Sensitivity plots were constructed for all studies addressing recognition of overweight. For subgroup analyses, sensitivity and specificity of the different studies were pooled using stata 12 (StataCorp, College Station, TX, USA) weighing for study size.

Results

Study selection and characteristics

The electronic search resulted in 2497 hits. Screening the titles and abstracts resulted in 106 articles for which the full text was assessed. Finally, 51 articles were included in this systematic review (Fig. 1). (Jackson et al. 1990; Baughcum et al. 2000; Goodman et al. 2000; Myers & Vargas 2000; Young‐Hyman et al. 2000; Maynard et al. 2003; Boutelle et al. 2004; Anderson et al. 2005; Carnell et al. 2005; Jeffery et al. 2005; Crawford et al. 2006; Eckstein et al. 2006; Hirschler et al. 2006; Jansen & Brug 2006; Kasemsup & Reicks 2006; Kroke et al. 2006; Lazzeri et al. 2006; Reifsnider et al. 2006; Skelton et al. 2006; Boa‐Sorte et al. 2007; Bracho & Ramos 2007; Gray et al. 2007; Hackie & Bowles 2007; Huang et al. 2007; May et al. 2007; Wald et al. 2007; Flowers 2008; Hirschler et al. 2008; Lampard et al. 2008; Mamum et al. 2008; Neumark‐Sztainer et al. 2008; Beatty 2009; De La et al. 2009; Garret 2009; Harnack et al. 2009; Hudson et al. 2009; Manios et al. 2009; Molina Mdel et al. 2009; Valdes et al. 2009; Warschburger & Kroller 2009; Abbott et al. 2010; Al‐Qaoud et al. 2010; Hernandez et al. 2010; Mathieu et al. 2010; Perrin et al. 2010; Rudolph et al. 2010; Tschamler et al. 2010; Vuorela et al. 2010; Zonana‐Nacach & Conde‐Gaxiola 2010; Hearst et al. 2011; Juliusson et al. 2011). These 51 studies were conducted in 18 different countries (Table 2). In two studies, parents had to give both a verbal description of their child's actual weight status and choose the image that best represented their child (Eckstein et al. 2006; Hernandez et al. 2010); therefore, these two articles are reported twice in the study characteristics and results.

Figure 1.

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Flowchart of the screening and selection process of the study articles.

Studies were published between 1990 and 2011. In total, the studies included over 35 000 child–parent couples; of these, by far the most were child–mother couples. The age of the children ranged from 2 to 18 years, with the largest group aged 2–6 years. Most families were recruited from schools or health care facilities.

Methodological quality

Studies using verbal descriptions had poor (6 articles), moderate (30 articles), good (8 articles) or excellent (3 articles) methodological quality. The quality of studies using image scales ranged from moderate (4 articles) to good (2 articles) (Table 1).

Combining all types of studies showed that it was unclear in most studies whether parents were unaware of the results of the weight measurement of their children before answering the question (this item scored unclear in 81% of the studies). The classification used for weight status and the number of non‐responders were mentioned in most articles. The item that was not mentioned in most articles was related to which equipment was used and whether that same equipment was used for all children (64% unknown).

Perception of weight status

Of the 35 103 children enrolled (i.e. the total number of children in studies using verbal descriptions and image scales), according to objective criteria 11 530 were overweight (32.9%). Of these overweight children, 4339 (37.6%) were correctly perceived as overweight by their parents, and the remaining 7191 (62.4%) were incorrectly perceived as normal weight. According to objective criteria 23 573 (67.1%) children had a normal weight. For 21 410 of these children, information was available on the percentage perceived to be correct or incorrect: Of these normal‐weight children, 664 (3.1%) were incorrectly perceived as overweight by their parents.

The six studies using image scales enrolled 1195 children. According to objective criteria, 392 of them were overweight (32.8%). Of these 392 overweight children, 52.3% were indeed perceived as overweight by their parents, and 47.7% were incorrectly perceived as normal weight by their parents. According to objective criteria, 803 (67.2%) children had a normal weight. Parental perception was recorded for 688 of them, and 40 (5.8%) of these children were incorrectly perceived as overweight.

A total of 32 studies using verbal descriptions quantitatively reported on both overweight and normal‐weight perception. Table 3 shows a forest plot of these studies reporting the percentages of parents who correctly assigned the overweight or normal‐weight status to their children. Specificity (correct perception of normal weight) ranged from 0.86 to 1.00. Figure 2 shows the ROC curves of these 32 studies.

Table 3.

Forest plot of studies using verbal descriptions (n = 32) reporting sensitivity and specificity of parental perception

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Figure 2.

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ROC curve based on the 32 studies using verbal descriptions reporting sensitivity and specificity of parental perception.

In total, 15 studies using verbal descriptions quantitatively reported on perception of only overweight children. Therefore, sensitivity (correct perception of overweight) was calculated for 47 (32 + 15) studies and ranged from 0.04 to 0.89. Figure 3 shows a forest plot of these studies. Again, it is shown that about 37% of the overweight children were perceived correctly by their parents.

Figure 3.

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Forest plot of studies using verbal descriptions reporting the percentage of parents who perceived their overweight children correctly (47 studies). The balls are proportional to study size; the dotted line is the pooled result adjusted for study size.

Subgroup analyses

The pooled sensitivity and specificity for each subgroup are shown in Table 4. Based on the 95% confidence intervals, there is a significant difference in sensitivity between the different age groups. The percentage of parents who misperceive the overweight of their children is higher in parents of children aged 2–6 years compared with parents of older children. However, there was no significant difference in specificity between the subgroups.

Table 4.

Pooled sensitivity and specificity for different subgroups (n = number of studies)

Subgroup Sensitivity Specificity
Based on child's age
Young children (2–6 years), n = 8 0.14 (95%CI:0.08–0.23) 0.99 (95%CI:0.97–0.99)
Older children, n = 24 0.47 (95%CI:0.40–0.55) 0.98 (95%CI:0.96–0.99)
Based on cut‐off for overweight
BMI>85% (WHO), n = 9 0.49 (95%CI:0.35–0.63) 0.98 (95%CI:0.95–0.99)
BMI>95% (CDC), n = 13 0.36 (95%CI: 0.23–0.51) 0.98 (95%CI:0.96–0.99)
IOTF Cole19, n = 7 0.32 (95%CI:0.19–0.49) 0.98 (95%CI:0.96–0.99)
Based on year of publication
Older studies (<2007), n = 10 0.29 (95% CI: 0.16–0.45) 0.97 (95% CI: 0.93–0.98)
Newer studies, n = 22 0.41 (95% CI: 0.31–0.52) 0.98 (95% CI: 0.97–0.99)
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CDC, Centre for Disease Control and Prevention; 95% CI, 95% confidence interval; IOTF, International Obesity Task Force; WHO, World Health Organization.

No significant difference in sensitivity or specificity was found between the different cut‐off points used to define overweight, or between the more recent and older studies. However, there is a positive trend towards a higher sensitivity in the later studies.

Discussion

The purpose of the present systematic review was to identify differences between parental perception and the actual weight status of children. Of the 35 103 children enrolled, 11 530 were overweight (32.9%). Of these, 4339 (37.6%) children were correctly perceived as overweight by their parents, while 7191 (62.4%) were misperceived as normal weight. This implies that there is a large proportion of parents that fail to recognise the overweight weight status of their child. This is especially true for parents of young children. Subgroup analysis revealed that 86% of the parents of children aged 2–6 years fail to recognise overweight of their child.

Figure 3 shows that especially the larger studies (using verbal descriptions) lay close to the pooled result, with the exception of two studies (Goodman et al. 2000; Al‐Qaoud et al. 2010). In terms of results, the smaller studies are often both positive and negative outliers. Of the nine relatively large studies with results close to the pooled results, the methodological quality is relatively high (moderate: 5 articles; good: 3 articles; excellent: 1 article) (Fig. 3, Table 1). Therefore, the pooled results seem to give a reliable estimate of the available data on this subject.

Studies using image scales for the perception of parents show a higher percentage of overweight children perceived correctly by parents compared with studies using verbal descriptions (52.3% vs. 37.6%). This suggests that parents do acknowledge the weight status of their overweight child but do not verbally label it as overweight. The reason for this reluctance might be a negative association with the word overweight because of stigmatisation of obese people in our society, as previous proposed by Neumark‐Sztainer et al. (2008) However, there are too few studies using image scales in the present review to draw firm conclusions about this.

It is noteworthy that children with a normal weight status are almost never seen as being overweight, while children with overweight are often perceived as normal‐weight children. This indicates that parents often label their children as normal weight, irrespective of the child's actual weight status. This implies that parental perception of the weight status of a child is an inadequate diagnostic tool for overweight. Weight status of children should therefore not be asked to parents, but height and weight should be measured instead.

Besides stigmatisation, another possible explanation for the poor sensitivity (misperception of overweight status by parent) could be the change in reference frame. Given the current high percentage of overweight children (and parents), the overweight status may be seen as being average and therefore perceived as ‘normal’ (Binkin et al. 2011). However, one might expect a difference between sensitivity in the older and newer studies, and this was not found.

Although different studies used different cut‐off points for the definition of overweight, the misperception of overweight seems to be universal. This is shown by our pooled results, where no significant differences were found between sensitivity and specificity scores of the different cut‐off points used by IOTF, CDC or WHO.

Strengths and limitations

The most recent reviews (Parry et al. 2008; Doolen et al. 2009; Towns & D'Auria 2009) searched electronic databases up to August 2007. The present review included 51 studies, of which 32 were not included in the previous reviews and were published after August 2007. This illustrates the topicality of the subject. Our review revealed no significant differences in sensitivity between the studies included in the earlier reviews and the more recent studies.

Our subgroup analyses revealed that misperception of overweight is even worse for parents of young children. Furthermore, the use of different definitions of actual overweight in terms of accurate perception of overweight did not affect the sensitivity and specificity.

Because by far most studies included child–mother and no child–father couples, no differences in misperception between genders of parents could be tested. It seems obvious to assume that overweight parents are less likely to perceive their child as being overweight. (Chaparro et al. 2011) Taking the weight status of the parents into account may help to elucidate whether there is a difference in perception between overweight and normal‐weight parents; however, because too few studies reported parents' weight status, no subgroup analyses could be performed on this.

Finally, cultural differences in terms of a healthy weight perception are likely to affect the perception of parents. In the present review, because most studies were conducted in western countries, no comparison could be made with non‐western countries.

Implications

Health care professionals should be aware of the frequent misperception of the overweight status of a child, especially in young children. This is particularly important in view of the consequences of overweight at early age, i.e. a rapid increase in bodyweight during the first year of life is significantly associated with overweight at age 12 years. (Vogels et al. 2006) Moreover, childhood‐onset overweight accounts for 25% of adult obesity and persists into a higher BMI in adulthood, as compared with adult‐onset obesity. (Freedman et al. 2001; Dietz & Robinson 2005).

Also, parental awareness of their child's overweight implies concern about the child's health and willingness to take appropriate action. (Wake et al. 2002; Soto & White 2010; Moore et al. 2012) Therefore, as a first step to counteract overweight, health care professionals should aim to make parents recognise the overweight of their child. For example, physicians could measure height and weight, calculate and interpret BMI and discuss the weight status of a child during a consultation, irrespective of the reason for consultation.

Conclusion

The 51 studies (covering 35 103 children) show that parents are likely to misperceive the weight status of their overweight child, especially in young children. Despite the recent focus on the prevention and treatment of overweight in children, only 37.6% of the overweight children were perceived as being overweight by their parents. The most important implication of these results is that health care professionals should be aware of this frequent misperception and help make parents aware of the overweight of their child so that treatment options can be discussed.

Source of funding

This work was financed by the department of general practice of the Erasmus Medical Center.

Conflicts of interest

The authors declare that they have no conflicts interest.

Contributions

MR‐M participated in the design of the study, selected the articles, extracted the data and drafted the manuscript. WDP participated in the design of the study, selected the articles, extracted the data, performed analyses and helped to draft the manuscript. MvM helped to analyse the data and draft the manuscript. PJEB revised the manuscript critically for important intellectual content. JCvdW participated in its design of the manuscript and has been involved in drafting the manuscript. All co‐authors participated in manuscript preparation and critically reviewed all sections of the text for important intellectual content.

Acknowledgements

The authors thank Marina Castel Sánches for translating the Spanish articles.

Appendix 1

Search string and hits

Publication date to 2011/01/17

PubMed: 1958

(Child*[tw] OR (adolescent[MeSH] NOT adult[mesh]))

AND

(Parent*[tw] OR father*[tw] OR mother*[tw] OR matern*[tw] OR patern*[tw])

AND

(body mass index*[tw] OR overweight[tw] OR obes*[tw] OR BMI [tw] OR Quetelet*[tw] OR weight status*[tw] OR weight gain[tw] OR weight concern*[tw] OR weight control*[tw])

AND

(percepti*[tw] OR view*[tw] OR perceiv*[tw] OR aware*[tw] OR recogni*[tw] OR notion[tw] OR judg*[tw] OR classif*[tw] OR concern*[tw] OR reported weight[tw])

Appendix 2 

Study results

Definition of weight status Number of participants suitable for this analysis (n) True negative* False positive † False negative ‡ True positive §
Verbal description
Weight status IOTF based on Cole et al.
Abbott et al. 2010 IOTF Cole 2148 1701 6 330 111
Carnell et al. 2005 IOTF Cole 564 416 3 136 9
Crawford et al. 2006 IOTF Cole 1116 778 35 209 97
Jansen & Brug 2006 IOTF Cole 524 n.a. n.a. 261 263
Juliusson et al. 2011 IOTF Cole 3770 3217 71 343 139
Lampard et al. 2008 IOTF Cole 329 191 10 40 88
Lazzeri et al. 2006 IOTF Cole 2835 n.a. n.a. 656 306
Mamum et al. 2008 IOTF Cole 2650 1890 98 319 343
Vuorela et al. 2010 IOTF Cole 606 485 3 79 39
Weight status by WHO
Al‐Qaoud et al. 2010 BMI>85th overweight 482 n.a. n.a. 401 81
Bracho & Ramos 2007 BMI>85th overweight 270 149 4 89 28
De La et al. 2009 BMI>85th overweight 576 481 5 50 41
Flowers 2008 BMI>85th overweight 57 28 2 10 17
Hearst et al. 2011 BMI>85th overweight 358 242 0 217 9
Hernandez et al. 2010 BMI>85th overweight 49 n.a. n.a. 35 14
Hirschler et al. 2008 BMI>85th overweight 620 409 9 106 97
Mathieu et al. 2010 BMI>85th overweight 1128 791 135 156 46
Neumark et al. 2008 BMI>85th overweight 307 n.a. n.a. 162 145
Perrin et al. 2010 BMI>85th overweight 96 51 0 20 25
Rudolph et al. 2010 BMI>85th overweight 150 88 7 6 48
Weight status by CDC
Anderson et al. 2005 BMI>85th overweight 82 n.a. n.a. 64 18
Boa‐Sorte et al. 2007 BMI>85th overweight 827 634 41 69 83
Boutelle et al. 2004 BMI>85th overweight 742 442 30 209 61
Eckstein et al. 2006 BMI>85th overweight 223 132 3 56 32
Gray et al. 2007 BMI>85th overweight 169 n.a. n.a. 49 21
Harnack et al. 2009 BMI>85th overweight 593 366 1 217 9
Hirschler et al. 2006 BMI>85th overweight 321 n.a n.a. 111 20
Huang et al. 2007 BMI>85th overweight 429 n.a. n.a. 300 129
Hudson et al. 2009 BMI>85th overweight 96 61 2 22 11
Kroke et al. 2006 BMI>85th overweight 253 220 0 9 24
Manios et al. 2009 BMI>85th overweight 1759 1100 22 472 165
May et al. 2007 BMI>85th overweight 228 n.a. n.a. 188 40
Maynard et al. 2003 BMI>85th overweight 5500 4173 75 725 527
Skelton et al. 2006 BMI>85th overweight 37 n.a. n.a. 25 12
Tschamler et al. 2010 BMI>85th overweight 193 131 3 27 32
Wald et al. 2007 BMI>85th overweight 612 359 2 128 123
Weight status other
Baughcum et al. 2000 BMI>90th overweight 304 202 3 78 21
Garret 2009 BMI>95th overweight 120 73 1 40 6
Goodman et al. 2000 BMI>95th obese 564 n.a. n.a. 222 342
Hackie & Bowles 2007 BMI>95th overweight 38 n.a. n.a. 23 15
Jackson et al. 1990 BMI>90th overweight 107 90 0 16 1
Jeffery et al. 2005 BMI>91th overweight, BMI>98th obese 272 189 31 27 25
Kasemsup & Reicks 2006 BMI>95th overweight 80 40 5 27 8
Molina Mdel et al. 2009 Must et al.19,20 1272 959 16 148 149
Myers & Vargas 2000 BMI>90th overweight 200 n.a. n.a. 71 129
Valdes et al. 2009 BMI>75th (at risk for) overweight, BMI>95th obese 141 n.a. n.a. 35 106
Young et al. 2010 BMI>95th overweight 111 10 1 21 79
Images scales
Weight status IOTF based on Cole et al.
Warschburger & Kroller 2009 IOTF Cole 142 n.a. n.a. 10 17
Weight status by WHO
Hernandez et al. 2010 BMI>85th overweight 150 90 11 33 16
Reifsnider et al. 2006 BMI>85th overweight 25 4 9 7 5
Zonana‐Nacach & Conde‐Gaxiola 2010 BMI>85th overweight 525 351 12 64 98
Weight status by CDC
Eckstein et al. 2006 BMI>85th overweight 223 127 8 52 36
Weight status other
Beatty 2009 Unknown 130 76 0 21 33
Open in a new tab

*Actual weight status normal weight, perception normal weight. †Actual weight status normal weight, perception overweight. ‡Actual weight status overweight, perception normal weight. §Actual weight status overweight, perception overweight. BMI, body mass index; CDC, Centre for Disease Control and Prevention; IOTF, International Obesity Task Force; n.a., not available; WHO, World Health Organization.

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