Abstract
Background
Perceptions of children's weight status may be important in obesity prevention and treatment.
Aims
This review identifies the prevalence of the underestimation of overweight status in children by parents/main carers, children, and healthcare professionals (HCP). The review critically synthesized both quantitative and qualitative evidence to explore the factors associated with this underestimation. The diverse methods used to assess this phenomenon are reported.
Methods
Pooled effect sizes were calculated using random‐effects model. Published studies, up to 2020, were accessed using the following search engines: CINAHL, EMBASE, PUBMED, and Psych‐Info and including the “Cited by” and “Related Articles” functions. Hand‐searching was used to retrieve further articles. Publication language and location had no bearing on the nature of the included studies.
Results
A total of 91 articles were included. In the quantitative studies, 55% (95% CI 49%–61%) of caregivers underestimated their child's level of overweight and obesity using a verbal scale and 47% (95% CI 36%–55%) using visual scales. Of the children studied, 34% (95% CI 25%–43%) underestimated their own level of overweight and obesity using both scales. In (n = 3) articles, HCPs reflected this misperception, but limited studies prevented meta‐analysis. Underestimation was associated with the child's age, gender, BMI and parental weight status, ethnicity and education. In the qualitative studies, parents/main carers of children with overweight and obesity described their child's weight in terms other than overweight, for example, “big boned,” “thick,” and “solid.”
Conclusion
The results confirm the prevalence of underestimation of child overweight status across international studies. Understanding the factors which lead to this inaccuracy may help to improve communication within the therapeutic triad and facilitate the recognition and management of children's overweight status.
Keywords: child, healthcare professionals, overweight, parents, underestimation and perceptions, weight
1. INTRODUCTION
Levels of childhood overweight and obesity continue to increase globally. 1 Approximately 41 million children aged 0–5 years are classified as overweight or obese, while 340 million children aged 5–19 years can be categorized as overweight or obese. 2 Childhood overweight is a highly complex condition with biological, behavioral, social, economic, environmental, and cultural causes. 3 The widespread nature of childhood overweight is a cause for concern since it is associated with a range of negative medical and psychosocial effects, both short and long‐term. 4
Changes in diet, physical activity levels and, more recently sedentary activity are internationally considered to underpin interventions for the management of both adult and childhood obesity. 5 To enact behavior change it is necessary to achieve concordance which, in the case of childhood overweight and obesity, involves the therapeutic triad of the child (if sufficient cognitive capacity), their parents/main carers, and healthcare professionals (HCP) involved in their care. Effective weight control interventions for children are strongly informed by the degree to which the overweight and obesity perceptions of children, parents/main carers and HCP are accurate and consistent with one another. 6 It is, therefore, essential that weight‐related interventions are applied using an understanding of and effective working with key stakeholders and their perceptions of child overweight status. 7
It is generally accepted that a significant barrier to intervention is that parents underestimate their children's overweight status. 8 Furthermore, there is some limited evidence that children themselves and HCP may also underestimate. 9 In‐depth engagement and cooperation across the therapeutic triad is required for concordance—a dynamic which would be threatened by misaligned perceptions of the situation. 6 The psychological resistance that sometimes arises in parents due to the perceived link between childhood obesity, stigma, and blame, may result in their denial of a HCP's diagnosis, which decreases their receptiveness to the proposed interventions. 10
Data from several studies suggest that negative emotions like anger and shame may lead to resistance in the form of refusing to take advice or ignoring referral appointments. Previous research has demonstrated that HCP can perceive conversations around weight to be “difficult” and thus avoid raising the subject at all. 11 Understanding how sociodemographic, anthropometric, and cognitive factors, that may influence underestimation, may help to pre‐empt these “difficult” conversations, facilitate the recognition of children's overweight status, unify the therapeutic triad and help to notify the improvement of future weight‐related communications.
Earlier reviews in this area focused on parental perceptions toward child weight and repeatedly demonstrated that parents tend to underestimate their child weight. 12 , 13 , 14 The most recent meta‐analysis searched databases up to 2013, reporting that 50.7% of parents underestimate their children's weight if they are living with overweight or obesity. 5 The current systematic review and meta‐analysis aimed to update our knowledge by statistically identifying the prevalence of the underestimation of children's overweight status in children aged ≤19 years old in a wider sample (parents/main carers, children themselves and HCP). In addition, this review critically synthesized both quantitative and qualitative evidence to extend our understanding by investigating the factors associated with this underestimation. The systematic review also examined the diversity of methods used to assess this phenomenon.
2. METHODOLOGY
Studies, including quantitative and qualitative data on parents/main carers, children, and healthcare professional's underestimation of child overweight status, were systematically collected using the following search engines: CINAHL, EMBASE, PUBMED, and Psych‐Info from 1 January 2000 to 30 December 2020. Studies eligible for inclusion were qualitative and quantitative research that included children aged ≤19 years. In addition, the studies were also eligible for inclusion if they assessed parents/main carers, children, and healthcare professional's perceptions of children's weight using both a verbal scale (e.g., asking participants to complete a forced‐choice rating scale whereby each response category was based on a medical weight standard) or a visual scale (e.g., selecting an image from a range of pictures or silhouettes [linked blind to BMI and weight status]) that best represented the child's current size. The purposefully inclusive search terms (there is no standard terminology used in the literature) were “parents/main carers, child, HCP, overweight, obesity, weight, and underestimations.” Boolean operators were used to group the terms (see Table 1), thereby facilitating a more wide‐ranging search. In addition, a reference list of the identified literature was then hand‐searched and the “Cited by” and “Related Articles” functions in the search databases were also used to retrieve further relevant articles. Publication language and location had no bearing on the nature of the included studies. The participants were the parents/main carers of children with overweight/obesity, children with overweight/obesity or HCP. It should be noted that data were only on parents/main carers' assessments of their own children and not assessments of other children. Similarly, the children's assessment were of themselves and not other children, whereas the HCP′ assessment was generalized. Exclusion criteria included studies that do not provide anthropometric measurements with which to compare perceptions, as well as studies focused on perceptions toward “underweight” or “normal weight” participants only.
TABLE 1.
Search terms used
| The following phrases were altered to meet the search requirements of each single database AND | |||
|---|---|---|---|
| OR | OR | OR | OR |
| Parent* | Perception* | Weight | Child* |
| Carer* | Underestimation* | “OverWeight” | Adolescents* |
| Guardian* | Underdetection* | “BodyWeight” | Children |
| Caregiver* | Belief* | “OverWeight” | Infant* |
| Mother* | Recognition* | “BodyWeight” | Youth |
| Maternal | View* | Obese* | Healthcare |
| Father* | Attitude* | Professionals | |
| Paternal parent* | Perspective* | Physicians | |
| Family grandparent* | Healthcare provider | ||
2.1. Systematic review registration
The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO); registration number: CRD42018085823.
2.2. Quality assessment
A modified Newcastle‐Ottawa Scale adapted for single use in a specific context 15 was used to assess the quality of the 91 included studies. Following the authors' guidelines each study was assessed on the following criteria: methods used to select participants (i.e., sampling bias), methods used for controlling confounding (i.e., performance bias), statistical methodology (i.e., detection bias), and what the methods used to measure the outcome variables are (i.e., information bias). This scale measures the risk on a scale of 0 (high risk of bias) to 3 (low risk of bias) (see Table 2).
TABLE 2.
Results for quality assessments
| Authors | Methods used to select participants (sampling bias) | Adequate sample size for the outcome of interest (performance bias) | Methods used for controlling confounding variables (performance bias) | Appropriate statistical methods (detection bias) | Handling missing data (detection bias) | Methods of the outcome measure (information bias) | Objective assessment method of the outcomes (information bias) |
|---|---|---|---|---|---|---|---|
| Abbott et al. 16 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Adams et al. 17 | 0 HR | 3 LR | 2 MR | 3 LR | 3 LR | 2 MR | 3 LR |
| Akerman et al. 18 | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR | 3 LR |
| Aljunaibi et al. 19 | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR | 3 LR |
| Al‐Mohaimeed 20 | 3 LR | 3 LR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Al‐Qaoud et al. 21 | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Arcan et al. 22 | 3 LR | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Baughcum et al. 23 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Bossink‐Tuna et al. 24 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Boutelle et al. 25 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Brann 26 | 2MR | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Brannon et al. 27 | 3 LR | 3 LR | 2 MR | 3 LR | 3 LR | 2 MR | 3 LR |
| Campbell et al. 28 | 2 MR | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Carnell et al. 29 | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Chaparro et al. 30 | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Chen et al. 31 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Chaimovitz et al. 9 | 3 LR | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Crawford et al. 32 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| de Hoog et al. 33 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| de La et al. 23 | 2 MR | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Duarte et al. 34 | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Eckstein et al. 35 | 3 LR | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Eli et al. 36 2014 | 3 LR | 3 LR | 3 LR | 3 LR | 0 HR | 3 LR | 3 LR |
| Esenay et al. 37 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Etelson et al. 38 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Fisher et al. 36 | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Garrett‐Wright 39 | 2 MR | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Gauthier and Gance‐Cleveland 40 , 2016 | 2 MR | 1 HR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Genovesi et al. 41 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Guevara‐Cruz et al. 42 | 3 LR | 3 LR | 3 LR | 3 LR | 0 HR | 3 LR | 3 LR |
| Ha et al. 43 | 2 MR | 3 LR | 3 LR | 3 LR | 0 HR | 3 LR | 3 LR |
| Hackie et al. 44 | 2 MR | 0 HR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Hager et al. 45 | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Harnack et al. 46 | 2 MR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR | 3 LR |
| He and Evans et al. 47 | 2 MR | 0 HR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Hearst et al. 48 | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Hudson et al. 49 | 2 MR | 3 LR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Jackson et al. 50 | 3 LR | 3 LR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Jansen and Brug 51 | 3 LR | 3 LR | 3 LR | 3 LR | 0 HR | 3 LR | 3 LR |
| Jones et al. 52 | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Júlíusson et al. 28 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Kasemsup and Reicks 53 | 2 MR | 0 HR | 3LR | 3 LR | 0 HR | 3 LR | 0 HR |
| Kaufman‐Shriqui et al. 54 | 2 MR | 0 HR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Kersey et al. 55 | 0 HR | 3 LR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Kroke et al. 56 | 2 MR | 0 HR | 2 MR | 3 LR | 3 LR | 2 MR | 3 LR |
| Lampard et al. 57 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Laraway et al. 58 | 2 LR | 3 LR | 3 LR | 3 LR | 0 HR | 2 MR | 3 LR |
| Lazzeri et al. 59 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Lopes et al. 60 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Lydecker and Grilo 61 | 2 MR | 3 LR | 0 HR | 3 LR | 3 LR | 0 HR | 0 HR |
| Linchey et al. 62 | 0 HR | 0 LR | 3 LR | 3 LR | 3 LR | 3 MR | 3 LR |
| Molina de Faria et al. 63 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Mamum et al. 64 | 2 MR | 3 LR | 0 HR | 3 LR | 2 MR | 3 LR | 3 LR |
| Manios et al. 65 | 3 LR | 3 LR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Mathieu et al. 66 | 2 MR | 3 LR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Maximova et al. 67 | 3 LR | 3 LR | 2 MR | 3 LR | 2 MR | 3 LR | 3 LR |
| Maynard et al. 68 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| McKee et al. 69 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Miller et al. 70 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Moore et al. 71 | 3 LR | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Moschonis et al. 72 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Musaad et al. 73 | 3 LR | 3 LR | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR |
| Myers and Vargas 74 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Perrin et al. 75 | 2 MR | 0 HR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Petricevic et al. 76 | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Ra et al. 77 | 2 MR | 3 LR | 2 MR | 3 LR | 0 HR | 3 LR | 3 LR |
| Redsell et al. 72 | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Rosas et al. 78 | 2 MR | 0 HR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Regber et al. 79 | 2 MR | 3 LR | 2 MR | 3 LR | 3 LR | 2 MR | 3 LR |
| Reifsnider et al. 80 | 2 MR | 0 HR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Robinson and Sutin 81 | 3 LR | 3 LR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Rudolph et al. 73 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3LR |
| Ruiter et al. 82 | 0 LR | 3 LR | 3 LR | 3 LR | 0 HR | 3 LR | 0 HR |
| Rodrigues et al. 83 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Shrewsbury et al. 84 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Skelton et al. 85 | 0 HR | 0 HR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Spurrier et al. 86 | 0 HR | 0 HR | 3 LR | 3 LR | 3 LR | 2 MR | 0 HR |
| Tarasenko et al. 6 | 3 LR | 3LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Thompson et al. 87 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Tschamler et al. 88 | 2 MR | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Twarog et al. 89 | 3 LR | 3 LR | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR |
| Vanhala et al. 43 | 0 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Vuorela et al. 90 | 3 LR | 3 LR | 2 MR | 3 LR | 2 MR | 3 LR | 3 LR |
| Vrijkotte et al. 91 | 0 HR | 3 LR | 3 LR | 0 HR | 3 LR | 3 LR | 3 LR |
| Wald et al. 92 | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Webber et al. 93 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| Wen and Hui 93 | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 2 MR | 3 LR |
| West et al. 94 | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 0 HR |
| Wong et al. 95 | 2 MR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
| Yao and Hillemeir. 96 | 2 MR | 0 HR | 2 MR | 3 LR | 0 HR | 3 LR | 3 LR |
| Young‐Hyman et al. 97 | 0 HR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR | 3 LR |
Note: *0 HR (HIGH RISK), 1 and 2 MR (MODERATE RISK), 3LR (LOW RISK).
2.3. Data extraction
Table 3 shows the summary characteristics of 91 studies included in this review. Data was extracted based on the study characteristics. These included authors/date, country and ethnic background, total number of participants, age of children and adolescents, sampling and recruitment; setting, respondents who provided the data, the overweight and obesity criteria applied, percentage of underestimation, weight status; and factors associated with underestimation were also extracted. Given that part of the aim of this systematic review was to examine the diversity of methods used to evaluate underestimations of children's overweight status, data on the verbatim questions that were asked of participants, verbatim response options, stated justifications for questions and/or responses, whether the participants were aware of weight status before answering, and whether participants were told of weight status, were also extracted. For the qualitative studies, the data of the participants' estimations, thoughts and views of children's weights were synthesized, with particular attention to overweight and obesity to produce a narrative understanding of the phenomena of interest.
TABLE 3.
Characteristics of the included studies
| Author, country |
|
Sampling, recruitment and settings | Question/s and answer/s | Cut‐off applied |
|
Factors associated with under‐estimation |
|---|---|---|---|---|---|---|
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Note: *OWOB, Overweight or Obese; OW, Overweight; OB, Obese; NHANES, The National Health and Nutrition Examination Survey; NA, Not Applicable; HCPs, Healthcare Professionals; WIC, Women, Infants and Children.
2.4. Statistical methods
After the extraction of quantitative data, the main effect sizes for the percentage of underestimation by parents/main carers and children using both visual and verbal scales were determined using STATA 14 and a meta‐analysis was performed using R program (There was insufficient data to consider underestimation in HCP). For each study, the effect size was calculated for the reported adjusted proportion of the participants who underestimated children's overweight weight status. A random‐effects meta‐analysis model was used in the study since the studies stem from different populations and design‐related heterogeneity. 105 To test heterogeneity between‐studies, the χ 2 with a statistic Q was used to examine the null hypothesis that all studies have the same true effect, 36 namely H0: τ 2 = 0. Given that the Q‐test sometimes may fail to detect heterogeneity when the number of samples is small (i.e., less than 10), 106 the statistics I 2 was also used to assess the proportion of the observed heterogeneity, 107 as it is not affected by sample size. I 2 values range from 0% to 100% with three levels of I 2: low, moderate, and high corresponding to values of 25%, 50%, and 75%. 106 In addition, the 95% CI around the I 2 statistic was also calculated to determine whether the heterogeneity is present. Overall, τ 2, Q‐test and I 2 were used in this research to decide whether the estimated effects are homogeneous. Thereafter, pooled effect sizes were estimated via random effects models, since the studies are based on different populations. To visualize the overall estimates of the study effects with corresponding confidence intervals, forest plots were used. 108
Sensitivity analyses of the meta‐analyses were conducted using a range of visual approaches including difference in values (DFFITS), Cook's distances, studentized deleted residuals, Cov‐ratios, and estimates of heterogeneity. This identified some potentially outlying studies, but with a low impact on overall estimate sizes, so they were retained in the meta‐analyses. In evaluating heterogeneity among the studies, it was apparent that there was a significant influence in all data‐sets, therefore, random effects models were applied to all studies.
3. RESULTS
3.1. Literature search
A total of 4348 citations of potentially relevant references were identified with 3906 excluded after title screening. After an abstract and full text screening, a further 357 records were excluded. The reasons for the exclusions included lack of anthropometric measurements (n = 67), an absence of an assessment of weight perceptions (n = 58), and abstracts only (n = 22). After the exclusions, 91 studies fulfilling the inclusion criteria were included. Figure 1 depicts the results of the search strategy based on the PRISMA checklist. 109
FIGURE 1.
PRISMA flow diagram of the search strategy
3.2. Study selection and characteristics
Table 3 shows the included studies (n = 91). The majority were quantitative, non‐experimental, cross‐sectional studies (n = 88), while a relatively small number (n = 3) were either qualitative only 72 , 100 or mixed methods. 87 Verbal scales alone were used in the majority of the studies (n = 76), while visual scales alone were employed in eight studies, five of which applied both verbal and visual scaling. 9 , 35 , 59 , 86 , 110 The studies were conducted across 20 different countries; 50% were conducted in European countries, 41% in the United States of America, 9% across Asia. All the included studies were in the English language and involved 24,774 participants‐children, parents/main carers and HCP. While (n = 29) studies did not report on ethnicity, the ethnic group that appeared with the greatest frequency across the studies were Hispanic, African American, White, Native American, and Asian. In terms of weight status, the majority of the studies included children ranging from all weight categories (n = 82), while for six studies, most children were classified as either overweight or obese. 17 , 21 , 34 , 37 , 38 , 44 , 45 , 50 , 56 , 61 , 67 , 74 , 75 , 81 , 89 , 97 , 99 , 103 , 111 , 112
3.3. Child weight status categorization
3.3.1. Objective measures
Across the studies, all were based on weight to height ratios with different criteria for categorization to determine a child's weight status. The International Obesity Task Force's (IOTF) sex‐specific and age‐specific cut‐offs were used in (n = 30) studies, while (n = 24) studies classified children as at risk of overweight when their BMI is between 85th and 95th and overweight when their BMI is ≥to the 95th percentile (Centers for Disease Control and Prevention‐Pre 2010). The World Health Organization (WHO) growth standards were used in nine of the studies. Spurrier et al. 86 used the 90th percentile as the cut‐off point for overweight, consistent with the CDC growth chart. The CDC post‐2010 was employed in several studies, which considers overweight to be a BMI between the 85th and 95th percentiles, while obesity is considered a BMI of greater than or equal to the 95th percentile (n = 17). Kroke et al. 56 utilized German reference curves, classifying children as obese, where BMI was greater than or equal to the 90th percentile, while obesity was linked to the 97th percentile. Esenay et al. 37 utilized the Turkish growth curves, which classify overweight based on the 85th and 95th percentiles and obesity as greater than or equal to the 95th percentile. Finally, Young‐Hyman et al. 97 employed the National Centre Health Statistics, 1990 as the cut‐off point, which considers adolescents in the 95th to 99th percentiles to be classified as overweight, while those greater than the 99th percentile are classified as obese.
3.3.2. Subjective measures
Across 80 of the studies, the participants verbally classified their children's or their own weight status with a forced‐choice rating scale, whereby participants described their weight status by selecting a category that was based on medicalized weight related standards. In 20 cases, a numerical Likert‐type scale was employed, in which a child's weight was considered along a spectrum, from very underweight to very overweight. Across the included studies, differing terms were used to describe overweight and obesity (e.g., “underweight” to “obese,” “underweight” to “overweight,” “somewhat thin” to “somewhat heavy,” “markedly underweight” to “markedly overweight” and “thin” to “fat”). One study relied on a visual analogue scale, where caregivers were requested to mark the spot on the line correlated with their child's weight status. 38
In 13 studies, visual evaluations of sketches, silhouettes, photographs, and figures where used. In a group of silhouettes, participants were asked to select the figure that described their own child's or their own weight status. The majority used the validated pictorial instrument by Collin et al. 99 (n = 6). Duarte et al. 34 and Hager et al. 45 used the Toddler Silhouette Scale (TSS) asking parents/carers, “Which picture looks most like your child?” Chaimovitz et al. 9 compared parents', children's, and physicians' perceptions of children's weight using a body image scale to indicate the figure that most correctly describe the child's weight. Children alone were asked to select which silhouette looks most like their body shape in Robinson et al. 81 and Maximova et al. 67
Eckstein et al. 35 examined a tool that involves gender‐specific and age‐range‐specific outlines of children to evaluate parental views of their child's body weight. When compared to written questions, images facilitated greater accuracy in the categorization of a child's weight based on their height. Furthermore, Lazzeri et al. 59 reported that mothers tended to have more precise views of their children's nutritional status when selecting silhouettes corresponding to BMI, rather than when using multiple‐choice questions. Although Moschonis et al. 72 reported that mothers' assessments of their children's weight status were more accurate when using verbal rather than visual classification tools, the study relied on outdated NCHS growth charts from 1979 which depicted only pre‐pubescent children. Chaimovitz et al. 9 also employed verbal and visual scales for the assessment of perceived weight status, the intention being to safeguard against the influence of weight‐related terminologies used in the measure. The rate of weight status underestimation was comparable across the two scales, which is consistent with our meta‐analysis which provides very similar estimates of the extent of underestimation by parents/carers, regardless of the use of verbal or visual scales. The same process of underestimation of overweight and obesity was also found when HCP were asked whether each child was classified as underweight, having a healthy weight, overweight, or obese. Although there was insufficient data to perform a meta‐analysis, Spurrier et al. 86 Chaimovitz et al. 9 and Tarasenko, Rossen and Schoendorf 6 all reported underestimation of overweight by a significant number of HCP. These studies included general practitioners (GPs) and pediatricians as well as physicians from hospitals, medical centers, and clinics. Among the reasons proposed for why HCP may underestimate children's overweight status is that, HCP do not take weight measurements or provide weight management guidance because their patients do not seem to be overweight or obese. 111
Phenomenological methods were employed by Redsell et al. 72 Eli et al. 100 and Thompson et al. 87 in order to gain insight into parents' perceptions of their children's weight status. These studies adopted qualitative research designs with semi‐structured interviews and focus groups. The results from the studies indicated that mothers conceptualized a child's weight differently and no participant held to the medical definition of childhood obesity which the researchers proposed. Instead a preschool child was considered to have a healthy weight if they could take part in a specific activity, appeared healthy, were happy, and were not bullied. 72 , 87 , 100 Eli et al. 100 reported that no participant described the weight status of preschool children as “obese” or “overweight” but used terms such as “chunky,” “stout,” “chubby,” “stocky,” “big boned,” “robust,” “solid,” and “pudgy.”
3.4. Methodological quality
Objective outcome measures were employed in almost every study (n = 89) except one where weight and height were reported by parents. 61 In (n = 63) studies, it was not clear whether the experimental equipment was standardized and information was rarely given as to whether the objective child weight assessment process involved identical equipment across the entire sample. In the majority of studies (n = 80), data were not gathered as to whether participants already knew about the child's weight status. Weight classification methods, confounding variables, statistical analysis methods and the possibility of non‐respondent bias were identified in almost all studies as issues that could have reduced the methodological quality of the studies (see Table 2). Re; the diversity of the methods used to assess underestimation of overweight status, 75% of the included studies offer no explanation or justification for using specific terminology in question and/or responses in the verbal assessment method. The methodological quality ranged from high to low quality; however, the majority were relatively high in most of the studies (see Table 2). Therefore, the results seem to give a reliable estimate of the available data on this subject.
3.5. Meta‐analyses of underestimation
The main finding produced from the analysis of the quantitative studies is that the prevalence of underestimation of overweight is high among parents/main carers and children. When parents/main carers used a verbal scale (79 studies), 55% underestimated overweight and obesity (95% CI 48%–61%) (see Figure 2). Similarly, when using a visual scale (see Figure 3), the prevalence of underestimation by parents was 47% (95% CI 36%–55%). Children also tended to underestimate their weight (see Figure 4) with a prevalence estimate of 34% (95% CI 25%–43%). Although there was insufficient data to perform a meta‐analysis, Spurrier et al. 86 Chaimovitz et al. 9 and Tarasenko, Rossen and Schoendorf 6 reported that underestimation of overweight also applied to a significant number of HCP with a range of (20%–60%).
FIGURE 2.
Forest plot for the summary of point estimates of effect sizes for caregivers' underestimation of their child's overweight status using verbal assessment scale
FIGURE 3.
Forest plot for the summary of point estimates of effect sizes for caregivers' underestimation of overweight status is their children using visual assessment scale
FIGURE 4.
Forest plot for the summary of point estimates of effect sizes for children's underestimation of their overweight status
The studies examined a number of factors that might contribute to inaccuracy in identifying children who were affected by overweight or obesity. These factors included the child's age where the overweight status of younger children was more likely to be underestimated than older children. 32 , 35 , 61 , 68 , 82 , 83 The child's gender was a factor that was found to be associated with the participants underestimation, as overweight and obesity in females was more accurately recognized than in males. 16 , 43 , 61 , 68 , 82 , 83 , 104 Another factor was the child's current BMI. Children of higher BMIs were more likely to be correctly identified as overweight/obese, 16 , 34 , 43 , 45 , 47 , 68 suggesting that children close to the overweight but not obesity level were hardest for participants to classify. Maternal characteristics contributed to misidentification of children's overweight. Mothers with obesity were more likely to perceive their child's weight status incorrectly. 61 , 67 , 83 Both child and parent ethnicity were also positively associated with the overall underestimation of the children's weight status in two studies. 63 , 89 , 91 Parents with a lower education were more likely to underestimate their child's weight than relatively well educated parents. 33 , 41 , 62 , 83 , 91 , 98
Homogeneity assessment for point estimates of effect sizes of parental/main carers underestimation of their child's weight status in studies using the verbal assessment scale revealed high heterogeneity: Q‐statistic = 5218.9705, p‐value < 0.001. Similarly, homogeneity assessments, for point estimates of effect sizes of parental/main carers underestimation of overweight and obesity, in studies using the visual assessment scale, revealed high heterogeneity: Q‐statistic = 200.1098, p‐value < 0.001. In children based studies, homogeneity assessment for point estimates of effect sizes of the underestimation of overweight and obesity, also revealed high heterogeneity: Q‐statistic = 258.3483, p‐value < 0.001.
4. DISCUSSION
The current systematic review and meta‐analysis has statistically identified the prevalence of underestimation of child's overweight across a wide age range and across parents/main carers, children themselves and HCP. This review has shown that children's overweight status is frequently underestimated and is consistent with the earlier reviews conducted by Parry et al. 12 Doolen et al. 13 Rietmeijer‐Mentink et al. 14 and Lundahl et al. 5 However, it extends these works with a meta‐analysis that demonstrates that the majority of parents/main carers (55%, 95%CI 49%–61%) underestimated their children's level of overweight, while a substantial proportion of children underestimated their overweight status (34%, 95% CI 18%–54%). HCP shared this misperception despite the low number of studies preventing a meta‐analysis. This finding is in accordance with earlier literature, which shows that the underestimation of overweight is also very common in adults. 9 The findings of this review are of concern if one accepts that alignment is required within the therapeutic triad for a trusting relationship and concordance. 9 When one or more parties enters conversations minimizing or rejecting advice highlighting the need for intervention, it is reasonable to suggest that tensions might result unless time and consideration is paid to align beliefs.
To the authors' knowledge, this is the first systematic review of this topic which considers ways in which features of study design might affect the prevalence of the underestimation of overweight status, in addition to study quality. This systematic review has addressed studies which used both a verbal scale (e.g., asking participants to complete a forced‐choice rating scale whereby each response category was based on a medical weight standard) and/or a visual scale (e.g., selecting an image from a range of pictures or silhouettes [linked blind to BMI and weight status] that best represented the child current size) but considered them separate for the meta‐analyses. Across the literature, a wide range of terminology was employed to label response options in verbal scaling. These differing labels, even when the same criteria underpin the scaling, have the potential to be interpreted differently by participants. In addition, there is a sizeable evidence‐base demonstrating that overweight adjectives, including medical terms, can lead to negative emotions. 8 , 9 , 10 , 13 , 29 In the qualitative studies, parents commonly describe their children in terms other than obese, such as “big boned,” “thick,” and “solid,” and demonstrate a strong desire to avoid labelling their child with medical terminology. 100 Perceived blame, internalized stigma, and negativity may generate resistance to the language of the discussion, prevent accurate overweight status classification, and ultimately trigger reduced intention to engage in behavior change. 9 , 10 The effect of this on our results is that the studies, which utilized terminology associated with negative emotion, might under‐report the prevalence of overweight status and yet the majority of included studies (n = 66) neglected to describe the questionnaire development process and failed to justify the weight‐related terminologies used, even when in‐paper references to previous uses of the questionnaire were consulted (n = 12).
Visual scales avoid the need for labeled response options and the issues involved in selecting neutral terminology. 9 However, the 13 studies using these methods are beset by the same variation in instruments (silhouettes, etc.) as the methodology utilizing verbal scales. Studies which allow direct comparison suggest that visual scales are more accurate than verbal scales. 59 In view of this consideration, studies using pictoral assessment methods for the views of parents and children result in a slightly less underestimation of overweight/obesity (47%) compared to verbal scale (55%). This result may further suggest that parents and children/adolescents do recognize the weight status but do not verbally label it as overweight. 14 This is perhaps because of the negative association with the word overweight and the stigma attached to people with obesity in society. 8 , 68 However, there is little evidence using pictorial assessment method in the current review to make informed conclusions on it.
Despite the diversity in the study design discussed above, it is noteworthy that such a large number of studies from across the world, have investigated this phenomenon and the meta‐analyses demonstrate such a clear effect. Any future studies investigating the prevalence of the underestimation of overweight status in children, particularly among caregivers, should be justified in the light of this. At this stage, more useful approaches will be applied in investigating family characteristics that are associated with overweight status underestimation as this review has suggested the influence of children's age (younger children), 32 , 35 , 61 , 68 , 82 , 83 gender (male), 16 , 43 , 61 , 68 , 82 , 83 , 104 children's current BMI (higher BMI), 16 , 34 , 43 , 45 , 68 and parental weight status (higher BMI), 61 , 67 , 83 ethnicity 63 , 89 , 91 and parental education levels (lower). 33 , 41 , 83 , 91 , 98 The way in which an individual perceives another individual is informed by their relationship, the perceived individual's characteristics, and the perceiving individual's characteristics. This is further compounded by their beliefs, and experiences which, in turn, influence their attitudes, thoughts, and feelings toward the perceived. 14 A clear knowledge of the factors which may lead to inaccuracy in assessing child overweight status may help to pre‐empt these “difficult” conversations, facilitate the recognition of children's overweight status and unify the therapeutic triad.
Jain et al. 113 report two important findings: firstly, that the mothers of young children with overweight tended to assume that as their child aged, grew taller, and engaged in more physical activity, their child's weight status would improve and secondly, that continuous rises in weight and height were indicative of positive nutrition and parenting. Alongside this, Genovesi et al. 41 reported that for some parents, overweight was considered a sign of good health. This may underpin why a child's overweight status is more likely to be underestimated by caregivers when the child is younger. Older children were found to be able to identify their own overweight status better compared to parents of younger children. 16 This could be caused by their own perception of their weight compared to their peers. A number of studies included in this review report that participants underestimate overweight status less among female children when compared to male counterparts. 38 , 43 , 61 , 68 , 82 , 83 , 89 , 104 Drawing on a representative sample, one of the included studies reports that accurate identification of overweight status among mothers was three times higher for female children when compared to males. 68 Similarly, Fisher, Fraser, and Alexander 112 found that while 67% of parents of overweight males do not recognize this status, the proportion was 44% for females. According to Campbell et al. 28 mothers have a higher sensitivity to female body image and weight considerations, while for overweight male children, their weight status may be perceived as physically advantageous. It is unfortunate that such a small proportion of the literature included male caregivers (n = 27) and for those that did, no direct comparisons were made.
A number of studies found that a child's BMI plays a significant role in affecting underestimations of overweight status; children with higher BMIs were more likely to be identified correctly as having an overweight status. 12 , 16 , 17 , 34 , 43 , 45 , 68 , 84 Therefore, children at the lower end of the overweight range (based on a BMI‐for‐age percentile) were more likely to be underestimated. This blurring at the overweight cut‐off level accounts, perhaps for norm‐comparison in a society where higher BMIs are more common. 114
Maternal overweight weight status was a variable considered in a number of studies 61 , 64 with Moschonis et al. 110 reporting that the underestimation of child overweight status was 1.44 times more likely among mothers with overweight compared to mothers without overweight status. Qualitative work by McPherson et al. 115 addresses this by suggesting that because parents with a high BMI have been subjected to social stigma, they are more likely than underweight and healthy weight parents to want to safeguard their children from the provoking labels associated with overweight status. However, Linchey et al. 62 found no association between parent weight status and underestimation. Despite the suggestion that lower levels of maternal education are associated with the underestimation of overweight in children 41 , 44 , 48 , 62 , 83 , 91 , 98 there are some inconsistencies in the evidence by Adams et al. 17 Carnell et al. 29 and He and Evans 47 suggesting no link between maternal educational levels. In contrast, Ruiter et al. 82 found that the parents who had a high level of education were more likely to underestimate their child's overweight status. Ethnicity was also positively associated with the overall underestimation of child's weight status in two studies. 63 , 89 , 91 Molina et al. 63 found white children were less likely to be underestimated than non‐white. The greater acceptance of larger body size in some cultures may account for these differences. 111 In addition, parental underestimation of child's overweight and obesity has been reported to be particularly common among Hispanic individuals, 89 an ethnic group with very high level of overweight and obesity prevalence and a likelihood to identify larger body sizes as being more normal. 111 In the recent study by Linchey et al. 62 parent race/ethnicity was not associated with underestimating child weight status. However, this study is limited by unequal ethnic groups (White, Hispanic, Asian, black), with a small percentage of African American (3.4%) which makes it difficult to fully examine the associations by ethnicity.
The study has found that there is much work to be done to elicit the relationship between parent/main caregiver, child and HCP's underestimation of weight status. A greater focus on the factors associated with HCP underestimation could provide a greater opportunity for a clearer understanding. Future studies could investigate additional factors such as the effect of male parents/main carers on the tendency to underestimate child overweight with multivariate study designs to allow a more complete and detailed description of any interactions between characteristics, and more consistent data collection methods with an emphasis on visual scaling.
This systematic review and meta‐analysis is associated with a number of strengths and limitations. A key strength is that it includes both quantitative and qualitative studies, which allows greater understanding. Over and above the existing knowledge in this area, the study sought to examine the perceptions of parents/carers, children, and HCP. This review includes participants from a range of socioeconomic and cultural backgrounds, with a wide age range of children (up to 19 years old) in both experimental and population settings. However, an important limitation of this systematic review has been the lack of a statistical examination of HCP' perceptions, which stems from the scarcity of relevant studies in the literature. Additionally, gender‐based disparities in the parental tendency to underestimate child overweight were not tested, since the majority of the included studies examined mother‐to‐child rather than father‐to‐child dyads. Lastly, the results could suffer from publication bias due to the fact that some of the unpublished studies were not included.
This systematic review's findings indicate that when the prevalence of underestimation of child weight status is acknowledged, viable interventions can be promoted which involve parents, children, and HCP. For the purpose of raising awareness among parents of children with overweight and obesity, it is necessary to ensure that HCP themselves have an adequate understanding of these conditions. This could be facilitated if HCP engage directly with the various ways in which children and their parents define overweight, and to gain insight into the long‐term consequential health factors of being categorized as overweight and obese. 116
As emphasized by Puhl et al. 10 the psychological resistance that sometimes arises in parents due to the perceived link between childhood obesity, stigma, and blame, may result in their denial of a healthcare professional's diagnosis, which decreases their receptiveness to proposed interventions. Hence, HCP should engage directly with concerns over stigma when discussing childhood overweight and obesity with parents, assuring them that they are not to blame for the condition, and that their participation in the cooperative management of their children's overweight condition represents a beneficial step forward. Additionally, HCP should refrain from engaging parents in such a way as to instill guilt or a sense of being judged. Lastly, sensitive framing of each discussion regarding child weight status should be a top priority.
5. CONCLUSION
The results of this wide‐reaching systematic review confirm that the underestimation of child overweight status is highly prevalent. Those that design child weight management interventions should expect that for many parents/main carers and children, identifying and problematizing their child's overweight status will be unexpected and requires extra consideration to align beliefs. It may also lead to negative emotions and resistance. Although understanding the factors which lead to inaccuracy in assessing child's overweight status may help to pre‐empt “difficult” conversations and facilitate the recognition of children's overweight status, much work is required. Future studies could usefully consider a wider range of parents/main carers, child and HCP characteristics, utilize multivariate study designs, and use more consistent data collection methods with an emphasis on visual scaling.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
Abrar Alshahrani carried out the literature search, analyzed the data and wrote the manuscript. Farag Shuweihdi revised meta‐analysis. Judy Swift provided critical feedback to the manuscript. Amanda Avery provided critical feedback and helped shape the research, analysis and manuscript.
ACKNOWLEDGMENT
Abrar Alshahrani is currently undertaking a PhD funded by the Saudi Arabian Government and is on secondment from the University of Jazan.
Alshahrani A, Shuweihdi F, Swift J, Avery A. Underestimation of overweight weight status in children and adolescents aged 0‐19 years: a systematic review and meta‐analysis. Obes Sci Pract. 2021;7(6):760‐796. 10.1002/osp4.531
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