Introduction The Delaware Survey of Children’s Health (DSCH), sponsored by Nemours, is a surveillance instrument, administered by telephone, with results from more than 3,000 households in Delaware with children ages birth to 17. The DSCH, which was administered in 2006, 2008 and 2011, provides data on trends in children’s weight status, health-related behaviors, and parental perception of children’s weight.1

This brief discusses parental perception of children’s weight. As a part of the DSCH, parents reported their child’s height and weight and were asked whether their child was underweight; at a normal weight; somewhat overweight; or significantly overweight. Height and weight were validated by data from health care providers. Survey results reveal a significant gap between how parents of overweight and obese children classify their children and the clinical classification of their children’s weight. Eighty percent of parents of overweight children and over half (58.7 percent) of parents of obese children surveyed in Delaware in 2011 reported that their child was at a healthy weight. This is similar to the findings from the 2006 and 2008 surveys.1

The Complexity of Parental Awareness of Overweight and ObesityThe American public considers childhood obesity to be a major public health threat, on par with tobacco use and violence.2 In recent years, major initiatives have been launched to combat the epidemic, and public support for interventions has remained strong. At the same time, national surveys show that the majority of parents of children who are overweight or obese report that their children are of normal weight.3-6 Delaware data are consistent with what has been found nationally.

There may be many reasons for parents reporting inaccurately. Studies have shown that some parents do not understand the term “overweight” or the link between overweight and poor health. Studies have also found some parents believe that a heavier child is healthier, preferring large body types, or feeling that a larger child reflects positively on the parents. It is also possible that some parents of overweight or obese children may be aware but unwilling to state that their child is overweight or obese. The social stigma of being labeled overweight may keep some parents from acknowledging a situation that they actually recognize.7

The Youngest Children Are the Most MisclassifiedThe gap between parental reports and the reality of children’s weight is most pronounced among the youngest Delaware children, those ages 2 through 5 years. Over 80 percent (80.7 percent) of parents of the obese toddlers and preschoolers surveyed said their children were at a normal weight. None said that their children were significantly overweight; 15.6 percent said they were somewhat overweight; and 3.7 percent said that they were underweight.1

OVERWEIGHT AND OBESE CHILDREN:“AT A NORMAL WEIGHT,” ACCORDING TO PARENTS

Data Brief #1 2014

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02006 2008 2011

Percentage of Parents Who Perceive Their Overweight or Obese Children to Be Normal Weight by Gender of the Child. 1

78.5% 80.5%

59.8% 60.0%

Overweight

Obese

79.5%

58.7%

Hardly any of the parents of overweight 2-5 year olds reported a weight problem; almost 95 percent of this group said their children were at a normal weight.1

Young children may be particularly difficult for parents to identify as overweight or obese. Even some medical professionals seem prone to misclassify preschool children. A 2010 study conducted among medical students, resident physicians and community physicians, using only visual cues, found that only 15 percent of respondents correctly identified a 3-year-old boy, whose BMI was >95th percentile for his age, as obese. Only 21 percent correctly identified another girl who was overweight at the 90-95th percentile BMI-for-age. No significant difference was found in total accuracy between physicians and trainees. Parents may experience the same misperceptions when using only visual cues.8

Although young children may be the hardest to identify as overweight or obese, the stakes in doing so may be the highest. Recently-released research following more than 7,000 children from kindergarten through eighth grade found that a third of the children who were overweight in kindergarten were obese by eighth grade. The study also documented a relative decrease in the incidence of obesity after age five. The case for intervening early has never been so strong, but misperceptions of young children’s weight status remain a serious barrier.9

After Age Five, Most Parents Are Still InaccurateAlmost 60 percent (59.2 percent) of parents of obese 6- to 11-year-olds reported that their children were of normal weight, as did almost three-quarters (73.5 percent) of parents of overweight 6- to 11-year-olds. Although there is more accuracy among these parents than among the parents of the youngest children, these figures are cause for significant concern.1

Among Delaware parents of adolescents, ages 12-17, the DSCH found somewhat higher levels of accuracy, but notably, the majority of parents of overweight and obese children still reported their children were less overweight than they actually were. Seventy nine percent of parents of overweight adolescents said their children were at a normal weight; 36.8 percent of parents of obese adolescents reported normal weight, and over half of these parents (50.8 percent) said that their child was “somewhat overweight,” when the correct classification would be “significantly overweight.”

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Parents More Accurate About Obese and Overweight FemalesParents in Delaware are somewhat more accurate about girls’ weights than boys; 40.1 percent of parents of obese girls said they were “somewhat overweight” when surveyed. Only 23.8 percent of parents of obese boys said the boys were overweight. Obese girls were also more likely to be accurately classified as “significantly overweight” than boys; 10.2 percent of girls’ parents said they were “significantly overweight, while only 3.6 percent of boys’ parents indicated the same.1

Similarly, parents of overweight girls are more likely to see them as overweight; 18.8 percent of overweight girls had parents who said this was the case (1.3 percent of these girls’ parents said they were “significantly overweight”). Among overweight boys, only 12.9 percent of Delaware parents reported them to be overweight and virtually none (0.2 percent) said they were “significantly overweight.”1 This finding corresponds to results from a number of studies across the country. Researchers speculate that parents of girls may compare their children to a “thin ideal” for the female body and therefore be more likely to recognize a problem. Overweight boys may be seen as more normal, as larger boys may be considered to have a physical advantage.

Differences in Reporting Among Races and EthnicitiesAlthough parents in Delaware, regardless of race or ethnicity, generally say their overweight or obese children are at a normal weight, there is some variation in the degree of misclassification by race and ethnicity. Parents

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02006 2008 2011

Parents Who Perceive Their Obese Child as “Healthy Weight”1

82.3%

63.5%

Wei

ghte

d Pe

rcen

t

Age 2-5

Age 6-11

Age 12-17

44.3%

89.4%

67.3%

26.0%

80.7%

59.2%

36.8%

Parents Who Perceive Their Overweight Child as “Healthy Weight”1

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02006 2008 2011

84.8%

67.7%

Wei

ghte

d Pe

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Age 2-5

Age 6-11

Age 12-17

82.6%

88.1%85.0%

74.2%

94.7%

73.5%79.0%

of obese African-American children are the most likely of the races/ethnicities studied in the DSCH to report accurately — less than half (45.9 percent) say their obese children are at a normal weight; 46.6 percent say they are “somewhat overweight” and 7.5 percent say they are “significantly overweight, “ which is clinically correct.

Parents of obese white children are the least likely to say that their children are obese — 62.8 percent report that their obese children are at a normal weight; 28.2 percent say the obese children are “somewhat overweight” and 6.3 percent report accurately, that the children are “significantly overweight.” Parents of Hispanic children fall between these two groups in terms of accuracy — 55.6 percent report a normal weight for obese children, with 37.2 percent saying the children are “somewhat overweight” and 6.6 percent reporting accurately.1

However, race and ethnicity play out differently when parents report on overweight, as contrasted with obesity. Whereas obese African-American children were the most likely to be accurately classified by their parents, this is not the case for overweight African-American children. Almost 90 percent (88.6 percent) of overweight African-American children in Delaware were reported as at a normal weight; 87.3 percent of white children were classified as normal, as were 85 percent of Hispanic children.1

Research on how race affects parental perception of weight is less definitive than research on gender and parental perception. One study of school-aged children showed African-American parents underestimating their child’s weight classification more often than white parents6 — a finding opposite to the DSCH results. Other studies have found that African-Americans, Asians and Caucasians were more likely to classify their overweight child as overweight than Hispanic parents or parents from other groups.7

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02006 2008 2011

Parents Who Perceive Their Obese Child as “Healthy Weight”1

65.5% 65.1%

52.9% 55.3%

Male

Female

66.1%

48.4%

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Parents Who Perceive Their Overweight Child as “Healthy Weight”1

88.0%80.0%

67.6%

80.0%

Male

Female

83.5%

76.2%

Why Parental Perception Matters and What Can Be DoneObesity and overweight are health risks for children, not only in adulthood, but also during the childhood years. A growing body of evidence points out that children as young as 10 are now diagnosed with weight-related disease. Parents who do not recognize or acknowledge their child’s weight problem cannot address a fundamental issue with the child’s health. In fact, 79 percent of parents of obese children surveyed for the DSCH indicated that their children were in “excellent” or “very good” health. 1 This large majority of parents of obese children were not aware of or not acknowledging the serious health risks faced by their children.

Solutions to this problem are not simple. Public health and health professionals need to avoid inadvertently stigmatizing children. Societal attitudes toward overweight and obese children and youth are negative and many children endure bullying and other damaging attitudes and behavior. Moreover, research has documented that accurate classification of adolescent overweight may result in unhealthy behaviors from parents, such as encouragement to diet, instead of support for healthier eating, more physical activity and generally good health habits.4 Differences in parental perception by gender and race also indicate a need for sensitive and culturally competent messages; discussions of body size can easily offend or be misinterpreted.

At the same time, there is a clear need for health professionals to assist families with this issue, and evidence that concern expressed by a health professional results in a changed view of the child’s weight status. A study conducted using DSCH data showed that when parents of obese children, 6-11 years old, hear concerns from a health professional, their perception shifts. Before a health professional expressed concern, 79.4 percent of the parents said their obese children were at a normal weight; 20.5 percent said that the children were overweight, but not obese. After the conversation with a health professional, 19.4 percent of parents were accurate and described their child as obese; 58.2 percent said the child was overweight; and only 22.4 percent — down from 79.4 percent — said the child was at a normal weight. Similar findings were obtained from a sample of adolescents, with marked improvement in parental perception after a health professional expressed concerns.10

The Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity call for health professionals to provide prevention messages to all families, but also to intervene with families when children have a weight problem. The recommendations explicitly recognize the importance of social and environmental change to reduce the obesity epidemic but also focus on the ways health care providers can contribute through patient care. Training and support for effective interventions, including motivational interviewing, may help providers to deal with this important and delicate subject. Community support for health promotion and obesity prevention efforts can provide a positive context for parents, health providers, and children and youth in changing behaviors.11

Insert Chart 3. here.

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*Data for charts from http:/datacenter.nemours.org

References

1. NHPS Data Center. Nemours Children’s Health System website. http://datacenter.nemours.org. Accessed August 20, 2014.

2. Evans WD, Finkelstein EA, Kamerow DB, Renaud JM. Public perceptions of childhood obesity. Am J Prev Med. Jan 2005;28(1):26-32.

3. Wake M, Salmon L, Waters E, Wright M, Hesketh K. Parent-reported health status of overweight and obese Australian primary school children: a cross-sectional population survey. Int J Obes Relat Metab Disord. May 2002;26(5):717-724.

4. Neumark-Sztainer D, Wall M, Story M, van den Berg P. Accurate parental classification of overweight adolescents’ weight status: does it matter? Pediatrics. Jun 2008;121(6):e1495-1502.

5. Lundahl A, Kidwell KM, Nelson TD. Parental underestimates of child weight: a meta-analysis. Pediatrics. Mar 2014;133(3):e689-703.

6. West DS, Raczynski JM, Phillips MM, Bursac Z, Heath Gauss C, Montgomery BE. Parental recognition of overweight in school-age children. Obesity (Silver Spring). Mar 2008;16(3):630-636.

7. Towns N, D’Auria J. Parental perceptions of their child’s overweight: an integrative review of the literature. J Pediatr Nurs. Apr 2009;24(2):115-130.

8. Eckstein KC, Mikhail LM, Ariza AJ, Thomson JS, Millard SC, Binns HJ. Parents’ perceptions of their child’s weight and health. Pediatrics. Mar 2006;117(3):681-690.

9. Cunningham SA, Kramer MR, Narayan KM. Incidence of childhood obesity in the United States. N Engl J Med. Apr 24 2014;370(17):1660-1661.

10. Enev T. What is ‘normal’? discrepancies between BMI classification vs. perceived weight status in social context. 141st APHA Annual Meeting and Expo. Boston, MA; 2013.

11. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. Dec 2007;120 Suppl 4:S164-192.

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