Younger children, non-Hispanic Black and male children who are overweight (body mass index (BMI) 85th percentile) are at greater risk for being misperceived by their parents as having a healthy or normal weight, but less is known about the risk for weight misperception in the subpopulation of children with obesity (BMI95th percentile). We assessed the gender, age and racial/ethnic differences in parental misperception of healthy or normal weight status in children with obesity.
We analyzed the data of 1445 children and adolescents aged 6–15 years with obesity obtained from the National Health and Nutrition Examination Surveys conducted from 2005 to 2012. Parental perception of the child’s weight was obtained during an in-home interview. Anthropometric data on body weight were collected from the children during their physical and used to calculate gender and age-specific BMI percentiles. Logistic regression was used to calculate the adjusted odds ratios for parental misperception of their child’s obesity as being ‘about the right weight’, using parents who perceived their children with obesity as being ‘overweight’ for reference.
Boys aged 6–15 years with obesity were more likely to be misperceived as being ‘about the right weight’ by their parents (adjusted odds ratio (aOR): 1.40 (1.12–1.76) vs girls, P=0.0038). The subpopulations of children with obesity who were significantly less likely to be misperceived included girls aged 11–15 years (aOR: 0.46 (0.29–0.74) vs girls 6–10 years, P=0.0016) and Hispanic males (aOR: 0.58 (0.36–0.93) vs White males, P=0.02).
Significant age differences in the odds for parental misclassification of obesity as ‘about the right weight’ were detected in female children, but not males. Hispanic males with obesity were significantly less likely to be misperceived as being ‘about the right weight’ when compared with their non-Hispanic White peers.
The childhood years are a crucial time period for parents to implement effective preventative measures against overweight/obesity in their child, including the development and maintenance of healthy eating and exercise habits.1, 2, 3 Importantly, children who develop obesity at a young age are more likely to remain obese during adolescence and adulthood4, 5 and children with obesity are at greater risk for developing diabetes, hypertension and other adverse cardiovascular health outcomes.1, 6, 7, 8
The last few decades have seen a decreasing trend in the percentage of parents who correctly perceive their overweight/obese child as being overweight, possibly indicative of an increasing societal acceptance of excess body weight as a new norm.9 The accurate perception of a child’s weight may be important in both preventing and treating overweight/obesity, particularly among children who are obese or severely obese.8, 10 For example, children with obesity whose parents are unaware of their unhealthy weight status are significantly less likely to avoid energy-dense foods or get regular physical activity.6
Recent analyses examining parental misperception of healthy weight status in children with overweight/obesity have indicated that male, non-Hispanic Black and Hispanic children with excess weight are at the highest risk of being misperceived as having a normal or healthy weight.9, 11, 12 In addition, a number of studies have demonstrated that older children above the age of 5 years with unhealthy weight status are less likely to be misperceived as having a healthy weight when compared with children of pre-school age.13, 14 Such analyses have been informative, however, there is less data available on parental misperception of healthy or ‘about right’ status in the subpopulation of children with obesity (body mass index (BMI) 95th percentile). Although parents of children with obesity are significantly more likely to recognize that their child’s weight is unhealthy compared with children who are slightly overweight, recent data indicates that more than one in four children with obesity have parents who perceive the child to be about the right weight for their age.8
Using the data obtained from the National Health and Nutrition Examination Survey (NHANES) conducted from 2005 to 2012, we examined the age, gender and racial/ethnic differences in parental misperception of obesity as being ‘about the right weight’ in children and adolescents aged 6–15.
Materials and methods
The NHANES is an ongoing, stratified, multi-stage probability sample of the US non-institutionalized population designed to represent the health and nutritional status of the general population. A detailed description of NHANES has been published elsewhere.15 The data from NHANES has been de-identified by the CDC, which gave our study exemption from the Georgia Southern University Institutional Review Board. We obtained data on 1683 children aged 6–15 years with obesity who were surveyed during the 2005–2012 NHANES. After excluding those with missing data on parent/head of household education (n=58), household income (n=118) or biologically invalid body measurements (n=76), our final study population was 1445 children aged 6–15 years.
Body mass index
Anthropometric data on body weight was collected in the CDC Mobile Examination Center and used to calculate gender and age-specific BMI percentiles using the CDC 2000 Growth Charts.16 Classification of the child’s weight was made according to guidelines from the American Academy of Pediatrics Expert Panel on Childhood Obesity.7 Children classified as having obesity (95th BMI percentile), were retained for analysis.
Parental perception of child’s weight
Information on perception of the child’s weight status was obtained from a parent or proxy (referred to hereafter as parent) in the early-childhood section of the Family Questionnaire, conducted as part of the in-home interview.15 For the 2005–2008 NHANES, the parent was asked by the NHANES Data Collector, ‘Do you consider <SP> now to be ‘overweight’, ‘underweight’, or ‘just about the right weight?’ For the 2009–2012 NHANES, the parent was asked, ‘How do you consider <SP>’s weight: ‘overweight’, ‘underweight’, or ‘just about the right weight?’ Parents who responded ‘overweight’ were considered to have correctly perceived their child’s weight status, whereas those who said ‘underweight’ or ‘about the right weight’ were considered to have misperceived the child’s weight status. None of the children included in the study had parents who refused to give a perception of the child’s weight or reported being unsure of what the child’s weight status was.
We conducted a cross-sectional analysis on the data of 1445 US children and adolescents aged 6–15 years with obesity obtained during the 2005–2012 NHANES. SAS procedures for surveys with appropriate weighting and nesting variables were used. We used a multivariate logistic regression model to model the association between parent perception of the child’s weight and gender, and also controlled for several covariates including, age, race, household income, head of household education and survey year. The adjusted odds ratios for parental misperception of their child’s obesity as being ‘about the right weight’ were calculated using parents who perceived their children with obesity as being ‘overweight’ for reference. The results are presented as adjusted odds ratios with 95% confidence intervals.
More than one in three children with obesity were perceived as being ‘about the right weight’ by their parent. (Table 1) Boys aged 6–15 years with obesity were significantly more likely to be identified as being ‘about the right weight’ by their parent when compared with their female peers (adjusted odds ratio (aOR): 1.40 (1.12–1.76) vs girls; Figure 1). Both Hispanic children and children aged 11–15 years with obesity were significantly less likely to be perceived as being ‘about the right weight’ by their parent when compared with their peers (Hispanic aOR: 0.67 (0.48–0.95) vs non-Hispanic Whites) and age (11–15 years aOR: 0.58 (0.41–0.83) vs age 6–10 years).
The results from gender-stratified models revealed significant racial and age disparities in parental misclassification of their child's weight (Table 2). Hispanic males with obesity were significantly less likely to be perceived as being ‘about the right weight’ by their parents when compared with their other male peers (aOR: 0.58 (0.36–0.93) vs non-Hispanic White males); however, no significant racial differences in parental perception of obesity as ‘about the right weight’ were observed among the female population (aOR: 0.84 (0.47–1.50) vs non-Hispanic White females). In terms of age, females aged 11–15 years with obesity were significantly less likely to be identified as being ‘about the right weight’ by their parents when compared with their younger peers (aOR: 0.46 (0.29–0.74) vs girls aged 6–10 years), yet no significant age differences in the parental perception of overweight existed among male children with obesity (aOR: 0.69 (0.45–1.06) vs boys aged 6–10 years).
Our results indicate that more than one in three children with obesity have parents who consider their child’s weight to be about right for their age, and that there are significant gender, racial/ethnic and age differences among children with obesity whose parents are unaware of their child’s unhealthy weight status. We observed that male with obesity are significantly more likely to be perceived by their parents as being about the right weight for their age as compared with females, whereas parents of older female adolescents and Hispanic males with obesity are significantly more likely to be aware of their child’s elevated weight status.
Although factors related to parental misperception of overweight/obesity in children whose BMI is in the 85th or higher percentile have been well analyzed, less is known about the underlying factors behind parental misperception of weight in the subpopulation of children who have obesity (BMI95th percentile). A 2009 analysis by De La et al.17 analyzing parental perceptions of weight status among children aged 5–15 years in Utah conducted separate analyses for parents of children who are overweight (BMI=85th–94th percentile) and with obesity (BMI95th percentile). The parents were asked to classify their child’s weight as being ‘extremely overweight’, ‘somewhat overweight’, ‘about right’, ‘somewhat underweight’ or ‘extremely underweight’. Among the subpopulation of parents whose child had obesity, none of the parents classified their child as being ‘extremely overweight’, 72% identified their child as being ‘somewhat overweight’ and 28% of the parents perceived their child’s weight as being ‘about right’. A 2014 meta-analysis on parental underestimation of a child’s weight by Lundahl et al.18 assessed 171 studies and observed that overweight children with a lower age or lower mean BMI were significantly less likely to be perceived as overweight by their parents. This finding supports the idea that while parents of children who are slightly overweight may perceive their child to still be about the right weight for their age this should be less common for children with obesity.19
Although multiple studies have indicated that feedback from parents on body weight is more prevalent among female children than males,10 the impact of large number of parents who perceive their male child with obesity as being ‘just about the right weight’ should be studied. Of particular interest was our finding that Hispanic males with obesity were significantly more likely to be perceived as overweight when compared with non-Hispanic White males. Although previous literature has found that parents of non-Hispanic black children and Hispanic children of pre-school age are significantly more likely to underestimate the weight of their child,11, 12 our results indicate that, among school-age children and adolescents, Hispanic males with obesity have the highest odds of being perceived as overweight by their parents relative to peers of other races. A 2005 analysis by Olvera et al.20 comparing intergenerational weight perceptions between Hispanic mothers and their children found that the mothers were more inclined to perceive average body weight figures as being attractive for their sons, whereas viewing the actual body weight of their daughters to be the preferred ideal shape. While these findings suggest the possibility of a gender-specific cultural body ideals among Hispanic mothers, there are significant differences between the analysis by Olvera et al. and our analysis that limit the ability to draw comparisons.
A number of recent studies have indicated that older children with overweight/obesity are significantly less likely to be identified by parents as having healthy or normal weight when compared with younger peers.13, 14 Our results indicate that increased age of the child significantly reduced the odds for parental classification of obesity as being ‘about the right weight’ in females, but not males. This particular finding has a number of implications that warrant further analysis. First, if parental awareness of elevated weight status in children and adolescents leads to weight-teasing or excessive focus on weight/diet, this age effect could be related to the known increase in body dissatisfaction and disordered eating during adolescence among girls.21, 22 Longitudinal analysis regarding the relationship between parental perception of a child’s weight and subsequent potential for development of eating disorders in adolescence would be necessary to assess this relationship. Second, it is also possible that the gender × age effect in parental perception of weight in adolescent females may arise as a result of the changes associated with puberty. A recent analysis by Biro et al.23 indicated that females with obesity are more likely to experience earlier onset and completion of puberty, relative to their healthy weight female peers. It is possible that parents may be more perceptive of excess weight on post-pubescent females as compared with pre-pubescent females or males, which may be related to the ‘thin ideal’ figure that is emphasized in the media and society.24, 25 Further research in this area would be especially useful for understanding the psychosocial factors related to weight perception in adolescents and their parents. Longitudinal analysis on changes in parental perceptions of weight status in pre-pubescent and post-pubescent females would help to further assess this relationship.
Our analysis is not without limitations. First, the data from NHANES is cross-sectional, which prevents us from making directional conclusions or causal inferences about the relationship between the age, gender, and/or race/ethnicity of a child with obesity and their odds of being accurately perceived as overweight by their parents. The Early-Childhood Questionnaire is administered to a parent or proxy of the children who are selected to take part in NHANES. Because the NHANES survey does not indicate whether or not the parent was the one who answered the questions for the child, our analysis may not solely be a reflection of parental perception of the child’s weight, and may include proxy responses from the child’s grandparent, guardian or close family friends.
There are also several strengths to our study. First, the NHANES is conducted in several communities across the United States and includes oversampling to ensure the data set is nationally representative, which allows our results to be a reflection of current trends in parental weight perception of children with obesity. Second, we chose to focus on children with obesity (BMI95th percentile), which provides a unique view into parental misperception of obesity as being ‘about the right weight’, as opposed to children who may be slightly overweight at a BMI of the 85th percentile for their age/gender. Identifying the factors related to parental misperception of obese status as being ‘about right’ could enable health professionals to tailor obesity prevention and outreach programs.
Our results indicate that a significant number of children with obesity have parents who are unaware of the child’s unhealthy weight status and consider them to be about the right weight. Parents of children with obesity who are unaware of the child’s unhealthy weight status are less likely to seek treatment for their child’s weight7 and less likely to take necessary steps to ensure the child is receiving a healthy diet and exercising;1, 6, 8, 10 however, it remains to be seen what impact parental weight misperception has on the trajectory of their child’s weight. These findings indicate a need for ongoing longitudinal research on the association of parental weight misperception among youth with obesity and adoption of healthful weight-control strategies, disordered weight-control behaviors, mental health outcomes and weight change.
About this article
JPT had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. JPT and KRS were involved in the design and conduct of the study. Collection, management, analysis and interpretation of the data were also done by JPT and KRS. All the authors were involved in the preparation, review or approval of the manuscript. The decision to submit the manuscript for publication was also taken by all the authors.
Child's Nervous System (2016)