*Purpose:* To assess the frequency and accuracy of weight comments received from different sources among Chinese adolescents and the relation of weight comments to weight misperception.*Methods:* In the Hong Kong Student Obesity Surveillance (HKSOS) project 2006-07, 22612 form 1 to 7 students (41.5% boys) completed a questionnaire on obesity. Students were asked if they had received serious "too fat" or "too thin" comments over the past 30 days from family members, peers and professionals, and the accuracy of the comments was assessed against the actual weight status. Weight misperception was defined as discordance between the actual and perceived weight status. Logistic regression was used to calculate adjusted odd ratios (ORs) for weight misperception by weight comments received.*Results:* One in three students received weight comments, most commonly from mother for both "too fat" and "too thin" comments. Health professional was the most accurate source of weight comments, yet less than half the comments were correct. Receiving incorrect weight comments was significantly associated with weight misperception in all sex-weight status sub-groups, particularly among obese girls. In contrast, student who received correct weight comments were less likely to have weight misperception.*Conclusions:* Weight comments were commonly received by Chinese adolescents in Hong Kong, yet most of the comments were inaccurate, and such incorrect comments were associated with weight misperception. Family members, peers and professionals should realize the potential adverse effects of their weight comments and adolescents should be taught how to correctly assess their weight status to reduce misperceptions.
WS Lo Weight comments by others and weight misperceptionTitle: Frequency and accuracy of weight comments by others, and the association with weight misperception among Hong Kong adolescents Running Title: Weight comments by others and weight misperception WS Lo, SY Ho*, KK Mak, YK Lai, TH Lam for the Hong Kong Student Obesity Surveillance (HKSOS) project Department of Community Medicine and School of Public Health, The University of Hong Kong, Hong Kong SAR, China All correspondence: Health Li Ka Shing Faculty of Medicine The University of Hong Kong 21 Sassoon Road, Pokfulam, Hong Kong SAR, China Tel: (852) 2819 9883 Fax: (852) 2855 9528 Email: email@example.com Dr. SY Ho Department of Community Medicine and School of Public1*WS Lo Weight comments by others and weight misperceptionFrequency and accuracy of weight comments by others, and the association with weight misperception among Hong Kong adolescents WS Lo, SY Ho*, KK Mak, YK Lai, TH Lam for the Hong Kong Student Obesity Surveillance (HKSOS) project Department of Community Medicine and School of Public Health, The University of Hong Kong, Hong Kong SAR, China Abstract (249 words) Purpose To assess the frequency and accuracy of weight comments received from different sources among Chinese adolescents and the relation of weight comments to weight misperception. Methods In the Hong Kong Student Obesity Surveillance (HKSOS) project 2006-07, 22612 form 1 to 7 students (41.5% boys) completed a questionnaire on obesity. Students were asked if they had received serious "too fat" or "too thin" comments over the past 30 days from family members, peers and professionals, and the accuracy of the comments was assessed against the actual weight status. Weight misperception was defined as discordance between the actual and perceived weight status. Logistic regression was used to calculate adjusted odd ratios (ORs) for weight misperception by weight comments received. Results One in three students received weight comments, most commonly from mother for both "too fat" and "too thin" comments. Health professional was the most accurate source of weight comments, yet less than half the comments were correct. Receiving incorrect weight comments was significantly associated with weight misperception in all sex-weight status sub-groups, particularly among obese girls. In contrast, student who received correct weight comments were less likely to have weight misperception. Conclusions Weight comments were commonly received by Chinese adolescents in Hong Kong, yet most of the comments were inaccurate, and such incorrect comments were associated with weight misperception. Family members, peers and professionals should realize the potential adverse effects of their weight comments and adolescents should be taught how to correctly assess their weight status to reduce misperceptions.2*WS Lo Weight comments by others and weight misperceptionKeywords Kong IntroductionWeight misperception, weight comments, adolescents, Chinese, HongWeight concerns and body dissatisfaction are common among adolescents (1-3). While most girls want to be thinner, more boys desire to be more muscular (4, 5). Several studies have found that the prevalence of weight teasing on adolescents was high (6-8). Neumark-Sztainer et al reported in a large US study that 25% secondary school students had been teased several times in the past year about their weight (6). Sensitive to weight-related influences, adolescents experience tremendous pressure from weight teasing, contributing to poorer self-esteem and body image, and unhealthy weight-control attempts (diet pills, unhealthy diet behaviors, binge eating etc.) (6-10).Existing Western studies were implicit whether weight teasing was about being too fat or too thin, but given the high prevalence of obesity and the associated negative image, the former was more likely. Although the effects of teasing over thinness areuncertain, several studies found that adolescents who perceived themselves as too thin were also more likely to have anxiety and depression, compared with adolescents who perceived themselves as having normal weight (11, 12). Such kind of weight teasing would be more relevant in developing countries such as China, where underweight is also common (13).Few studies had specifically investigated the prevalence and effects of weight teasing by family members such as grandparents and professionals, other than peers and parents (6-8, 10). Other than parents, grandparents in Asian countries also have3*WS Lo Weight comments by others and weight misperceptiongreat influences on adolescents' eating beliefs and patterns, especially in three-generation households with grandparents being the main caregivers of the children (14). The effect of weight comments by grandparents on adolescent weight perception is unknown. Apart from family and friends, adolescents may also receive weight comments from teachers, social workers and health professionals, but again little is known about their accuracy and effects on adolescent weight perceptions.Previous studies mainly focused on weight teasing, which included disparaging nicknames and making fun of others' weight and body shape (6-8, 15). To the best of our knowledge, no study has focused on serious weight comments which may include those made out of good intentions and examined whether correct, incorrect or even conflicting (contradicting weight comments) weight comments areindependently associated with weight misperception in adolescents.In the present study we extended the existing research in three ways:First, westudied family members such as parents, siblings and grandparents, as well as teachers, social workers and health professionals, as sources of weight comments and we examined them separately. comments. Second, we examined the accuracy of those weightThird, we investigated the effects of different types (correct, incorrectand conflicting) of weight comments on weight misperception. We hypothesized that adolescents who received incorrect weight comments were more likely to have weight misperception than those who received accurate weight comments.Methods4*WS Lo Weight comments by others and weight misperceptionProcedures The present study was part of a large population-based study, the Hong Kong Student Obesity Surveillance (HKSOS) project. Stratified cluster sampling was applied, and the schools were sampled with stratification by school district, source of funding, language of instruction (Chinese/ English), religion background(Christian/Others/None) and single sex/co-education to represent all main stream non-international secondary schools in Hong Kong. Forty-two schools were invitedto join this survey. All Form 1 to 7 students (equivalent to Grade 7-12 in US) in selected schools were invited to participate through an informed consent. In2006-2007, the baseline survey was self-administered during normal school hours under the supervision of trained researchers or teachers. Ethical approval wasgranted by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster. The one-month test-retest reliability ofmeasures used in this study was assessed with 1147 students (31.3% boys; mean age=14.8±1.6) from 3 of the participating schools.Measures BMI and actual weight status Height (cm/inch) and weight (kg/lb) were self-reported by the participants to the nearest integer. The intraclass correlation coefficients (ICC) between the test-retest height and weight data in 1147 subjects were high (0.95 and 0.85, respectively), and the values were comparable to previous research (16). It was also shown in anotherstudy that self-reported anthropometric data was highly correlated with measured data in adolescents (17). cutoffs (18), Using sex-specific Hong Kong local weight-for-height (WFH) were defined as underweight (<80% medianparticipantsweight-for-height), normal weight (80% - 120% median weight-for-height) and obese5*WS Lo Weight comments by others and weight misperception(>120% median weight-for-height).Body mass index (BMI) was calculated byweight (kg) divided by height in squared (m2).Prevalence of weight comments received To assess the prevalence of weight comments received by the students, students were asked whether they had received serious "too fat" comments over the past 30 days from the following sources (yes/no): 1) family members including father, mother, siblings, grandpa, grandma and other relatives; 2) peers including friends and classmates; 3) professionals including teachers, social workers and health professionals; and 4) others including domestic helpers and neighbors. A similarquestion was asked to assess serious "too thin" comments received over the past 30 days. Agreements between the test and retest responses were high, ranging from 75% to 95%.Accuracy and types of weight comments The accuracy of the weight comments was assessed against the actual weight status. Weight comments as "too fat" was treated as "correct" when the individual was defined as obese by the local WFH references (18), and was "incorrect" if the individual had normal weight or was underweight. The same principle applied for weight comments as "too thin". Students who received both "too fat" and "too thin" comments were treated as receiving "conflicting comments", while students who did not receive any weight comments were classified as "no weight comments received", which was the reference group.Weight perception6*WS Lo Weight comments by others and weight misperceptionA standard perceived weight question asking students to describe their weight status in terms of very thin, thin, normal, fat and very fat (19) was asked. Students were defined as having "weight misperception" if they failed to describe their weight status according to actual weight status. Those who correctly described their weight statusaccording to the local references were classified as "correct perception", which was the reference group.Data analysis Potential confounders considered were age (as a continuous variables), place of birth (Hong Kong, or elsewhere), the highest parental education ( primary, secondary, or tertiary), family affluence (relatively poor, medium, or relatively wealthy) and BMI although adjusting for these factors did not change the estimates for the weight perception and psychosocial health problems by more than 5.0% (20) in our sample as a whole or when stratified by sex and weight status.Missing values on place of birth (0.6%), highest parental education (12.8%) and housing type (1.0%) were imputed using multiple imputation (21). The optimal estimates were obtained based on the imputed database (with the average of 5 imputed values), and they were virtually identical to those obtained using the original database (22), however, the statistical significance was slightly strengthened by the inclusion of the additional cases. Only results from the imputed database are reported here. No imputation was done on the main independent and the outcome variables.Logistic regression models with robust standard errors accounting for school7*WS Lo Weight comments by others and weight misperceptionclustering effects were used. Potential multicollinearity between independent variables was examined by correlation coefficients (r= 0.007 to 0.44), and none of them were greater than 0.8 (23). The main analyses were stratified by sex asperceived weight status, prevalence and accuracy of weight comments received were both significantly different in boys and girls (ie, effect modification). Statistical analyses were performed using STATA 9.0.ResultsIn the present study, 31603 students aged 11 to 18 years were recruited. Of the recruited sample, students were excluded from analyses if they did not provide self-reported height and weight information (N=2319). As the maximum reference values for height of the local WFH cutoffs were 175cm in boys and 165cm in girls, students who exceeded the height limits were also excluded (N=738). Also excluded were those with a BMI smaller than 10 or greater than 50 (24). After excluding questionnaires with incomplete data, 22612 (41.5% boys) were included in the present analysis. Table 1 shows the prevalence rates of underweight and obesity defined by local WFH references were 8.7% (8.6% for boys; 8.7% for girls) and 12.4% (16.1% for boys; 9.7% for girls), respectively. Weight comments were common: 29% of them received weight comments for "too fat" and 26.9% for "too thin" in the past 30 days.Table 2 summarizes the sources of "too fat" and "too thin" weight comments. Mother was the most frequent source of "too fat" comments for both boys and girls,8*WS Lo Weight comments by others and weight misperceptionfollowed by siblings and classmates. Generally a higher proportion of girls received "too fat" comments than boys from all the sources except grandfather, although more boys than girls were obese, as defined by local cutoffs. A slightly lower proportionof adolescents received "too thin" comments overall, but mother remained the most common source. The proportion of girls receiving "too thin" comments from their classmates and friends nearly doubled that in boys. The last two columns of Table 2 show that grandparents, teachers, social workers and health professionals gave more "too thin" comments to both boys and girls.9*WS Lo Weight comments by others and weight misperceptionTable 1 Basic characteristics of participants (N=22612) Characteristics Age (years, mean, SD) Form (%) Junior (F1-F3) a Senior (F4-F7)2 aBoys (N=9375) 14.6 (1.70) 61.7 38.3 19.5 (3.29) 8.6 75.3 16.1 12.2 64.1 23.7 73.6bGirls (N=13237) 14.7 (1.70) 58.2 41.8 18.9 (2.73) 8.7 81.6 9.7 11.9 67.2 21.0 74.6 25.4 34.9 54.3 10.8 33.8 25.8All (N=22612) 14.7 (1.70) 59.6 40.4 19.2 (2.99) 8.7 79.0 12.4 12.0 65.9 22.1 73.9 26.1 36.4 52.6 10.9 29.0 26.9BMI (kg/m ,mean, SD) Weight status by local references (%) Underweight Normal Obese Parental education level (%) Primary or below Secondary Tertiary or above Place of birth (%) Hong Kong Other places Family affluence (%) Relatively poor Medium Relatively wealthy26.4 38.6 50.3 11.1Received weight comments as "too 22.3 fat" in the past 30 days Received weight comments as "too 28.4 thin" in the past 30 daysaF1-F3 is equivalent to grade 7 to grade 9; F4-F7 is equivalent to grade 10 to grade 12. b Other places: Mainland China (majority), Macau, Western countries and others.10*WS Lo Weight comments by others and weight misperceptionTable 2 Sources of weight comments reported by boys and girls Too fat (%) Boys 14.45.3 9.0 4.1 1.0 0.6 1.2Too thin (%)FamilyFather Mother Siblings Grandfather Grandmother Other relativesGirls p Boys Girls 26.1 <0.001 22.2 18.97.7 17.0 10.6 0.7 1.5 4.4 <0.001 <0.001 <0.001 0.024 <0.001 <0.001 <0.001 <0.001 8.7 15.1 3.9 2.0 2.5 3.6 4.7 4.2 7.1 12.4 2.8 1.3 2.7 4.4Ratio (Too fat/Too thin) p Boys Girls <0.001 0.65 1.38<0.001 <0.001 <0.001 <0.001 0.45 0.009 <0.001 <0.001 0.61 0.60 1.05 0.50 0.24 0.33 1.11 1.00 1.08 1.37 3.79 0.54 0.56 1.00PeersClassmates Friends7.55.2 220.127.116.11 8.9<0.001 6.511.47.8 7.7<0.001 1.151.181.08 1.16ProfessionalsTeachers Social workers Health professionalsa a2.10.8 0.4 0.92.21.0 0.4 0.90.500.07 0.77 0.892.81.3 0.5 18.104.22.168 0.6 1.20.970.63 0.39 0.870.750.62 0.80 0.750.790.71 0.67 0.75Others 5.5 4.7 0.012 6.5 4.5 Others include neighbors and domestic helpers.<0.001 0.851.04Figures 1 and 2 show the accuracy of weight comments from different sources when compared with actual weight status among those who received comments. Ingeneral, boys received more accurate "too fat" comments than girls from all the sources other than grandfather. The accuracy of "too thin" comments wascomparable in both sexes from all the sources except mother and siblings. Health professionals was the most accurate source of both "too fat" and "too thin" comments yet more than half of the comments were incorrect.11*WS Lo Weight comments by others and weight misperceptionFigure 1Accuracy of weight comment as "too fat" from family, peers andprofessionals by sex (descending order) [supplied as separate file: figure 1]Figure 2Accuracy of weight comment as "too thin" from family, peers andprofessionals by sex (descending order" [supplied as separate file: figure 2]12*WS Lo Weight comments by others and weight misperceptionTable 3 shows different types of weight comments received stratified by sex, weight perception and actual weight status. Around 9.0% boys and 7.5% girls received both"too fat" and "too thin" comments (conflicting weight comments) from different sources. Subjects with weight misperception significantly received more incorrect weight comments than those with correct weight perception in both boys and girls (p<0.001).Table 4 shows the main effects of different types of weight comments and weight misperception. Weight misperception was common in our sample (47% in boys and56% in girls). Students who received incorrect weight comments were significantly more likely to have weight misperception compared with students who did not receive any weight comments in all sex-weight status sub-groups, but the association was most obvious in obese girls. Normal weight students who received conflictingcomments were significantly more likely to have weight misperception (OR=1.73 for boys and 1.93 for girls) than those who did not receive any weight comment. While the association was insignificant in either underweight or obese groups, boys who received conflicting weight comments were more likely to have weight misperception, whereas girls who received conflicting comments were less likely to have weight misperception. In contrast, students who received correct weight comments weresignificantly less likely to have weight misperception no matter they are boys or girls, nor which weight status they belonged to. adjusting for BMI and other SES variables. All the effects remained even after13*WS Lo Weight comments by others and weight misperceptionTable 3 Distribution of adolescents weight perception stratified by sex, weight status a and different types of weight comments received Weight comments received No weight Correct Incorrect Conflicting comments Boys (N=9375) Correct weight perception (N=4958)Underweight Normal weight Obese16.954.6 51.211.40 16.2 2.08.16.9 8.1 8.963.538.5 75.7 37.9Weight misperception (N=4417)Underweight Normal weight Obese1.915.1 8.835.63.5 40.6 13.910.013.8 9.1 15.252.567.5 50.3 62.1Girls (N=13237) Correct weight perception (N=5812)Underweight Normal weight Obese19.065.7 62.819.81.0 27.8 1.06.56.7 6.7 5.754.726.6 65.5 30.5Weight misperception (N=7425)Underweight Normal weight Obesea2.022.3 17.047.115.0 50.3 19.38.311.1 8.0 9.942.651.6 41.6 53.8Using the sex-specific local weight-for-height (WFH) cutoffs, our subjects were defined as underweight (<80% median WFH), normal weight (80% - 120% median WFH) and obese (>120% median WFH).14*WS Lo Weight comments by others and weight misperceptionTable 4 Adjusted odds ratio (95% confidence interval) for weight misperception in relation to different types of weight comments received by sex and weight status a (N=22612) Types of Adjusted b p Adjusted c p weight comments received Boys UW None 1 1 Correct 0.16 <0.001 0.16 <0.001 (0.11-0.22) (0.11-0.22) Incorrect d Conflicting 1.19 0.6 1.25 0.3 (0.78-1.80) (0.80-1.94) NW None Correct Incorrect Conflicting 1 3.76 (3.32-4.25) 1.71 (1.41-2.06) 1 0.11 (0.08-0.14) 4.29 (2.54-7.23) 1.03 (0.77-1.39) 1 0.17 (0.14-0.22) 7.74 (2.85-21.1) 0.84 (0.55-1.28) 1 2.80 (2.59-3.03) 1.86 (1.62-2.14) 1 0.16 (0.10-0.24) 10.39 (4.74-22.8) 1 3.73 (3.28-4.23) 1.73 (1.43-2.09) 1 0.11 (0.08-0.15) 4.75 (2.79-8.09) 1.07 (0.80-1.44) 1 0.18 (0.14-0.23) 6.88 (2.68-17.68) 0.74 (0.45-1.20) 1 2.89 (2.67-3.13) 1.93 (1.67-2.23) 1 0.17 (0.11-0.26) 12.7 (5.24-30.83)<0.001 <0.001<0.001 <0.001OBNone Correct Incorrect Conflicting<0.001 <0.001 0.9<0.001 <0.001 0.7Girls UWNone Correct Incorrect Conflicting<0.001 <0.001 0.5<0.001 <0.001 0.2NWNone Correct Incorrect Conflicting<0.001 <0.001<0.001 <0.001OBNone Correct Incorrect<0.001 <0.001<0.001 <0.00115*WS Lo Weight comments by others and weight misperception0.93 0.9 0.97 0.9 (0.51-1.70) (0.53-1.79) a Using the sex-specific local weight-for-height (WFH) cutoffs, our subjects were defined as underweight (<80% median WFH), normal weight (80% - 120% median WFH) and obese (>120% median WFH). UW=Underweight; NW= Normal weight; OB=Obese. b Adjusted for age. c Adjusted for age, highest parental education, family affluence, BMI and school effect. d OR cannot be calculated due to the insufficient number in the group (Underweight boys with weight misperception did not receive any incorrect comments).Conflicting16*WS Lo Weight comments by others and weight misperceptionDiscussionThe most important finding of the present study is that despite the high rates of reported weight comments, less than one fifth of the comments (Figure 1 and 2) were accurate in both adolescent boys and girls. The low accuracy of the weightcomments is alarming, as we also found that adolescents who received incorrect weight comments were more likely to have weight misperception than those who received correct weight comments.Our findings are in line with the previous research that girls received significantly more weight comments as fat from family members and peers than boys (6, 8). While previous research focused mainly on family as a group or on parents only, we also examined the prevalence of weight comments from other family members such as siblings and grandparents. The most common source of "too fat" comments wasmade by mother, followed by siblings. However, girls received significantly more comments from siblings than boys. It is suggested in the literature that parentalcomments posed indirect effects on adolescents by increasing the amount of teasing by siblings (7). Although adolescents reported few weight comments bygrandparents, it is interesting to note that grandparents gave a lot more "too thin" comments than "too fat" comments (Table 2). It is speculated that as larger body size is seen as a sign of health and wealth in traditional Chinese society and due to their own experience of poverty and hunger, grandparents tended to prefer their grandchild to eat more and weigh more (14).One exception was noted, however, that a lower proportion of adolescents in our study received weight comments from peers than from their family members, although the reported prevalence of weight comments by family members is comparable with another study (8). As we included not only the negative weight teasing but also weight comments out of good intention, the proportion of weight comments from peers might have become less. As we further analyzed, we found that senior grade students reported a significantly higher proportion of weight comments than their junior counterparts (data not shown) as they were more susceptible to peers interaction (25).17*WS Lo Weight comments by others and weight misperceptionHealth professionals, as might be expected, provided the most accurate source of weight comments, although only less than half of the comments were correct. Thisfigure was lower than an US study that 76% of obese adolescents were identified by physicians in clinical visits (26). Moreover, around 60% of physicians couldaccurately estimate the body size of adolescents between age 12 to 18 years in a recent Canadian study (27). These findings may imply that health professionals in Hong Kong are less trained in assessing weight status for adolescents, especially when anthropometric data is not routinely measured in clinical visits due to short consultation time, lack of space and appropriate equipment (28). No wellestablished observational instrument for defining weight status for children and adolescents is available. Borderline cases may be difficult to be identified as weightand height keep changing in adolescents. This is supported by a study in Australia showing that physicians experienced greater difficulties in defining weight status of a child with a BMI just above or just below the cut-off points of overweight and obesity (28).Nearly half of our students had weight misperception (Table 3), and this finding is comparable to that of a recent local publication (29). The lack of knowledge about and access to growth charts probably made it difficult for adolescents to evaluate their weight status objectively. Moreover, as adolescents are susceptible to socialinfluences (3, 30, 31), weight comments and opinions from family and peers would be expected to produce effects on weight perception, as suggested by the Tripartite Influence Model (9, 32). However, our study found that the accuracy of weight comments from parents and peers was low. A population-based survey in Hong Kong (33) have shown that one third of adults misperceived their own weight status, while two studies in the UK and US, respectively, observed that only 25%-35% of parents correctly identified their obese adolescent child (17, 34). Although theliterature suggested that having obese parents was positively associated with parental report of adolescent obesity (17), whether parental obesity is related to increased frequency of weight comments and accuracy is still unclear.Using students who did not receive any weight comments during the past 30 days as the reference group (Table 4), we found that in both sexes, students receiving incorrect weight comments were more likely to have weight misperception in all 318*WS Lo Weight comments by others and weight misperceptionweight groups. Students in normal weight group but receiving conflicting weight comments were also more likely to have weight misperception, while insignificant trends were found in those who were underweight or obese. In contrast, students receiving correct comments were more likely to have accurate weight perception. Results of the present study suggested that weight comments are not always harmful: correct comments out of good intentions have a potential benefit for building correct weight perception among adolescents, which may in turn lead to healthy lifestyles and weight managements. Further studies on this area are warranted.In the present study, a territory-wide sample was recruited and therefore the sample size was large enough to allow for comparisons between sex and across different weight status groups. Although some participants were excluded due to missing data, our remaining sample was very similar to the corresponding population group in Hong Kong in terms of sex, age, and residential district (all Cohen effect sizes (35) 0.2) (data not shown), which showed that subjects included in the analysis were representative to the Hong Kong adolescent population. Moreover, a variety of sources of weight comments was included, hence allowed us to examine the effect of weight comments more in depth. However, several limitations should be taken into Anthropometric data and the frequency of Our test-retest measures, however,account in interpreting the findings.weight comments received were self-reported.revealed that the self-reported height and weight data were highly reliable, and these findings are comparable with other similar studies (17, 36). Although the actual prevalence of weight comments may be lower as adolescents with weight concerns maybe more sensitive to the comments, the test-retest reliability of these self-reported data was high in the present study. Furthermore, the prevalence of receiving weight comments was limited to the past 30 days in order to reduce recall error. In addition, we are also not able to compare the impact of individual source of weight comments on weight misperception. According to Keery (7), weight teasing fromfather and elder brothers was associated with higher psychosocial distress than mother and sisters. The effect of teasing or comments is expected to be different onopposite sex. Therefore, future research gathering more information about family composition may enhance our ability to understand the effects of weight comments by sex. The association of receiving incorrect weight comments and weight19*WS Lo Weight comments by others and weight misperceptionmisperception with negative psychosocial health problems should be clarified by longitudinal studies.Our findings suggest that weight comments are common in Chinese adolescents by family members and peers, yet the accuracy of these comments is relatively low. Family members, peers and professionals should realize the potential adverse effects of their weight comments and adolescents should be taught how to correctly assess their weight status to reduce misperceptions. Health professionals should give more advice on adolescents' weight status and implications for tracking the height and weight regularly and using growth charts for children and adolescents are worth discussing.Acknowledgements The study was supported by the University Research Committee, Strategic Research Theme on Public Health, University of Hong Kong.20*WS Lo Weight comments by others and weight misperceptionReferences Xie B, Chou C-P, Spruijt-Metz D, Reynolds K, Clark F, Palmer PH, et al. Weight Perception and Weight-Related Sociocultural and Behavioral Factors in Chinese Adolescents. Preventive Medicine 2006; 42: 229-234. Field AE, Camargo Jr CA, Taylor CB, Berkey CS, Roberts SB, Colditz GA. Peer, Parent, and Media Influences on the Development of Weight Concerns and Frequent Dieting among Preadolescent and Adolescent Girls and Boys. 2001, pp 54-60. Presnell K, Bearman SK, Stice E. Risk Factors for Body Dissatisfaction in Adolescent Boys and Girls: A Prospective Study. International Journal of Eating Disorders 2004; 36: 389-401. Knauss C, Paxton SJ, Alsaker FD. Relationships Amongst Body Dissatisfaction, Internalisation of the Media Body Ideal and Perceived Pressure from Media in Adolescent Girls and Boys. Body Image 2007; 4: 353-360. Marion Kostanski AFEG. Current Conceptualisation of Body Image Dissatisfaction: Have We Got It Wrong? 2004; 45: 1317-1325. Neumark-Sztainer D, Falkner N, Story M, Perry C, Hannan PJ, Mulert S, et al. Weight-Teasing among Adolescents: Correlations with Weight Status and Disordered Eating Behaviors. International Journal of Obesity & Related Metabolic Disorders: Journal of the International Association for the Study of Obesity 2002; 26: 123-131. Keery H, Boutelle K, van den Berg P, Thompson JK. The Impact of Appearance-Related Teasing by Family Members. Journal of Adolescent Health 2005; 37: 120-127. Eisenberg ME, Neumark-Sztainer D, Story M. Associations of Weight-Based Teasing and Emotional Well-Being among Adolescents. Archives of Pediatrics & Adolescent Medicine 2003; 157: 733-738. Keery H, van den Berg P, Thompson JK. An Evaluation of the Tripartite Influence Model of Body Dissatisfaction and Eating Disturbance with Adolescent Girls. Body Image 2004; 1: 237-251. Lieberman M, Gauvin L, Bukowski WM, White DR. Interpersonal Influence and Disordered Eating Behaviors in Adolescent Girls: The Role of Peer Modeling, Social Reinforcement, and Body-Related Teasing. Eating Behaviors 2001; 2: 215-236. ter Bogt TFM, van Dorsselaer SAFM, Monshouwer K, Verdurmen JEE, Engels RCME, Vollebergh WAM. Body Mass Index and Body Weight Perception as Risk Factors for Internalizing and Externalizing Problem Behavior among Adolescents. Journal of Adolescent Health 2006; 39: 27-34. Daniels J. Weight and Weight Concerns: Are They Associated with Reported Depressive Symptoms in Adolescents? Journal of Pediatric Health Care 2005; 19: 33-41. Wang Y, Monteiro C, Popkin BM. Trends of Obesity and Underweight in Older Children and Adolescents in the United States, Brazil, China, and Russia. The American Journal of Clinical Nutrition 2002; 75: 971-977. Jingxiong J, Rosenqvist U, Huishan W, Greiner T, Guangli L, Sarkadi A. Influence of Grandparents on Eating Behaviors of Young Children in Chinese Three-Generation Families. Appetite 2007; 48: 377-383. Thompson JK, Cattarin J, Fowler B, Fisher E. The Perception of Teasing Scale (Pots): A Revision and Extension of the Physical Appearance Related Teasing Scale (Parts). Journal of Personality Assessment 1995; 65: 146 - 157. Brener ND, McManus T, Galuska DA, Lowry R, Wechsler H. Reliability and Validity of Self-Reported Height and Weight among High School Students. Journal of21*WS Lo Weight comments by others and weight misperceptionAdolescent Health 2003; 32: 281-287. Goodman E, Hinden BR, Khandelwal S, Goodman E, Hinden BR, Khandelwal S. Accuracy of Teen and Parental Reports of Obesity and Body Mass Index. Pediatrics 2000; 106: 52-58. Leung SS, Cole TJ, Tse LY, Lau JT, Leung SS, Cole TJ, et al. Body Mass Index Reference Curves for Chinese Children. Annals of Human Biology 1998; 25: 169-174. Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National Patterns of Physician Activities Related to Obesity Management. Archives of Family Medicine 2000; 9: 631-638. Rothman K, Greenland S. Modern Epidemiology. 2nd edn. Lippincott-Raven Publishers: Philadelphia, PA, 1998. Harel O, Zhou XH, Harel O, Zhou X-H. Multiple Imputation: Review of Theory, Implementation and Software. Statistics in Medicine 2007; 26: 3057-3077. Horton NJ, Kleinman KP. Much Ado About Nothing: A Comparison of Missing Data Methods and Software to Fit Incomplete Data Regression Models. The American Statistician Feburary 2007; 61: 12. Tabachnick BG, Fidell LS. Using Multivariate Statistics. Allyn & Bacon: Needham Heights, MA, 2001. Wong JP, Ho SY, Lai MK, Leung GM, Stewart SM, Lam TH, et al. Overweight, Obesity, Weight-Related Concerns and Behaviours in Hong Kong Chinese Children and Adolescents. Acta Paediatrica 2005; 94: 595-601. Sweeting H, West P, Sweeting H, West P. Gender Differences in Weight Related Concerns in Early to Late Adolescence. Journal of Epidemiology & Community Health 2002; 56: 700-701. O'Brien SH, Holubkov R, Reis EC. Identification, Evaluation, and Management of Obesity in an Academic Primary Care Center. Pediatrics 2004; 114: e154-159. Chaimovitz R, Issenman R, Moffat T, Persad R. Body Perception: Do Parents, Their Children, and Their Children's Physicians Perceive Body Image Differently? Journal of Pediatric Gastroenterology & Nutrition 2008; 47: 76-80. Spurrier NJ, Magarey A, Wong C, Spurrier NJ, Magarey A, Wong C. Recognition and Management of Childhood Overweight and Obesity by Clinicians.[See Comment]. Journal of Paediatrics & Child Health 2006; 42: 411-418. Cheung C, Ip L, Lam S, Bibby H. A Study on Body Weight Perception and Weight Control Behaviours among Adolescents in Hong Kong. Hong Kong Medical Journal 2007; 13: 16-21. Hutchinson DM, Rapee RM. Do Friends Share Similar Body Image and Eating Problems? The Role of Social Networks and Peer Influences in Early Adolescence. Behaviour Research and Therapy 2007; 45: 1557-1577. Lee S, Lee AM. Disordered Eating in Three Communities of China: A Comparative Study of Female High School Students in Hong Kong, Shenzhen, and Rural Hunan. International Journal of Eating Disorders 2000; 27: 317-327. Thompson JK, Shroff H, Herbozo S, Cafri G, Rodriguez J, Rodriguez M. Relations among Multiple Peer Influences, Body Dissatisfaction, Eating Disturbance, and Self-Esteem: A Comparison of Average Weight, at Risk of Overweight, and Overweight Adolescent Girls. Journal of Pediatric Psychology 2007; 32: 24-29. Department of Health. Population Health Survey 2003/2004. Hong Kong, 2005. Jeffery AN, Voss LD, Metcalf BS, Alba S, Wilkin TJ. Parents' Awareness of Overweight in Themselves and Their Children: Cross Sectional Study within a Cohort (Earlybird 21). British Medical Journal 2004: bmj.38315.451539.F451537.22*WS Lo Weight comments by others and weight misperceptionCohen J. Statistical Power Analysis for the Behavioral Sciences. revised edn. Academic Press: New York, 1977. Brener ND, Eaton DK, Lowry R, McManus T. The Association between Weight Perception and Bmi among High School Students. Obesity Research 2004; 12: 1866-1874.23*Figure 1Accuracy of weight comment as "too fat" from family, peers andprofessionals by sex (descending order)Health-related professionals33.9 27.944.2 45.9**Teachers *** Father *** Mother *** GrandmotherGrandfather 22.426.6 49.4 45.0 22.7 49.1 19.4 19.7 38.6 16.9 20.8 6.4 0 5 10 14.3 15 20 25 30 35 40 45 50 55 37.4 Girls 42.9 Boys 28.1 25.5 42.8*** Classmates *** Siblings *** Friends *** Other relativesSocial workersAccuracy of weight comments as "too fat" from different sources (%)Key: *p<0.05; **p<0.01; ***p<0.001 between boys and girls*Figure 2Accuracy of weight comment as "too thin" from family, peers andprofessionals by sex (descending order)Health-related professionals Teachers Classmates Friends Other relatives Social workers Grandmother Father 16.3 21.8 19.1 21.8 19.0 23.4 17.5 23.0 16.8 19.1 16.1 0 5 10 15 20 25 21.126.5 24.6 26.7 25.6 24.3 24.4 25.0 27.832.5 31.4*SiblingsGrandfatherGirls Boys* Mother303540455055Accuracy of weight comments as "too thin" from different sources (%)Key: *p<0.05; **p<0.01; ***p<0.001 between boys and girls*