Published online July 2, 2007
PEDIATRICS Vol. 120 No. 1 July 2007, pp. e112-e119 (doi:10.1542/peds.2006-2143)
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ARTICLE

Parental Ability to Discriminate the Weight Status of Children: Results of a Survey

Jeannie S. Huang, MD, MPHa,b, Karen Becerra, DDSa, Thaghar Oda, MDa, Edward Walker, BSa, Ronghui Xu, PhDc, Michael Donohue, PhDc, Iris Chena, Violeta Curbelo, MDd and Adam Breslow, MDd

c Division of Biostatistics and Bioinformatics
a Department of Pediatrics, University of California, San Diego, California
b Department of Gastroenterology, Children's Hospital San Diego, San Diego, California
d Children's Primary Care Medical Group, San Diego, California


   ABSTRACT
TOP
 ABSTRACT
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 LIMITATIONS
 CONCLUSIONS
 REFERENCES
 
OBJECTIVES. In this study we aimed to explore parents' weight perceptions of their children and of unrelated children.

METHODS. Parents of children ≤18 years of age who were attending pediatric clinics throughout San Diego County, California, were surveyed concerning their children's weight status and the weight status of unrelated children in various age groups. Height and weight were measured, and weight status was determined for both the parent and child. The influence of various demographic variables on parents' weight perceptions and the relationship between parents' perceptions of weight of their children and parents' perceptions of weight of unrelated children were evaluated. Multivariate regression modeling was applied to identify predictors of parents' perceptions of weight of their own children.

RESULTS. Of 1098 parents surveyed, 87% were women, 74% were white, and 46% reported Hispanic ethnicity. Seventy percent of the parents surveyed were overweight or obese, and 39% of their children were at risk for overweight or overweight. Sixty-one percent of parents correctly identified their children's weight status, and parents were able to correctly identify the weight status of unrelated children in 58% of reviewed photographs. Parents' weight perceptions of their children were not related to their ability to determine the weight status of unrelated children or to their ideal weight selections among unrelated children. In a multivariate logistic regression analysis, parental ability to correctly assess their child's weight status was associated with their child's age and weight status.

CONCLUSIONS. Parents' perceptions of their own children's weight status are influenced by their children's characteristics and do not seem to correspond with their weight perceptions of unrelated children. Parental recognition of weight issues in their offspring may be impeded by their inability to apply criteria used to ascertain the weight status of unrelated children to their own children.

Key Words: childhood obesity • parenting • weight perception • weight status

Abbreviations: AROW—at risk for overweight

Overweight in children is a national health concern with increasing prevalence rates in children of all ages over the past 2 decades.1 Health morbidities associated with overweight in children and adolescents include type 2 diabetes,2 obstructive sleep apnea,3 liver disease,4 hypertension and increased cardiovascular risk,5 and poor quality of life.6

One frequently cited reason as to why childhood overweight is on the rise is the failure of parents to recognize the overweight status of their children.7–12 Recognition rates of the heavier weight status of at risk for overweight (AROW) and/or overweight children by parents vary widely (from 6.2% to 66.7%7–15) and may reflect different populations and assessment methods. Certain child and parent characteristics, such as child weight status,7–13,15 child age,9,13 child sex,10,12,15 and parental education level,8 have been suggested to influence parental recognition of overweight in their children. Investigators have proposed that lack of parental recognition of the overweight status of their children may reflect a general inability of parents to distinguish abnormal from normal weight status because of the increasing prevalence of heavier body types in the general population.10,11 However, data are lacking regarding whether parental perceptions of weight of unrelated children are similar to their perceptions of the weight of their own children.

This study evaluated parents' perceptions of weight of their children and of unrelated children and explored the influence of various demographic variables on these weight perceptions. To assess parental ability to assess the weight status of unrelated children, we developed a photograph survey of various-aged children of different weights. Our a priori hypothesis was that parents' perceptions of weight of their own children are positively associated with their perceptions of weight of unrelated children and reflect public perceptions of weight of children as others have suggested.10,11


   PATIENTS AND METHODS
TOP
 ABSTRACT
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 LIMITATIONS
 CONCLUSIONS
 REFERENCES
 
Participants and Setting
All of the aspects of the study were reviewed and approved by the University of California, San Diego, internal review board. Informed consent was obtained from parents before study performance, and assent was obtained in children ≥7 years of age. Parents were recruited at the time of their child's appointment at local pediatricians' offices in the greater San Diego area, representing various sociodemographic, racial, and ethnic populations. Parents with children aged 0 to 18 years old were eligible for participation. Parents of children photographed for the photograph questionnaire were not eligible for participation in the questionnaire study.

A total of 1461 parent-child pairs were surveyed for this questionnaire representing 1098 families and 1106 parents. Only data from 1 parent-child pair per family were entered into the current study analyses. In cases where >1 parent-child pair was examined in a given family (in 363 families), data from the child whose first name came last alphabetically were entered into the analysis. In cases where both father and mother participated (in 8 families), data from the father were entered. Ultimately, 1098 parent-child pairs were represented in the study population.

Study Performance
After study procedures were reviewed and informed consent was obtained, parents surveyed were presented 12 photographs of children in 4 age categories (infant, toddler [1–3 years], 4–6 years, and 10–12 years) in the order listed in Table 1 and asked to determine whether photographed children were underweight, normal weight, AROW, or overweight. Subsequent to this initial survey, parents were then presented all of the photographs within a particular age category and asked to select the photograph that best depicted their ideal weight type for that age category. Parents were also asked to give an opinion regarding the weight status of their own child according to the weight categorizations of underweight, normal weight, AROW, and overweight. Demographic information was collected. Surveys were performed in both English and Spanish according to parental preference.


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  		TABLE 1 Survey Photographs

 
Heights and weights were measured in both parent and child, and BMI was calculated. Parent weight category was assigned according to National Center for Health Statistics BMI categorical definitions16: x < 18.5 kg/m2, underweight; 18.5 ≤ x < 25 kg/m2, normal weight; 25 ≤ x < 30 kg/m2, overweight; and x ≥ 30 kg/m2, obese. Weight status for children ≥2 years of age was defined according BMI for age and sex percentile definitions of underweight (x ≤ 5%), normal weight (5% < x < 85%), AROW (85% ≤ x < 95%), and overweight (x ≥ 95%), as defined by the Maternal and Child Health Bureau, Health Resources and Services Administration, the Department of Health and Human Services.17 Children <2 years of age were similarly assigned weight status on the basis of sex-specific weight-for-height percentiles and the following definitions: underweight (x ≤ 5%), normal weight (5% < x < 85%), AROW (85% ≤ x < 95%), and overweight (x ≥ 95%).

Photograph Questionnaire
Children of various weights and ages were photographed in both the anteroposterior and lateral positions (Fig 1). Informed consent was obtained from parents and assent obtained from children ≥7 years of age before photographing the pictured children in accordance with University of California internal review board requirements. Photographed children's weight categories were determined according to BMI-for-age and sex percentiles (≥2 years) and weight-for-height age and sex percentiles (<2 years) as described above. The age categories represented were as follows: infant (<1 year), toddler (1–3 years), child (4–6 years), and older child (10–13 years). Infants were photographed in the seated position in diapers. Older children were photographed standing in their undergarments. Anonymity of photographed patients was preserved via superimposing a black bar over identifying facial features. In each category, 3 photographs representing the 4 different weight categories were selected. For "normal weight," we selected children in the midrange of the normal spectrum (ie, 25%–75%) to better represent the typical normal child. Table 1 lists the demographics and weight status of the child photographed according to the order of presentation in the survey. The presentation order of the photographs was determined randomly.


Figure 1
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  		FIGURE 1 Sample photograph used in survey.

 
Definition of Variables
For surveyed parents, racial response categories included: white, black, Asian, or other; for statistical analyses, these groups were collapsed according to white or nonwhite origin. Other demographic variables were collapsed into dichotomous categories, including the following: ethnicity (Hispanic versus non-Hispanic), sex (male versus female), home language (English [including monolingual and bilingual English-speaking homes] versus other), family size (1 vs >1 child), parent education status (any college or more versus high school education or less), income (poverty versus above poverty), number of family generations in the United States (≥2 vs <2), participant child age (≥4 vs <4 years), parent age (≥30 vs <30 years), and weight status (AROW and overweight versus normal weight and underweight). Poverty level was defined according to the US Census Bureau 2005 statistics for families.18

Characteristics of photographed children evaluated for these analyses were represented as follows: child sex (male versus female), child ethnicity (Hispanic versus non-Hispanic), child race (white versus nonwhite), child age (infant or toddler versus 4–6 or 10–14 years), and child weight status (AROW or overweight versus normal weight or underweight).

Parent responses for the photograph survey and for weight assignments for their own children were coded as correct or incorrect. Parental ability to correctly identify the weight status of unrelated children was represented as the number of photographed unrelated children for whom weight status was correctly identified (of 12). Parental ability to correctly identify the weight status of AROW or overweight unrelated children was represented as the number of photographed AROW or overweight children correctly identified (of 7). Parent-selected weight ideals in each age category were coded as AROW or overweight versus normal weight or underweight.

Statistical Analyses
Demographic data were summarized using descriptive statistics. Univariate analyses of parental ability to correctly identify unrelated children's weight status by selected parent factors were performed using the Wilcoxon rank sum test. To assess the association between unrelated child characteristics and parental ability to correctly identify the weight status of unrelated children, the generalized estimating equation approach was used because of correlated outcome data (because each parent rated all of the 12 unrelated children's weight statuses).19 Univariate analyses of parental ability to correctly identify the weight status of their own child by selected factors were performed using logistic regression. The effect of the relationship between child weight and child age on parental ability to correctly identify the weight status of their own children was also evaluated because of data from previous studies.9,13

Multivariate logistic regression analysis was then applied to identify predictors of parental ability to correctly identify their child's weight status that are independently significant after adjusting for other variables (Table 5). Receiver operating characteristic evaluation for the logistic regression model was performed.


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  		TABLE 5 Logistic Regression Analysis of Parental Ability to Correctly Identify Their Child's Weight Status and Selected Characteristics in the Entire Cohort

 
Statistical analyses were performed on questionnaire responses by using JMP 5.0 statistical software (SAS Institute, Cary, NC) and the R statistical package 4.13.20,21 Significance for all of the analyses was set at P < .05.


   RESULTS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 LIMITATIONS
 CONCLUSIONS
 REFERENCES
 
A total of 1098 parents were surveyed. Demographics are presented in Table 2. Of those reporting Hispanic ethnicity, 96% were white, 1% were black, and 3% were Asian/other.


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  		TABLE 2 Demographic Data

 
Surveyed parents were able to correctly identify the weight status of 7 (6–8) (median [interquartile range]) of 12 presented photographs and of 3 (3–4) of 7 presented photographs of AROW or overweight photographed children. Parents who were women (P = .004) and had >1 child (P = .03) were more likely to correctly assess the weight status of unrelated children compared with category counterparts. Parents were more likely to correctly assess the weight status of unrelated children if the photographed children were ≥4 years of age but were less likely to correctly assess the weight status of unrelated children if they were male, Hispanic, or AROW or overweight (Table 3). In contrast, race of photographed children did not significantly affect the ability of surveyed parents to correctly assess weight status.


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  		TABLE 3 Odds Ratio for Parental Ability to Correctly (Versus Incorrectly) Identify the Weight Status of Unrelated Children According to Photographed Child Variables

 
Sixty-one percent of surveyed parents correctly identified their own child's weight status. Among parents of AROW or overweight children, 30% correctly identified their own child's weight status. Parents who were non-Hispanic, of normal weight or underweight, had normal weight or underweight children ≥4 years of age, spoke English at home, had received more than a high school education, with incomes above poverty criteria, and whose families had been in the United States for ≥2 generations were more likely than comparison parents to correctly identify the weight status of their own children (P < .05; Table 4).


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  		TABLE 4 Odds Ratios for Parental Ability to Correctly (Versus Incorrectly) Identify the Weight Status of Their Own Children, According to Selected Variables

 
Parental ability to correctly assess the weight status of their children was not related to their ability to correctly assess the weight status of unrelated children (P = .71). Selection of normal ideal body types among various aged-unrelated children by parents was also not related to parental ability to correctly identify the weight status of their own children (P > .15 for all age categories; Table 4).

Multivariate Regression Analysis
Multiple logistic regression analysis of parental assessment of their own child's weight status identified significant associations between parental assessment of their child's weight status and child characteristics. Results are displayed in Table 5. Area under the curve from the receiver operating characteristic was 0.78 for the model.


   DISCUSSION
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
LIMITATIONS
 CONCLUSIONS
 REFERENCES
 
To our knowledge, we present the first study evaluating parents' perceptions of weight of unrelated children and their relationship with parents' perceptions of weight of their own children. Our study also assessed a number of socioeconomic and racioethnic variables to control for potential confounding factors. Although we did demonstrate that similar child variables (ie, child age and actual weight status) may have affected parental ability to determine the weight status of both related and unrelated children, we did not find a direct association between parental assessment of their children's weight status and parental assessment of the weight status of unrelated children. The implications of our findings are discussed below.

In our cohort, parental assessments of the weight of their children were associated with primarily child characteristics. In particular, correct parental assessment of the weight of their child was associated with child age and weight status. Parents of children who were school aged (≥4 years) and of normal or underweight status were more likely to correctly assess the weight status of their children as compared with parents of younger and AROW or overweight children. Independent investigations have also demonstrated similar associations between child age and weight status and parental assessment of their child's weight.7–13,15 Several investigators10,12,15 have also reported that there may be differences in how mothers interpret the weight status of their children according to their children's sex. Baughcum et al8 demonstrated a significant association between education level and preschool mothers' assessment of the weight status of their children. We did not demonstrate any association between parents' assessments of weight of their children and child sex. Although we did demonstrate univariate associations between parents' perceptions of weight of their children and parent education level, this association was not found to be significant once other socioeconomic demographics were entered into a multivariate model. Possible explanations of the discrepancies between our results and the outcomes of other studies might include our evaluation of a much broader age range of children, inclusion of fathers, and our cohort size.

In our cohort, parental ability to assess the weight status of unrelated children was associated with child characteristics, including age, ethnicity, sex, and weight status. Specifically, parents were more likely to correctly assess the weight status of unrelated children who were ≥4 years of age, non-Hispanic, female, and normal or underweight as compared with their counterparts. Parental ability to correctly identify the weight status of unrelated children may have reflected their exposure to children with these characteristics as reflected by the majority of child participants being ≥4 years of age, non-Hispanic, female, and normal or underweight. In addition, we demonstrated that mothers and parents of families with ≥2 children were more likely than fathers and parents of only 1 child to correctly identify the weight status of photographed children. Assuming that mothers were the primary caregivers to the children represented in this study, as reflected by their attendance at scheduled pediatric care visits, we propose that the comparatively better ability of mothers and parents of ≥2 children to discern the weight status of unrelated children found in our cohort may reflect increased exposure of these individuals to children of different weights and ages.

In our study, parents were more likely to correctly identify the weight status of school-aged (≥4 years old) and normal and underweight children than of younger, AROW, or overweight children, independent of their affiliation with the children. This finding, taken in conjunction with previous studies demonstrating a reduced ability for parents to identify the overweight status of younger children,9,13 suggests a general public misperception of what constitutes normal weight for younger children. Recent studies demonstrate a growing prevalence of overweight and AROW among toddlers and preschool children.22,23 In addition, a review of longitudinal, prospective studies evaluating the relationship between obesity in childhood and adulthood demonstrates that the risk of adult obesity is increased among overweight infants and toddlers.24 Our results and similar findings by other investigators identify a need for public reorientation regarding the definition of appropriate weight for infants and toddlers and suggest that early intervention during the first 2 years of life should be incorporated into prevention and treatment campaigns for childhood obesity.

Although our study data demonstrated that child age and weight status similarly affect parental ability to assess the weight status of unrelated and related children, we also demonstrated that parental assessment of the weight status of their children was not related to parental assessment of the weight status of unrelated children or to parents' ideal body type selections among unrelated children. Our findings suggest that although parents may concur with public weight perceptions for younger and overweight children, they may also demonstrate weight perceptions unique and specific to their child. Alternatively, the demonstrated lack of application of subjective weight criteria to their own children (we showed no association between parental ability to correctly identify their own child's weight status and parent-selected body type ideals among unrelated children) may reflect parents' frank denial of or unwillingness to accept their children's weight status. Parents may also use different criteria to define overweight status or to assign health-related concerns for their children. Jain et al14 demonstrated that mothers did not believe that their children were overweight if their children were active and had a healthy diet and/or a good appetite. Also, a recent study by Eckstein et al9 found that parental level of health-related concern for their child was more associated with their perception of the child's activity level than the child's weight status. Taken together, individualized interventions may be required to help parents uniformly recognize weight status, and particularly overweight, in all of their children.

Parental involvement is important for weight reduction and healthy weight maintenance in children. Parents have a strong influence on children's dietary intake and level of activity, and parental encouragement has been shown to be important for adoption of healthy eating and physical activity behaviors by their children.25,26 Although not all overweight treatment studies have found that parental participation significantly improves treatment results, the interventions documenting the largest and longest-term decreases in percentage of overweight include parental participation as an integral component.27,28 Crucial to parental involvement in weight maintenance efforts among children is parental recognition of overweight in their children and a heightened level of health concern for their overweight children. Studies demonstrate that parental recognition of the overweight status of their children and of health risk associated with overweight is associated with parental readiness for action with regard to their child's weight.29 Interventions targeting parental recognition of their child's weight status may, thus, be important for healthy weight maintenance in children.

Pediatricians and other clinicians who evaluate families on a regular basis may be ideally situated to promote and encourage healthy weight perceptions and parental awareness of their child's weight status given their personal interaction with parents and children on a recurrent basis. The frequent well-child visits typically scheduled in the first 2 years of life between pediatricians and families may provide the early opportunities needed for preventative and treatment interventions among children at risk. Physician involvement has been shown to promote weight loss behaviors and efforts30–33 and weight loss success among adult patients.31 Published expert panel guidelines currently advocate for screening for childhood overweight via the clinician's office and regular clinician-family discussions regarding weight management.17 However, recent data suggest that physician adoption of expert recommendations for the treatment and prevention of childhood overweight are still suboptimal.34,35 Therefore, additional research is needed to understand how best to implement early screening practices for overweight among children and encourage clinician discussions with families regarding what is an appropriate and healthy weight for their child.


   LIMITATIONS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 LIMITATIONS
CONCLUSIONS
 REFERENCES
 
The findings of this study are subject to a number of limitations. First, limited representation of body types in our photograph questionnaire (only 3 photographs per age group) may not have adequately represented parental ability to assess the weight status of unrelated children or body type ideals in each age category. Although we restricted the number of photographs presented to reduce the time requirement of the study for feasibility, we nevertheless did represent a wide variety of body types in our questionnaire, as well as a broad spectrum of child characteristics (ie, by race, ethnicity, and sex). In addition, we chose to represent the normal weight body type in our photograph questionnaire (only 1 per age group) by children who plotted at the midrange of normal. Thus, selection of children in other weight categories (eg, AROW or overweight) in each age group would have represented a true deviation from the norms for age. Furthermore, whereas other studies have used figure sketches without exact correlation to actual BMI-for-age and sex percentiles to represent body types for selection by survey participants, we provided actual representations (photographs) of children with known BMI-for-age and sex percentiles for selection. Thus, we were able to accurately compare and interpret demonstrated differences in perceived and actual weight status. Second, our analyses only accounted for parental ability to recognize the weight status of 1 of their children. Therefore, for parents with >1 child, we were not able to comment on whether ability to recognize weight status differed between children or whether assessment of 1 child was representative of their ability to assess the weight status of all of their children. Third, our study represents a cross-sectional evaluation and therefore cannot comment on whether current parent ability to recognize the weight status of their children at a given age adequately reflects their ability to recognize the weight status of their children in the past or future. Additional study is therefore needed to address these remaining concerns.


   CONCLUSIONS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 LIMITATIONS
 CONCLUSIONS
REFERENCES
 
We demonstrate that parental assessment of their child's weight status is not associated with parental ability to determine the weight status of unrelated children. Parents' perceptions of children's weight are influenced by child characteristics. Pediatricians and other clinicians who regularly evaluate children should monitor and discuss the weight status of children with their parents as early as possible to promote parental awareness of the weight status of their children.


   ACKNOWLEDGMENTS
 
This research was supported by a grant from the Resthaven Children's Health Fund and also partially supported by General Clinical Research Center grant NIH M01 RR000827.

We gratefully acknowledge our research volunteers and referring medical providers of the Children's Primary Care Medical Group (especially Marvin Zaguli, MD, John Hansen, MD, Marshall Littman, MD, and Robert Bjork, MD).


   FOOTNOTES
 
Accepted Dec 12, 2006.

Address correspondence to Jeannie S. Huang, MD, MPH, Department of Pediatrics, 200 W Arbor Dr, MC 8450, San Diego, CA 92103. E-mail: jshuang{at}ucsd.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 LIMITATIONS
 CONCLUSIONS
 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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 ICAN: Infant, Child, & Adolescent NutritionHome page
J. S. Huang, M. Donohue, K. Becerra, and Ronghui Xu
Relationship Between Parents' and Children's Weight Perceptions Results of a Survey
ICAN: Infant, Child, & Adolescent Nutrition, February 1, 2009; 1(1): 15 - 20.
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