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ARTICLE |
Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, United Kingdom
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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METHODS. Children from years 3 and 6 (6–7 and 10–11 years old) in London schools were measured in school, and parents were sent information on the child's weight status. Children and parents completed questionnaires 6 weeks before and 4 weeks after the feedback; 358 children and 287 parents completed both questionnaires. The main outcome measures (parental feeding practices, parental perception of child weight, child body esteem, child eating behavior, and weight-related teasing) were assessed before and after feedback. Qualitative data on health-behavior change and parents’ and children's views of the measurement and feedback process were collected at follow-up.
RESULTS. Fifty-one percent of the parents (n = 398) volunteered for child measurements and weight feedback. Feedback was not associated with changes in child feeding among parents of healthy-weight children, but dietary restriction increased in parents of overweight girls. Among healthy-weight children, restrained eating decreased and body esteem increased, but there were no significant changes among the overweight group and no changes in reports of teasing. Perceptions of child overweight did not increase significantly, but 50% of the parents of overweight children reported positive changes in health behaviors. The majority (65%) of parents wanted weight feedback on a regular basis, and most children enjoyed the measuring process.
CONCLUSIONS. Weight feedback was acceptable to the majority of parents participating in an "opt-in" measurement and feedback program; adverse effects were minimal for children and parents, even when feedback indicated overweight. However, a minority of participants found it distressing, which highlights the importance of managing the process sensitively, particularly for families with overweight children.
Key Words: weight feedback • body image • teasing • dietary restraint
Abbreviations: NCMP—National Child Measurement Programme
In 2005, the National Child Measurement Programme (NCMP) was launched in the United Kingdom to monitor rates of childhood obesity. In the context of the program, weight feedback is currently only given to parents if they specifically request it, although this policy has recently been reviewed, and in the future feedback may be given to all parents unless they specifically opt out (see www.ic.nhs.uk/pubs/ncmp0607). Recent research suggests that relatively few parents of overweight children are aware that their child would be considered overweight.1–3 Feedback as part of the NCMP would provide an opportunity to give parents accurate information on their child's weight.
With appropriate advice and support, the information that their child is overweight could be a valuable stimulus to parents to engage with healthy weight control. However, given the cultural sensitivities around weight, there are concerns that it could also lead to adverse psychological consequences. "Labeling" the child as overweight could cause parents to become excessively concerned or impose harmful levels of dietary restriction. Children themselves may be distressed if they hear themselves described as overweight, and weighing could cause weight-related teasing, with consequences for self-esteem. There is also a risk of children initiating unhealthy weight-control behaviors.4
Two studies in the United States have examined the acceptability of school-based weight feedback. One study found that parents who received information on their child's BMI were more aware of their child's weight status and positive about receiving annual weight information; although a significant minority initiated diet-related activities, which the authors highlighted as a cause for concern.5 The other study also found positive reactions to school-based BMI screening with parental notification, and <8% of parents planned diet-related activities.6
We are not aware of any studies that have used standardized measures to assess the effects of weight feedback on parental feeding or children's eating behavior and body esteem. The present study was, therefore, designed to compare parents’ and children's reactions to a weighing and measurement program that included weight feedback given to the parents in families with overweight or healthy-weight children. The study was approved by the University College London Research Ethics Committee.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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The primary aim was to examine the potential of the intervention to cause distress to children, and we used child body esteem as the outcome for our power analyses. Power calculations indicated that 40 overweight children were required to detect a 3-unit change in child body esteem among the overweight children. This would require 200 children in total, assuming 20% of the sample to be overweight. A 3-unit change represents a moderate effect size7 with 80% power based on a 6.2 SD score from a previous study using this measure.8 Assuming a 30% participation rate, it was necessary to invite 
600 children to take part in the study.
Parents of all of the children in year 3 (6–7 years old) and year 6 (10–11 years old) (n = 786) in the 6 participating schools were informed of the study by letter and invited to participate. Those who declined were invited to give their reasons. Children in year 6 completed baseline questionnaires in class with a researcher available to answer questions. Children in year 3 completed the baseline questionnaires individually with a researcher. Parental questionnaires were sent to the homes by the school.
Within 6 weeks of collecting the baseline data, trained researchers measured the children's weight in kilograms to the nearest 0.1 kg on portable electronic Tanita scales (Tanita Corporation, Tokyo, Japan), and height in centimeters to the nearest 0.1 cm using a Leicester stadiometer (Seca, Birmingham, United Kingdom). Weighing and measuring were conducted with each child individually and in a screened area to ensure privacy. BMI percentiles were based on United Kingdom reference data.9 Children were categorized as overweight (91st–97th percentile) or very overweight (98th percentile), as recommended by the 2006 Department of Health care pathway for the management of overweight and obesity (see www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4134408). There is currently no consensus regarding appropriate cutoffs to indicate underweight in children. The World Health Organization Expert Committee on Anthropometry recommends using the fifth percentile to define thinness in adolescence but has no recommendations for younger children.10 In the present study, we consulted with school nurses and a pediatrician and decided to use the term "underweight" only for children lower than the 0.5th percentile to keep to a minimum the number of parents who might be alarmed.
Parents were sent individually tailored letters from the research team with qualitative and quantitative feedback on their child's measurements, along with simple healthy diet and physical activity advice. Telephone numbers for the research team and school nurse were given for additional support. Parents and children completed a follow-up questionnaire 4 weeks after the feedback had been sent, administered in the same manner as the baseline questionnaire.
Intervention Materials
Formative research was conducted to ensure that the measurement and feedback were handled as sensitively as possible. This included telephone interviews with parents, teachers, and school nurses about the presentation of the feedback. A project steering committee composed of a consultant community pediatrician, a clinical psychologist, a dietician, and a medical statistician evaluated the materials. We reported the child's height, weight, and BMI percentile, accompanied by the statement: "This means your child is in the [underweight, healthy weight, overweight, very overweight] category for their age, height and gender." When weight feedback indicated that a child was overweight, the language used was neutral and did not imply parental responsibility. Supporting materials contained practical advice for healthy lifestyle changes appropriate for children of all weights developed by Weight Concern (see www.weightconcern.org.uk), presented in a nonjudgemental manner to minimize feelings of blame or anxiety. A list of resources was also provided, and parents were given advice on how to talk to their child about weight if they chose to (materials available on request).
Main Outcome Measures
Parents’ perception of their child's weight was assessed before and after feedback with the question, "How would you describe your child's weight at the moment?" with response options of "very underweight," "underweight," "about right," "overweight," or "very overweight." Feeding practices were assessed with 2 subscales of the Child Feeding Questionnaire: monitoring (how much parents oversee their child's eating) and restriction (how much parents actively restrict their child's access to foods),11 completed before and after feedback. At follow-up, parents were asked how they felt about the feedback, whether they had made changes to family diet or physical activity, and whether they would like information on their child's weight on a regular basis in the future.
Children completed the Body-Esteem Scale12 and the restraint subscale of the Dutch Eating Behavior Questionnaire for Children.13 Weight-related teasing was assessed using an adapted version of the Perception of Teasing Scale, which asks the child to rate the frequency of teasing by parents, siblings, teachers, and other children on a scale from never to very often.14 Demographic information collected at baseline from parents included the child's ethnicity and parental education.
Statistical Analysis
Analysis of covariance was used to assess differences in follow-up scores in relation to the child's weight group (healthy weight versus overweight), controlling for baseline values, gender, age (year group), and parental education,15 followed by t tests to compare prefeedback and postfeedback scores. Where there were interactions between weight group and age or gender, analyses were conducted separately according to subgroup. Scores on child body esteem, child restraint, and parental monitoring had a skewed distribution, but because the residual scores were normally distributed, transformation was unnecessary. Intraclass correlations showed a negligible effect of clustering according to school for either parent or child outcome variables.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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All of the children whose parents had provided consent agreed to be weighed and measured, and all met the inclusion criteria of being able to stand on weighing scales and height measures unaided. Because some children were not in school on the day of measuring, complete data (anthropometry and baseline and follow-up questionnaires) were available for 358 children (89% of those who volunteered to participate). A total of 357 parents (90%) completed the baseline questionnaire, and 287 parents (72%) completed baseline and follow-up. There were no significant differences in any outcome between parents who completed or failed to complete the follow-up questionnaire. Analyses are all based on the sample with complete data. The majority (248 [79%]) of children were white, 4% (n = 12) were black Caribbean, 3% (n = 8) were black African, 5% (n = 15) were Asian, 8% (n = 24) were of mixed ethnicity, and 1% (n = 5) were Chinese. Only 1% of the parent sample had no educational qualifications, 33% had obtained GCSE or equivalent (school examinations taken at age 16 years in the United Kingdom), 20% had obtained A levels or equivalent (school examinations at 18 years), and 46% had completed university education. Although the numbers of respondents from ethnic minorities were representative of the schools, the sample size precluded analysis of ethnic differences.
Anthropometrics
Only 1 of the participating children had a BMI in the category that we defined as underweight (<0.5th percentile), 83% (n = 297) were healthy weight (0.5th–90.0th percentile), 13% (n = 45) were overweight (91st–97th percentile), and 4% (n = 16) were very overweight (>98th percentile). For all of the analyses, underweight and healthy-weight groups were combined, as were the overweight and very overweight groups.
Parental Weight Perceptions
Few parents described their child as either "very underweight" or "very overweight," so these responses were merged with the adjacent categories. Among parents of healthy-weight children, 12% (n = 28) selected "underweight," 87% (n = 202) "about right," and 1% (n = 2) "overweight" before feedback. Among parents of overweight children, none described their child as underweight, 61% (n = 26) chose "about right," and 39% (n = 17) chose overweight. Parents were more accurate at identifying daughters as overweight than sons (59% vs 27%; P = .036).
After feedback, there was little change in perceived weight status among parents of healthy-weight children. Slightly more parents of overweight children identified their child as overweight (from 40% to 49%), although this increase did not reach statistical significance in this sample size.
Parental Feeding Style
Parental monitoring of children's eating at baseline did not vary according to weight group, and the difference between groups at follow-up after controlling for baseline monitoring scores and covariates was not significant. However, monitoring declined overall (see Table 1) from before to after feedback.
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Health Behaviors
At follow-up, significantly more parents of overweight (49%) than healthy-weight children (12%) reported dietary changes (P < .001). The same was true for physical activity (48% vs 10%; P < .001). Changes included trying to have structured family mealtimes, reducing unhealthy snacking, introducing more fruits and vegetables to the family diet, and creating opportunities for unstructured physical activity (Appendix 2).
Child Body Esteem
Body esteem was lower in overweight than in healthy-weight children at baseline (Table 2). At follow-up, there was a significant weight group-by-year interaction (F3,296 = 18.62; P < .001), so data were analyzed separately according to year. After adjusting for baseline scores and covariates, body esteem scores at follow-up differed significantly according to weight group in year 6 (F1,128 = 24.94; P < .001). Posthoc tests showed that body esteem increased significantly in healthy-weight children in this year group (P = .027), whereas it was unchanged in overweight children (Table 2).
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Teasing
Few children reported higher rates of teasing, so responses were categorized into "never teased" vs "ever teased." At baseline, overweight children were significantly more likely than healthy-weight children to report teasing by other children (38% vs 17%; P < .001), parents (18% vs 8%; P = .017), and siblings (39% vs 22%; P = .007). There was no evidence for increases in teasing after weight feedback in any subgroup (see results from teasing from other children in Table 2).
Subjective Reactions to Weighing and Weight Feedback
The majority (66%) of parents wanted weight feedback on a regular basis, with no difference according to child weight group. We received only 2 telephone calls from concerned parents. The parents who called had been aware that their children were overweight before receiving feedback but found it upsetting to see this written down. They were also worried about the impact on their children of seeing the feedback. In the full sample, 21% of parents took the opportunity to make comments on the measuring and feedback, and we assume that parents who were particularly concerned would be more likely to respond. The responses indicated mixed reactions, with some parents finding the feedback helpful and informative and others identifying upset to themselves or their child (Appendix 3).
The majority of children (n = 351 [96%]) either said they "enjoyed it" or found it "OK." A small number of healthy-weight children (n = 9 [3%]) and overweight children (n = 4 [7%]) reported "not liking" or even "hating" the process. Most of these children (9 of the 13) were in year 6. The majority (n = 340 [94%]) said they would be willing to be weighed and measured again next year, but 5% (n = 14) of healthy-weight children and 10% (n = 6) of overweight children did not want the process repeated. Again, the majority (n = 17) were in the older year group.
Children also provided reactions to the measuring process (Appendix 4) and, like their parents, opinions varied. Some enjoyed the process and the opportunity it gave to talk about their health, but others expressed discomfort with weighing and felt that it gave an opportunity for teasing.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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Consistent with previous studies, many parents were unaware that their child was overweight,1–3 although awareness in the present sample was somewhat higher, suggesting an element of selection into the study based on parental awareness. Without feedback, parents are likely to remain unaware that their child's weight could be affecting his or her health,16 but even with feedback, not all of the parents were convinced of their child's overweight status. However, despite many of the parents who were sent "overweight" feedback apparently not changing their view of their child's weight status, very few wrote comments suggesting they thought the information was wrong. Interestingly, 30% of parents who continued to describe their child as at a healthy weight reported making healthy lifestyle changes after feedback, which could indicate a positive reaction to the feedback despite rejection of the weight status label.
The possibility of giving parents feedback indicating that their child is underweight is an important issue. Because there are no established recommendations for the identification of children in this category, we chose a very low limit to avoid causing parents concern. We acknowledge the potential for there to be children in our healthy-weight group who would be classed as underweight were another definition used. In the event, we had 1 child in our underweight group, but there would have been only 6 had the fifth percentile been used as the cutoff. Future studies will need to consider the threshold to use and the advice to be given to this group.
Relatively few parents reported negative emotional reactions in the comments section, although there were some (n = 7) who were either upset themselves or reported that their child was upset. It is possible that this would be mitigated if weight feedback became more routine, but these results strongly suggest that services need to be in place for families faced with the information that their child is overweight. There was little evidence of parents becoming overly vigilant about their child's eating after weight feedback, although parental restriction increased modestly for overweight girls. However, the role of restriction in child feeding is controversial. It is often vilified,17 yet some forms of restriction may be helpful.18,19 Qualitative reports from parents indicated that restrictive dietary changes were actions such as reducing unhealthy snacks and soft drinks, which are more likely to be beneficial than harmful.20,21
Another major concern, often expressed by parents, was that children themselves could be adversely affected, particularly through weight-related teasing, decreases in body esteem, or the onset of unhealthy dieting practices.4 In this sample, there was no evidence of any increase in weight-related teasing. Body esteem and restrained eating were also unchanged in the overweight children, although this contrasted with improvements in body esteem in the healthy-weight children. Without a control group, it is not possible to determine whether this reflected changes related to the feedback among children whose parents received healthy-weight feedback or developmental changes that the overweight children did not share in. However, given the relatively short time interval and the fact that body esteem often goes down with age in girls,22 the most likely explanation would seem to be that healthy-weight feedback had a positive effect on body esteem. However, the results highlight the need for particular care with weighing and measuring among older children, perhaps giving them the opportunity to discuss any concerns with a health professional.
The present study used brief written material about healthy eating and activity for families that was developed by Weight Concern to accompany the feedback. This was sent to all of the participants, regardless of weight group. Parents responded very positively to this, but it will be important to identify the forms of support and advice that are best received and have the most impact on family eating and activity patterns. Such support could be in written form, but some families who learn that their child is overweight may want input from a health professional.
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LIMITATIONS OF THE STUDY |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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APPENDIX 1: COMMENTS FROM PARENTS WHO ACTIVELY DECLINED PARTICIPATION IN THE STUDY |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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"Although I feel that weight is not a true indicator of a healthy lifestyle. I have no problem with this survey being carried out, but feel strongly that this should not be done within a school environment. With weight issues being a problem as children get older, to have this kind of survey during school hours brings peoples weight to everyone's attention. This kind of survey should be done at home or within a medical facility."
"We are concerned that [child name] may become concerned about her height and weight which currently does not cause her anxiety. Since hearing about the study, [child name] has been heard to say that she is going on a diet which we do not think is appropriate at this stage of her development."
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APPENDIX 2: EXAMPLES OF DIETARY AND PHYSICAL ACTIVITY CHANGES MADE BY PARENTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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"I have tried to make sure we eat together more often in order that [my son] will try more foods that we [the parents] eat."
"More vegetables and fruit, reduce snacks, reduced fizzy drinks."
"We talk more about food and the value to our health ... he does try different fruits now."
"Try to limit treats more often. Encourage to have a piece of fruit/vegetables if [my son] says he's hungry."
"My daughter is spending much less time playing computer games, she also walks much more than beforehand."
"Try to encourage more physical activity, i.e. playing in the garden, jumping on the trampoline, etc and really keep track of how much time spend watching TV."
"Making more of an effort to walk all or part of the way to school."
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APPENDIX 3: PARENTAL COMMENTS REGARDING WEIGHING AND MEASURING IN SCHOOL AND PROVISION OF FEEDBACK |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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"He [child] opened the envelope and cried. It caused a lot of upset but it did reassure me after my research that we have a very healthy diet."
"I was aware that my child was overweight and was quite upset and shamed of myself when I received the measurements. The study has made me think long and hard about the health of the entire family and I am taking positive steps to improve this."
"I don't think children should be made too aware of their weight. Too much anorexia and bulimia around as it is. It is more important for children to be taught about healthy eating, exercise and keeping healthy. Would be really concerned if they were weighed regularly as good self-esteem is incredibly important. Concerned that some parents could have told their children they were overweight from your survey and could upset their child."
"Feedback such as this helps parents to question whether or not they are doing the right things otherwise it's all too easy to get stuck into a particular routine."
"The only thing I want to comment on is that this process made [child's name] aware of something he has never even considered i.e. weight/appearance ... I wouldn't do it again because although it was all OK I was uncomfortable about him realising that weight/height/appearance is sometimes an issue. The end of innocence!"
"This has been a great idea in my opinion. Although my daughter is not overweight or unhealthy I have taken on board suggestion and am applying them."
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APPENDIX 4: COMMENTS FROM CHILDREN REGARDING THE WEIGHING PROCESS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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"I think that if there are rude children who think it's funny to tease someone about their weight then being weighed in school is a perfect opportunity."
"It was OK because other children didn't know what your weight was so they couldn't talk about it."
"Sometimes I feel a bit sad because I don't want anyone knowing my weight."
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Address correspondence to Jane Wardle, PhD, Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, Gower Street, London WC1E 7HN, United Kingdom. E-mail: j.wardle{at}ucl.ac.uk
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject Introduction of the NCMP in the United Kingdom has sparked controversy about giving parents feedback on their child's weight status. No studies have evaluated the impact of weight feedback on parents and children by using standardized measures.
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| What This Study Adds Most parents were positive about receiving feedback, but a minority of them were distressed. Adverse effects were minimal, with no significant negative impact on children's self-esteem, restrained eating, or weight-related teasing, but there was an increase in dietary restriction in parents of overweight girls.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONLIMITATIONS OF THE STUDYCONCLUSIONSAPPENDIX 1: COMMENTS FROM...APPENDIX 2: EXAMPLES OF...APPENDIX 3: PARENTAL COMMENTS...APPENDIX 4: COMMENTS FROM...REFERENCES |
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