OVERWEIGHT AND OBESE CHILDREN:
“AT A NORMAL WEIGHT,”
ACCORDING TO PARENTS
The Delaware Survey of Children’s Health (DSCH),
sponsored by Nemours, is a surveillance instrument,
administered by telephone, with results from more than
3,000 households in Delaware with children ages birth to
17. The DSCH, which was administered in 2006, 2008
and 2011, provides data on trends in children’s weight
status, health-related behaviors, and parental perception of
children’s weight.1
This brief discusses parental perception of children’s
weight. As a part of the DSCH, parents reported their
child’s height and weight and were asked whether their
child was underweight; at a normal weight; somewhat
overweight; or significantly overweight. Height and weight
were validated by data from health care providers.
Survey results reveal a significant gap between how
parents of overweight and obese children classify their
children and the clinical classification of their children’s
weight. Eighty percent of parents of overweight children
and over half (58.7 percent) of parents of obese children
surveyed in Delaware in 2011 reported that their child was
at a healthy weight. This is similar to the findings from the
2006 and 2008 surveys.1
100
Overweight
90
Obese
80
70
60
80.5%
78.5%
59.8%
50
79.5%
60.0%
58.7%
40
30
20
10
0
2006
2008
2011
Percentage of Parents Who Perceive Their Overweight or Obese Children to Be
Normal Weight by Gender of the Child. 1
The Complexity of Parental Awareness of
Overweight and Obesity
The American public considers childhood obesity to be
a major public health threat, on par with tobacco use
and violence.2 In recent years, major initiatives have been
launched to combat the epidemic, and public support
for interventions has remained strong. At the same time,
national surveys show that the majority of parents of
children who are overweight or obese report that their
children are of normal weight.3-6 Delaware data are
consistent with what has been found nationally.
There may be many reasons for parents reporting
inaccurately. Studies have shown that some parents do
not understand the term “overweight” or the link between
overweight and poor health. Studies have also found some
parents believe that a heavier child is healthier, preferring
large body types, or feeling that a larger child reflects
positively on the parents. It is also possible that some
parents of overweight or obese children may be aware but
unwilling to state that their child is overweight or obese.
The social stigma of being labeled overweight may keep
some parents from acknowledging a situation that they
actually recognize.7
The Youngest Children Are the Most
Misclassified
The gap between parental reports and the reality of
children’s weight is most pronounced among the youngest
Delaware children, those ages 2 through 5 years. Over
80 percent (80.7 percent) of parents of the obese toddlers
and preschoolers surveyed said their children were at
a normal weight. None said that their children were
significantly overweight; 15.6 percent said they were
somewhat overweight; and 3.7 percent said that they
were underweight.1
Data Brief #1 2014
Introduction
Among Delaware parents of adolescents, ages 12-17,
the DSCH found somewhat higher levels of accuracy,
but notably, the majority of parents of overweight and
obese children still reported their children were less
overweight than they actually were. Seventy nine percent
of parents of overweight adolescents said their children
were at a normal weight; 36.8 percent of parents of
obese adolescents reported normal weight, and over half
of these parents (50.8 percent) said that their child was
“somewhat overweight,” when the correct classification
would be “significantly overweight.”
Hardly any of the parents of overweight 2-5 year olds
reported a weight problem; almost 95 percent of this
group said their children were at a normal weight.1
Young children may be particularly difficult for parents
to identify as overweight or obese. Even some medical
professionals seem prone to misclassify preschool
children. A 2010 study conducted among medical
students, resident physicians and community physicians,
using only visual cues, found that only 15 percent of
respondents correctly identified a 3-year-old boy, whose
BMI was >95th percentile for his age, as obese. Only
21 percent correctly identified another girl who was
overweight at the 90-95th percentile BMI-for-age. No
significant difference was found in total accuracy between
physicians and trainees. Parents may experience the same
misperceptions when using only visual cues.8
Although young children may be the hardest to identify
as overweight or obese, the stakes in doing so may be the
highest. Recently-released research following more than
7,000 children from kindergarten through eighth grade
found that a third of the children who were overweight in
kindergarten were obese by eighth grade. The study also
documented a relative decrease in the incidence of obesity
after age five. The case for intervening early has never
been so strong, but misperceptions of young children’s
weight status remain a serious barrier.9
After Age Five, Most Parents Are Still
Inaccurate
Almost 60 percent (59.2 percent) of parents of obese 6- to
11-year-olds reported that their children were of normal
weight, as did almost three-quarters (73.5 percent) of
parents of overweight 6- to 11-year-olds. Although there
is more accuracy among these parents than among the
parents of the youngest children, these figures are cause
for significant concern.1
Page 2
Parents More Accurate About Obese and
Overweight Females
Parents in Delaware are somewhat more accurate about
girls’ weights than boys; 40.1 percent of parents of
obese girls said they were “somewhat overweight” when
surveyed. Only 23.8 percent of parents of obese boys
said the boys were overweight. Obese girls were also
more likely to be accurately classified as “significantly
overweight” than boys; 10.2 percent of girls’ parents
said they were “significantly overweight, while only 3.6
percent of boys’ parents indicated the same.1
100
Age 2-5
Age 6-11
90
Weighted Percent
80
Age 12-17
89.4%
82.3%
80.7%
70
60
67.3%
63.5%
59.2%
50
44.3%
40
36.8%
30
26.0%
20
10
0
2006
2008
2011
Parents Who Perceive Their Obese Child as “Healthy Weight”1
100
Age 2-5
94.7%
90
Weighted Percent
80
88.1%
84.8%
Age 12-17
85.0%
79.0%
74.2%
70
60
Age 6-11
73.5%
67.7%
50
82.6%
40
30
Differences in Reporting Among Races
and Ethnicities
20
10
0
2006
2008
Parents Who Perceive Their Overweight Child as “Healthy Weight”1
Page 3
Similarly, parents of overweight girls are more likely
to see them as overweight; 18.8 percent of overweight
girls had parents who said this was the case (1.3 percent
of these girls’ parents said they were “significantly
overweight”). Among overweight boys, only 12.9 percent
of Delaware parents reported them to be overweight and
virtually none (0.2 percent) said they were “significantly
overweight.”1 This finding corresponds to results from
a number of studies across the country. Researchers
speculate that parents of girls may compare their children
to a “thin ideal” for the female body and therefore be
more likely to recognize a problem. Overweight boys may
be seen as more normal, as larger boys may be considered
to have a physical advantage.
2011
Although parents in Delaware, regardless of race or
ethnicity, generally say their overweight or obese children
are at a normal weight, there is some variation in the
degree of misclassification by race and ethnicity. Parents
100
Male
100
90
Female
90
80
80
70
70
60
50
66.1%
65.1%
65.5%
52.9%
60
55.3%
48.4%
40
20
20
10
10
2008
2011
Parents Who Perceive Their Obese Child as “Healthy Weight”1
80.0% 80.0%
83.5%
76.2%
67.6%
40
30
2006
Female
88.0%
50
30
0
Male
0
2006
2008
2011
Parents Who Perceive Their Overweight Child as “Healthy Weight”1
Parents of obese white children are the least likely to say
that their children are obese — 62.8 percent report that
their obese children are at a normal weight; 28.2 percent
say the obese children are “somewhat overweight”
and 6.3 percent report accurately, that the children are
“significantly overweight.” Parents of Hispanic children
fall between these two groups in terms of accuracy —
55.6 percent report a normal weight for obese children,
with 37.2 percent saying the children are “somewhat
overweight” and 6.6 percent reporting accurately.1
However, race and ethnicity play out differently when
parents report on overweight, as contrasted with obesity.
Whereas obese African-American children were the
most likely to be accurately classified by their parents,
this is not the case for overweight African-American
children. Almost 90 percent (88.6 percent) of overweight
African-American children in Delaware were reported
as at a normal weight; 87.3 percent of white children
were classified as normal, as were 85 percent of Hispanic
children.1
of obese African-American children are the most likely
of the races/ethnicities studied in the DSCH to report
accurately — less than half (45.9 percent) say their obese
children are at a normal weight; 46.6 percent say they
are “somewhat overweight” and 7.5 percent say they are
“significantly overweight, “ which is clinically correct.
Page 4
Research on how race affects parental perception of
weight is less definitive than research on gender and
parental perception. One study of school-aged children
showed African-American parents underestimating
their child’s weight classification more often than white
parents6 — a finding opposite to the DSCH results. Other
studies have found that African-Americans, Asians and
Caucasians were more likely to classify their overweight
child as overweight than Hispanic parents or parents
from other groups.7
Why Parental Perception Matters and
What Can Be Done
Obesity and overweight are health risks for children,
not only in adulthood, but also during the childhood
years. A growing body of evidence points out that
children as young as 10 are now diagnosed with
weight-related disease. Parents who do not recognize or
acknowledge their child’s weight problem cannot address
a fundamental issue with the child’s health. In fact, 79
percent of parents of obese children surveyed for the
DSCH indicated that their children were in “excellent”
or “very good” health. 1 This large majority of parents of
obese children were not aware of or not acknowledging
the serious health risks faced by their children.
Solutions to this problem are not simple. Public health
and health professionals need to avoid inadvertently
stigmatizing children. Societal attitudes toward
overweight and obese children and youth are negative
and many children endure bullying and other damaging
attitudes and behavior. Moreover, research has
documented that accurate classification of adolescent
overweight may result in unhealthy behaviors from
parents, such as encouragement to diet, instead of support
for healthier eating, more physical activity and generally
good health habits.4 Differences in parental perception
by gender and race also indicate a need for sensitive and
culturally competent messages; discussions of body size
can easily offend or be misinterpreted.
At the same time, there is a clear need for health
professionals to assist families with this issue, and
evidence that concern expressed by a health professional
results in a changed view of the child’s weight status. A
study conducted using DSCH data showed that when
parents of obese children, 6-11 years old, hear concerns
from a health professional, their perception shifts.
Before a health professional expressed concern, 79.4
percent of the parents said their obese children were
at a normal weight; 20.5 percent said that the children
were overweight, but not obese. After the conversation
with a health professional, 19.4 percent of parents were
accurate and described their child as obese; 58.2 percent
said the child was overweight; and only 22.4 percent —
down from 79.4 percent — said the child was at a normal
weight. Similar findings were obtained from a sample
of adolescents, with marked improvement in parental
perception after a health professional expressed concerns.10
*Data for charts from http:/datacenter.nemours.org
Page 5
The Expert Committee Recommendations Regarding
the Prevention, Assessment, and Treatment of Child
and Adolescent Overweight and Obesity call for health
professionals to provide prevention messages to all
families, but also to intervene with families when children
have a weight problem. The recommendations explicitly
recognize the importance of social and environmental
change to reduce the obesity epidemic but also focus
on the ways health care providers can contribute
through patient care. Training and support for effective
interventions, including motivational interviewing, may
help providers to deal with this important and delicate
subject. Community support for health promotion and
obesity prevention efforts can provide a positive context
for parents, health providers, and children and youth in
changing behaviors.11
Insert Chart 3. here.
References
1.
NHPS Data Center. Nemours Children’s Health System website. http://datacenter.nemours.org. Accessed August 20, 2014.
2. Evans WD, Finkelstein EA, Kamerow DB, Renaud JM. Public perceptions of childhood obesity. Am J Prev Med. Jan 2005;28(1):26-32.
3.
Wake M, Salmon L, Waters E, Wright M, Hesketh K. Parent-reported health status of overweight and obese Australian primary school children: a cross-sectional population survey. Int J Obes Relat Metab Disord. May 2002;26(5):717-724.
4.
Neumark-Sztainer D, Wall M, Story M, van den Berg P. Accurate parental classification of overweight adolescents’ weight status: does it matter? Pediatrics. Jun 2008;121(6):e1495-1502.
5.
Lundahl A, Kidwell KM, Nelson TD. Parental underestimates of child weight: a meta-analysis. Pediatrics. Mar 2014;133(3):e689-703.
6.
West DS, Raczynski JM, Phillips MM, Bursac Z, Heath Gauss C, Montgomery BE. Parental recognition of overweight in school-age children. Obesity (Silver Spring). Mar 2008;16(3):630-636.
7.
Towns N, D’Auria J. Parental perceptions of their child’s overweight: an integrative review of the literature. J Pediatr Nurs. Apr 2009;24(2):115-130.
8.
Eckstein KC, Mikhail LM, Ariza AJ, Thomson JS, Millard SC, Binns HJ. Parents’ perceptions of their child’s weight and health. Pediatrics. Mar 2006;117(3):681-690.
9.
Cunningham SA, Kramer MR, Narayan KM. Incidence of childhood obesity in the United States. N Engl J Med. Apr 24 2014;370(17):1660-1661.
10.
Enev T. What is ‘normal’? discrepancies between BMI classification vs. perceived weight status in social context. 141st APHA Annual Meeting and Expo. Boston, MA; 2013.
11.
Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. Dec 2007;120 Suppl 4:S164-192.
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