Childhood Obesity: Do Parents Recognize This Health Risk?

Debra Etelson,* Donald A. Brand,* Patricia A. Patrick, and Anushree Shirali

Abstract ETELSON, DEBRA, DONALD A. BRAND, PATRICIA A. PATRICK, AND ANUSHREE SHIRALI. Childhood obesity: do parents recognize this health risk? Obes Res. 2003;11:13621368. Objective: This study examined parents understanding of excess weight as a health risk, knowledge of healthy eating habits, and recognition of obesity in their children. Research Methods and Procedures: An anonymous questionnaire was distributed during well-care visits involving children 4 to 8 years of age at a pediatric faculty practice. Parents indicated their level of concern about excess weight and other familiar health risks using a four-point Likert scale, answered multiple-choice questions concerning healthy eating patterns, and communicated their perceptions about their childs weight using a visual analog scale. A parents perception was considered accurate if it deviated from the childs growth chart percentile by 30 points. Results: Of the 83 parents surveyed, 23% (19/83) had overweight children ( 95th percentile of age- and genderspecific BMI growth charts). These parents did not differ from other parents in their level of concern about excess weight as a health risk or in their knowledge of healthy eating patterns, but the two groups of parents did differ in the accuracy of their perceptions about their childrens weight. Only 10.5% of parents of overweight children (2/ 19) perceived their childs weight accurately compared with 59.4% of other parents (38/64; p 0.001). Parents of overweight children invariably underestimated their childrens weight. The median difference between their perception and the growth chart percentile was 45 points. Discussion: Given that most parents of overweight children fail to recognize that their child has a weight problem, pediatricians should develop strategies to help these parents correct their misperceptions. Key words: child, body weight, caregivers, weight perception, health-risk appraisal

Introduction
Obesity is now considered to be the most prevalent nutritional disease of children and adolescents in the United States (1). An estimated 15% of 6- to 11-year-old children are overweight (i.e., they fall at or above the 95th percentile of BMI for their age and sex) (2). Excessive weight during childhood stems from several interacting factors, including poor diet and exercise habits. Dietary preferences and physical activity patterns are probably shaped early in childhood, influenced by parental practices and familial environment (3,4). It follows that obesity prevention programs, to be successful, will require parental participation (5). Such participation, in turn, will depend on parents ability to recognize that their child is overweight, to understand that obesity puts the child at risk for associated short-term and long-term health problems, and to provide healthy, balanced meals that will help their child lose weight. Parents do not typically consult growth charts to determine whether a child is overweight. Instead, they notice when a child becomes inactive or suffers from teasing by other children. Parents may tend to define obesity as a condition accompanied by severe physical impairment, especially compromised mobility. They may also believe that a childs size is inherited and that the child will eventually shed excess weight with age (6). Whereas we know that parental participation is vital for successful obesity treatment programs (7,8), we know less about how well parents recognize obesity in their own children. Before instructing parents about dietary and exercise regimens, clinicians must first verify that parents know when they have a child with a weight problem and why they

Received for review March 3, 2003. Accepted in final form September 9, 2003. *Department of Pediatrics, Department of Medicine, Primary Care Research Unit, and School of Medicine, New York Medical College, Valhalla, New York. Address correspondence to Debra Etelson, Department of Pediatrics, New York Medical College, Munger Pavilion, 3rd Floor, Valhalla, NY 10595. E-mail: debra_etelson@nymc.edu Copyright 2003 NAASO

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need to be concerned. This study explored the degree to which parents recognize excess weight in their own children, understand the health risks of obesity, and have a basic knowledge of healthy eating habits.

Research Methods and Procedures

Study Design This survey of parents of children 4 to 8 years of age used an anonymous, self-administered questionnaire to assess parental attitudes about excess weight in childhood, knowledge about healthy eating habits, and perception about their own childs weight. Questionnaires were distributed at routine well-care visits at a private pediatric faculty practice located in suburban Westchester County, New York, which is affiliated with New York Medical College. The patient population served by the practice is 70% white, 12% Asian, 10% African American, 5% Hispanic, and 3% other or unknown. Approximately 21% of patients have Medicaid insurance. Data Collection From March 1 through June 30, 2000, a member of the research team examined the appointment log each day to identify patients who were 4 to 8 years old and were scheduled for a well-care visit. (The appointment log contained the childs name, date of birth, and reason for visit.) The investigator wrote a sequential code number next to the name of each patient in the log who met the above criteria and wrote the same code on a blank questionnaire that she then attached to the patients chart. When the parent and child arrived, the receptionist handed the questionnaire to the parent and invited her or him to complete it in the waiting room (which took 3 to 4 minutes) and return it to the receptionist. Parents were informed that the survey was voluntary, and those who completed and returned it were presumed to have given implicit consent to participate. Periodically, a research assistant copied down the code numbers from recently completed questionnaires left with the receptionist, found the corresponding names on the printed appointment log, obtained the medical records of those children, recorded the height and weight data obtained at the well-care visit (after removal of shoes and heavy clothing, and using scales that were calibrated each morning), and then discarded the names, retaining only the codes and associated heights and weights. The printed appointment logs containing the names and codes were also discarded. This procedure assured the anonymity of the study data, but still allowed us, through the codes, to link the objective height and weight data to the subjective questionnaire responses. The study was approved by the institutional review board of New York Medical College.

Questionnaire The questionnaire contained 18 questions, 8 of which were included to help obscure the studys exact topic of interest childhood obesity. These extra questions asked about such matters as the need to cover electrical outlets and place guards on upstairs windows. To further obscure the exact study objective, Child Health and Safety Questionnaire was the title printed at the top of the questionnaire. By broadening the apparent scope of the study, these measures were intended to make the questionnaire feel more innocuous to parents who might feel uncomfortable with the topic of obesity. The 10 pertinent questions addressed three topics: attitude toward childhood obesity as a health risk, knowledge of healthy eating patterns, and perception of ones own childs weight. Attitude Toward Childhood Obesity. The questionnaire asked parents how concerned they would be about their childs health if (1) someone in their household were a smoker, (2) their child did not like reading aloud in school, (3) their child were overweight, (4) someone in the childs class at school had AIDS, (5) the child were not toilet trained by 3 years of age, (6) the child had a history of many sunburns, and (7) the child watched more than 20 hours of television per week. The parent answered each of these questions by marking responses on a four-point Likert Scale ranging from not at all concerned to extremely concerned. Items 1, 2, 4, 5, 6, and 7 made it possible to assess parental attitudes toward childhood obesity relative to other conditions they might perceive as health risks. Knowledge of Healthy Eating Patterns. Two multiplechoice questions were included to assess parental knowledge of healthy eating habits. The first question asked how much juice parents thought it was healthy for their child to drink each day (1 to 2 juice boxes, 3 to 4 juice boxes, 5 to 6 juice boxes, or 7 to 8 juice boxes, where 1 juice box 8 oz). The second question asked how often the parent felt it was appropriate to eat at fast food restaurants (once a month, once a week, 3 times/wk, or 5 times/wk). Perception of Childs Weight. A visual analog scale (9) was used to assess parental perceptions of their childs weight (Figure 1). The scale consisted of a 10-cm line with ends labeled extremely underweight and extremely overweight. Parents were asked to mark the spot on the line indicating how they perceived their childs weight. Visual analog scales have been applied to various healthrelated measurements including pain assessment (10), functional status (11), and psychological measurements (12), but they have not previously been used to assess perceptions about weight. Most studies that have tested the validity and reliability of the scale have found it to be a generally satisfactory measure (9). Its main advantage for research purposes is that it tends to produce more normally distribOBESITY RESEARCH Vol. 11 No. 11 November 2003 1363

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Table 1. BMI percentiles of children in the study, based on standard growth charts (14)
Figure 1: Visual analog scale used to assess parents perceptions of their childs weight.

Percentile 25 25 to 49 50 to 74 75 to 94 95

Girls (N 43) 2 10 9 12 10

Boys (N 40) 3 8 9 11 9

uted data and greater variation in scores than scales which offer a fixed number of discrete choices. Analysis Parental attitudes toward health risks and their knowledge of healthy eating patterns were summarized by computing, for each question, the proportion of parents who gave each response. Results were also stratified based on the childs BMI percentile derived from standard growth charts. The stratified analysis used the following percentile ranges: 25, 25 to 49, 50 to 74, 75 to 94, and 95. Parental perceptions of their childs weight were assessed by interpreting the marks they placed on the 10-cm visual analog scale as percentiles. A ruler was used to measure the distance from the left end of the line (labeled extremely underweight) to the mark. If, for example, a parent placed the mark at the halfway point or 5.0 cm from the leftwe interpreted that to indicate that the parent believed his or her childs weight fell near the 50th percentile. Using the height and weight measurements obtained at the well-care visit, we derived each childs actual age- and gender-specific BMI percentile from U.S. growth charts published by the Centers for Disease Control (13). We computed the percentile from the formula and data tables used to produce these charts (14). This method produced exact percentiles by eliminating the need for visual interpolation from the printed charts. Each parents perceived percentile was compared with the childs actual percentile based on the objective height and weight data. In the example given above, if the objective data placed the child at the 78th percentile, we concluded that the parent had underestimated the childs weight by 28 percentile points. While parents were not explicitly instructed to interpret the visual analog scale in terms of percentiles, this comparison provided a reasonable assessment of the direction and approximate magnitude of the difference between perceived and actual BMI. 2 or Kruskal-Wallis nonparametric ANOVA tests, as appropriate, were used to compare responses of parents whose children fell into each of the five percentile ranges. These tests assessed whether parents whose children fell into different weight categories differed in their concerns about excess weight relative to other health risks, their knowledge of healthy eating patterns, and the
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accuracy of their perceptions of their childs weight. When analyzing the data on parents levels of concern about various health risks including excess weight in childhood, responses were collapsed into two categories (not at all or a little concerned vs. quite or extremely concerned) to increase statistical power to detect differences. We also analyzed parents attitudes toward excess weight and other health risks as a function of their perceptions of their childs weight. We did this by using t tests to compare the mean perceived percentiles (marks on the visual analog scale) between the two collapsed response categories for each of the potential health risks. A significance level of 0.05 was used for all comparisons.

Results
Eighty-three of the 91 parents who were invited to fill out the questionnaire completed it (91%). Forty of the 83 children were boys (48%), 43 were girls (52%), and the mean age was 5.8 1.4 years. Nineteen children (23%) had a BMI at or above the 95th percentile for age and sex (Table 1). Attitude Toward Excess Weight in Childhood Figure 2 summarizes the questionnaire data concerning parental attitudes toward excess weight in childhood and other conditions they might perceive as health risks. Parents level of concern about excess weight was similar to their level of concern about a history of many sunburns or prolonged television watching78% of parents would be quite or extremely concerned about excess weight vs. 76% about sunburns and 67% about too much television. Parents were more concerned about weight than about reluctance to read aloud at school (56% would be quite or extremely concerned), the presence of another child at school who had AIDS (34%), or late toilet training (36%). They were less concerned about weight than about passive tobacco smoke in the household (83% would be quite or extremely concerned). The above attitudes did not differ significantly between parents of overweight chil-

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Figure 2: Parental attitudes about excess weight and other conditions they might perceive as health risks to a child.

dren and other parents, nor was there any relationship between these attitudes and parents perceptions of their childs weight. Knowledge of Healthy Eating Patterns Responses to the questions concerning juice consumption and fast food meals suggest that most parents had basic knowledge of healthy eating patterns with respect to these two issues. Two-thirds of respondents indicated that children should drink no more than two juice boxes (16 oz) per day, and virtually all respondents recommended limiting fast-food meals to once a week or less (Table 2). Responses did not differ significantly between parents of overweight children and other parents. Perception of Childs Weight We considered a parents perception to be accurate if the mark on the visual analog scale differed from the actual BMI percentile by 30 points. By that definition, 48% of parents (40/83) accurately perceived their childs weight. Accuracy varied widely across percentile ranges; parents of overweight children exhibited the lowest accuracy (Figure 3). Parents whose children fell into the 25, 25 to 49, 50 to 74, 75 to 94, and 95 percentile ranges exhibited accuracy rates of 60.0%, 100.0%, 72.2%, 17.4%, and 10.5%, respectively (p 0.001). The median differences between perceived and actual percentiles were 29, 5, 21.5, 38, and 45, respectively (p 0.0001). As indicated in Figure 3, all parents of children in the two highest percentile ranges (75 to 94 and 95) underestimated their childrens weight.

typically continue to have a weight problem through adulthood (16), when they risk the well-known comorbidities of adult obesity (17). Parents can help prevent obesity in their own children only if they feel motivated (because they appreciate the health risks of obesity), know what to do

Table 2. Responses to multiple-choice questions assessing

parental awareness of healthy eating habits grouped according to whether the parents child was overweight ( 95th percentile)* Percentile <95th (N 64) Juice boxes per day 1 to 2 3 to 4 5 to 6 7 to 8 Not answered Fast food meals Once a month Once a week Three times a week Five times a week Not answered 64% 31% 2% 0% 3% 33% 63% 0% 0% 5% >95th (N 19) 79% 21% 0% 0% 0% 47% 47% 5% 0% 0%

Discussion
Obese children face an increased risk of cardiovascular disease, type I diabetes, asthma, and sleep apnea (15). They

* None of the differences between the two groups ( 95th vs. 95th percentile) were statistically significant. 1 juice box 8 oz.

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Figure 3: Difference between parental perceptions of their childrens weight and actual BMI percentiles. *Based on growth chart (13).

(because they understand healthy eating and exercise habits), and comprehend that their child is at risk (because they recognize obesity when they see it). This study demonstrated that parents, in general, do appreciate the health risks of childhood obesity, as evidenced by the manner in which respondents ranked these risks relative to other possible health risks. They thought that an overweight child faces health risks about as serious as the risk of excessive sun exposure and more serious than the risk of casual contact
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with a person infected with the AIDS virus. The study also suggests that most parents have a basic understanding of healthy eating habits, at least with respect to the importance of avoiding excessive sugar (from too much juice) and fat (from too much fast food). In contrast, only one-half of surveyed parents accurately judged their childs weight (within 30 percentile points). The significance of these findings becomes especially clear when one stratifies the results according to whether a

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parents own child was overweight. Whereas parents of overweight children did not differ from other parents in their responses to questions about excess weight as a health risk or questions about healthy eating patterns, parents of overweight children differed markedly in the accuracy of their judgment about their childs weight. Only 10.5% of parents in the former group (2/19) perceived their childs weight accurately compared with 59.4% of parents in the latter group (38/64; Figure 3). Is it possible that parents inaccurate estimates may have arisen, in part, from difficulty interpreting the visual analog scale that would have led to confusion about how to place a mark at a logical position? To give parents the benefit of the doubt, we allowed a wide margin of error in our definition of accurate. If, for example, a childs weight fell at the 97th percentile based on objective measurements, we accepted the parents estimate as accurate if the mark fell anywhere in the right-most third of the line (i.e., above the 67th percentile). It seems unlikely that a parent having a realistic perception of a childs weight would miss a target of that size. Our study surveyed parents at a single faculty practice. We do not know the extent to which our survey would yield similar results in other practices, but a few previous investigations involving various socioeconomic groups have examined parental perceptions of their childrens weight, and our findings are quite consistent with this previous research. One study of preschool children and their low-income mothers found that only one in five parents of obese children recognized that their children were overweight (5). Other studies have examined the effect of cultural norms on parental perceptions (18,19). A study of predominantly Hispanic parents of obese children between the ages of 2 and 5 revealed that 36% of parents did not perceive their obese child as overweight (19). While our study demonstrated that parents of overweight children systematically underestimate their childrens weight, the study did not assess the reasons for the misperceptions. It is possible that parents do, indeed, recognize obesity in general but hesitate to label their own children as overweight or obese at a young age, even in an anonymous survey. In that case, they may consciously or unconsciously underestimate their childs weight. We tried to minimize this effect by administering a general health and safety questionnaire that included but did not focus exclusively on weight as a health issue. We hoped that this approach would produce more genuine, less guarded responses by reducing parental anxiety about a potentially sensitive topic. However, it is difficult to know how well this effort succeeded. Even parents who realize that they have an obese child and recognize this condition as a health risk may not know that obese children are more likely to become obese adults.

In that case, they might perceive their childs excess weight to be a temporary problem, one that their child will outgrow. Parents need to be involved in obesity prevention programs. For such programs to be successful, however, pediatricians and other health care professionals must facilitate parental awareness of obesity. The physician might, for example, show and explain the growth chart to the parent during the visit. The parent could then see not only the patients current weight but also the weights of past years and compare those with demographic norms. If indicated, the physician could also take this opportunity to recommend weight checks more frequently than once a year. Recognition and acknowledgment are a critical first step, but effective treatment requires behavioral modification involving diet and physical activity. Achieving these goals will depend on ongoing support and reinforcement from health care professionals and families, as well as school and community policies that support healthier lifestyles. These measures, along with efforts to help parents recognize obesity, will help control this growing epidemic among our children.

Acknowledgments
This study was funded, in part, by Award 1D12HP00022 from the Health Resources and Services Administration.
References 1. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. 1998;101:518 25. 2. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999 2000. JAMA. 2002;288:1728 32. 3. Hill JA, Trowbridge F. Childhood obesity: future directions and research priorities. Pediatrics. 1998;101:570 4. 4. Kiess W, Reich A, Muller G, et al. Clinical aspects of obesity in childhood and adolescence diagnosis, treatment and prevention. Int J Obes Relat Metab Disord. 2001;25:S75S0. 5. Baughcum AE, Chamberlin LA, Deeks CM, Powers SW, Whitaker RC. Maternal perceptions of overweight preschool children. Pediatrics. 2000;106:1380 6. 6. Jain A, Sherman SN, Chamberlin LA, Carter Y, Powers SW, Whitaker RC. Why dont low-income mothers worry about their preschoolers being overweight? Pediatrics. 2001; 107:1138 46. 7. Dietz WH, Gortmaker SL. Preventing obesity in children and adolescents. Annu Rev Public Health. 2001;22:33753. 8. Golan M, Weizman A, Apter A, Fainaru M. Parents as the exclusive agents of change in the treatment of childhood obesity. Am J Clin Nutr. 1998;67:1130 5. 9. McDowell I, Newell C. Measuring Health: A Guide to Rating Scales and Questionnaires. New York: Oxford University Press; 1996. 10. Huskisson EC. Measurement of pain. Lancet. 1974;2:1127 31. OBESITY RESEARCH Vol. 11 No. 11 November 2003 1367

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11. Guyatt GH, Townsend M, Berman LB, Keller JL. A comparison of Likert and visual analogue scales for measuring change in function. J Chronic Dis. 1987;40:1129 33. 12. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med. 1988;18:100719. 13. Centers for Disease Control and Prevention. 2000 CDC Growth Charts: United States. Available online at http:// www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical _charts.htm (Accessed July 2002). 14. Centers for Disease Control and Prevention. 2000 CDC Growth Charts: United States. Percentile Data Files with LMS Values. Available online at http://www.cdc.gov/nchs/about/ major/nhanes/growthcharts/datafiles.htm (Accessed July 2002).

15. Wang G, Dietz WH. Economic burden of obesity in youths aged 6 to 17 years: 1979 1999. Pediatrics. 2002;109:1 6. 16. Laessle RG, Uhl H, Lindel B, Muller A. Parental influences on laboratory eating behavior in obese and non-obese children. Int J Obes Relat Metab Disord. 2001;25:S60 S2. 17. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. 1999;282:15239. 18. Young-Hyman D, Herman LJ, Scott DL, Schlundt DG. Care giver perception of childrens obesity-related health risks: a study of African American families. Obes Res. 2000; 8:241 8. 19. Myers S, Vargas Z. Parental perceptions of the preschool obese child. Pediatr Nurs. 2000;26:2330.

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