Parents' Underestimations of Child Weight: Implications for Obesity Prevention
Introduction
Approximately 1 in 5 children in the United States are obese, a trend that has remained steady over the last 10 years (Ogden et al., 2016). Given the increasing incidence of type 2 diabetes in children (Lipman et al., 2013) and the increased risk of hypertension, heart disease, arthritis, sleep apnea and premature death in adulthood associated with obesity (Hirko et al., 2015, Karnik and Kanekar, 2015), obesity prevention remains a public health challenge for nurses. Although national childhood obesity rates have somewhat leveled off, progress is frustratingly slow (Segal, Rayburn, & Martin, 2016). One reason for this delay may be that parents lack awareness of their child's overweight or obesity status. Previous studies have documented that over 60% of parents underestimated their child's weight status (Lundahl et al., 2014, Rietmeijer-Mentink et al., 2013, Tompkins et al., 2015), a trend that appears to be increasing over time (Foster and Hale, 2015, Parry et al., 2008). Because parental engagement is central to effective interventions around weight management, parents' underestimation of their child's weight may be a barrier. When parents fail to recognize their child as overweight, they are less likely to participate in healthy lifestyle behaviors with their children (Lundahl et al., 2014).
The contextual factors that influence why parents underestimate the weight of their overweight or obese children are not well known (Foster & Hale, 2015). Recent studies have reported varied results for how social determinants of health including parental race, ethnicity, income, education, and child age and gender predict parents' underestimation of child weight status. Some studies reported significant associations between race, income (Black et al., 2015), and education (Towns & D'auria, 2009) and parent underestimation of child weight, while others did not find such associations (Doolen et al., 2009, Eckstein et al., 2006, Lundahl et al., 2014, Towns and D'auria, 2009, Warschburger and Kroller, 2009). Evidence on the relationship between child age and parent underestimation of child weight status is also mixed. Some have reported that parents were more likely to underestimate weight status when the child was younger (Lundahl et al., 2014, Rietmeijer-Mentink et al., 2013), while others reported more underestimation of weight status in older children (Black et al., 2015). Parents were more likely to underestimate overweight status in their boys, incorrectly classifying them as underweight or normal weight (Black et al., 2015, Lundahl et al., 2014, Towns and D'auria, 2009).
In one study, Garrett-Wright (2011) added parent health literacy as a predictor variable, finding that lower parent health literacy was significantly associated with parent's inaccurate estimation of child weight status. This first study to include health literacy was conducted using a sample of parents with preschool age children. Further exploration of how health literacy and other social determinants of health affect parent perception of child weight status in older, school age children extend upon the findings of this earlier study. Because parents presumably have influence over the healthy lifestyle behaviors for their family, the school-age years may present a critical time to target weight reduction or overweight/obesity prevention efforts.
The purpose of this study was to examine how health literacy and other social determinants of health predicted parents' underestimation of child weight status. Influenced by the ecological model proposed by Bronfenbrenner (1986), we hypothesized that parent factors (race, ethnicity, income, education, and health literacy) interacting with child factors (age, gender, and weight status) may influence parent underestimation of child weight status. A model of parent underestimation of child weight status was presented with both parent and child factors as predictor variables (Fig. 1).
Section snippets
Sample
A convenience sample of children and their parent/guardian were recruited from a local children's museum of science and history. Inclusion criteria were children 7–13 years old and their parent/guardian who spoke sufficient English to participate in research activities. Exclusion criteria included children or parents who were not cognitively or physically able to participate in the research activities. The research team recruited participating children and parents on Tuesday evenings and
Data Analysis
Descriptive statistics included the frequency and percentages for categorical variables and means (SD) for continuous variables. Because the dataset is assumed to have a two-level data structure: Level 1 (child) and Level 2 (parent) and parents have different number of children, a mixed-effects linear model was conducted using random effects modeling. Random effects modeling examined the association between selected predictor variables (parent race, ethnicity, income, education, and health
Results
Participants included 160 parents and 213 children; 53 parents had more than one child participate in the study. Because almost all parents underestimated child weight, the one parent who overestimated their child's weight was removed from the sample. Parents' mean age was 39 years, and they were 28.7% non-White and 32.5% Hispanic. Over half of parents were college educated or higher, and almost half reported annual incomes over $70,000 (see Table 1). More Hispanic parents were assessed with
Discussion
The focus of this study was to explore the potential factors that may contribute to this trend of parent underestimation of their children's weight status. Our results support the trend reported in the literature that increasing numbers of parents underestimate the weight of their children, failing to recognize child overweight and obesity (Tompkins et al., 2015). The primary findings from our study suggest higher percentages of parents underestimated the weight status of their overweight and
Nursing Practice and Research Implications
Nurses should be aware that many parents underestimate the weight status of their children, and the findings from this study indicate consistent underestimation of overweight children in particular. Whether parents respond to public health messaging by engaging their children in healthy behaviors such as increasing consumption of nutrient-dense foods and physical activity may be a function of how they perceive their child's weight status. Campaigns such as MyPlate and Let's Move! may not
Funding
This work was supported by the Alma and Robert D. Moreton Research Award. The funding source had no involvement in the study design, data collection, analysis, or interpretation or in the writing of this manuscript or in the decision to submit the article to JPN for publication consideration.
Acknowledgements
Thank you to Debbie Cockerham, the Managing Director, Research and Learning Center Fort Worth Museum of Science and History for her support of our research at the museum site; to the nursing, nutrition, and psychology undergraduate students who helped with data collection, entry, and editorial assistance; and to the children and parents for their time and energy to participate in this study.
References (25)
Parental perception of preschool child body weight
Journal of Pediatric Nursing
(2011)- et al.
Parental perceptions of their child's overweight: An integrative review of the literature
Journal of Pediatric Nursing
(2009) - et al.
Child obesity cut-offs as derived from parental perceptions: Cross-sectional questionnaire
The British Journal of General Practice
(2015) Ecology of the family as a context for human development: Research perspectives
Developmental Psychology
(1986)About child and teen BMI
(2015)- et al.
Parental disconnect between perceived and actual weight status of children: A metasynthesis of the current research
Journal of the American Academy of Nurse Practitioners
(2009) - et al.
Using the “Newest vital sign” to assess health literacy in children
Journal of Pediatric Health Care
(2013) - et al.
Parents' perceptions of their child's weight and health
Pediatrics
(2006) - et al.
Perceptions of weight and health practices in Hispanic children: A mixed-methods study
International Journal of Pediatrics
(2015) - et al.
Body mass index in young adulthood, obesity trajectory, and premature mortality
American Journal of Epidemiology
(2015)