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S. Regber1, M. Novak2, G. Eiben3, K. Bammann4,5, S. De Henauw6, J. M. Fernández-Alvira7, W. Gwozdz8, Y. Kourides9, L. A. Moreno7, D. Molnár10, I. Pigeot11, L. Reisch8, P. Russo12, T. Veidebaum13, I. Borup1 and S. Mårild14
1 Nordic School of Public Health NHV, Gothenburg, Sweden; 2Department of Emergency and Cardiovascular Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 3Department of Public Health and Community Medicine, Public Health Epidemiology Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 4Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany; 5BIPS-Institute for Epidemiology and Prevention Research, Bremen, Germany; 6Department of Movement and Sport Sciences, Ghent University, Ghent, Belgium; 7GENUD (Growth Exercise, Nutrition and Development) Research Group, University School of Health Sciences (EUCS), University of Zaragoza, Zaragoza, Spain; 8Department of Intercultural Communication & Management, Copenhagen Business School, Frederiksberg, Denmark; 9Research & Education Institute of Child Health/Strovolos, Cyprus; 10Department of Pediatrics, University of Pécs, Pécs, Hungary; 11Department of Biometry and Data Management, BIPS-Institute for Epidemiology and Prevention Research, Faculty 03 Mathematics and Computer Science, University of Bremen, Bremen, Germany; 12Epidemiology & Population Genetics, Institute of Food Sciences, CNR, Avellino, Italy; 13National Institute for Health Development, Tallinn, Estonia; 14Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Received 16 March 2012; revised 19 June 2012; accepted 17 July 2012
What is already known about this subject
• Parents of children with overweight and obesity tend to underestimate their children’s weight. • Most studies show no association between parental education level and accurate parental perception of a child’s weight category. • Studies show no consistent relationship between parental weight perception and the child’s gender.
What this study adds
• Parental underestimation of children’s weight category for children in the overweight and obesity categories was found across eight European countries. • Regional diﬀerences indicated a more accurate parental weight perception in Northern and Central Europe. • A high proportion of parents in Southern Europe were concerned about future underweight or overweight in their children.
Objectives: To evaluate parental perceptions of and concern about child's body weight and general health in children in a European cohort. Design: Cross-sectional multi-centre study in eight European countries. Participants: 16 220 children, ages 2–9 years. Methods: Parents completed a questionnaire regarding children's health and weight and concern about
overweight and underweight. Objective children's weight categories from the International Obesity Task Force were used. Logistic regression models were utilized to identify predictors of accurate weight perception.
Results: Parental weight perception corresponded overall to children's mean body mass index (BMI) z-scores, with important exceptions. About one-third of the total indicated concern about underweight, paradoxically most often parents of children in the overweight or obesity categories. In 63%, parents of
Address for correspondence: Mrs S Regber, Nordic School of Public Health NHV, PO Box 12 133, SE-402 42 Gothenburg, Sweden. E-mail: firstname.lastname@example.org © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity. Pediatric Obesity ••, ••–••
Parental perceptions of and concerns about child's body weight in eight European countries – the IDEFICS study
A total of 31 543 subjects were informed and invited to take part in the study. Few studies have linked parental weight and health perceptions and weight concern with children's measured anthropometric data in large cohorts from different cultural settings. parents of pre-school children reported worsened overall health only when children's body mass index (BMI) exceeded the 99th percentile (7). Ethical approval was given by research ethics committees at each centre in the eight participating countries.4 (95% CI 2. impaired glucose tolerance. hypertension and liver disorders are likely to increase in parallel with increasing childhood obesity (3). Conclusion: Parents of children categorized as being overweight or obese systematically underestimated weight. 2–9 years old. weight perception. weight concern.and lifestyle-induced health effects in children and infants (IDEFICS) study. among these. obesity. as a largely preventable health threat. This attitude may be related to the fact that parents usually fail to recognize the presence of overweight and obesity in their children (8). Recruitment was made through schools and kindergartens. (ii) analyze parental weight perception by country in children categorized as underweight. e.7). (iii) identify predictors for accurate parental weight perception in children with underweight. Keywords: Cohort of European children. a total of 43 million children under the age of five were overweight. where parents were asked for informed consent.g. Compared to Southern Europe. The baseline survey was conducted between September 2007 and June 2008 in eight IDEFICS study centres in Belgium. Estonia. ORIGINALRESEARCH children in the overweight category marked ‘proper weight’. Pediatric Obesity ••.2. Methods Participants This analysis is based on the Identification and prevention of dietary. overweight or obesity and (iv) evaluate total and country-specific parental concern about overweight and underweight in a cohort of European children stratified by measured BMI categories. who participated (51% response rate). mainly because of environmental and societal changes leading to an imbalance between energy intake and expenditure (1). parent. Germany. Introduction The World Health Organization (WHO) estimated that in 2010. Hungary. overweight or obese. and the perception of the severity of an illness is essential to carry out lifestyle changes. Regber et al.. Measurement for weight and height and parental questionnaire completion were required to be valid for inclusion in the data analysis. The aims of this study were to (i) describe parental perceptions of weight and health in a large cohort of European children with measured BMI. Italy. Spain and Sweden.2) in Central Europe. ORs for accurate parental weight perception were 4. has high priority (2). The two main aims of the IDEFICS study are to (i) study health in children in relation to lifestyle and biological traits to understand factors triggering overweight and obesity risk and (ii) develop and evaluate a primary prevention program to tackle childhood obesity and related comorbidities.2 | S. The WHO states that childhood obesity is one of its most serious challenges for the 21st century and. A detail description of the IDEFICS survey has been published elsewhere (9). parents seldom see obesity as a health problem. Parents differed regionally regarding accurate weight perception and concern about overweight and underweight.1–8. Parents have a crucial impact on the family's lifestyle and can act as key players in preventing childhood obesity (5). the most severe acute consequence is the psychosocial discrimination or social isolation (4). For the child.4 (95% CI 3. and 16 220 children met these requirements. central and local training sessions were held with field staff (10). However. A necessary consequence of prevention is health-related action (6). normal weight. 95% confidence interval [CI] 6.7–4. The highest response rate was in Sweden (66%). The strongest predictor for accurate parental weight perception for children with overweight and obesity was BMI z-score (odds ratio [OR] = 7. In addition. ••–•• . Serious obesity-related morbidities such as type 2 diabetes. Europe © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity.3–6. Weight was measured on an electronic scale (TANITA BC 420 SMA.0) in Northern Europe and 3. and the lowest response rate was in Spain (41%) (9). there were 16 224 children. Cyprus. Anthropometric data A manual for standard operating procedures was used at all IDEFICS centres to standardize procedures.
multivariable-adjusted logistic regressions (using a forward stepwise method) were performed to identify the independent predictors of accurate weight perception. All P-values are two sided.. normal weight. overweight or obesity categories. Logistic regression models were used to identify independent predictors of accurate parental weight perception about children in the overweight and obesity categories. Northern Europe was represented by Estonia and Sweden. Germany) with the children in light clothing. We omitted ‘fair’.05 were considered statistically significant. covering a broad range of variables such as behavioural factors. parent concern that a child will become overweight and European geographic region. GmbH & KG. ‘good’. the category ‘very bad’ was used in <1% in all countries). For comparing responses by country. Parent responses regarding concern about a child's becoming overweight or underweight were obtained from a four-point Likert scale of responses to the question: ‘How concerned are you about your child becoming overweight/underweight?’ The response options were ‘unconcerned’. Chicago. attitudes and values. The International Obesity Task Force (IOTF) BMI (Kg/m²) cut-offs were used to obtain the measured BMI categories of thinness I–III. ‘a little concerned’.. Central Europe by Hungary. Potential predictors for accurate weight perception included BMI z-score. Parental descriptions of children's general health were derived from a five-point Likert scale with the response options ‘very good’. these two categories were maintained. For purposes of this study. To investigate parental weight perceptions by country for children in the underweight. To test differences between countries. The questionnaire was translated from English into each of the eight languages and then back-translated (16). dietary and sedentary habits and parental perceptions. and values <0. ‘bad’ and ‘very bad’. Parental perception was considered accurate if (i) parents of children with thinness grades III and II or obesity responded ‘much too underweight/overweight’. Secondly. ••–•• ORIGINALRESEARCH GmbH. Hamburg. The non-parametric Spearman's rank correlation coefficient was used to assess the relationship between children's measured BMI and parental weight perception. Descriptive statistics were used to analyze the data from the parental questionnaire. univariate regression (unadjusted) analyses were carried out to identify the potential predictors of accurate weight perception. Height was measured barefoot.e. USA). Descriptive statistics are presented as percentages or mean values with standard deviations. Italy and Spain. ‘slightly too underweight’. Firstly. ‘fair’. ‘concerned’ or ‘very concerned’. IL. overweight and obesity (11.Parents' perception of their child's weight | 3 Parental questionnaire Parents answered a self-administrated questionnaire consisting of 70 questions. we combined ‘good’ and ‘very good health’ into one category. underweight/overweight’ were rarely used. ‘bad’ and ‘very bad health’ because they were rarely used (range 2% in Sweden to 16% in Estonia. normal weight. Pediatric Obesity ••. However. for exploring whether parents of children in the overweight and obesity categories discriminated between ‘slightly too overweight’ or ‘much too overweight’. the options ‘concerned’ and ‘very concerned’ were combined. only underwear. i. In presenting the results. education. Classification of parent educational level was made according to the International Standard Classification of Education (ISCED) (17). i. (13–15). age. Parental perception of children's weight categories was examined using a five-point Likert scale with the following options: ‘much too underweight’. ‘proper weight’.0 (SPSS Inc.e. The BMI z-score was calculated according to Cole et al. Our preliminary analyses showed differences between countries in parental response patterns regarding perceptions and concerns that largely followed a geographical gradient. medium (3 and 4) and high (5 and higher). Germany and Belgium and Southern Europe by Cyprus. gender. Therefore. the ISCED levels were combined into three levels of education: low (0–2). T-shirts and socks. ‘good health’. The responses ‘much and slightly too underweight’ were combined into the category ‘underweight’ and ‘much and slightly too overweight’ into ‘overweight’ as preliminary analyses indicated that the responses ‘much too Statistical analysis All statistical analyses were carried out using the Predictive Analytic Software. with a portable stadiometer (SECA 225. Germany). version 18. (ii) parents of children with thinness grade I or overweight responded ‘slightly too underweight/overweight’ or (iii) parents of children with normal weight responded ‘proper weight’. Sindelfingen. ‘slightly too overweight’ and ‘much too overweight’. we used chi-square tests for categorical variables and the Kruskal–Wallis test for continuous variables. Three separate regression analyses were carried out (i) all children in the © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity. .. some of the response options were recombined. the countries were studied separately as well as grouped according to their geographical region.12).
Remaining variables were significant in the adjusted model. 95% confidence interval [CI] 6. Likewise. 3a). Parental education was not significant.9% responded that their child had a ‘proper weight’. older age of the child. 70% for Italy and 77% for Spain compared to the proportions in Central and Northern Europe ranging between 51% in Hungary to 58% in Sweden (Fig. (87%. Parents of children in the obesity category also responded that their children had ‘proper weight’. The strongest association was seen for BMI z-score (OR = 7.6% responding ‘slightly too overweight’. with 69.6% in Estonia to 98.7).1– 8.7% of cases. Children in the normal weight category were perceived as ‘proper weight’ by their parents in a range from 72% in Spain to 88% in Sweden and Estonia or as ‘underweight’ in a range from 9% in Sweden to 28% in Spain (Fig. while only 2. Among parents of children in the normal weight category. Pediatric Obesity ••. In four countries. ORIGINALRESEARCH overweight and obesity categories. The response numbers and proportions on the study questions were as follows: weight perception. For children in the overweight category. 80. © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity. Predictors for accurate parental weight perception of children in different weight categories Results from unadjusted logistic regression models in the first analysis of overweight and obesity indicated that higher BMI z-score. Across weight categories in the total cohort.3% of instances. while gender. general health perception. Regber et al.2% answered ‘slightly or much too overweight’ (Table 2). 3b).2.3% in Sweden (Table 1). respectively (n = 15 537. with the lowest rate of 5% in Germany to 32% in Spain. Note that ‘good health’ when compared across weight categories and by country ranged from 73% in Italy to 99% in Sweden. The study centres in Italy. The response option ‘much too overweight’ was used by only 5% of parents in Spain to 21% in Belgium (Fig. 16. n = 14 499 (89%. Responses ‘much too underweight’ and ‘much too overweight’ were rarely used in children with thinness grades II and III or obesity. The values were 90%. n = 14 559 (90%. respectively (Table 2). n = 15 528 (96%. Children in the underweight category were perceived as ‘proper weight’ by their parents in a range from 60% in Estonia to 16% in Spain (Fig. Education level showed a large variation among parents across the countries (Table 1).9% answered ‘slightly or much too underweight’. 93%. range 87% Cyprus to 99% Italy). parents responded ‘underweight’ when their children fell into the obesity category. Instead. 92% and 88% for children in the thinness. The distribution by gender was even within all countries and for children of pre-school and primary school age. with Cyprus having the highest proportion of parents perceiving their child in this category as being underweight (14%). 2).4 | S. The proportions of parents perceiving ‘proper weight’ in Southern Europe were 70% for Cyprus. range 56% Cyprus to 97% Sweden) and underweight. The main parent respondent was female n = 13 452. children in the thinness grade I or overweight categories were assessed as ‘slightly too underweight/overweight’ only in 45% and 33. in a range from 83. range 87% Cyprus to 99% Italy). range 56% Cyprus to 97% Sweden). being a girl. (ii) children in the obesity category only and (iii) children in the underweight category only. Results Study population characteristics The total study population consisted of 16 220 children. respectively. age and parental concern about a child's becoming overweight. Spain and Cyprus had the highest proportion of children in the overweight and obesity categories. parental concern about future overweight and parents being from Central or Northern Europe were significantly associated with accurate weight perception (Table 3). Results obtained from regression analyses are presented as odds ratios (ORs). A vast majority of parents across the countries considered their child's general health to be ‘good’. Parental perceptions about weight and health in the total sample and by country Parental weight perceptions about children showed a trend corresponding to children's mean BMI z-score (Fig. the geographical variation was more obvious. 3c). data not shown). 3d). 1). In the adjusted model. normal weight. overweight and obesity categories. while ‘proper weight’ was chosen in 49% and 63. an accurate perception had a significant positive association with BMI z-score. while the lowest was seen in Belgium and Sweden. the perception ‘good health’ showed little difference. concern about a child's becoming overweight. education and European regions were not significant. range 80% Cyprus and Germany to 95% Hungary). n = 15 537 (96%. ••–•• . in both cases for children in the underweight category (Fig. The second analysis was limited to parents of children with obesity and the perception ‘much too overweight’ as the dependent variable considered as an ‘accurate perception’. ‘slightly too’ was used in children with obesity.
2) 144 (0.3 1039 1527 2065 1051 6.8) (78.5) (1.9) (51.17) (2.5) (1.7) 60 (2.15 92 237 1531 205 1793 (20.7) (69.9) (12.36) (6.1) (11.3) (1.8) 1096 (50.3) (2.7) 10 (0. + very conc.7) (51.0) (7.02 36 160 1413 200 1722 (51.5) (65.5) (1.5) 1081 592 39 -0.7) 303 (12.2) 613 (25.23) (4.7) 9 (0.1) (34. II and III * Health perception (good + very good)† Weight perception (slightly + much too overweight)† Weight perception (much too overweight)† Weight perception (slightly + much too underweight) Concerned becoming overweight (conc.8) (1.6) (54.3) 392 (26.7) 4 (0.8) (72.1) (1.6) 1632 (75.7) (91.7 1043 883 1719 850 5.5) (50.2) 762 (31.0) (10.9) 2810 (18.3) (70.1) (98.3) 127 (7.3) (83.817).4) (74.4) (57.5) (11.1) 228 (14.4) (52.6) 691 407 129 0.1) 343 (16.9) (37.5) 301 (16.8) (47.9 859 860 1809 934 5.2) 214 (11.4) (76.3) 25 (1.4) (1.5) (54.7) 216 (13.7) 147 (7.05 149 288 1726 403 2282 (44.6) 777 (54.5) (1.8) (49.4) (2.41) (5. Pediatric Obesity ••.6) (14.9) 677 (50.0) (50.4) 1018 1199 57 0. P < 0.5) 47 (2.3) (7.4) (22.6) 114 (7.7) (2.1) (9.3) (33. IOTF.37 88 223 1085 111 1427 (56.5) (53.8) (52.9) (49.6) (87.05 437 507 1202 103 1951 (19.6) (2.5) (10.7) 506 (22.1) (1.5) 404 1277 434 1.8) (40.6) 687 (50.0 7378 8842 (50.1 974 1275 1507 773 5.9) (59.5) (74.24) (5.2) (67.45) (19.6) 145 (8.8) (45.9) 216 1257 22 0.5) 408 (20.7 918 891 1175 474 19 -0. 5 ORIGINALRESEARCH .7) (49.0) (50.8) (1. Values are numbers (%) unless stated otherwise All countries Cyprus Italy Spain Hungary Germany Belgium Estonia Southern Europe Central Europe Northern Europe Sweden 16 220 8261 6.0) 567 (22.5) 2379 1226 6.)† 4596 (31. body mass index.45) (8.0) Parents' perception of their child's weight 39 (2.5) 1078 671 50 0.9) (92. standard deviation.2) 12 (0. total by country Boys Age (year).8) (1.9) (14.9) (91.5) (1.4) 514 (27.3) (6.4) (40.2) (10.4) (20. mean (SD) Obesity* Overweight* Normal weight* Thinness grades I. mean (SD) Pre-school age 2 to < 6 years Primary school age 6 to < 10 years Parental education – High Medium Low BMI z-score.2) 813 (56.4) (84.16) (2.1) (96.1) (59.4) 4335 (29.8) (1.1 954 1425 2249 1164 6.1) (60.5) (11.6) (2.1) 10 (0.25 1126 2061 11 270 1763 14 345 1790 (11. + very conc.2) (45.2 876 1189 1926 978 5.1) 226 (11.2) | © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity.0) (8.3) (56. using chi square for categorical variables and Kruskal–Wallis test for continuous variables.6) (19.Table 1 Characteristics of the population by country.8) 203 (12.9) (1.3) 222 (10.8) (42.3) (1.)† Concerned becoming underweight (conc.4) (1. ••–•• *BMI categories by IOTF.6) (50.3) (11.8) (43.6) (50.3) (15.4) (28.1) 370 (20.2) 370 1054 343 0.1) (1.7) (94.17 44 123 1476 283 1780 (63.36 211 345 1559 264 2003 (59. International Obesity Task Force.6) 364 (16.07 69 178 1278 194 1387 (51. BMI.001 for differences between countries for all variables except for sex (P = 0.5) (42.4) (96.8 715 792 2566 1285 6. † Values are numbers (%) for parents responding. SD.8) 259 (13.8) 6033 6931 1093 0.22) (4.5) (59.9) (1.8) (11.4) (4.6) 219 (12.8) (14.7) Participants.0) (14.5) 14 (0.0) (50.
8) (0.0) (80.6 | S.0) (16.564.1) (0.01 (two tailed). ORIGINALRESEARCH Figure 1 Distribution of body mass index (BMI) z-scores in subgroups that correspond to parental perception of children's weight categories.4) (51.7) (30. rs = 0. International Obesity Task Force.6) 0 0 1 6 10 127 144 (0.0) (0. Figure 2 Parental perception of good health* in their children by weight categories according to International Obesity Task Force (underweight = thinness grades I.3) (15. © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity. *Spearman's correlation coefficient.1) (0.1) (33.5) 20 121 621 1742 48 29 2581 (27. n = 15 537. Pediatric Obesity ••.7) (0. Values are numbers (%) of parents responding Weight categories according to IOTF Parental perception of child's body weight.2) (18. All eight countries combined.7) (16.6) (10. n = 15 528. IOTF.548.6) 37 72 676 8735 1245 163 10 928 (50. ••–•• .6) (0.1) (2.1) (0.0) (0.1) (45. All eight countries combined (n = 15 528).7) (69. II and III).4) (49.0) (0.8) (0.3) (2.9) 73 237 1379 10 799 1968 1072 15 528 (100) (100) (100) (100) (100) (100) (100) Spearman's correlation coefficient.2) (70. n (%) Much too underweight Slightly too underweight Proper weight Slightly too overweight Much too overweight Total Thinness grade III Thinness grade II Thinness grade I Normal weight Overweight Obese Total 14 44 77 86 1 7 229 (19.5) (11.4) (2. P-value < 0. rs = 0.7) (1. *Good health = good health + very good health.6) (5. Table 2 Summary of parental weight perception by children's actual weight categories according to IOTF.9) (63.001 (two tailed). Regber et al.4) 2 0 4 230 664 746 1646 (2. P Յ 0.
24.6). BMI z-score was not associated with accurate weight perception. ••–•• ORIGINALRESEARCH Figure 3 Parental perception about children's weight status by weight categories according to International Obesity Task Force in children in the (a) underweight (n = 1689). in addition.46–0. Parental accurate weight perception was significant for age (OR = 1. 95% CI 1.Parents' perception of their child's weight | 7 The BMI z-score was the strongest predictor (OR = 13. parents in Northern Europe were less likely to perceive their children's underweight compared with parents in Southern Europe (OR = 0.17– 1.62). Overweight in panel a + b is the sum of the perceptions 'slightly' and 'much too overweight'.16. 95% CI 2.12–3. © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity.65.77. 95% CI 0. (c) overweight (n = 1968) and (d) obesity (n = 1072) categories in eight countries. 95% CI 8.92). In the adjusted model. .0–21. The third analysis was limited to parents of children in the underweight category and the perception ‘slightly or much too underweight’ as the dependent variable and considered as an ‘accurate perception’. Pediatric Obesity ••.32) and concern for underweight (OR = 2. (b) normal weight (n =10 799).
34††† (1. central = Hungary.24††† (1.62) † © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity.08NS (0.18) 1.cat) Low Medium Europe‡ – South (ref.51††† (3.73) NA 2.73††† (1.77††† (2.19† (1. ‘concerned’ and ‘very concerned’.17–1. n = 1763 Unadjusted OR (95% CI) Multivariable adjusted OR (95% CI) Coefficients Multivariable adjusted OR (95% CI) Overweight and obese.26–1.55††† (0.77–7.00 1.82††† (2. Table 3 Multiple logistic regression analysis of predictors of parental accurate perception of children in the overweight and obesity categories (n = 3187). Europe divided into three geographical areas: north = Estonia and Sweden.68–1.88† (0.40) NA 1.83) 1.00 BMI z-score Age (scale 2. § Concern for overweight/underweight has been dichotomized = ‘unconcerned’ and ‘a little concerned’ = reference category vs.41) 12. n = 1126 Unadjusted OR (95% CI) Multivariable adjusted OR (95% CI) Underweight.34) 0.19–23. NS.25–3.95) 6.20–3.46NS (0.12–3. Italy and Spain.42) 1.00 1.96†† (1.77) NA 7. body mass index.68–2.34–1.65† (0.86NS (0.07–1.77–0.02–21.93–39. obesity category (n = 1126) and underweight category (n = 1763) (OR = odds ratio.001.98) 3.99NS (0.70–2.37) 1.37††† (2.97–2.42–0.31††† (2. n = 3187 Unadjusted OR (95% CI) 6. †††P < 0.08) 0.2†† (6.48) 1.28) 1.96NS (0. BMI.16††† (8.14††† (1.23–8.21††† (1. not applicable.25–4.92–1. The model predicts perception of ‘slightly too overweight’ or ‘much too overweight’ among children in the overweight or obesity categories.21) 1.16†† (2. Regber et al.22–1.42††† (1.69) 0.61††† (1.81NS (0.) Central North Concern for overweight§ Concern for underweight§ 7.76–1.cat.44††† (3.28NS (0.05.) Education – High (ref.11) 1. south = Cyprus. Pediatric Obesity ••.ORIGINALRESEARCH 8 | S.89–1.13NS (0.66) 1.56–1.92NS (0.64) 3. ††P < 0.70–4.33†† (1.92) NA 2. n.cat. not significant.36) 1.47) NA 0.81††† (3.30–5.06–8.99) 1. NA.00 1.9–1.59) 2.9) Gender (boys = ref. Germany and Belgium. ‡ .12NS (0.0–9.52) 0.32) 1.27) 0.99) 0.10) NA 1.21) 4. ••–•• P < 0.41††† (1.01.03–1.00 3. number of subjects.61–1.71–4.11NS (0.33–1.51) 1.21) 1.73–1. ‘much too overweight’ in the obesity category and ‘slightly too underweight’ or ‘much too underweight’ in the underweight category Obese.63–1.64) 0.04) 1.52) 1.14–1.00 13.44) 1.72††† (5.01††† (4.46–0.47–2. CI = confidence interval).
All eight countries combined. overweight. the proportion of parents who were unconcerned showed an opposite pattern. but Italy stood out with 75. Nevertheless. 4a). Parental concern about underweight showed no clear trends related to BMI categories. ••–•• ORIGINALRESEARCH Figure 4 (a) Parents concerned that their child will become overweight. The results showed that parents in general perceived their children in all weight categories as healthy and that parental perceptions about children's weight corresponded overall to objective IOTF weight categories. respectively (Fig. respectively. with about 50–54% in Southern Europe and below 32% in Northern and Central Europe. n = 14 559. normal weight and underweight categories. 23%. overweight and obesity. Parents responding as ‘very concerned’ about their children being overweight in the future increased by weight category from 10%. while the corresponding proportions in Northern Europe were 0% to 6%. All eight countries combined. 12%. We also studied parents who were concerned about underweight and overweight simultaneously (data not shown) and found that ‘very concerned’ and ‘concerned’ about a child's becoming overweight and underweight were present in 15% of the total cohort. II and III). Parents of children in the obesity and overweight categories in Southern Europe had these double concerns in a range from 25% to 39%. we investigated parental perceptions of and concerns about children's weight and health. n = 14 499. II and III). Pediatric Obesity ••. by weight categories according to International Obesity Task Force (IOTF) (underweight = thinness grades I. In contrast. Concern about a child's becoming underweight exhibited a similar regional pattern.2% of parents having this concern (Table 1). Parents of children in the overweight or obesity categories were very concerned about their children becoming underweight in 22% and 20% of cases compared to only 16% of parents of children who were in the thin categories (Fig.9% of parents. (b) Parents concerned that their child will become underweight. . 4b).Parents' perception of their child's weight | 9 a Unconcerned % 80 70 60 50 40 30 20 10 0 A little concerned Concerned Very concerned 76 62 38 38 23 8 7 10 Underweight 27 27 23 14 12 12 16 8 Overweight Obese Normal weight b Unconcerned % 80 70 60 50 40 30 20 10 0 A little concerned Concerned Very concerned 54 41 26 17 16 16 14 15 51 45 22 17 10 18 18 20 Underweight Normal weight Overweight Obese Parental concern about overweight or underweight in the total sample and by country Concern about their children becoming overweight in the future was seen in an average of 29. with values of 22%. we found a significant proportion of parents in all countries who perceived their children's weight differently than indicated by objec- © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity. normal weight. by weight categories according to IOTF (underweight = thinness grades I. 23% and 38% for children in the categories of underweight. Discussion In this study. 14% and 10% of parents whose children were in the obesity.
We might speculate that concern about underweight could contribute to overweight by triggering parents to exaggerate feeding of their children. Our results have implications for preventive interventions. i. which is in accordance with other studies (23. Another interpretation of the observed perceptions. Childhood obesity is also a social and psychological problem associated with stigmatization and individual responsibility (19). In the total study population. The reverse was seen in the underweight categories where parents from Spain and Italy perceived their children's underweight accurately.22. We found remarkable differences between Southern and Northern/Central Europe in parental weight concern about their child's becoming either overweight or underweight.10 | S. by the general wish of people to present themselves and their children at the best (6). For accurate weight perception. may be that the obtained responses were affected by a social desirability bias. exceeding the proportion seen for children in the thinness categories. also more often in Southern Europe.e. The proportion of parents perceiving normal weight children as underweight was highest in Italy and Spain.21. ••–•• . or perhaps a more intrusive ‘obesogenic environment’ (20) in some regions. Parents also often lack health awareness about overweight or obesity (21. parents being concerned about future overweight and parents living in Central or Northern Europe. The observation that girls are more likely than boys to be identified as overweight by the parents has also been noted in some other studies (21. Several factors may explain this tendency among parents of children with overweight or obesity to underestimate elevated weight deviation. Having both concerns may imply the presence of a more universal uneasiness. (27) in mothers of pre-school children classified as overweight. Pediatric Obesity ••. Regber et al. which also may influence responses. of which weight concerns may be just one part. This concern about underweight was remarkably frequent among parents with children in the obesity and overweight categories. established long before the ‘obesity epidemic’. a higher proportion of parents in Southern Europe perceived children in the overweight category as being of a ‘proper’ weight.25). Our findings regarding parental perceptions correspond to several other studies. age and concern about future overweight emerged as statistically significant. other determinants lose influence on the parental ability to have an accurate weight perception. The increasing prevalence of obesity among children and adults is likely to shift weight norms upwards (8. the proportion of parents concerned about a child's becoming underweight was not clearly weight related. In addition. The uneven regional distribution may be important to study. Therefore.18).22. One important aspect is to start at an early age (28. Because parents saw children in all weight categories as healthy.22) but not in all (23). we found that both these concerns appeared simultaneously in a significant proportion of parents.. In contrast. children of normal weight were categorized as being underweight (22. we found that the proportion of parents concerned about their child's becoming overweight in the future increased with increasing BMI. the measured BMI was the most important determinant for children with overweight and obesity. all procedures including measurements and questionnaires were standardized. being a girl. It should ORIGINALRESEARCH © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity. An accurate parental weight perception in children in the overweight and obesity categories was positively associated with higher BMI z-score. children with overweight or obesity were categorized as having proper weight (8. In other studies. tive measurements: children in the underweight category were classified as ‘proper weight’. We could not show that parent education affected weight perceptions about the children. only BMI z-score. children in the overweight category as ‘proper weight’ and children in the obesity category depicted as ‘slightly too overweight’ instead of ‘much too overweight’.29) and parental early recognition of children at risk of becoming obese is indispensable for parental readiness to make changes towards a healthy lifestyle (28). weight deviations may seem unimportant and shift perceptions about what would be considered normal. In some.24).26). Also. This fear about underweight in children with overweight has been noted earlier by Baughcum et al. Weight perception also differed between Southern and Northern/Central Europe among parents in all weight categories. To respond ‘much too overweight’ might therefore give parents a feeling of guilt and failure. which also holds for parents of children in the underweight categories. In IDEFICS. as it may be associated with a parallel gradient in the prevalence of overweight and obesity in the eight European study centres (9). The BMI cut-offs in the IOTF standard definitions of weight categories in children (11) are linked to the adult BMI cut-offs for adult weight categories. the geographic differences detected here are likely to be associated with cultural or societal differences. older age of the child. It seems to be reasonable that with increasing age and more obvious weight deviation.24). When we restricted our analysis of predictors to children in the obesity category and the parental perception of ‘much too overweight’. normal weight children were classified as ‘underweight’.
and manuscript writing. We are also grateful for support by grants from the Västra Götalandsregionen research funds and Forskningsrådet för arbetsliv och socialvetenskap (FAS) and from the Nordic School of Public Health NHV. The study had certain strengths and limitations: it included more than 16 000 children with a thorough and standardized health examination from eight centres in Europe. data analysis.30) but not by all (31). The parents need support from primary healthcare professionals. Therefore. 016181.. data analysis. anthropometric measures should always be taken before counselling parents on nutrition and lifestyle. data collection and manuscript writing. LR participated in study design. data interpretation and writing the manuscript. especially the parental questionnaire. TV Conclusion A significant proportion of parents in the total cohort either overestimated or underestimated their children's weight status when compared to their actual measured weight category. differences by country resulting from parental interpretation and (mis)understanding of specific questions cannot be ruled out. Parents have an important role here. GE performed data interpretation and manuscript writing. . PR contributed to data collection. but they have a limited capability on their own to act as gatekeepers for many reasons. where each centre included 1500– 2000 children. limiting the possibility of studying the influence of parental gender. Another important concept for prevention is the protection of children from the dangers of the ‘obesogenic’ environment (33). i. Monitoring children's measured BMI development and inform parents from an early age is a tool in a population-based prevention strategy of childhood obesity advocated by some researchers (18. SDH participated in study design and data collection. YK participated in data collection. literature search. social norms and media and marketing exposures (34). Because the response rate was about 51%. MN did data analysis. data interpretation and manuscript writing.idefics. and the local communities for their support. where all parents were invited. data analysis. The mere identification of obesity by nurses in school health care significantly improved 1-year BMI development compared to non-identified children with obesity (32). Technological Development and Demonstration (RTD) framework programme under contract no. it is also important to be aware that parents often do not estimate their child's weight status correctly. In the clinical setting. DM participated in study design and data collection. ••–•• ORIGINALRESEARCH future underweight in children in the overweight and obesity categories strengthens the argument that parents need support from healthcare professionals for objective information about their children's weight status. JMF-A performed data collection. data interpretation. generation of figures and tables and writing the manuscript.24. allowing for assessment of differences among countries and cultures. generation of figures and manuscript writing.Parents' perception of their child's weight | 11 also be noted that the proportion of parents concerned about underweight was highest in Southern Europe where the prevalence of overweight and obesity is highest. Although site visits were conducted for quality control and the field staff underwent central and local training sessions (16). data collection. We propose routine screening of children's height and weight to identify children with weight deviations and to help parents promote healthy habits in the family. We gratefully acknowledge the financial support of the European Community within the sixth Research. KB participated in study design. a selection bias may be present with an over-representation of well-educated and ‘healthinterested’ families (9). The contribution by each author was as follows: SR performed data analysis.eu). data interpretation.e. The regional differences in our study are of interest for further analysis and likely relate to the environment in the different regions and the healthcare system. The children were recruited through kindergartens or schools. data collection. Conflict of interest statement No conflict of interest was declared.29. Food Quality and Safety projects in FP6 (FOOD). LAM contributed to study design. We thank the participating children and parents. literature search. parents considered their children to be healthy irrespective of their weight category. Pediatric Obesity ••. data interpretation and manuscript writing. In general. IP contributed to study design. The European regional differences with higher concern about overweight and obesity in Southern Europe and a more accurate weight perception in Central and Northern Europe may be studied further in relation to regional differences in the prevalence of overweight and obesity. WG performed data interpretation and manuscript writing. Acknowledgements This work was done as a part of the IDEFICS study (http://www. generation of figures and manuscript writing. A seemingly irrational concern about © 2012 The Authors Pediatric Obesity © 2012 International Association for the Study of Obesity. Responders were to a great extent mothers. data interpretation.
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