Parental Perceptions of Children's Weight Status in 22 Countries: The WHO European Childhood Obesity Surveillance Initiative: COSI 2015/2017

Abstract

Introduction: Parents can act as important agents of change and support for healthy childhood growth and development. Studies have found that parents may not be able to accurately perceive their child's weight status. The purpose of this study was to measure parental perceptions of their child's weight status and to identify predictors of potential parental misperceptions.

Methods: We used data from the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative and 22 countries. Parents were asked to identify their perceptions of their children's weight status as "underweight," "normal weight," "a little overweight," or "extremely overweight." We categorized children's (6-9 years; n = 124,296) body mass index (BMI) as BMI-for-age Z-scores based on the 2007 WHO-recommended growth references. For each country included in the analysis and pooled estimates (country level), we calculated the distribution of children according to the WHO weight status classification, distribution by parental perception of child's weight status, percentages of accurate, overestimating, or underestimating perceptions, misclassification levels, and predictors of parental misperceptions using a multilevel logistic regression analysis that included only children with overweight (including obesity). Statistical analyses were performed using Stata version 15 1.

Results: Overall, 64.1% of parents categorized their child's weight status accurately relative to the WHO growth charts. However, parents were more likely to underestimate their child's weight if the child had overweight (82.3%) or obesity (93.8%). Parents were more likely to underestimate their child's weight if the child was male (adjusted OR [adjOR]: 1.41; 95% confidence intervals [CI]: 1.28-1.55); the parent had a lower educational level (adjOR: 1.41; 95% CI: 1.26-1.57); the father was asked rather than the mother (adjOR: 1.14; 95% CI: 0.98-1.33); and the family lived in a rural area (adjOR: 1.10; 95% CI: 0.99-1.24). Overall, parents' BMI was not strongly associated with the underestimation of children's weight status, but there was a stronger association in some countries.

Discussion/conclusion: Our study supplements the current literature on factors that influence parental perceptions of their child's weight status. Public health interventions aimed at promoting healthy childhood growth and development should consider parents' knowledge and perceptions, as well as the sociocultural contexts in which children and families live.

Keywords: Childhood Obesity Surveillance Initiative; Childhood obesity; Parental perceptions; Weight; World Health Organization/Europe.

Fig. 1

Parents' perception^a of their child's weight status among children classified as normal weight, overweight (excluding obesity), and obesity according to the WHO definition. COSI/WHO Europe round 4 (2015–17). For an explanation of the country abbreviations, see Table 1. ^aParents' perception was not analyzed for children with obesity from Denmark, San Marino, and Tajikistan due to the limited number of available observations. Pooled estimates were calculated for the following age groups/countries: 7 year olds from BUL, CZH, DEN, KGZ, GEO, LVA, LTU, MAT, MNE, RUS, POR, SPA, TJK, TKM, and TUR; 8 year olds from ALB, CRO, ITA, POL, ROM, and SMR; and 9 year olds from KAZ. COSI, Childhood Obesity Surveillance Initiative; BUL, Bulgaria; CZH, Czechia; DEN, Denmark; KGZ, Kyrgyzstan; GEO, Georgia; LVA, Latvia; LTU, Lithuania; MTA, Malta; MNE, Montenegro; RUS, Moscow city-Russian Federation; POR, Portugal; SPA, Spain; TJK, Tajikistan; TKM, Turkey; TUR, Turkmenistan; ALB, Albania; CRO, Croatia; ITA, Italy; POL, Poland; ROM, Romania; SMR, San Marino; KAZ, Kazakhstan.

Fig. 2

Percentage of children with overweight (including obesity) according to WHO's definition who are perceived by their parents as with under/normal weight and adjORsa of parents' incorrect perception related to country. COSI/WHO Europe round 4 (2015–17). aadjORs of parents' perception of their child's weight status as with under/normal weight (compared to being perceived as “a little overweight” or “extremely overweight”) among children with overweight (including obesity) and 95% CI were estimated through a multilevel logistic regression model with random effects for primary sampling units. Besides country, a pooled model included child's sex and age in months, urbanization grade of child's place of residence (urban or rural), the relation between the respondent and the child (father or mother), and educational attainment and weight status of the parent who filled in the form. Pooled estimates were obtained including the following age groups/countries: 7 year olds from BUL, GEO, LVA, LTU, MNE, POR, SPA, TUR, and TKM; 8 year olds from ALB, CRO, ITA, POL, and ROM; and 9 year olds from KAZ. adjORs, adjusted ORs; CI, confidence interval; COSI, Childhood Obesity Surveillance Initiative; BUL, Bulgaria; GEO, Georgia; LVA, Latvia; LTU, Lithuania; MNE, Montenegro; POR, Portugal; SPA, Spain; TUR, Turkmenistan; TKM, Turkey; ALB, Albania COR, Croatia; ITA, Italy; POL, Poland; ROM, Romania; KAZ, Kazakhstan.