Beyond Oblivobesity: Seven Myths About Parental Misperception of Children's Weight

To the Editor:

In a recent editorial in Childhood Obesity, Katz commented on the phenomenon of parents' misperception of children's excess weight. ¹ Although the editorial focused on engaging children and their families in obesity management, he challenged a common belief in the weight misperception literature, which is to combat misperception of excess weight with objective information. Upon review of the misperception literature, we believe there is value in going “beyond oblivobesity” to consider a number of misunderstandings related to the conceptualization, interpretation, and attempt to address the discrepancy between perceived and actual weight status of children.

1. Parents are unaware of their children's obesity. Most studies on parental weight misperception have relied on anthropometric measures (e.g., BMI) to determine children's weight status. ² Given that these metrics only provide an indirect estimate of obesity, parental unawareness of child obesity can only ever be estimated indirectly as well. Further, unawareness is just one aspect of weight misperception; the latter not only implies that parents are unaware of their children's actual weight status, but also that they assign to their children a weight status other than the actual status. Compared to unawareness, misperception may exert a greater influence on whether parents choose to “accept” objective data (e.g., BMI plotted on a growth chart) showing that their children meet the clinical definition for obesity.

2. Parents fail to recognize their children's weight problem. Conceptually, it is important to differentiate between misclassifying the identity of a condition (which is the main focus of studies on perceived weight status) and being concerned about a condition (perceiving it as a problem). Health concern in general, and weight concern in particular, depend on (1) the severity attached to the consequences of the condition and (2) the perceived personal susceptibility to those consequences. In this regard, accurate recognition of excess weight is necessary, but not sufficient, to be concerned about obesity. For instance, both Genovesi and colleagues ³ and Jain and colleagues ⁴ found that most parents in their studies were aware of, but not concerned about, their children's excess weight.

3. Parents will not take preventive actions to address obesity unless a weight problem is recognized. Compared to parents who failed to recognize their children's excess weight, Neumark-Sztainer and colleagues ⁵ found that those who recognized it correctly were not more likely to promote healthier lifestyle behaviors for their children. Qualitative evidence has shown that children's psychosocial well-being and quality of life were more common reasons for parents to engage in pediatric weight management versus concerns about children's weight and physical health.^6,7 It is sometimes forgotten in the dominant discourse about nutrition, physical activity, and obesity that individuals may perform healthy lifestyle behaviors not because a problem exists or because one is expected, but for the simple sake of living a healthy and enjoyable life.

4. Parents who do not recognize their children's obesity are in denial. Given that children's excess weight is visually apparent, it is often assumed that parents should recognize it unless they are in denial. As a defense or coping mechanism, ⁸ denial denotes a causal attribution to account for weight misperception that cannot be demonstrated by simply comparing the perceived and actual weight status. Misperception needs to be differentiated from its attributed factors for two main reasons. First, it leaves open the possibility of alternative explanations for the discrepancy between the subjective and objective weight status. Second, it highlights the need for further data to determine whether parents are in denial or whether their weight misperception is owing to other factors. Although researchers' attributions to misperception have been reported in the literature, little is known about healthcare providers' attributions, which can play a key role in healthcare decisions. For instance, healthcare providers might act differently depending on whether they attribute misperception to parents' lack of understanding of obesity or to denial, and if attributed to denial, whether they perceive it as a moral failure or a coping mechanism.

5. Accurate information will correct parental misperception of child excess weight. Parents should be informed about their children's weight status, but providing anthropometric data (1) may not correct weight misperceptions, (2) may have unintended consequences, and (3) may not lead to expected behavioral changes. Indeed, parents may distrust growth charts as a method of determining whether their children meet the criteria for obesity, ⁴ while negative feedback is more likely to be subject to biases than confirmatory information. ⁹ Qualitative research has shown that how and by whom anthropometric data are shared can influence families' perceptions of this information. ¹⁰ As highlighted by Katz, ¹ if not delivered in a sensitive manner, accurate information about weight status may embarrass or stigmatize children and blame parents. Informing parents about their children's actual weight status can increase their awareness about excess weight, but the impact of this knowledge on weight concern and preventive behaviors is limited. ¹¹ Focusing exclusively on providing objective information when parents do not feel confident to address children's excess weight may lead parents to discredit the source of information, misperceive children's weight status, or downplay the severity of the problem, all of which can represent as coping strategies.

6. Parents' misperceptions represent a personal failure to correctly assess children's actual weight status. Several factors have been suggested to account for parents' misperception of excess weight in their children, including the normalization of excess weight as it has become more common in society, visual recognition and social comparison as unreliable methods of weight assessment, reluctance to use clinical terms (“obese”) owing to perceptions of bias and stigma, denial of excess weight to avoid the responsibility of taking corrective actions, misunderstanding obesity, and weight size preferences across ages, sexes, and ethnicities.^12,13 Although individual-level factors might exert a direct influence on parental weight misperceptions, societal factors, including weight-related values and norms, are also influential, which highlights the complexity of the phenomenon.

7. Obesity management should focus on improving children's lifestyle habits to enhance health rather than on weight. Providing family-centered care includes respecting the values, needs, and desires of children and their families. ¹⁴ Although the foundation of pediatric weight management includes a focus on healthy nutrition and physical activity, parents may decline treatment if they perceive their children to already practice healthy lifestyle habits. ¹⁵ Whether focusing on improving lifestyle habits or weight management per se, this dichotomy predetermines the focus of conversations with families. Motivation for undertaking preventive actions varies from family to family, so it is necessary for healthcare professionals to explore parents' and children's values in order to identify what matters most to them; subsequently, weight management can be linked to their values, which might relate to health, lifestyle habits, weight loss, social acceptance, having their clothes fit better, and so on. This approach is consistent with the philosophy and practice of motivational interviewing, which is an effective tool to enhance motivation for weight management. ¹⁶

In summary, parents should be informed, in a sensitive, clear, and objective manner, about their children's weight status and associated health risks. However, it is important to recognize that this information may not correct misperceptions, and even if perception accuracy improves, this change may not translate into preventive actions. Emphasis must be placed on motivating parents and children to manage excess weight with awareness of excess weight as just one pathway. Ultimately, the primary issue may not be if or how to address misperception, but how to enhance motivation for pediatric weight management.