Parental Perceptions of Obesity in School Children and Subsequent Action

Abstract

Background:

Despite perceiving their child as being above a healthy weight, many parents do not intervene. Little is known about the factors influencing parental action. We assessed parental perception of child's weight status, the prevalence of mitigating parental action, and the underlying factors.

Methods:

We studied 20,242 children and adolescents from 6 centers across China. Anthropometry was measured by research nurses. Parents answered questionnaires, including their perception of their child's weight status, and any subsequent weight treatment.

Results:

A total of 3254 children had obesity (16.1%), with 63.0% correctly perceived as overweight by their parents. These children were more likely to be older (≥8 years; p < 0.0001), have severe obesity [adjusted relative risk (aRR) 1.41; p < 0.0001], and have mothers with overweight/obesity (aRR 1.15; p < 0.0001). In particular, parents of children aged <8 years were over five times more likely to perceive their child with overweight/obesity as “thin” than parents of teenagers. Conversely, girls, older children/adolescents, and urban youth were more likely to be wrongly perceived by parents as having an overweight issue. Only one in four children (27.8%) with available information received treatment for their perceived weight problem. Children with severe obesity were more likely to be treated (aRR 1.34; p < 0.0001), as were children of mothers with overweight/obesity (aRR 1.18; p = 0.002).

Conclusions:

Only one in four Chinese children perceived as overweight by their parents received treatment for their weight problem. Given that overweight/obesity in childhood tracks into adulthood and many parents did not intervene despite perceiving an overweight problem in their child, interventions for childhood obesity need to extend beyond parental perception of children's weight status.

Introduction

Childhood obesity is an emerging public health problem in China.¹ Although its prevalence has not yet reached the levels observed in other developed countries,² increasing prevalence of childhood obesity remains a concern due to adverse long-term health consequences on mortality and morbidity.^3–5 The obesity rate in boys aged 7–12 years in the urban areas of Shandong increased dramatically from just 0.1% in 1985 to 12.0% in 2014, with a notably higher rise among boys from rural areas in the same province (from 0.05% to 15.6%).⁶ In Shenyang, the obesity rates among children and adolescents increased from 9.0% in 2010 to 12.6% in 2014.⁷

Since over one-third of children with overweight and approximately half of adolescents with overweight develop into adults with obesity,² childhood and adolescence are important periods to prevent the progress of this condition.⁸ However, recent reviews have found that over half of parents fail to identify that their child has overweight and/or obesity,^9,10 limiting the potential for intervention. Chinese parents are not exempt from this phenomenon; parents across China have frequently been shown to misperceive their child's weight status, and in particular, underperceive the weight status of children with overweight or obesity.^11–17

The increasing prevalence of childhood obesity has been proposed as a potential explanation for these findings¹⁸; it may simply be that parents can no longer recognize childhood overweight or obesity because it is so common. However, while the worldwide prevalence of childhood obesity has risen, rates of parental misperception have remained relatively stable for two decades, suggesting that increasing prevalence is not solely responsible for this issue.⁹ An alternative explanation is that fear of weight-related stigmatization may discourage parents from acknowledging their children as having overweight or obesity.¹⁹

Consistent with health behavior theories where accurate perception of health risk is a precursor to taking action to reduce that risk,^20,21 some^11,22 but not all¹² studies have shown that when Chinese parents do correctly perceive their child as having overweight or obesity, they are more likely to take action to reduce their child's weight. However, a large proportion of children remain untreated, despite having parents who correctly perceive them as overweight.^11,22

Parents may not necessarily view health and weight as inter-related. For example, parents across eight European countries generally reported their children as being in good health, regardless of what they believed their weight status to be.²³ Furthermore, parents report numerous barriers to prevention of childhood obesity, such as lack of financial resources or knowledge required for implementation of healthy behaviors.²⁴ Thus, although parents may recognize their child as being above a healthy weight, they may not necessarily believe that this is detrimental to their child's overall well-being, or that they are capable of intervening.

To the best of our knowledge, no previous study has examined the factors associated with Chinese parental decisions to intervene when they believe their child to be above a healthy weight. Thus, we aimed to examine the association between the parental perception of overweight in Chinese children and their likelihood to subsequently intervene to mitigate the weight issue. In addition, given that some parents do not believe child health and weight are linked, and many report significant barriers to prevention of childhood obesity, we assessed a range of sociodemographic factors influencing this decision.

Methods

Data were obtained from a cross-sectional study of children attending local primary, secondary, and high schools in six geographically representative areas in China in 2009–2010 (Beijing, Chongqing, Nanning, Shanghai, Tianjin, and Zhejiang).²⁵ Children were excluded from the study if they had chronic heart, lung, or kidney disease, endocrine or metabolic disease, or other chronic illnesses.

All participants were examined by clinical research nurses at their respective schools. Participants were measured while wearing an examination gown. Weight was measured with electronic scales, and standing height on a stadiometer to the nearest 1 mm, while bare feet and wearing nothing on the head. BMI was calculated and transformed into percentiles adjusted for age and sex based on the WHO standards.^26,27 Child's overweight was defined as BMI ≥85th to <95th percentile, obesity as BMI ≥95th percentile, and severe obesity as BMI ≥99th percentile. Waist circumference was measured at the midway between the lowest rib and the superior iliac crest, and hip circumference around the fullest part of the hips with participants standing with their feet together.

Questionnaires were sent home from school with the children to be completed by their parents. The recorded information included maternal and paternal occupations, weight and height. In addition, parents were specifically asked about their perception of their child's body size (overweight/normal/thin/don't know), and whether the child received any treatment or intervention to address their perceived weight problem. It should be noted that it is unknown which parent (or other caregiver) completed the questionnaire, as this information was not collected.

Maternal and paternal BMI were calculated; overweight/obesity was defined as BMI ≥25 kg/m² and obesity as BMI ≥30 kg/m². Maternal and paternal levels of education were used as indicators of socioeconomic status, and were estimated based on broad categories of occupation: low education included laborers, peasants, fishermen, and those without stable employment; average–high education included managers, clerks, service staff, professionals, teachers, and health care professionals.

Ethics Approval

This study was approved by the Medical Ethics Committee of the Children's Hospital of Zhejiang University School of Medicine (ethics approval number: 2009013). Written informed consent from parents (or guardians) and children (where appropriate) was obtained.

Statistical Analyses

Descriptive data are provided as means ± standard deviations or n (%). Univariate comparisons between groups were undertaken using one-way ANOVA and chi-square tests. Multivariable logistic regression models were run to evaluate binary outcomes of interest (i.e., likelihood of correct parental perception and likelihood of being treated for a weight problem), adjusting for a range of dichotomous predictors of interest. These were specifically as follows: child sex, child age (<8 years vs. 8–12 years vs. ≥13 years), child BMI (<99th vs. ≥99th percentile), area of residence (urban vs. rural), maternal and paternal education levels (low vs. average–high), and mother and father with overweight/obesity (yes vs. no). For parental recognition of overweight, we chose to focus on children at the upper end of the BMI spectrum (i.e., with obesity), as it would be of greater interest to identify the factors associated with failure to recognize a weight problem in this particular group. This is particularly relevant as children with obesity are those in most need of intervention.

In addition, we examined other associations between the parent's perception of their child's weight status across the BMI range, specifically looking at both parental extreme underestimation (i.e., where a child with overweight/obesity was perceived as “thin”) and overestimation of the child's weight status. Analyses were performed in SPSS v25 (IBM Corp, Armonk, NY) and SAS v9.4 (SAS Institute, Cary. NC). All tests were two tailed, with statistical significance set at p < 0.05. Results from multivariable models are provided as the adjusted relative risks (aRRs) and respective confidence intervals (95% CIs).

Results

Participants

From the original 22,950 children and adolescents, we examined 20,242 participants with data available on parental perception of their child's weight status (Fig. 1), including 3254 (16.1%) with obesity. The characteristics of our study population across the six geographical areas are provided in Supplementary Table S1.

Figure 1.

Diagram showing the flow of participants in this study on Chinese children and adolescents. Values are n and the respective percentage from the preceding subset.

Overall, 3435 (17.0%) caregivers believed that their child was overweight (Fig. 1), with 2050 of the 3254 children with obesity (63.0%) correctly recognized as overweight by their parent. Table 1 shows the range of parental perceptions of their child's weight status.

Table 1.

Association between Parental Perception and the Child's BMI Status in China

Child's BMI status	Parental perception
Child's BMI status	“Thin,” n (%)	“Normal,” n (%)	“Overweight,” n (%)	“Don't know,” n (%)	Total
Underweight/normal weight	3734 (25.0)	9939 (66.6)	845 (5.7)	402 (2.7)	14,920
Overweight	52 (2.5)	1402 (67.8)	540 (26.1)	74 (3.6)	2068
Obesity	51 (1.6)	1081 (33.2)	2050 (63.0)	72 (2.2)	3254
Total	3837	12,422	3435	548	20,242

Underweight/normal weight was defined as BMI for age and sex <85th percentile, overweight as ≥85th percentile and <95th percentile, and obesity ≥95th percentile, according to World Health Organization's standards.

Parental Recognition of Obesity

Table 2 describes the familial characteristics of children with obesity who were correctly perceived as overweight or not. Marked differences in the accuracy of parental perception were observed for children aged <8 years compared with older children and adolescents (45.0% vs. 66.9% and 75.5%, respectively; p < 0.0001), and for children with severe compared with less severe obesity (77.0% vs. 52.5%; p < 0.0001) (Table 2). In addition, both mothers and fathers with overweight/obesity were more likely to correctly identify their children with obesity as overweight (p < 0.0001), as were mothers with lower levels of education (p < 0.0001; Table 2). Finally, children living in urban areas were marginally more likely to be identified as having a weight problem compared with their rural counterparts (p = 0.006; Table 2). Father's education level and the child's sex did not appear to affect the accuracy of parental perception (Table 2).

Table 2.

Demographic and Anthropometric Characteristics among 3182 Children with Obesity in China Who Were Correctly Perceived as Overweight or Not

Characteristic	Levels	Parental perception of children with obesity
Characteristic	Levels	Correct, n (%)	Incorrect, n (%)	p
N		2050 (64.4)	1132 (35.6)
Sex	Male	1382 (63.2)	804 (36.8)	0.38
Sex	Female	668 (67.1)	328 (32.9)	0.38
Age group, years	<8	263 (45.0)	321 (55.0)	<0.0001
	8–12	1308 (66.9)	647 (33.1)
	≥13	479 (74.5)	164 (25.5)
Child's BMI	>95th and <99th percentile	857 (52.5)	775 (47.5)	<0.0001
Child's BMI	≥99th percentile	1193 (77.0)	357 (23.0)	<0.0001
Area of residence	Urban	1360 (66.7)	679 (33.3)	0.006
Area of residence	Rural	464 (61.1)	296 (38.9)	0.006
Maternal education	Low	832 (67.2)	406 (32.8)	<0.0001
Maternal education	Average–high	864 (60.6)	562 (39.4)	<0.0001
Paternal education	Low	696 (66.0)	358 (34.0)	0.69
Paternal education	Average–high	996 (62.5)	597 (37.5)	0.69
Maternal BMI status	Underweight/normal weight	1333 (60.3)	877 (39.7)	<0.0001
Maternal BMI status	Overweight/obesity	583 (75.1)	193 (24.9)	<0.0001
Paternal BMI status	Underweight/normal weight	839 (59.9)	562 (40.1)	<0.0001
Paternal BMI status	Overweight/obesity	1074 (68.1)	503 (31.9)	<0.0001

Obesity in the child was defined as a BMI for age and sex ≥95th percentile; parental overweight/obesity was defined as BMI ≥25.0 kg/m². Correct perception—child with obesity and parent responded “overweight”; incorrect perception—child with obesity and parent responded “normal,” “thin,” or “don't know.” Total n was 3182, except for area of residence (n = 2799; 88.0%), maternal education (n = 2664; 83.7%), paternal education (n = 2647; 83.2%), maternal BMI status (n = 2986; 93.8%), and paternal BMI status (n = 2978; 93.6%).

The multivariable model incorporating all parameters listed in Table 2 showed that older children were more likely to have their weight status correctly identified compared with younger ones: 8–12 years vs. <8 years [aRR 1.43 (95% CI 1.28–1.59); p < 0.0001] and teenagers vs. <8 years [aRR 1.47 (95% CI 1.30–1.66); p < 0.0001]. The weight status of children with severe obesity (≥99th percentile) was also more likely to be correctly perceived compared with peers with less severe obesity [aRR 1.41 (95% CI 1.32–1.50); p < 0.0001]. In addition, mothers with overweight/obesity were more likely to correctly perceive their child as overweight compared with those who were slimmer [aRR 1.15 (95% CI 1.08–1.22); p < 0.0001]. None of the other parameters were associated with likelihood of an accurate parental perception of their child's weight status (data not shown).

Parental Extreme Underestimation of Child's Weight Status

Notably, 1.9% (103/5322) of children with overweight or obesity were actually perceived by their parents as “thin” (Table 1). Parents of the youngest children (<8 years) were over five times more likely to perceive their child with overweight/obesity as “thin” compared with parents of teenagers (Table 3). Further, children with an unhealthy weight whose parents were underweight or normal weight were twice as likely to be classified as “thin” (Table 3).

Table 3.

Demographic and Anthropometric Characteristics among School Children and Adolescents in China Whose BMI Status Was Extremely Underestimated by Their Parents

Characteristic	Levels	Child with overweight or obesity
Characteristic	Levels	Correct perception, n (%)	Extreme underestimation, n (%)	p
N		2590 (96.2)	103 (3.8)
Sex	Male	1594 (96.0)	67 (4.0)	0.54
Sex	Female	996 (96.5)	36 (3.5)	0.54
Age group, years	<8	306 (91.6)	28 (8.4)	<0.0001
	8–12	1592 (96.1)	64 (3.9)
	≥13	692 (98.4)	11 (1.6)
Area of residence	Urban	1666 (96.5)	60 (3.5)	0.32
Area of residence	Rural	594 (95.7)	27 (4.3)	0.32
Maternal education	Low	1047 (95.7)	47 (4.3)	0.27
Maternal education	Average–high	1080 (96.7)	37 (3.3)	0.27
Paternal education	Low	883 (96.0)	37 (4.0)	0.91
Paternal education	Average–high	1233 (96.1)	50 (3.9)	0.91
Maternal BMI status	Underweight/normal weight	1705 (95.4)	83 (4.6)	0.002
Maternal BMI status	Overweight/obesity	709 (97.9)	15 (2.1)	0.002
Paternal BMI status	Underweight/normal weight	1098 (94.7)	62 (5.3)	<0.001
Paternal BMI status	Overweight/obesity	1310 (97.3)	37 (2.7)	<0.001

Child overweight or obesity was defined as a BMI for age and sex ≥85th percentile; parental overweight/obesity was defined as BMI ≥25.0 kg/m². Correct perception—parent responded “overweight”; Extreme underestimation—parent responded “thin.” Total n was 2693, except for area of residence (n = 2347; 87.2%), maternal education (n = 2211; 82.1%), paternal education (n = 2203; 81.8%), maternal BMI status (n = 2512; 93.3%), and paternal BMI status (n = 2507; 93.1%).

Subsequent Treatment for Weight Concern

Among the 3435 parents who believed that their child was above a healthy weight, 2575 (75.0%) responded whether their child received any treatment or intervention for their weight problem (Fig. 1). However, only 716 (27.8%) of these children were reportedly treated as a result (Fig. 1).

A greater proportion of children with severe obesity were reportedly treated for a weight problem (+7.5 percentage points; Table 4). However, no other characteristics in the child or family differed between the children perceived as overweight who were treated or not (Table 4).

Table 4.

Demographic and Anthropometric Characteristics among the 2575 Children Who Were Perceived as Overweight, and Whose Parents Reported Whether They Were Subsequently Treated for Their Perceived Weight Problem

Characteristic	Levels	Treated, n (%)	Not treated, n (%)	p
N		716 (27.8)	1859 (72.2)
Sex	Male	411 (28.9)	1012 (71.1)	0.19
Sex	Female	305 (26.5)	847 (73.5)	0.19
Age group, years	<8	103 (32.1)	218 (67.9)	0.17
	8–12	411 (27.5)	1085 (72.5)
	≥13	202 (26.6)	556 (73.4)
Child's BMI status	<99th percentile	410 (25.1)	1226 (74.9)	<0.0001
Child's BMI status	≥99th percentile	306 (32.6)	633 (67.4)	<0.0001
Area of residence	Urban	519 (29.1)	1265 (70.9)	0.38
Area of residence	Rural	143 (24.5)	438 (75.4)	0.38
Maternal education	Low	270 (26.7)	742 (73.3)	0.16
Maternal education	Average–high	334 (29.5)	799 (70.5)	0.16
Paternal education	Low	220 (26.7)	605 (73.3)	0.28
Paternal education	Average–high	373 (28.9)	916 (71.1)	0.28
Maternal BMI status	Underweight/normal weight	461 (26.7)	1263 (73.3)	0.06
Maternal BMI status	Overweight/obesity	212 (30.5)	483 (69.5)	0.06
Paternal BMI status	Underweight/normal weight	312 (27.7)	815 (72.3)	0.82
Paternal BMI status	Overweight/obesity	361 (28.1)	922 (71.9)	0.82

Parental overweight/obesity defined as BMI ≥25.0 kg/m². Analyses included all available treatment data for the children whose parents perceived them as “overweight” (irrespective of the child's actual BMI status). Total n was 2575, except for area of residence (n = 2365; 91.8%), maternal education (n = 2145; 83.3%), paternal education (n = 2114; 82.1%), maternal BMI status (n = 2419; 93.9%), and paternal BMI status (2410; 93.6%).

In the multivariable model accounting for all factors listed in Table 4, children with severe obesity were 34% more likely to be treated for a weight problem than those with a lower BMI [aRR 1.34 (95% CI 1.14–1.56); p < 0.001]. In addition, children of mothers with overweight/obesity were more likely to be treated [aRR 1.18 (95% CI 1.02–1.38); p = 0.031]. None of the other predictors were associated with the likelihood of the child being treated for the perceived weight problem (data not shown).

Parental Overestimation of Child's Weight Status

It was relatively uncommon for parents to perceive their underweight or normal weight child as “overweight” (5.8%; 845/14,518). Nonetheless, parents were more likely to overestimate the weight status of girls, older children/adolescents, and those living in urban areas (Supplementary Table S2). In addition, underweight/normal weight children whose parents had overweight/obesity were nearly twice as likely to be classified as “overweight” (Supplementary Table S2).

Discussion

Our study found that approximately two-thirds (63.0%) of Chinese parents correctly identified their child with obesity as being overweight, but only one in four parents (27.8%) who believed their child to be above a healthy weight reported actually treating their child for the perceived weight issue. While a number of familial factors influenced an accurate perception of the child's weight status, we found fewer factors markedly affecting parental decision to undergo treatment.

Approximately one-third (37.0%) of the parents in our study underestimated the weight status of their child with obesity. Recent studies in China have shown that between 42.9% and 59.5% of parents did not correctly recognize the weight status of their child with overweight or obesity.^11,12 However, our study specifically focused on parental perception of weight status in children with obesity only, possibly accounting for our lower rate of misperception. We did not find a statistically significant association between parental perceptions of child weight status and child sex. While this finding is consistent with a previous study in 15 Chinese provinces and municipal cities,¹¹ it contrasts with several previous studies in China.^12–14,22

There was some indication that children with obesity of mothers with lower education levels were more likely to have their weight status correctly perceived by their parent. However, this association was not observed in our multivariable model. While it seems reasonable to assume that higher parental educational levels would be associated with greater frequency of accurate perception of child weight status, previous studies in China,^13,17,28 and one in Taiwan,²⁹ have found no such association. Further, it has been suggested that those with higher education levels may be more influenced by social desirability bias as they are likely to be more aware of the health consequences of obesity, and thus more likely to under-report this in their children.³⁰ This trend was further observed among children with obesity who had not been perceived as overweight; both fathers and mothers with higher levels of education were more likely to underestimate their children's weight status. However, no such trend was observed for extreme parental underestimation of the weight status of children living with overweight or obesity.

Children with obesity correctly perceived as being above a healthy weight tended to be older, live in urban areas, have more severe obesity, and have parents who themselves had overweight or obesity. In addition, extreme parental underestimation of children with overweight or obesity tended to occur more frequently in younger children, and those with normal weight or underweight parents. Overall, our analyses showed a clear pattern of greater underestimation of weight status among parents of younger children. Age differences in parental perception of obesity have been previously shown, with many studies finding that parents more frequently misperceive the weight status of younger children,^9,10,12 hence our results add further to that literature. Also, parental underestimation of weight status in children with lower BMI has been found in China,¹² although Yao and Hillemeier showed the opposite.¹⁷

Heavier mothers being more likely to correctly perceive their child's weight status has also been observed in the mainland Chinese population,^11,15,17 and among Chinese mothers living in Australia.¹⁵ In fact, our multivariable model showed that children with mothers who had overweight or obesity themselves were 15% more likely to be correctly recognized as having a tendency to have obesity. One possibility for this increased likelihood is that mothers with overweight or obesity are generally more weight conscious, and thus more likely to recognize obesity in their children.¹⁷ Interestingly, normal or underweight children of mothers with overweight or obesity were also more likely to have their weight status overestimated by their parents; further suggesting that these mothers may be hypervigilant to weight issues. We also found that children with obesity who had fathers with overweight or obesity were more likely to have their weight status accurately perceived, as well as overestimated in the case of normal or underweight children, suggesting that this trend may not be specific to mothers. However, the former did not remain significant in the multivariable model looking at accurate parental perception of obesity.

Previous Chinese studies have demonstrated that mothers who did perceive their child as overweight were more likely to encourage their child to increase physical activity levels and/or alter their diet than mothers who did not perceive their child as such.^11,22 However, ours is the first to investigate differences between Chinese children who were perceived as above a healthy weight by their parents and either treated or not treated for the weight problem. Almost three-quarters (72.2%) of our participants who were perceived as being above a healthy weight by their parents did not receive any kind of treatment. We had hypothesized that children perceived as overweight with better educated parents would be more likely to be treated, but this was not the case.

Qualitative research has shown that although some parents do consider a lack of parental education as a key reason for the increasing prevalence of childhood obesity, they may not necessarily believe this applies to them.³¹ In addition, in the United Kingdom, parents who received letters about their child's weight status assumed that this feedback was intended for parents who were less educated than themselves.³² However, this particular subgroup of parents in our study (i.e., those who perceived their child as overweight but did not treat them) had themselves reported their children as overweight, thus were not rejecting an assessment on their children's weight status received from an external source. In addition, there is evidence that many Chinese families favor children with overweight, believing them to be healthier. For example, a 2007 study in Jiangsu Province found that >40% of parents of overweight children wanted their children to maintain their weight or were not concerned about their weight problem.²⁸ Therefore, it is possible that while parents in our study did consider their children to be overweight, they believed this to be positive and not a potential health risk.

Nonetheless, we did find that children with severe obesity were 34% more likely to be treated for their perceived weight problem than children with a lower BMI. In Portugal, parents of children with overweight had more concerns about weight status in children with higher BMI percentiles.³³ Elsewhere, parents of children with overweight and obesity cited visual cues of their child's weight status as motivators to enroll them in a weight treatment program.³⁴ Children with extreme obesity would be more noticeably above a healthy weight, and this may explain why they were more likely to be treated.

Surprisingly, while older children with obesity were more likely to be recognized as having a weight problem, a greater proportion of younger children were actually treated for perceived obesity. It may be that younger children who are more noticeably affected by obesity prompt more parental or medical concern, thus encouraging their families to act to reduce their weight. However, it should be noted that age did not remain significant in the multivariable model, although maternal weight status did play a role, with children of mothers with overweight or obesity being more likely to be treated.

Accurate parental perception of their child's weight status has long been considered an important prerequisite to tackle childhood obesity,^9,35 prompting public health efforts in the United Kingdom, for example, to educate parents about their child's overweight or obesity problem.³⁶ However, our study showed that the majority of Chinese parents who perceived their children as overweight did not take action to address the problem. Indeed, in the United Kingdom, parents who received feedback from a child weight screening program regarding their overweight status reported minimal lifestyle changes.³⁷ Furthermore, recent longitudinal studies on Dutch,³⁸ Irish,³⁵ and Australian³⁹ children have noted a paradoxical trend—where parental identification of a child as overweight has been associated with an increased risk of future weight gain. Thus, it appears that the sole focus on accurate identification of a child's overweight or obesity problem by their parent may not offer a straightforward solution to address the increasing problem of childhood obesity. Previous studies have shown that accurate parental perception of child's weight status increases when the parents perceive their child's overall health to be declining.⁴⁰ This suggests that parents view weight and health as linked when health is noticeably impaired, and that parental education focusing on the health consequences of obesity may be helpful. However, this may be particularly difficult in China where traditional belief is that a child with overweight is healthier.²⁸

The main limitation of our study was the lack of information on which parent completed the questionnaire. There are differences in parental roles and the parent's interaction with the child,⁴¹ so it is plausible that collecting information exclusively from the more involved parent could result in more accurate data. We were also unable to determine the extent to which children were treated for their perceived overweight. In addition, our study asked parents to assess their child's weight status by selecting a written option. A review of parental perceptions of Asian children's weight suggested that asking parents to select their child's weight status by using visual options (e.g., silhouettes or pictures) may be less subject to stigma and therefore more accurate.⁴² Further, the study was cross-sectional in design, and consequently we cannot infer causal pathways. However, a strength of our study is our large population, which comprised of school children across a number of Chinese localities, including both rural and urban areas. In addition, children's anthropometry was measured by trained nurses and not self-reported, providing accurate data on the children's weight status.

Conclusions

Accurate parental perception of childhood obesity is considered important to address this issue.^9,35 However, our study confirms that a large proportion of parents in China fail to identify their child's weight problem, and importantly, even if they do perceive their child as overweight, the majority do not report taking action to address this issue. We also observed that children with severe obesity were 34% more likely to be treated. At this stage, the most effective treatment is bariatric surgery for adolescents, with lifestyle modifications preferred for younger children.⁴³ However, given that surgery is associated with risks and potential complications and lifestyle modifications have limited success for children with severe obesity,⁴³ earlier intervention is preferable. This, considered alongside the likely role of stigma in parental recognition (or specifically acknowledgment) of childhood obesity,¹⁹ would suggest that focusing solely on increasing accurate parental perception of their child's excessive weight is unlikely to be effective for the reduction of childhood obesity. We instead encourage better understanding of the specific factors associated with parental-led behavioral change, and to couple such efforts with public health strategies and pediatrician education to teach caregivers about the importance of a healthy weight throughout childhood, and how this can impact overall child health.

Footnotes

Acknowledgments

We are grateful to Dr. Yannan Jiang (University of Auckland) for her assistance with translation of the original questionnaire, and to Ministry of Science and Technology of the People's Republic of China—National Key Research and Development Programme of China (No. 2016YFC1305301); National Natural Science Foundation of China (Nos. 81570759 and 81270938); Science Technology Department of Zhejiang Province (Nos. 2014C03045-2 and 2016C33130); Health Commission of Zhejiang Province—Key Disciplines of Medicine (No. 11-CX24); and the Fundamental Research Funds for the Central Universities (No. 2017XZZX001-01). J.G.B.D. is the recipient of a travel fellowship from the New Zealand-China Non-Communicable Diseases Research Collaboration Centre.

Author Disclosure Statement

The authors have no other financial or nonfinancial conflicts of interest to disclose that may be relevant to this work. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of this article.

Supplementary Material

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