Children, their parents, and health professionals often underestimate children’s higher weight status

The systematic review and meta-analysis, synthesising the available evidence from the scientific literature, included 87 studies conducted worldwide between 2000 and 2018, involving 24,774 children aged 0-19 years old and their parents.

“Despite attempts to raise public awareness of the obesity problem, our findings indicate that underestimation of child higher weight status is very common,” says Abrar Alshahrani from the University of Nottingham, UK, who led the research.

“This misperception is important because the first step for a health professional in supporting families is a mutual recognition of higher weight status. This is particularly important for the child themselves, the parents, and the health professionals who look after them. Our study also found a tendency for health professionals to underestimate weight which suggests that overweight children may not be offered the support they need to ensure good health.”

Worldwide, there has been a more than 10-fold increase in the number of children and adolescents with obesity in the past four decades, increasing from 5 million girls in 1975 to 50 million in 2016, and from 6 million to 74 million boys. In Europe, 19-49% of boys and 18-43% of girls are overweight or have obesity, representing approximately 12-16 million overweight youth, very few of whom receive adequate treatment.

Previous research in adults has shown that accuracy of body weight perception is associated with lifestyle behaviours, efforts to lose weight, and medical visits.

In this study, Alshahrani and colleagues from the University of Nottingham investigated the prevalence of, and risk factors associated with, underestimation of children’s higher weight status. They conducted a systematic review and meta-analysis of qualitative and quantitative studies that assessed caregivers, children, and healthcare professional’s perceptions of children’s weight and compared this with recognised medical standards for defining overweight including the International Obesity Task Force cut-offs based on anthropometric measurements (height, weight, and circumference of waist and hip).

Results showed that over half (55%) of parents underestimated the degree of overweight in their children, whilst over a third (34%) of children and adolescents also underestimated their own weight status. Healthcare professionals shared this misperception, but limited studies prevented quantification.

Parents of younger children were less likely to perceive their child as overweight, and were less accurate at judging the weight of boys than girls.

Additionally, parents who were overweight themselves, and with less education, were also less likely to accurately assess their child’s higher weight. The authors note that ethnicity and cultural norms may also have an effect on parental misperception, as some cultures prefer a larger body type and may not identify their child as overweight.

Interestingly, in qualitative studies, parents commonly described their children as “big boned,” “thick,” or “solid” rather than using the medical term obese, and expressed a strong desire to avoid labelling their child with medical terminology.

“Identifying weight problems in childhood and adolescence is a unique window of opportunity to have a lifetime impact on health,” says Alshahrani. “The results suggest that underestimation of child overweight status is highly prevalent. Addressing the factors which lead to inaccuracy in assessing child weight will have a positive impact on communication between children, parents, and health professionals, and aid the mutual recognition of children’s higher weight status.”

The authors acknowledge that their findings show observational associations, so conclusions about cause and effect cannot be drawn. They point to several limitations, including the lack of statistical examination of healthcare professionals’ perceptions due to the scarcity of relevant studies, and potential gender bias as the majority of studies only examined mother-child body weight perceptions.