Preplanned Studies: Perceptions of Primary Caregivers on Children’s Weight Status Versus Actual Weight Status in Children Aged 6–15 Years — China, 2021

The prevalence of childhood overweight and obesity has been increasing rapidly worldwide (1). In the 2020 Report on Chinese Residents’ Chronic Diseases and Nutrition, the rates of overweight and obesity among Chinese children aged 6–17 years were reported to be 11.1% and 7.9%, respectively. Childhood obesity is associated with both physical and mental health problems during childhood, as well as a range of non-communicable diseases in adulthood, such as cardiovascular diseases, hypertension, and Type II diabetes (2–3). Parents who have accurate perceptions of their children’s weight status and are concerned about their health are more likely to take action to modify the weight-related behaviors of overweight or obese children (4). Primary caregivers’ misperceptions may influence the weight management of their children. Therefore, enhancing primary caregivers’ perception of a child’s weight status is essential in the prevention and control of obesity. To the best of our knowledge, few studies have explored primary caregivers’ perceptions of children’s weight status among a nationwide sample of Chinese children and their primary caregivers.

The aim of this study was to examine the consistency between primary caregivers’ perceptions of Chinese children’s weight status and their actual weight status. Data were collected from the Nutrition Improvement Program for Rural Compulsory Education Students (NIPRCES) in China in 2021. Demographic information, anthropometric measurements of children, and primary caregivers’ perceptions of children’s weight status were obtained from 160 key monitoring counties between September and December 2021. The monitoring counties included 70 national pilot counties and 60 local pilot counties where NIPRCES was implemented, as well as 30 counties without NIPRCES. In each county, eight schools were selected, with approximately 40 students per class selected in each grade. The fasting weight and height of children aged 6–15 years were measured by trained investigators via standardized protocols. Weight was measured to the nearest 0.1 kg using an electronic scale and height to the nearest 0.1 cm using a height meter. Body mass index (BMI) was calculated using weight and height (BMI=kg/m²). Children with stunting (assessed by height standards) were excluded. The remaining children were classified into three groups: wasting, normal weight, and overweight/obesity, according to their BMI [based on the Chinese Screening Standards for Malnutrition of School-Age Children and Adolescents (WS/T 456-2014) and Screening for Overweight and Obesity Among School-Age Children and Adolescents (WS/T 586-2018)]. Information about the relationships of primary caregivers to children and primary caregivers’ perceptions of children’s weight status was collected by trained investigators using a specifically designed questionnaire. Primary caregivers’ perceptions were assessed with the question, “Do you consider your child’s body image to be (too thin, thin, normal weight, fat, too fat)?” The responses were categorized as “thin” (too thin and thin), “normal weight”, and “fat” (fat and too fat). A total of 171,872 primary caregivers and child pairs were included in the study. The perception and weight status were considered consistent when the primary caregiver’s response matched the child’s actual weight status (e.g., thin vs. wasting; normal-weight vs. normal-weight; fat vs. overweight/obesity). The agreement between primary caregivers’ perceptions and children’s weight status was measured using Kappa coefficient. The Kappa values reflected the following: less than 0.00=poor agreement, 0.00–0.20=slight agreement, 0.21–0.40=fair agreement, 0.41–0.60=moderate agreement, 0.61–0.80=substantial agreement, 0.81–1.00=almost perfect agreement. Statistical analyses were performed using SAS (version 9.4; SAS Institute Inc., Cary, USA).

The general characteristics of the children, their actual weight status, and the primary caregivers’ perceptions of the children’s weight status are presented in Table 1. Based on BMI data, 22.7% of the children were classified as “overweight/obesity”, 70.4% as “normal weight”, and 6.9% as “wasting”. The prevalence of overweight/obesity was found to be higher among males, urban children, children aged 6–8 years or 9–11 years, and those residing in eastern or central China (Table 2). However, according to primary caregivers’ responses, only 12.9% perceived their children as “fat”, while 59.0% considered them “normal weight”, and 28.1% identified them as “thin”.

Most of the primary caregivers were the children’s parents (88.4%), followed by grandparents (7.8%), and other relationships (3.8%). In this study, it was observed that a mere 59.9% of primary caregivers accurately gauged their child’s weight status. However, 35.2% of the caregivers underestimated, and 4.9% overestimated their child’s weight status (Supplementary Table S1). The agreement between primary caregivers’ perceptions and the actual weight status of their children was found to be fair (kappa=0.253). Among normal-weight children, 32.0% of primary caregivers underestimated their child’s weight status. Furthermore, more than half (55.6%) of the primary caregivers with overweight or obese children were found to underestimate their child’s weight status, classifying them as “normal weight” (51.2%) or “thin” (4.4%) (Table 3).

Consistency between primary caregivers’ perceptions and children’s weight status across various age groups, regions, and areas is illustrated in Supplementary Table S1. Primary caregivers of males and younger children had more underestimation about children’s weight status compared to caregivers of females and older children. For example, the underestimation rate among primary caregivers of 6–8-year-old males reached 47.1%. Underestimation rates were higher among primary caregivers of children residing in eastern and central regions in China (37.9%, 38.2%) compared to those in western China (32.1%). Furthermore, underestimation rate was higher in urban areas than in rural areas (37.8% vs. 34.0%).