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Keywords:

  • childhood obesity;
  • health risk appraisal;
  • minority health;
  • parent health awareness

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Objective: To examine care giver perception of children's weight-related health risk in African American families.

Research Methods and Procedures: One-hundred and eleven families (representing 48 boys and 63 girls) screened for participation in a diabetes prevention study participated. Care givers completed a health awareness questionnaire that assessed their perception of the child's weight, eating habits, appearance, exercise habits, and health risk. The care givers also reported each subject's family history of obesity, diabetes, and other chronic diseases. After a physical examination, height and weight were used to compute an age- and sex-adjusted body mass index for each child.

Results: Despite the fact that a substantial number of children were obese (57%) and super-obese (12%), only 44% of the care givers perceived the child's weight to be a potential health problem. Regression analysis showed that 21% of the variance in parental perception of obesity-related health risk could be predicted by child age, body mass index, perception of frame size, and perception of exercise habits.

Discussion: A number of reasons for the apparent minimization of child health risk are discussed, including cultural differences in the acceptance of a large body habitus, lack of knowledge about the connection between childhood obesity and future health risk, and an optimistic bias in the perception of personal health risk.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

The incidence of obesity is increasing in the population at large, and at a higher rate in minority populations (1, 2, 3). Obesity increases the risk of developing other chronic diseases such as hypertension, diabetes, coronary heart disease, and several types of cancer (4, 5). The national trend toward overweight includes children, where the incidence of overweight/obesity is now one in five (6). Studies to date indicate that body mass index (BMI) becomes relatively fixed by adolescence (7) and that children who are obese are likely to remain obese as adults (8). It is very difficult for obese adults to permanently lose weight (9). Because genetics cannot be modified, prevention strategies must focus on basic lifestyle changes such as eating behaviors and activity patterns (10, 11). Efforts to prevent obesity will have to start with children (11).

Unlike adults, children are only partially responsible for their eating and exercise choices. Parents and other care givers exert an influence over the diet and exercise patterns, especially when children are young (12, 13, 14). Efforts to prevent obesity will have to change care givers’ attitudes and behaviors in order to impact the eating and activity patterns of their children (15).

Parents and care givers may not initiate preventive changes unless they first perceive that their child is at risk for some adverse outcome (16, 17). Therefore, it is important to understand care giver perception of child body weight and health risk. Some studies have shown large racial differences in perception of body weight and in weight loss behaviors in adolescents (18, 19, 20), preadolescents (21), and adults (22, 23). However, no studies assessing African American care givers’ evaluation of obesity-related health risk in their children were found.

Family history of obesity-related comorbidity might influence care giver perception of child risk. Parent eating habits and willingness to engage in diet and exercise modification could influence their willingness to implement diabetes prevention strategies in their children. Families can also differ in their beliefs about their ability to prevent disease conditions. Individual and cultural differences in the perception of appropriate body size and shape (24, 25) might also contribute to parents’ perception of overweight as a health concern or as a sign that the child is healthy and well-fed. Little is known about adult perceptions of the relationship between body weight and health in children.

This study was undertaken as part of a larger program to test the efficacy of alternative weight maintenance strategies for 5- to 10-year-old children in African American families. The goal of this analysis was to examine how African American care givers perceive size and body weight of their children and to assess the contribution of parental report of health habits and family history of chronic disease to perception of health risk, in a sample of obese African American children who are at increased risk for developing weight-related diseases, especially diabetes (26, 27, 28, 29).

Research Methods and Procedures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Subjects

The study sample was derived from a pool of African American children, most of whom were obese, who were recruited through multiple sources, but primarily by identification through chart review at their primary health care sites. Children and their primary care givers were invited to be screened for participation in the study if the child's weight for height was greater than the 90th percentile at the most recent clinic measurement, if the child had no other conditions that would interfere with participation in a weight-management program, and if the child was between their fifth and eleventh birthdays. The recruitment letter described the connection between obesity and diabetes in African Americans and offered to test the children for diabetes. The letter stated that, if the child did not have diabetes but was overweight, the child would be screened for eligibility to participate in a weight-management program, the goal of which was diabetes prevention.

This sample of 111 respondents (48 male, 63 female) represents approximately 6% of 1750 families who had received recruitment letters. Follow-up phone calls were made within 2 weeks of receipt of the letter inviting families to screen for the program. During these calls, the purpose and design of the program were explained, as well as the fact that the family was being contacted because their child reached a weight criteria, i.e., greater than 90% weight for height for his or her age at the most recent primary care clinic visit within the past year. A total of 149 children were screened in the clinic, but only 111 completed the Health Awareness Interview.

The primary care giver was defined as the individual with whom the child resides a majority of his or her time and who assumes primary responsibility for the child's well-being. In all cases, there was no difficulty identifying a primary care giver, although this individual was not always the child's guardian. Informed consent was obtained from the child's legal guardian.

Assessments

All measures reported here were collected during the first or second screening visit, before the care giver knew whether their child was eligible to participate in the intervention program but after informed consent was obtained. Each child was screened for diabetes using either a urine glucose or oral glucose tolerance test. No children were found to have diabetes (31).

Physical Examination of Child and Family Health History.

A standardized physical examination of the child and family health history were obtained by the study physician or nurse practitioner. Height and weight were used to compute the z-BMI value. The mean and standard deviation of BMI (=kg/m2) for age and gender were obtained from Hammer et al. (30) and used to compute a z-score by subtracting the mean from actual BMI and dividing by the standard deviation. Pubertal status was determined by a board certified pediatric endocrinologist or a supervised pediatric endocrine fellow using Tanner staging (31, 32).

Health Awareness Interview.

In a face-to-face standardized interview, care givers were asked to rate their child's weight appropriateness (“Which best describes your child's weight: underweight, just right, overweight, very overweight?”), frame size (“Which best describes your child's general appearance: small frame, medium frame, large frame?”), their child's eating habits (“Which answer best describes your child's eating habits: eats too little, eats just right, eats too much?”), and their perception of the child's weight-related health risk (“Do you think your child's weight is a health problem: Yes, No?”). Care givers were also asked about attempts at weight management for themselves and the child. Presence of first and second degree relatives with obesity, diabetes, and other chronic conditions (hyper-cholesterolemia or hypertension) was ascertained. The parents were asked to rate the child's exercise habits (“Describe the amount of exercise your child gets: not enough, the right amount, too active?”) and to report how much time a day the child spends in physical activity.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Description of Sample

The characteristics of the children are presented in Table 1. Forty three percent of the sample were boys (n = 48) and 57% were girls (n = 63). The boys were significantly older by a half year (p = 0.05). Boys and girls did not differ on height, weight, BMI, or z-BMI. Tanner stage for genital development was determined for 63% of the children with 75% in Stage 1, and 25% in Stage 2. The primary care givers included mothers (62%), fathers (5%), mothers and fathers (12%), grandmothers (14%), and others (7%).

Table 1.  Characteristics of children by gender
 BoysGirls
 NMeanSDNMeanSD
  • *

    Boys and girls differ based on t test; p < 0.05.

Age*488.31.4637.81.5
Height (cm)48133.09.763131.311.9
Weight (kg)4841.411.06342.614.6
BMI4823.13.96324.05.0
z-BMI483.31.4633.31.6

A Hollingshed two-factor socioeconomic status (SES) measure (33) was available for the care givers of 64 of the 111 children used in this analysis. SES status was not related to care giver perception of child's weight, child's appearance, or eating habits; percentage of family members with chronic illnesses; or perception of health risk. Care givers with higher SES measurements were more likely to report their children getting the right amount of exercise (p = 0.01). Comparison of the families for which SES was available with those for whom it could not be ascertained showed no differences in child's weight, care giver perceptions of child's appearance, eating and exercise habits, or perception of health risk. Families for whom SES data were not available were less likely to report having family members who were either overweight (p = 0.03) or diabetic (p = 0.03). There was a relationship between SES and z-BMI (r = 0.27, p = 0.03) but no association between z-BMI and the presence or absence of SES data. Higher SES was associated with greater z-BMI.

Weight and Family Health History

Children were grouped into four categories according to their z-BMI value. Those with a z-BMI ≤ 1.65 kg/m2, putting them below the 95th percentile, were not heavy enough (normal weight) to be eligible for the intervention study. Those children between the 95th and 99th percentiles (z-BMI > 1.65 and < 2.32 kg/m2) were classified as heavy, and between the 99th percentile and 5 standard deviations above the mean were classified as obese. Children whose z-BMI was more than 5 standard deviations above the mean were classified as super-obese.

Nine percent of the children screened were normal weight, 22% were heavy, 57% were obese, and 12% were super-obese. Table 2 presents descriptive statistics and responses to the Health Awareness Interview as a function of the child's weight category.

Table 2.  Perception of child health risk
VariableNormal (N = 11)Heavy (N = 24)Obese (N = 63)Super-obese (N = 13)Total (N = 111)
  • Normal (z-BMI ≤ 1.65), overweight (1.65 < z-BMI ≤ 2.33), obese (2.33 < z-BMI ≤ 5.0), super-obese (z-BMI >5.0).

  • *

    χ2 (p < .01).

  • χ2 (p < .001).

Child referred for weight evaluation*1 (9%)0 (0%)6 (10%)5 (38%)12 (11%)
Child received services for weight1 (9%)0 (0%)6 (10%)2 (15%)9 (8%)
Ever given a diet0 (0%)0 (0%)5 (8%)2 (15%)7 (6%)
Referred for weight health problems0 (0%)0 (0%)2 (3%)2 (15%)4 (4%)
Family members overweight9 (82%)19 (79%)50 (79%)12 (92%)90 (81%)
Family members losing weight5 (45%)10 (42%)29 (46%)6 (46%)50 (45%)
Diabetic family members7 (64%)18 (75%)39 (62%)10 (77%)78 (70%)
Child's weight     
Too thin1 (9%)1 (4%)1 (2%)0 (0%)3 (3%)
Just right9 (82%)10 (42%)9 (14%)0 (0%)28 (25%)
Little heavy1 (9%)13 (54%)42 (67%)7 (54%)63 (57%)
Very overweight0 (0%)0 (0%)11 (17%)6 (46%)17 (15%)
Child's frame size*     
Small2 (18%)2 (8%)0 (0%)0 (0%)4 (4%)
Medium6 (55%)14 (58%)29 (46%)4 (31%)53 (48%)
Large3 (27%)8 (33%)33 (52%)9 (69%)53 (48%)
Believe weight is health problem0 (0%)6 (25%)32 (51%)7 (54%)45 (41%)
How much does child eat     
Too little1 (9%)1 (4%)0 (0%)1 (8%)3 (3%)
Just right5 (45%)8 (33%)21 (33%)2 (15%)36 (32%)
Too much5 (45%)15 (63%)42 (67%)10 (77%)72 (65%)
Well-balanced diet     
Balanced5 (45%)11 (46%)33 (52%)10 (77%)59 (53%)
Wrong foods6 (54%)13 (54%)30 (48%)3 (23%)52 (47%)
Child Exercise     
Not enough8 (73%)15 (63%)39 (62%)12 (92%)74 (67%)
Just right3 (27%)9 (38%)23 (37%)1 (8%)36 (32%)
Too much0 (0%)0 (0%)1 (2%)0 (0%)1 (1%)
Exercise time per day     
>2 hours2 (18%)8 (33%)18 (29%)6 (46%)34 (31%)
1–2 hours4 (36%)9 (38%)27 (43%)7 (54%)47 (42%)
<1 hour5 (45%)7 (29%)18 (29%)0 (0%)30 (27%)

Despite the large number of children who were extremely overweight (obese and super-obese), only 11% of all children had ever been referred for medical evaluation because of their weight. Eight percent of the children had received prior treatment related to weight problems, and only 6% of the children had ever received dietary services or been placed on a therapeutic diet.

Many families reported a family history of obesity, diabetes, and other chronic illnesses such as hypertension and hypercholesterolemia. Currently, 45% of care givers reported that a least one family member was actively trying to lose weight.

Parents were asked to categorize their children's body weight as underweight, just right, overweight, and very overweight. There was a significant difference in categorization as a function of weight category, with more parents of the obese and super-obese children describing their children as overweight or very overweight (p = 0.0001). However, in the super-obese children, only 46% of the care givers described the child as very overweight. Care givers were also asked to describe their child's frame size as small, medium, or large with more parents of children in the obese and super-obese groups describing them as having a medium or large frame (p = 0.04). When parents were asked, “Do you think your child's weight is a health problem?,” 44% answered “Yes.”

Care givers were asked to describe the child's eating habits in terms of the amount and kind of food the child typically eats. Three percent of parents reported their child ate too little. Thirty-two percent said their child ate just the right amount of food, and 65% said their child ate too much. A slight majority of parents believed their child ate a well-balanced diet, whereas 47% rated their child as eating the wrong foods.

Two-thirds of care givers reported that their child did not get enough exercise, one third believed their child got the right amount of exercise, and one care giver described their child as getting too much exercise. When asked how much physical activity the child got, 27% reported less than an hour per day, 42% responded between 1 and 2 hours per day, and 31% said more than 2 hours per day.

Regressions

Because the question about parental perception of health risk was scored as a dichotomous variable (yes or no), hierarchical logistic multiple regression was used to determine which variables predicted parental perception of the child's weight as a health risk. We first considered the physical characteristics of the child and family. We then considered subjective parental perception of the child's relative weight, frame size, eating habits, and exercise behaviors.

In the first block, age, gender, and z-BMI were entered to determine if perception was related to the child's measurable physical characteristics. Variance accounted for by this model was 14.3% (p = 0.0002). Examination of t tests on the beta weights showed that age (p = 0.01) and z-BMI (p = 0.0009) made a significant contribution to the prediction of perceived risk. Older and heavier children were more likely to be seen as at-risk. Gender was dropped from further regressions.

The second block of variables tested was related to family history of obesity and obesity-related comorbidity (diabetes, hypertension, and hypercholesterolemia). After controlling for age and z-BMI, these variables did not significantly improve the prediction of perceived risk (p = 0.54). Family history of illness variables were dropped from further regression analyses.

The third set of predictors included perceptions of the child's weight and frame size increasing the percentage of variance accounted for to 16.3% (p = 0.11). Because frame size (small, medium, large) made a marginal contribution to the regression (p = 0.11), it was retained in the final analysis. Children reported to have a larger frame size were perceived to be at greater risk.

The final block of variables included parental perceptions of overeating and exercise. These variables increased the percentage of variance accounted for to 21.1% (p = 0.01) with only the amount of exercise (p = 0.01) making a significant contribution. Table 3 presents the results of the final logistic regression model.

Table 3.  Results of hierarchical regression analysis predicting parental perception of child's health risk
StepVariableBetaPR2P
1   0.1430.0002
 Age0.3950.01  
 z-BMI0.5410.0009  
2   0.1630.11
 Frame size (1 = small … 3 = large)0.6650.11  
3   0.2110.01
 Perception of exercise (1 = too little … 3 = too much)−1.150.01  

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Care givers of obese African American 5- to 10-year-old children were asked whether their child's weight was perceived to be a health risk. A number of factors expected to influence this attitude or opinion were assessed. Presence of weight-related comorbidity in first and second degree relatives, eating and exercise habits of the child, perception of body size and appearance, and dieting history in the child and care giver were assessed. Only age, evaluation of frame size, degree of overweight, and parental report of child's exercise level predicted care giver perception of risk. Despite almost 70% of our sample being frankly obese, only 44% of care givers perceived their child's weight to be a health problem. Clinical intuition that family history of obesity, diabetes, and heart disease would influence parental perception of the child's weight-related health risk was not confirmed.

This sample of families is not representative of the larger pool from which they were drawn. The families screened represented less than 10% of the general pool identified by weight for height at last medical examination and does not include children who do not receive regular medical care. Clearly, the majority of the care givers voted with their feet, i.e., they did not choose to have their child screened for diabetes. A few families expressed concern about participation in research, asking whether any experimental procedures would be used on their child. Often parental concerns could be assuaged through the thorough explanation of the study design. Occasionally, care givers were adamantly against having their child participate in a research program. Perhaps care givers who chose not to screen their children for diabetes or participate in a weight-management program did not perceive their child's weight to be worthy of attention at the present time, believed the children might grow out of being overweight, felt incapable of altering their child's weight status, or did not perceive their child to be significantly overweight.

The later explanation is supported by studies indicating differences in perceptions of ideal body weight between black and white adolescent (18, 19) and adult (20, 24) females. In general, African American women are more tolerant of a larger body size, less likely to be dieting when they are in fact normal weight, and less likely to use extreme measures to lose weight (24). This is true despite the fact that African American women are on average more likely to be overweight, and have higher rates of weight-related chronic disease than European Americans (1, 2, 3). Smith et al. (34) examined body image in 1837 men (45% African American) and 1895 women (51% African American) who participated in the coronary artery risk development in young adults (CARDIA) study. They found that women were more dissatisfied with their appearance than men. After controlling for age, BMI, and education, black women were more satisfied with their appearance than whites suggesting that black women are content with a larger body habitus than white women.

Less is known about body image in men and boys. However, when actual and ideal size is compared in adult males, the distribution is usually bimodal with some males wishing to lose weight and a substantial number wishing to gain weight (34, 35). What has been missing from these studies is an examination of how African American care givers perceive the size and shape of their children. Our findings suggest that a similar tolerance of a larger body habitus in children may be operating in this population.

These parents rightfully assessed their children to be healthy at the present time. However, the majority misjudged the appropriateness of their child's size, eating, and exercise habits relative to their actual weight. Many did not make the association between their child's weight and risk for the health problems that were so prevalent among family members. One potential explanation of this lack of association may lie in what Weinstein (36) calls optimistic biases about personal risks.

An optimistic bias occurs when one minimizes one's personal health risk. That is, one sees other people as being at risk but does not see oneself as having a similar degree of risk. A number of reasons are offered for this bias. First, if individuals believe that signs of vulnerability appear early, then lack of those signs in the present may be interpreted as being exempt from future risk (36). These care givers rightfully judged their children to be healthy. Their health in the present may have reduced parental perception of future risk.

Second, failure to make the connection between childhood obesity, adult obesity, and weight-related chronic diseases may have allowed parents to underestimate their child's risk for diabetes. Prevention campaigns target middle aged and elderly individuals who are obese. Because many care givers did not perceive their children to be overweight even though they were overweight, this “campaign” stereotype may have led care givers to conclude that their child did not fit the description of a person at risk for developing obesity-related diabetes.

Third, humans are prone to optimistic bias as a coping mechanism. Optimism is associated with less depression. Seeing chronic disease as an inevitable part of their child's future is perhaps too stressful for care givers, especially if they do not see a clear way to modify that risk. African Americans and their families have higher rates of obesity, diabetes, and hypertension than European Americans (1, 2, 3) and have poorer outcomes associated with these disease entities (37). Perceived lack of control over disease outcomes and a tendency to see one's own health risk as less than that of others may also contribute to the optimistic bias that their children will not succumb to these devastating health problems (38).

The most successful weight loss programs for children are family-based (39), and directing weight loss interventions to children alone does not produce rigorous and sustained results (40). If mothers are experiencing less incentive and less success with their own weight management, they may be less likely to attempt to change their child's weight status. National surveys have shown that as many black women engage in weight control practices as often as white women, but black men are less likely than white men to practice weight control (22, 23). However, black women are less likely than white women to enroll in weight loss programs (41) and often do not do as well (42).

A number of reasons for the apparent minimization of child health risk include cultural differences in the acceptance of a large body habitus, lack of knowledge about the connection between childhood obesity, behavior, and future health, and an optimistic bias in the perception of personal health risk. Getting parents interested in taking steps to prevent obesity or obesity-related chronic diseases in their children will involve educating them about the health risks associated with childhood obesity and making the connection between childhood obesity and early onset type 2 diabetes. To reach African Americans, these messages will need to be made culturally sensitive and address cultural differences.

Care giver perception of weight as a health risk was asked in a global fashion. It is possible that results may have been different if parents were asked whether their child's weight placed them at higher risk for developing diabetes, hypertension, or high cholesterol. Specific questions need to be asked regarding disease vulnerability in these children, as well as the care givers’ preferences regarding their child's future weight and body size. As this is an ongoing project that will assess the efficacy of weight-management interventions, we will also have the opportunity to assess changes in care givers’ attitudes about control over disease outcomes and to come to a better understanding of the factors that contribute to the perception of health risk in children.

There is a growing epidemic of type 2 diabetes in minority children related to population increases in obesity (43). Childhood obesity and early onset type 2 diabetes is a public health problem. Childhood obesity is not a character flaw of the child or a failure in parenting. Powerful social, economic, and environmental changes that influence family lifestyle drive this epidemic (44, 45). Prevention of obesity and diabetes must become a priority, population-based, public health initiative. Prevention requires action at all levels, from individual clinical intervention to social marketing to the passage of legislation that addresses such issues as safe urban areas for walking and cycling, physical education in schools, and healthy school lunches. Ultimately, the goal is to encourage primary care givers to adopt behaviors that will prevent obesity and weight-related diabetes in this high-risk population.

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  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
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