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Department of Family Medicine, University of Wisconsin Madison, 777 South Mills Street, Madison, WI 53715. E-mail: email@example.com
Objectives: Pediatric obesity is a significant and increasing problem in Native-American communities. The aim of this study was to determine whether parents and other caregivers from three Wisconsin tribes recognized overweight children. We also assessed caregiver attributes associated with levels of concern for risk of future overweight and chronic disease.
Research Methods and Procedures: Data were obtained from child health screenings and caregiver surveys. Participants included 366 kindergarten-through-second grade child–caregiver dyads. Children's BMI percentiles were calculated and compared with caregiver responses. We assessed the relationships between predictors of caregiver concern for health risk factors and recognition of overweight.
Results: Twenty-six percent of children were overweight (≥95th percentile), and 19% were at risk for being overweight (≥85th to <95th percentile) using Centers for Disease Control standards. Caregivers recognized only 15.1% of overweight children. Factors predictive of child overweight recognition included a child BMI >99th percentile and grandmother as caregiver. Overall, caregivers were more concerned about diabetes and cardiovascular disease than obesity. Parents with diabetes and heart disease were more concerned than others about risk for these diseases; however, only diabetic parents made a connection between child weight status and future risk of obesity-related disease. Child sex, child age, and parental education level were not significant predictors for caregiver recognition of an overweight child.
Discussion: Most caregivers did not recognize overweight children or associate excess weight with increased risk of disease. When designing community interventions, it is crucial to incorporate caregivers’ attitudes and beliefs regarding childhood overweight and risk of future disease.
The incidence of obesity in both adults and children is steadily increasing. Currently, 64% of U.S. adults are either overweight or obese (1). The number of children who are overweight has tripled from 5% to 15% between 1980 and 2000, and the incidence of children with type 2 diabetes is on the rise, with the highest prevalence in Native-American youths (2, 3). Unfortunately, it has been shown that overweight children have a high risk of becoming overweight adults (4, 5, 6). It is becoming clear that childhood overweight needs to be addressed in early childhood, and the success of obesity treatment programs relies on active parent participation (7, 8). However, it is very difficult to engage parents in changing their child's eating and exercise patterns if they do not perceive their child as overweight, accept it as a problem, and recognize that excess weight puts their child at risk for comorbidities such as cardiovascular disease, diabetes, cancer, and hypertension (9, 10).
Recent studies have shown that 32% to 89.5% of parents do not recognize that their overweight child is overweight (11, 12, 13, 14). One study found that mothers who misclassified their overweight preschool children were more likely to have a high school education or less (12). A study of African-American parents found that, even if parents perceived their child as overweight, less than one-half of parents (43%) perceived obesity as a health risk, even if they had a family history of obesity and its complications (15). Previous studies including whites, African Americans, and Mexican Americans did not find race to be a significant factor when comparing parent recognition of childhood overweight.
Since the 1950s, the main cause of death among Native Americans has shifted from infectious to chronic diseases, which can be mitigated by lifestyle changes. Cardiovascular disease, type 2 diabetes, and cancer are now the leading causes of death in Native-American populations. These diseases, particularly diabetes, are strongly related to the increasing prevalence of obesity (16, 17, 18). Little research has been done in the upper midwest, despite the fact that Native-American communities in Wisconsin have some of the highest rates of cardiovascular disease and diabetes in the United States. These communities are concerned about the increasingly earlier onset and the financial and emotional burden these diseases place on families.
To date, we are not aware of any study that has examined caregiver attitudes toward childhood obesity specifically in Native-American populations. In our study, we examined attitudes of Native-American caregivers toward overweight in their kindergarten-to-second grade children. We hypothesized that caregivers’ recognition of overweight children and caregivers’ perception of risk of chronic disease would be significantly related to a variety of factors, such as child and caregiver sex, caregiver generation and education level, age of child, and parental history of obesity-related sequelae. The research was carried out as part of a larger participatory research project for obesity prevention called the Wisconsin Nutrition and Growth Study, currently underway with three Wisconsin tribes. The partners in this collaboration intend to use the results of this analysis to help develop community-based intervention projects.
Research Methods and Procedures
Three hundred sixty-six kindergarten-through-second grade children from three Wisconsin Native-American reservations participated in health screenings consisting of height, weight, hip and waist circumference, triceps and subscapular skinfold thickness, blood pressure, and finger stick blood draw for glucose, total cholesterol, and high-density lipoproteins. For the purpose of this analysis, we focused only on the child's BMI percentile. Caregivers filled out surveys for each child included in our dataset. We collected data for this investigation between October 2001 and November 2003 in a series of nine screenings.
The process of recruitment differed among the three communities. Two of the reservations have schools located on the reservation that agreed to allow health screenings during the school day. For these two communities, the school sent home parent surveys and consent forms with all kindergartners through second graders (4.5 to 8.5 years old) on two separate occasions before the health screenings, to be filled out by the parent or a primary caregiver. Screenings took place at school over a period of 2 to 3 days. Schools received $10.00 in compensation for each child screened, and child participants received a t-shirt and some small prizes.
Because the third reservation does not have a tribal school, screenings took place at several community health fairs on the reservation. Advertisements for the health fair were posted in the tribal newspaper and at various community locations. On the day of the health fair, children were screened after caregivers filled out a consent form and survey. Caregivers received $10.00 in cash for their participation, and children received a t-shirt and some small prizes.
Researchers obtained approval for the study from the tribal councils, tribal and public school boards, health boards, the University of Wisconsin Institutional Review Board, and the Indian Health Service National Institutional Review Board. Parents or guardians provided signed informed consent for their child's screening. Caregivers received screening results with an explanation of normal values, and both parents and tribal health clinics were notified if follow-up was needed with a health provider. Aggregate results were also presented to the tribes.
The same trained university researcher performed measurement of heights and weights for every child. Measurements of height were made with a portable stadiometer (Schorr Productions, Woonsocket, RI) to the nearest 0.1 cm. Weight was measured by an electronic balance that is incorporated into the Tanita Body Composition Analyzer (Tanita Corp., Arlington Heights, IL). Weight was measured without shoes and in light clothing to the nearest 0.1 kg. Sex- and age-specific percentiles for BMI (kilograms per meter squared) were used for child weight classification as determined by the Centers for Disease Control (i.e., underweight, <5th percentile of age and weight standards; normal weight, ≥5th to <85th percentile; at risk for overweight, ≥85th to <95th percentile; overweight, ≥95th BMI percentile) (19). Parent height and weight were collected from the survey. The use of self-reported weight and height in adults has been validated in previous studies (20, 21, 22, 23). According to the World Health Organization and Centers for Disease Control criteria, adults with a BMI ≥25 kg/m2 are overweight, and those with a BMI ≥30 kg/m2 are obese (24).
University researchers, in conjunction with community research teams, designed the survey to be culturally appropriate and nonjudgmental. Sixty-one questions covered demographics; child medical history (i.e., birth weight and length and breastfeeding); family history of diabetes and heart disease; caregiver concern for child's risk of obesity, diabetes, and heart disease; birthparent height, weight, and education level; and information on child diet, activity and television watching habits. We field-tested the survey during the first year and subsequently made slight modifications. Participants indicated who filled out the survey. To examine caregivers’ perceptions of their child's weight and risk of sequelae, caregivers responded to the question, “Are you concerned that this child might be at risk in the future for the following illnesses?” For each category (diabetes, heart disease, and overweight), possible responses included “no, a little, a lot, or already is overweight (has diabetes or heart disease).” We considered a caregiver to have recognized that their child was overweight if they responded “already is overweight.” Level of caregiver concern was evaluated by comparing “not concerned” to the different levels of expressed concern. Parental heart disease included “heart problems or high cholesterol.”
Descriptive analyses were conducted to understand distributions and relationships among the variables. Pearson's or Fisher's exact χ2 tests assessed the relationships among various predictors of caregiver concern for health risk factors and recognition of overweight. To answer several research questions, we analyzed caregiver responses as subsets [i.e., all caregivers, parents (mother and father), grandmothers, mothers, and fathers]. Consequently, the sample size for each analysis differs. Our age cut-offs for kindergarten through second graders were ≥54 months (4.5 years) and ≤102 months (8.5 years). For the purpose of testing the relationships between caregiver characteristics and recognition of overweight, we recoded the dependent variables into appropriate dichotomies. Specifically, when analyzing recognition that a child was overweight, we compared “already is overweight” to all of the other categories combined, because even though they may have been concerned, they did not recognize the child as overweight. Similarly, when analyzing level of concern about child's weight, we compared the “not concerned” responses to the combination of the remaining categories expressing some level of concern. Analyses were completed using SPSS version 11.5 (25). Significance for these analyses was set at p ≤ 0.05.
Description of Sample
We conducted a total of nine health screenings in three Wisconsin tribal communities, resulting in a total of 425 child screenings. Over 50% of children in the correct age group at each site were recruited. We have corresponding caregiver surveys for 366 of the 425 children screened. Our data analysis is from these 366 child–caregiver dyads. Child sex was evenly distributed, with 52% boys and 48% girls. Where caregiver information was completed, 74.1% were filled out by mothers, 9.7% by grandmothers, 8.6% by fathers, and 7.6% by other guardians. Caregiver type was not identified in one-quarter of the cases. Of children whose ethnicity was reported, 94% were Native American.
Child Characteristics and Caregiver Recognition of Overweight
Using the height and weight measurements obtained at screenings, we determined that 26% of the children were overweight, and 19.1% were considered at risk for overweight. Slightly more boys (28.0%) were overweight than girls (23.7%; not significant). Overweight children were more likely than others to have an obese parent (p < 0.055). As shown in Figure 1, parents of overweight children were significantly more concerned about future risk of overweight than parents of normal weight or at-risk weight children. However, only 15.1% of overweight children were recognized as being overweight by the responding caregiver. Overweight children who were recognized as “already overweight” by caregivers had a mean BMI significantly greater than overweight children who were not recognized as being overweight (p < 0.003). Overweight children who were recognized as such had a mean BMI >99th percentile. None of the caregivers incorrectly classified their at-risk or normal weight children as being overweight. There was no significant difference in recognition of overweight based on the child's age or sex.
Caregiver Characteristics and Recognition of Overweight
Several caregiver characteristics were significantly predictive of recognizing that a child was overweight and of level of concern about child weight. Grandmothers were significantly more likely than mothers to be concerned about overweight in children who were at risk or overweight (p < 0.003; Figure 2). Overweight mothers tended to be better at identifying their overweight children compared with normal weight and obese mothers (p < 0.07; Figure 3). Overall, 73.9% of the mothers were themselves either overweight or obese.
Fathers did not identify weight problems in their children. None of the fathers recognized an overweight child. Furthermore, of the fathers who responded to the question, all were either “not concerned” or only “a little concerned” about risk of overweight. All but 1 of the 23 fathers responding (96.0%) were themselves either overweight or obese. In addition, parents with diabetes and heart disease were not significantly more likely to recognize an overweight child. There was also no correlation between parent education level and recognition or concern about child's weight.
Caregiver Concern for Future Risk of Obesity-Related Diseases
Caregivers, in general, were more concerned about heart disease and diabetes than about their children's risk of being overweight. Overall, we did not find a significant relationship between recognition that a child was overweight and concern about future risk for obesity-related diseases. However, diabetic parents were significantly more concerned about risk of diabetes than nondiabetic parents, regardless of child weight (p ≤ 0.003). Diabetic parents were also significantly more concerned than others about risk of diabetes if the child was overweight verses normal weight (p ≤ 0.05). Almost one-half (46.2%) of diabetic parents of an overweight child were “a lot” concerned about diabetes risk compared with only 12.5% of nondiabetic parents of overweight children (p = 0.003; Figure 4).
Even though the study population is part of the Bemidji Area (Minnesota, Michigan, and Wisconsin), which has the highest rate of cardiovascular disease among all Indian Health Service areas (18), only 10.2% of caregivers were “a lot” concerned about their child's future risk of heart disease. Parents with heart disease were clearly more concerned about risk of heart disease than those without heart disease (p < 0.001). However, the sample size was insufficient to determine a significant difference between these parental groups in terms of concern about children's risk for heart disease when looking at only overweight children.
Formulating effective community interventions depends, in part, on local recognition of childhood weight problems and related future health risks. In this study, we found that only 15.1% of caregivers recognized an overweight child. Factors that significantly increased recognition of overweight were high child BMI percentile and caregiver generation. Parents with diabetes and heart disease were more concerned for future risk of these diseases. Only diabetic parents were able to significantly identify child overweight with risk of future diabetes. We found that overweight children were more likely to be recognized as overweight if their BMI was >99th percentile. Thus, the children had to be very overweight before they were likely to be viewed as overweight at all. This very low rate of overweight recognition is comparable with those reported by other investigators across ethnic groups in the United States (12, 13, 14).
It is important to understand why parents do not perceive their children as being overweight or worry about the consequences. Potentially, caregivers use a high threshold for defining overweight, are reluctant to label their own child as overweight, or some combination of these and other factors. For example, Jain et al. (26) reported that, in a small sample of mainly African-American women, overweight children were alternatively described as “thick” or “big boned.” These mothers expressed distrust of medical height–weight charts, felt that children could not overcome their genetic predisposition to obesity, saw younger children as having “baby fat” that they would grow out of when they got taller, or grew concerned about their child's weight only when it caused teasing or inactivity.
The reasons for low recognition of overweight in our sample remain unclear; however, several potential explanations have come from local community health care providers and the caregivers themselves during key informant interviews (H. Webert, personal communication, 2003). In general, it seems that big children are viewed more positively as “cute and healthy,” whereas “skinny” (i.e., normal weight) children are viewed more negatively as “underfed and sickly.” Some parents have reported experiencing social pressure to “fatten up” their babies. Some community leaders have reported competitions among mothers to see whose child is in the highest percentile for height and weight (H. Webert, personal communication, 2003). We also observed this kind of competition during the health screenings. This may indicate a misunderstanding of the commonly used weight percentile charts (i.e., if 50th percentile is good, then 95th percentile must be better).
Several of our findings contradict previous studies. Maynard et al. (13) found a significant difference in misclassification of at-risk for overweight 2- to 11-year-old children as overweight if the children were either girls or older and had mothers with a lower BMI than their children. In our study, there were no overestimations of weight category in either the normal or at-risk children, and none of these variables showed a significant relationship to overweight recognition. We may not have found a difference in weight perception between younger and older children or boys and girls because these children were all quite young, with a minimal age range, and these differences may not surface until adolescence. Baughcum et al. (12) also studied very young participants (23 to 60 months) and did not find sex to be a significant determinant of overweight recognition.
The issue of maternal weight status and parental education level as predictors of overweight recognition has proven to be complicated. We found that overweight mothers were significantly more likely to recognize an overweight child; however, obese mothers tended to be the least likely to recognize an overweight child compared with both normal and overweight mothers. This is counterintuitive. Previous studies have found that maternal weight status was either not significant or that mothers with lower BMIs were the most likely to overestimate a child's weight (12, 13). Our results also differed from the Baughcum study (12) because we did not find any difference in recognition of overweight based on parent's education level, even though we had sufficient numbers of responses from families with both lower and higher education levels. These discordant findings might reflect true variation between distinct populations or may simply be a result of differences in the respective research designs.
Our data suggest that grandmothers and parents with diabetes may have unique perspectives. We found that grandmothers were significantly more likely to be concerned about overweight in at-risk and overweight children than mothers. The reason for this generational difference is unclear. It may be tied to the fact that grandmothers are better able to compare children today to children from past generations. Within their lifetime, the grandmothers may have seen drastic changes in average body sizes and lifestyle, including the amount of television viewing, fast food consumption, exercise, and availability of “junk food.” They have also lived longer to see more family members and friends suffer from the consequences of obesity and, thus, may be able to recognize overweight children more readily. In addition, grandmothers are more likely to already have diabetes or heart disease themselves. Comparisons between these caregiver groups have not been studied previously, so we cannot know whether these findings are unique to the particular communities in our study.
It is encouraging that diabetic parents seem to appreciate the connection between childhood weight and future risk of diabetes. Parents with diabetes may understand the connection between excess weight and diabetes risk better than others, because they likely have received counseling by health care providers on improving glucose control through weight reduction. Alternatively, they may just be more willing to label a child as overweight because they have had firsthand experience with obesity-related disease.
This study had two key limitations. First, our sample was not randomly selected, although ∼50% of children in this age group were screened, thereby limiting generalizability to other communities, including other Native-American nations. Second, a number of variables could have been measured more effectively. We did not ask each caregiver filling out the survey their specific education level but asked only the highest grade that any adult in the household completed. This may be why no significant difference was detected based on education level. Also, because of the low frequency of recognition of overweight in our study, it may have been better to ask the question in two parts: first, “is your child overweight?” and second, regarding the level of concern. However, the majority of researchers thus far have found similarly poor rates of recognition with many different question formats. It is possible that this generation of parents have just come to perceive overweight children as normal weight children. Finally, further insight might have been gained by allowing space for open-ended responses as to why caregivers did or did not perceive their child to be overweight or at-risk for diabetes and heart disease.
Because the research reported here is part of a larger participatory collaboration between university researchers and tribal communities, the results were examined in consultation with community-based research teams at each tribe. In general, tribal researchers found the results useful and felt that the average person does not perceive obesity to be a disease but only to have some social stigma. Also, there is an overall feeling that “a big baby is a healthy baby.” The Inter-Tribal Heart Project surveyed 1376 people on two Chippewa reservations and the Menominee reservation between 1992 and 1994. This study found that 93% of participants recognized obesity as a risk factor for cardiovascular disease and diabetes (27). However, the question was asked about adult obesity in general and not pediatric obesity, which may explain the discrepancy. Finally, community-based researchers felt that fathers may be a significant target for intervention because they did not recognize the problem and tended to be responsible for family recreation and activity levels. Discussions of results with the community allow for joint interpretation of the data, increase the cultural and internal validity of the results, minimize harm by stigmatization, and maximize benefits (28).
To be successful, community interventions will need to incorporate understanding of caregiver attitudes and beliefs regarding childhood overweight and risk of future disease.
We thank all of the parents and children who participated in the screenings, the Bad River, Lac du Flambeau, and Menominee Reservations and community-based researchers, and the Great Lakes Inter-Tribal Council for support of this project. This work was supported by NIH Grants 5-K23HL068827-03 and 1-U269400014-01 and by CDC-Wisconsin DHFS Cooperative Agreement U50/CCU521340-03 for State Cardiovascular Health.