1. Introduction
Since the late 1980s, China has experienced a rapid rise in overweight/obesity, especially among young children. Early childhood obesity has become a major public health problem in China, with an estimated prevalence of 6 to 14% in urban, preschool-aged children [
1,
2,
3,
4]. Rapidly increasing burdens of childhood overweight/obesity have been attributed to recent modernization and nutritional transitions [
5,
6]. Levels of pediatric overweight in China have more than doubled since 1991, reaching an estimated 15% in 2011 [
7]. This prevalence is similar to that of Western countries, such as the US, where 15% of children were also reported to be overweight in 2011–2012 [
8,
9,
10]. Obesity during childhood is a strong predictor of obesity in adulthood and has been associated with poor cardiovascular health, in addition to elevated risk for type 2 diabetes, hypertension, and other non-communicable diseases [
11,
12,
13,
14]. Dietary habits have also been shown to form during early childhood and persist into adolescence and adulthood [
15]. Therefore, early interventions that target young children are crucial [
16].
Parents have a large influence on the eating behaviors of their children as they control the energy density and portion sizes of the foods that are consumed [
17,
18,
19]. Parental involvement has been shown to be critical in efforts to reduce childhood overweight/obesity [
20]. However, for parents to make positive changes in their children’s diets, they should have an accurate perception of their children’s weight statuses and understand the potential health consequences [
21,
22]. Studies in Europe and the US have shown that parents frequently underestimate their children’s weights, especially those of overweight/obese children [
23,
24]. A study conducted in Italy showed that a third off caregivers surveyed believed that greater child weight was an indication of good health. Caregiver education was also positively associated with the identification of childhood overweight as a health concern [
25]. In China, where grandparents or other family members are commonly the primary caregivers of children, studies have reported similar results with 40 to 72% of caregivers underestimating the weights of their overweight children [
26]. Furthermore, 65% of caregivers in China with an overweight child reported that they would not want to decrease their children’s weights [
27,
28,
29]. Little is known, however, about how caregiver attitudes on weight status relate to health behaviors in young, Chinese children.
Accordingly, the aim of this study was to understand how dietary behaviors and caregiver perceptions of child weight are related to child weight status among Chinese 2- to 6-year-old children. We conducted an observational, cross-sectional study in six urban preschools in Changsha (China). Findings from this study may be used to inform future interventions on the management of pediatric overweight/obesity among Chinese children.
4. Discussion
We report a high prevalence (61.6%) of caregiver underestimation of overweight/obesity among urban, Chinese preschoolers. Caregivers with male children and those from lower-middle income households were significantly more likely to underestimate their children’s overweight/obese weights. Furthermore, caregivers who underestimated weight were more likely to have children with poor appetites, less likely to worry about child weight status, and less likely to adopt dietary restrictions for their children. These findings suggest that accurate classification of child weight is an important factor in shaping the dietary behaviors for young children and may be a vital component of future interventions to manage pediatric overweight/obesity.
The high prevalence of overweight/obesity among young, Chinese children (17.8%) reported in this investigation was consistent with previous findings in Chinese populations [
1,
2,
3,
4]. Similar to findings in China, the US, and industrialized European countries, we also found a large proportion of caregivers with overweight/obese children underestimated their children’s weight status [
23,
24,
27,
28,
29]. However, to our knowledge, no studies have previously been conducted in China evaluating caregiver perceptions among children as young as 2-years old. Given the high prevalence of overweight among preschool-aged children reported in this study and others, early interventions should be prioritized for the management of pediatric overweight/obesity [
1,
2]. Interventions that focus on parenting and the early feeding environment have been suggested to be effective, which highlights the need to understand the role that caregiver perceptions play in shaping child weight during infancy and early childhood [
16].
Caregivers in our study were more likely to inaccurately classify the weights of male children than female children, which was consistent with previous findings among Chinese adolescents [
27]. The difference in ability to discriminate between the weights of male and female children may be attributable to gender norms. Whereas slender body types tend to be more favorable for girls, overweight boys may be perceived as strong [
36]. As a result, overweight daughters may elicit greater attention and scrutiny than sons. We also found that caregivers from households earning 7000 to 11,000 RMB per month were significantly more likely to underestimate child weight compared to those from households earning more than 11,000 RMB. However, there was no significant association for households earning less than 7000 RMB per month. This study is the first to our knowledge to report an association between lower-middle income households and caregiver underestimation of child weight status in China. Health knowledge and education among caregivers may be a potential explanation for our findings. In qualitative studies with low-income families in the US, mothers preferred to describe their overweight children as tall or big boned and believed that their children would grow out of being overweight [
37,
38]. However, further work is necessary to understand the association between household income and caregiver perceptions.
Inability to accurately identify children’s overweight statuses is problematic given that substantial evidence suggests that perceived level of concern is critical for motivating health-related behavioral changes [
21,
22]. Furthermore, studies demonstrate that parents play a pivotal role in the successful management of childhood obesity [
17,
18,
19,
20]. We found that caregivers of overweight/obese children who underestimated their children’s weights were less likely to worry about weight and more likely to want their child to maintain their current weight or gain weight. These results suggest that caregiver misperceptions of children’s overweight statuses may pose significant barriers to positive change.
A previous study conducted in the US reported that parental misperception of child weight was associated with unhealthy dietary behaviors [
39]. Specifically, we found that overweight/obese children with caregivers who underestimated their weights were more likely to have a poor appetite. Although there is evidence that supports an underlying genetic basis for appetite, parents have also been shown to play a critical role in the development of child eating behaviors and appetite [
15,
18]. It may be speculated that caregivers who fail to recognize their children’s overweight/obese weight statuses will also be less attentive to their dietary behaviors. It is also possible that caregivers of children with poor appetites are more likely to perceive them as undernourished, leading caregivers to underestimate their weight. The development of appetite in Chinese children is poorly understood and further work is required to fully elucidate the relationship between child appetite and caregiver perceptions.
Caregivers in our study who incorrectly classified child weight were less likely to implement dieting measures for their children, such as eating less meat and reducing overall dietary intake. This positive association between caregiver accuracy and dietary restriction is similar to findings from a US study, which reported that parents who correctly identified their children as overweight were more likely to encourage dieting [
40]. Additionally, we found that 12.5% of caregivers who underestimated their children’s overweight/obese status said that they attempted to increase food intake for their children (compared to 0% of caregivers who accurately classified child weight). Encouraging increased food consumption and restricting dietary intake have both been associated with long-term weight gain [
39,
40,
41]. The casual relationships between feeding practices and child weight gain are not well defined and may depend on more nuanced factors, such as parenting style. In our previous study, we found that parental BMI values were positively correlated with child BMI [
42]. Nevertheless, our findings identify well-intentioned, but potentially detrimental dietary practices employed by caregivers seeking to control their children’s weights.
Several limitations should be noted when interpreting our results. First, our investigation employed a cross-sectional design in a medium sized city in southern China. As a result, we were unable to report causality in our results and our findings may not be representative of the entire country. Second, we used self-reported data from caregivers, which were subject to social-desirability and other forms of response bias. Parental height and weight were also based on self-reported values, which may have been biased or inaccurate. Third, height and weight measurements of children came from physical examinations conducted by each school. This data may have been subject to measurement errors and inter-observer agreement was not assessed. Fourth, although our questionnaire was adapted from previously validated instruments and tested among Chinese populations, it was not validated in this particular study population [
29,
32]. Lastly, 14.2% of participants were excluded from the final analysis, primarily due to missing data. There were no significant differences, however, in weight status, age, sex, or primary caregiver identity between the included and excluded populations.