Parental misclassification of child overweight/obese status: The role of parental education and parental weight status
Introduction
Worldwide, the prevalence of childhood overweight and obesity rose 47.1% between 1980 and 2013 (Ng et al., 2014). In 1980, the prevalence of overweight and obesity combined in developed countries averaged 16.9% for boys and 16.2% for girls; by 2013 it had risen to 23.8% for boys and 22.6% for girls (Ng et al., 2014). This increase in the prevalence of youth obesity has imposed substantial costs on health care systems (Trasande and Chatterjee, 2009, Trasande et al., 2009). The greatest costs of childhood obesity, however, may be due to it increasing the risk of adult obesity, which is much more expensive. About a third of obese preschool children, and about half of obese school-age children, become obese adults (Serdula et al., 1993), and obesity in adults imposes significant costs on the health care system (Cawley et al., 2015b). Medical care costs are not the only adverse consequence of childhood obesity. Heavier children exhibit delayed skill attainment as preschoolers, tend to earn lower grades in school, and suffer discrimination and stigma (Cawley, 2010, Cawley and Spiess, 2008, Sabia, 2007, Puhl, 2011). Moreover, numerous studies using data from various developed countries have concluded that obesity lowers wages for adults – see the review in Cawley (2015).
In light of these levels and trends, policymakers in a number of countries have responded with a variety of policies to promote healthy eating, physical activity and healthy weight. However, as noted in previous studies such as Golan et al. (1998), parents have a key role to play in regulating their children’s diet and exercise. Indeed, a precondition for parents to improve their children’s diets, encourage them to be more physically active, or take them to see a doctor about their weight is for the parent to first recognize that their child is in fact overweight or obese. Therefore, one factor that could slow the identification of youth obesity, and reduce the effectiveness of programs to prevent and reduce childhood obesity, is parental misclassification of their child’s weight. That is, if the parents of truly overweight or obese children believe that their child is not overweight or obese, they may not seek medical advice, modify the child’s diet, or promote physical activity by the youth (Safefood, 2012). They may even disregard medical advice or discourage the child from changing their behavior. Thus, according to Rietmeijer-Mentink et al. (2013) and Young et al. (2010), the first step in treating childhood obesity is to identify it.
A large number of previous studies have examined (i) the extent to which parents, and mothers in particular, accurately report their child’s height and weight, which can be used to calculate their body mass index (BMI), and (ii) the accuracy of subjective parental assessments of their child’s weight status based on survey questionnaires or image grading. Studies which have examined the accuracy of parent-reported height and weight have found significant errors across a range of dimensions – see, for example, Davis and Gergen (1994), Scholtens et al. (2007), Dubois and Girad (2007) and Huybrechts et al. (2006).1
An alternative to asking parents to report their child’s height and weight is to instead ask them to report their perceptions of their child’s weight status. Again, a large number of previous studies have examined the extent to which such perceptions are consistent with more objective measures, such as BMI calculated from measurements. The findings from systematic reviews (Tompkins et al., 2015, Rietmeijer-Mentink et al., 2013, Doolen et al., 2009, Towns and D’Auria, 2009, Parry et al., 2008) generally show high levels of parental misclassification of their child’s weight status. The methodological quality of many of these studies has been questioned (Rietmeijer-Mentink et al., 2013), because of concern related to sample sizes which are often small and unrepresentative, a lack of robust multivariate analyses, limited sets of control variables, as well as a shortage of studies that look at misclassifications over time.2 Doolen et al. (2009: 165) concluded that the reasons for these misclassifications “are clearly missing from the research literature” and that “further research needs to explore the reasons for this phenomenon”.
Only a few studies to date have considered the socio-economic determinants or correlates of misclassifications and those that have done so have tended to focus on the role of parental education.3 In general these studies have found that higher levels of parental education are associated with a lower probability of misclassification (Baughcum et al., 2000, Boutelle et al., 2004, Manios et al., 2009, De Hoog et al., 2012, Hearst et al., 2011). On the other hand, Hudson et al. (2012) found no significant correlation between parental education and parental misclassifications using data for the same country we examine (the Republic of Ireland, henceforth Ireland).4
Within this context, the purpose of this paper is to examine: 1) the extent of parental misclassification of child weight; and 2) the correlates of such classification error, focussing in particular on the role of parental education and how it interacts with the parent’s own obesity status. In other words, it examines the extent to which parents’ subjective classifications of their child’s weight status are consistent with more objective clinical classifications of weight status based on independently measured weight and height, as well as analysing what factors are associated with any inconsistencies.
We investigate these research questions using data from the Growing Up in Ireland (GUI) study, a nationally representative longitudinal survey of children living in Ireland who were aged 9 years in the first wave of the study, and their parents. The richness of the dataset allows us to address many of the weaknesses and gaps in the existing literature; in particular, it allows us to examine more fully how misclassifications relate to parental education. Ireland has, like many nations of the world, experienced a rise in the prevalence of childhood obesity. In 2013, the prevalence of overweight and obesity combined in Ireland was 26.6% for boys (<20 years) and 26.5% for girls (<20 years) – see Ng et al. (2014). It is estimated that overweight and obesity raise medical costs in Ireland by 398.6 million Euro per year, or 2.8% (Perry, 2012).
The paper adds to the literature in a number of ways. First, it presents a much more in-depth analysis of the potential correlates of misclassifications than previous studies, focussing in particular on the role of parental education and parental weight status. While a small number of studies to date have considered these variables independently, none has examined how they might interact. This, as we demonstrate, is of critical importance in understanding the role of these respective factors on parental misclassifications. Second, we provide an assessment of different types of misclassifications. Third, the GUI data are nationally representative with a significantly larger sample size than almost every other study undertaken in this area to date. Fourth, the data also allow an examination of the accuracy of children’s classification of their own weight status. Thus, overall our analysis provides a much more comprehensive and robust assessment of the extent and potential drivers of misclassifications of child weight status.
The paper is structured as follows: Section 2 presents a detailed description of the data and variables that are used, Section 3 sets out our empirical approach, while Section 4 presents the main empirical results. Section 5 contains details of a number of extensions to the main analysis and Section 6 discusses the implications of our results and findings and concludes.
Section snippets
Data: Growing up in Ireland (GUI)
The data analysed comes from the first wave of the GUI survey conducted between September 2007 and June 2008. The GUI is a nationally representative face-to-face survey of children living in Ireland, which includes interviews with their parents, teachers and school principals, and examines issues concerning children with a view to assisting in policy formation and service provision for children. Wave 1 included 8568 children, representing approximately 14% of all 9 year olds in Ireland at that
Empirical approach
We estimate logit models for each of our three indicator variables relating to parental classification of child weight status; the general specification of these cross-sectional models is presented in Eq. (1). We assume the accuracy of the parental report is a linear function of the highest level of education achieved by the parent (), parental obesity status (), as well as an interaction term to test for differences in the effects of education for
Empirical results
Table 4 reports the frequency of parental misclassifications of child weight by parental education and parental obesity status. Unconditionally, misclassification is most common among those with the lowest level of education (16.33% among those with only lower secondary education) and falls monotonically with parental education; those with the highest education (college degree or postgraduate study) misreport in only 12.12% of cases. This trend is found to be statistically significant using an
Social desirability bias?
One of the key findings from our analysis is that obese parents who are well-educated are considerably more likely, all else equal, to provide a false negative misclassification of their child’s overweight status. A similar pattern across education was not found for false positives, or for non-obese parents. One possible reason for this is social desirability bias, which, in general, results from respondents seeking to present a positive image (Edwards, 1957). Studies have documented social
Discussion
This paper considers the extent of parental misclassification of child weight status and its correlates, focusing on the role of parental education and the parent’s own obesity status. We find that false negatives are much more common than false positives i.e. parents tend to underreport their child’s weight status. We also find evidence that better education is associated with more accurate reporting of child weight status by non-obese parents but less accurate reporting of child weight status
Conflict of interest
The authors declare no conflicts of interest.
Acknowledgements
The Growing Up in Ireland data have been funded by the Government of Ireland through the Office of the Minister for Children and Youth Affairs and have been collected under the Statistics Act, 1993 of the Central Statistics Office. The project has been designed and implemented by a joint ESRI/TCD Growing Up in Ireland Study Team. Cawley thanks the Robert Wood Johnson Foundation for its support through an Investigator Award in Health Policy Research.
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