PEDIATRICOBESITY

ORIGINALRESEARCH
doi:10.1111/j.2047-6310.2012.00093.x

S. Regber1, M. Novak2, G. Eiben3, K. Bammann4,5, S. De Henauw6, J. M. Fernndez-Alvira7, W. Gwozdz8, Y. Kourides9, L. A. Moreno7, D. Molnr10, I. Pigeot11, L. Reisch8, P. Russo12, T. Veidebaum13, I. Borup1 and S. Mrild14
1 Nordic School of Public Health NHV, Gothenburg, Sweden; 2Department of Emergency and Cardiovascular Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 3Department of Public Health and Community Medicine, Public Health Epidemiology Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 4Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany; 5BIPS-Institute for Epidemiology and Prevention Research, Bremen, Germany; 6Department of Movement and Sport Sciences, Ghent University, Ghent, Belgium; 7GENUD (Growth Exercise, Nutrition and Development) Research Group, University School of Health Sciences (EUCS), University of Zaragoza, Zaragoza, Spain; 8Department of Intercultural Communication & Management, Copenhagen Business School, Frederiksberg, Denmark; 9Research & Education Institute of Child Health/Strovolos, Cyprus; 10Department of Pediatrics, University of Pcs, Pcs, Hungary; 11Department of Biometry and Data Management, BIPS-Institute for Epidemiology and Prevention Research, Faculty 03 Mathematics and Computer Science, University of Bremen, Bremen, Germany; 12Epidemiology & Population Genetics, Institute of Food Sciences, CNR, Avellino, Italy; 13National Institute for Health Development, Tallinn, Estonia; 14Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

Received 16 March 2012; revised 19 June 2012; accepted 17 July 2012

What is already known about this subject

Parents of children with overweight and obesity tend to underestimate their childrens weight. Most studies show no association between parental education level and accurate parental perception of a childs weight category. Studies show no consistent relationship between parental weight perception and the childs gender.

What this study adds

Parental underestimation of childrens weight category for children in the overweight and obesity categories was found across eight European countries. Regional dierences indicated a more accurate parental weight perception in Northern and Central Europe. A high proportion of parents in Southern Europe were concerned about future underweight or overweight in their children.

Summary
Objectives: To evaluate parental perceptions of and concern about child's body weight and general health in children in a European cohort. Design: Cross-sectional multi-centre study in eight European countries. Participants: 16 220 children, ages 29 years. Methods: Parents completed a questionnaire regarding children's health and weight and concern about
overweight and underweight. Objective children's weight categories from the International Obesity Task Force were used. Logistic regression models were utilized to identify predictors of accurate weight perception.

Results: Parental weight perception corresponded overall to children's mean body mass index (BMI) z-scores, with important exceptions. About one-third of the total indicated concern about underweight, paradoxically most often parents of children in the overweight or obesity categories. In 63%, parents of
Address for correspondence: Mrs S Regber, Nordic School of Public Health NHV, PO Box 12 133, SE-402 42 Gothenburg, Sweden. E-mail: susann.regber@nhv.se 2012 The Authors Pediatric Obesity 2012 International Association for the Study of Obesity. Pediatric Obesity ,

ORIGINALRESEARCH

Parental perceptions of and concerns about child's body weight in eight European countries the IDEFICS study

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ORIGINALRESEARCH

children in the overweight category marked proper weight. The strongest predictor for accurate parental weight perception for children with overweight and obesity was BMI z-score (odds ratio [OR] = 7.2, 95% confidence interval [CI] 6.18.7). Compared to Southern Europe, ORs for accurate parental weight perception were 4.4 (95% CI 3.36.0) in Northern Europe and 3.4 (95% CI 2.74.2) in Central Europe.

Conclusion: Parents of children categorized as being overweight or obese systematically underestimated weight. Parents differed regionally regarding accurate weight perception and concern about overweight and underweight.
Keywords: Cohort of European children, obesity, parent, weight concern, weight perception.

Introduction
The World Health Organization (WHO) estimated that in 2010, a total of 43 million children under the age of five were overweight, mainly because of environmental and societal changes leading to an imbalance between energy intake and expenditure (1). The WHO states that childhood obesity is one of its most serious challenges for the 21st century and, as a largely preventable health threat, has high priority (2). Serious obesity-related morbidities such as type 2 diabetes, impaired glucose tolerance, hypertension and liver disorders are likely to increase in parallel with increasing childhood obesity (3). For the child, the most severe acute consequence is the psychosocial discrimination or social isolation (4). Parents have a crucial impact on the family's lifestyle and can act as key players in preventing childhood obesity (5). A necessary consequence of prevention is health-related action (6), and the perception of the severity of an illness is essential to carry out lifestyle changes. However, parents seldom see obesity as a health problem, e.g., parents of pre-school children reported worsened overall health only when children's body mass index (BMI) exceeded the 99th percentile (7). This attitude may be related to the fact that parents usually fail to recognize the presence of overweight and obesity in their children (8). Few studies have linked parental weight and health perceptions and weight concern with children's measured anthropometric data in large cohorts from different cultural settings. The aims of this study were to (i) describe parental perceptions of weight and health in a large cohort of European children with measured BMI; (ii) analyze parental weight perception by country in children categorized as underweight, normal weight, overweight or obese; (iii) identify predictors for accurate parental weight perception in children with underweight, overweight or obesity and (iv) evaluate total and country-specific parental concern about overweight and underweight

in a cohort of European children stratified by measured BMI categories.

Methods
Participants
This analysis is based on the Identification and prevention of dietary- and lifestyle-induced health effects in children and infants (IDEFICS) study. The two main aims of the IDEFICS study are to (i) study health in children in relation to lifestyle and biological traits to understand factors triggering overweight and obesity risk and (ii) develop and evaluate a primary prevention program to tackle childhood obesity and related comorbidities. A detail description of the IDEFICS survey has been published elsewhere (9). Recruitment was made through schools and kindergartens, where parents were asked for informed consent. A total of 31 543 subjects were informed and invited to take part in the study; among these, there were 16 224 children, 29 years old, who participated (51% response rate). The highest response rate was in Sweden (66%), and the lowest response rate was in Spain (41%) (9). The baseline survey was conducted between September 2007 and June 2008 in eight IDEFICS study centres in Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden. Measurement for weight and height and parental questionnaire completion were required to be valid for inclusion in the data analysis, and 16 220 children met these requirements. Ethical approval was given by research ethics committees at each centre in the eight participating countries.

Anthropometric data
A manual for standard operating procedures was used at all IDEFICS centres to standardize procedures. In addition, central and local training sessions were held with field staff (10). Weight was measured on an electronic scale (TANITA BC 420 SMA, Europe

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Parents' perception of their child's weight

Parental questionnaire
Parents answered a self-administrated questionnaire consisting of 70 questions, covering a broad range of variables such as behavioural factors, dietary and sedentary habits and parental perceptions, attitudes and values. The questionnaire was translated from English into each of the eight languages and then back-translated (16). Classification of parent educational level was made according to the International Standard Classification of Education (ISCED) (17). For purposes of this study, the ISCED levels were combined into three levels of education: low (02), medium (3 and 4) and high (5 and higher). Our preliminary analyses showed differences between countries in parental response patterns regarding perceptions and concerns that largely followed a geographical gradient. Therefore, the countries were studied separately as well as grouped according to their geographical region; i.e., Northern Europe was represented by Estonia and Sweden, Central Europe by Hungary, Germany and Belgium and Southern Europe by Cyprus, Italy and Spain. Parental perception of children's weight categories was examined using a five-point Likert scale with the following options: much too underweight, slightly too underweight, proper weight, slightly too overweight and much too overweight. Parental perception was considered accurate if (i) parents of children with thinness grades III and II or obesity responded much too underweight/overweight, (ii) parents of children with thinness grade I or overweight responded slightly too underweight/overweight or (iii) parents of children with normal weight responded proper weight. To investigate parental weight perceptions by country for children in the underweight, normal weight, overweight or obesity categories, some of the response options were recombined. The responses much and slightly too underweight were combined into the category underweight and much and slightly too overweight into overweight as preliminary analyses indicated that the responses much too

Statistical analysis
All statistical analyses were carried out using the Predictive Analytic Software, version 18.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to analyze the data from the parental questionnaire. To test differences between countries, we used chi-square tests for categorical variables and the KruskalWallis test for continuous variables. Descriptive statistics are presented as percentages or mean values with standard deviations. All P-values are two sided, and values <0.05 were considered statistically significant. The non-parametric Spearman's rank correlation coefficient was used to assess the relationship between children's measured BMI and parental weight perception. Logistic regression models were used to identify independent predictors of accurate parental weight perception about children in the overweight and obesity categories. Firstly, univariate regression (unadjusted) analyses were carried out to identify the potential predictors of accurate weight perception. Potential predictors for accurate weight perception included BMI z-score, age, gender, education, parent concern that a child will become overweight and European geographic region. Secondly, multivariable-adjusted logistic regressions (using a forward stepwise method) were performed to identify the independent predictors of accurate weight perception. Three separate regression analyses were carried out (i) all children in the

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ORIGINALRESEARCH

GmbH, Sindelfingen, Germany) with the children in light clothing, i.e., only underwear, T-shirts and socks. Height was measured barefoot, with a portable stadiometer (SECA 225, GmbH & KG, Hamburg, Germany). The International Obesity Task Force (IOTF) BMI (Kg/m) cut-offs were used to obtain the measured BMI categories of thinness IIII, normal weight, overweight and obesity (11,12). The BMI z-score was calculated according to Cole et al. (1315).

underweight/overweight were rarely used. However, for exploring whether parents of children in the overweight and obesity categories discriminated between slightly too overweight or much too overweight, these two categories were maintained. Parental descriptions of children's general health were derived from a five-point Likert scale with the response options very good, good, fair, bad and very bad. In presenting the results, we combined good and very good health into one category, good health. We omitted fair, bad and very bad health because they were rarely used (range 2% in Sweden to 16% in Estonia; the category very bad was used in <1% in all countries). Parent responses regarding concern about a child's becoming overweight or underweight were obtained from a four-point Likert scale of responses to the question: How concerned are you about your child becoming overweight/underweight? The response options were unconcerned, a little concerned, concerned or very concerned. For comparing responses by country, the options concerned and very concerned were combined.

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overweight and obesity categories, (ii) children in the obesity category only and (iii) children in the underweight category only. Results obtained from regression analyses are presented as odds ratios (ORs).

Results
Study population characteristics
The total study population consisted of 16 220 children. The distribution by gender was even within all countries and for children of pre-school and primary school age. The study centres in Italy, Spain and Cyprus had the highest proportion of children in the overweight and obesity categories, while the lowest was seen in Belgium and Sweden. Education level showed a large variation among parents across the countries (Table 1). The response numbers and proportions on the study questions were as follows: weight perception, n = 15 528 (96%; range 87% Cyprus to 99% Italy); general health perception, n = 15 537 (96%; range 87% Cyprus to 99% Italy); concern about a child's becoming overweight, n = 14 499 (89%; range 56% Cyprus to 97% Sweden) and underweight, n = 14 559 (90%; range 56% Cyprus to 97% Sweden). The main parent respondent was female n = 13 452, (87%; range 80% Cyprus and Germany to 95% Hungary).

Parental perceptions about weight and health in the total sample and by country
Parental weight perceptions about children showed a trend corresponding to children's mean BMI z-score (Fig. 1). Among parents of children in the normal weight category, 80.9% responded that their child had a proper weight, 16.9% answered slightly or much too underweight, while only 2.2% answered slightly or much too overweight (Table 2). Responses much too underweight and much too overweight were rarely used in children with thinness grades II and III or obesity. Instead, slightly too was used in children with obesity, with 69.6% responding slightly too overweight. Likewise, children in the thinness grade I or overweight categories were assessed as slightly too underweight/overweight only in 45% and 33.7% of cases, respectively, while proper weight was chosen in 49% and 63.3% of instances, respectively (Table 2). A vast majority of parents across the countries considered their child's general health to be good, in a range from 83.6% in Estonia to 98.3% in Sweden (Table 1). Across weight categories in the total cohort, the perception good health showed little difference. The values were 90%, 93%, 92%

and 88% for children in the thinness, normal weight, overweight and obesity categories, respectively (n = 15 537, data not shown). Note that good health when compared across weight categories and by country ranged from 73% in Italy to 99% in Sweden, in both cases for children in the underweight category (Fig. 2). Children in the underweight category were perceived as proper weight by their parents in a range from 60% in Estonia to 16% in Spain (Fig. 3a). Children in the normal weight category were perceived as proper weight by their parents in a range from 72% in Spain to 88% in Sweden and Estonia or as underweight in a range from 9% in Sweden to 28% in Spain (Fig. 3b). For children in the overweight category, the geographical variation was more obvious. The proportions of parents perceiving proper weight in Southern Europe were 70% for Cyprus, 70% for Italy and 77% for Spain compared to the proportions in Central and Northern Europe ranging between 51% in Hungary to 58% in Sweden (Fig. 3c). Parents of children in the obesity category also responded that their children had proper weight, with the lowest rate of 5% in Germany to 32% in Spain. In four countries, parents responded underweight when their children fell into the obesity category, with Cyprus having the highest proportion of parents perceiving their child in this category as being underweight (14%). The response option much too overweight was used by only 5% of parents in Spain to 21% in Belgium (Fig. 3d).

Predictors for accurate parental weight perception of children in different weight categories
Results from unadjusted logistic regression models in the first analysis of overweight and obesity indicated that higher BMI z-score, older age of the child, being a girl, parental concern about future overweight and parents being from Central or Northern Europe were significantly associated with accurate weight perception (Table 3). Parental education was not significant. Remaining variables were significant in the adjusted model. The strongest association was seen for BMI z-score (OR = 7.2, 95% confidence interval [CI] 6.1 8.7). The second analysis was limited to parents of children with obesity and the perception much too overweight as the dependent variable considered as an accurate perception. In the adjusted model, an accurate perception had a significant positive association with BMI z-score, age and parental concern about a child's becoming overweight, while gender, education and European regions were not significant.

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Table 1 Characteristics of the population by country. Values are numbers (%) unless stated otherwise
All countries Cyprus Italy Spain Hungary Germany Belgium Estonia Southern Europe Central Europe Northern Europe Sweden

16 220 8261 6.0 7378 8842 (50.9) (1.8) (45.5) (54.5) (42.9) (49.3) (7.8) (1.36) (6.9) (12.7) (69.5) (10.9) (92.3) 222 (10.7) 506 (22.6) 114 (7.7) 303 (12.1) 226 (11.5) 1078 671 50 0.36 211 345 1559 264 2003 (59.9) (37.3) (2.8) (1.45) (8.9) (14.5) (65.5) (11.1) (96.5) 404 1277 434 1.05 437 507 1202 103 1951 (19.1) (60.4) (20.5) (1.45) (19.4) (22.5) (53.4) (4.6) (87.6) 691 407 129 0.37 88 223 1085 111 1427 (56.3) (33.2) (10.5) (1.24) (5.8) (14.8) (72.0) (7.4) (96.4) 1018 1199 57 0.05 149 288 1726 403 2282 (44.8) (52.7) (2.5) (1.41) (5.8) (11.2) (67.3) (15.7) (91.2) 370 1054 343 0.15 92 237 1531 205 1793 (20.9) (59.6) (19.4) (1.23) (4.5) (11.5) (74.1) (9.9) (91.5) 1081 592 39 -0.17 44 123 1476 283 1780 (63.1) (34.6) (2.3) (1.17) (2.3) (6.4) (76.6) (14.7) (94.7) 147 (7.9) 216 1257 22 0.07 69 178 1278 194 1387 (51.5) (1.4) (40.1) (59.9) (51.8) (1.8) (43.3) (56.7) (51.3) (1.8) (47.4) (52.6) (50.1) (1.8) (40.5) (59.5) (50.9) (1.8) (42.4) (57.6) (50.8) (1.6) (54.2) (45.8) (49.4) (2.0) (50.0) (50.0) (14.4) (84.1) (1.5) (1.22) (4.0) (10.4) (74.3) (11.3) (83.6) 145 (8.8) 6033 6931 1093 0.25 1126 2061 11 270 1763 14 345 1790 (11.5)

2379 1226 6.1 954 1425

2249 1164 6.1 974 1275

1507 773 5.8 715 792

2566 1285 6.3 1039 1527

2065 1051 6.2 876 1189

1926 978 5.7 1043 883

1719 850 5.9 859 860

1809 934 5.7 918 891 1175 474 19 -0.02 36 160 1413 200 1722

(51.6) (2.0) (50.7) (49.3) (70.4) (28.4) (1.1) (1.16) (2.0) (8.8) (78.1) (11.1) (98.3) 127 (7.2)

144 (0.9) 2810 (18.1) 343 (16.6) 364 (16.3) 392 (26.5)

14 (0.7)

60 (2.7)

4 (0.3)

25 (1.0) 567 (22.7)

9 (0.5) 408 (20.7)

10 (0.5) 301 (16.2)

12 (0.7) 216 (13.1)

10 (0.6) 219 (12.4)

4335 (29.9)

677 (50.8)

1096 (50.6)

777 (54.2)

762 (31.8)

259 (13.4)

514 (27.8)

203 (12.5)

47 (2.7)

Participants, total by country Boys Age (year), mean (SD) Pre-school age 2 to < 6 years Primary school age 6 to < 10 years Parental education High Medium Low BMI z-score, mean (SD) Obesity* Overweight* Normal weight* Thinness grades I, II and III * Health perception (good + very good) Weight perception (slightly + much too overweight) Weight perception (much too overweight) Weight perception (slightly + much too underweight) Concerned becoming overweight (conc. + very conc.) Concerned becoming underweight (conc. + very conc.) 4596 (31.6) 687 (50.6) 1632 (75.2) 813 (56.2) 613 (25.2) 214 (11.1) 370 (20.1) 228 (14.0)

Parents' perception of their child's weight

39 (2.2)

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*BMI categories by IOTF. Values are numbers (%) for parents responding. P < 0.001 for differences between countries for all variables except for sex (P = 0.817), using chi square for categorical variables and KruskalWallis test for continuous variables. BMI, body mass index; IOTF, International Obesity Task Force; SD, standard deviation.

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Figure 1 Distribution of body mass index (BMI) z-scores in subgroups that correspond to parental perception of children's weight categories. All eight countries combined, n = 15 528. *Spearman's correlation coefficient, rs = 0.564, P 0.01 (two tailed).

Table 2 Summary of parental weight perception by children's actual weight categories according to IOTF. All eight countries combined (n = 15 528). Values are numbers (%) of parents responding
Weight categories according to IOTF Parental perception of child's body weight, n (%) Much too underweight Slightly too underweight Proper weight Slightly too overweight Much too overweight Total

Thinness grade III Thinness grade II Thinness grade I Normal weight Overweight Obese Total

14 44 77 86 1 7 229

(19.2) (18.6) (5.6) (0.8) (0.1) (0.7) (1.5)

20 121 621 1742 48 29 2581

(27.4) (51.1) (45.0) (16.1) (2.4) (2.7) (16.6)

37 72 676 8735 1245 163 10 928

(50.7) (30.4) (49.0) (80.9) (63.3) (15.2) (70.4)

2 0 4 230 664 746 1646

(2.7) (0.0) (0.3) (2.1) (33.7) (69.6) (10.6)

0 0 1 6 10 127 144

(0.0) (0.0) (0.1) (0.1) (0.5) (11.8) (0.9)

73 237 1379 10 799 1968 1072 15 528

(100) (100) (100) (100) (100) (100) (100)

Spearman's correlation coefficient, rs = 0.548; P-value < 0.001 (two tailed). IOTF, International Obesity Task Force.

Figure 2 Parental perception of good health* in their children by weight categories according to International Obesity Task Force (underweight = thinness grades I, II and III), n = 15 537. *Good health = good health + very good health.

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Parents' perception of their child's weight

The BMI z-score was the strongest predictor (OR = 13.16, 95% CI 8.021.6). The third analysis was limited to parents of children in the underweight category and the perception slightly or much too underweight as the dependent variable and considered as an accurate perception. In the adjusted model, BMI z-score was not associated with accurate

weight perception. Parental accurate weight perception was significant for age (OR = 1.24, 95% CI 1.17 1.32) and concern for underweight (OR = 2.77, 95% CI 2.123.62); in addition, parents in Northern Europe were less likely to perceive their children's underweight compared with parents in Southern Europe (OR = 0.65, 95% CI 0.460.92).

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Figure 3 Parental perception about children's weight status by weight categories according to International Obesity Task Force in children in the (a) underweight (n = 1689), (b) normal weight (n =10 799), (c) overweight (n = 1968) and (d) obesity (n = 1072) categories in eight countries. Overweight in panel a + b is the sum of the perceptions 'slightly' and 'much too overweight'.

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Table 3 Multiple logistic regression analysis of predictors of parental accurate perception of children in the overweight and obesity categories (n = 3187), obesity category (n = 1126) and underweight category (n = 1763) (OR = odds ratio, CI = confidence interval). The model predicts perception of slightly too overweight or much too overweight among children in the overweight or obesity categories, much too overweight in the obesity category and slightly too underweight or much too underweight in the underweight category
Obese, n = 1126 Unadjusted OR (95% CI) Multivariable adjusted OR (95% CI) Underweight, n = 1763 Unadjusted OR (95% CI) Multivariable adjusted OR (95% CI)

Coefficients Multivariable adjusted OR (95% CI)

Overweight and obese, n = 3187

Unadjusted OR (95% CI)

6.72 (5.777.83) 1.41 (1.341.48) 1.19 (1.031.37) 1.00 1.12NS (0.631.99) 0.96NS (0.611.51) 1.00 3.37 (2.704.21) 4.44 (3.305.98) 3.31 (2.714.10) NA 1.46NS (0.972.21) 1.28NS (0.682.41) 12.51 (3.9339.77) NA

7.2 (6.068.66) 1.34 (1.261.42) 1.61 (1.331.95)

6.01 (4.238.52) 1.42 (1.221.64) 0.81NS (0.561.18) 1.00

13.16 (8.0221.59) 2.14 (1.702.69)

0.88 (0.770.99) 1.21 (1.141.27) 0.92NS (0.761.11) 1.00 1.96 (1.203.21) 1.11NS (0.91.36) 1.00

1.24 (1.171.32)

1.13NS (0.891.44) 1.08NS (0.921.28) 1.00

BMI z-score Age (scale 2.09.9) Gender (boys = ref.cat.) Education High (ref.cat) Low Medium Europe South (ref.cat.) Central North Concern for overweight Concern for underweight 7.16 (2.1923.40) NA

1.73 (1.472.04) 1.33 (1.071.64) 3.81 (3.254.47) NA

0.86NS (0.681.08) 0.55 (0.420.73) NA 2.82 (2.253.52)

0.99NS (0.731.34) 0.65 (0.460.92) NA 2.77 (2.123.62)

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P < 0.05, P < 0.01, P < 0.001. Europe divided into three geographical areas: north = Estonia and Sweden; central = Hungary, Germany and Belgium; south = Cyprus, Italy and Spain. Concern for overweight/underweight has been dichotomized = unconcerned and a little concerned = reference category vs. concerned and very concerned. BMI, body mass index; n, number of subjects; NA, not applicable; NS, not significant.

Parents' perception of their child's weight

a
Unconcerned
% 80 70 60 50 40 30 20 10 0

A little concerned

Concerned

Very concerned

76 62

38 38

23
8 7 10 Underweight

27 27

23

14 12 12

16
8 Overweight Obese

Normal weight

b
Unconcerned
% 80 70 60 50 40 30 20 10 0

A little concerned

Concerned

Very concerned

54 41 26 17 16 16 14 15

51

45 22

17 10

18 18 20

Underweight

Normal weight

Overweight

Obese

Parental concern about overweight or underweight in the total sample and by country
Concern about their children becoming overweight in the future was seen in an average of 29.9% of parents, with about 5054% in Southern Europe and below 32% in Northern and Central Europe. Concern about a child's becoming underweight exhibited a similar regional pattern, but Italy stood out with 75.2% of parents having this concern (Table 1). Parents responding as very concerned about their children being overweight in the future increased by weight category from 10%, 12%, 23% and 38% for children in the categories of underweight, normal weight, overweight and obesity, respectively (Fig. 4a). In contrast, the proportion of parents who were unconcerned showed an opposite pattern. Parental concern about underweight showed no clear trends related to BMI categories. Parents of children in the overweight or obesity categories were very concerned about their children becoming underweight in 22% and 20% of cases compared to only 16% of parents of children who were in the thin categories (Fig. 4b).

We also studied parents who were concerned about underweight and overweight simultaneously (data not shown) and found that very concerned and concerned about a child's becoming overweight and underweight were present in 15% of the total cohort, with values of 22%, 23%, 14% and 10% of parents whose children were in the obesity, overweight, normal weight and underweight categories, respectively. Parents of children in the obesity and overweight categories in Southern Europe had these double concerns in a range from 25% to 39%, while the corresponding proportions in Northern Europe were 0% to 6%.

Discussion
In this study, we investigated parental perceptions of and concerns about children's weight and health. The results showed that parents in general perceived their children in all weight categories as healthy and that parental perceptions about children's weight corresponded overall to objective IOTF weight categories. Nevertheless, we found a significant proportion of parents in all countries who perceived their children's weight differently than indicated by objec-

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Figure 4 (a) Parents concerned that their child will become overweight, by weight categories according to International Obesity Task Force (IOTF) (underweight = thinness grades I, II and III), n = 14 499. All eight countries combined. (b) Parents concerned that their child will become underweight, by weight categories according to IOTF (underweight = thinness grades I, II and III), n = 14 559. All eight countries combined.

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tive measurements: children in the underweight category were classified as proper weight, normal weight children were classified as underweight, children in the overweight category as proper weight and children in the obesity category depicted as slightly too overweight instead of much too overweight. Several factors may explain this tendency among parents of children with overweight or obesity to underestimate elevated weight deviation. The increasing prevalence of obesity among children and adults is likely to shift weight norms upwards (8,18). The BMI cut-offs in the IOTF standard definitions of weight categories in children (11) are linked to the adult BMI cut-offs for adult weight categories, established long before the obesity epidemic. Childhood obesity is also a social and psychological problem associated with stigmatization and individual responsibility (19). To respond much too overweight might therefore give parents a feeling of guilt and failure, which also may influence responses. Because parents saw children in all weight categories as healthy, weight deviations may seem unimportant and shift perceptions about what would be considered normal. Another interpretation of the observed perceptions, which also holds for parents of children in the underweight categories, may be that the obtained responses were affected by a social desirability bias, i.e., by the general wish of people to present themselves and their children at the best (6). Weight perception also differed between Southern and Northern/Central Europe among parents in all weight categories. The proportion of parents perceiving normal weight children as underweight was highest in Italy and Spain. The reverse was seen in the underweight categories where parents from Spain and Italy perceived their children's underweight accurately. Also, a higher proportion of parents in Southern Europe perceived children in the overweight category as being of a proper weight. In IDEFICS, all procedures including measurements and questionnaires were standardized. Therefore, the geographic differences detected here are likely to be associated with cultural or societal differences, or perhaps a more intrusive obesogenic environment (20) in some regions. The uneven regional distribution may be important to study, as it may be associated with a parallel gradient in the prevalence of overweight and obesity in the eight European study centres (9). An accurate parental weight perception in children in the overweight and obesity categories was positively associated with higher BMI z-score, older age of the child, being a girl, parents being concerned about future overweight and parents living in Central

or Northern Europe. The observation that girls are more likely than boys to be identified as overweight by the parents has also been noted in some other studies (21,22) but not in all (23). We could not show that parent education affected weight perceptions about the children, which is in accordance with other studies (23,24). When we restricted our analysis of predictors to children in the obesity category and the parental perception of much too overweight, only BMI z-score, age and concern about future overweight emerged as statistically significant. It seems to be reasonable that with increasing age and more obvious weight deviation, other determinants lose influence on the parental ability to have an accurate weight perception. Our findings regarding parental perceptions correspond to several other studies. In some, children with overweight or obesity were categorized as having proper weight (8,21,22,25). In other studies, children of normal weight were categorized as being underweight (22,24). Parents also often lack health awareness about overweight or obesity (21,22,26). In the total study population, we found that the proportion of parents concerned about their child's becoming overweight in the future increased with increasing BMI. In contrast, the proportion of parents concerned about a child's becoming underweight was not clearly weight related. This concern about underweight was remarkably frequent among parents with children in the obesity and overweight categories, exceeding the proportion seen for children in the thinness categories. We might speculate that concern about underweight could contribute to overweight by triggering parents to exaggerate feeding of their children. This fear about underweight in children with overweight has been noted earlier by Baughcum et al. (27) in mothers of pre-school children classified as overweight. We found remarkable differences between Southern and Northern/Central Europe in parental weight concern about their child's becoming either overweight or underweight. In addition, we found that both these concerns appeared simultaneously in a significant proportion of parents, also more often in Southern Europe. Having both concerns may imply the presence of a more universal uneasiness, of which weight concerns may be just one part. Our results have implications for preventive interventions. One important aspect is to start at an early age (28,29) and parental early recognition of children at risk of becoming obese is indispensable for parental readiness to make changes towards a healthy lifestyle (28). For accurate weight perception, the measured BMI was the most important determinant for children with overweight and obesity. It should

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2012 The Authors Pediatric Obesity 2012 International Association for the Study of Obesity. Pediatric Obesity ,

Parents' perception of their child's weight

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also be noted that the proportion of parents concerned about underweight was highest in Southern Europe where the prevalence of overweight and obesity is highest. Monitoring children's measured BMI development and inform parents from an early age is a tool in a population-based prevention strategy of childhood obesity advocated by some researchers (18,24,29,30) but not by all (31). The mere identification of obesity by nurses in school health care significantly improved 1-year BMI development compared to non-identified children with obesity (32). In the clinical setting, it is also important to be aware that parents often do not estimate their child's weight status correctly. Therefore, anthropometric measures should always be taken before counselling parents on nutrition and lifestyle. Another important concept for prevention is the protection of children from the dangers of the obesogenic environment (33). Parents have an important role here, but they have a limited capability on their own to act as gatekeepers for many reasons, i.e., social norms and media and marketing exposures (34). The parents need support from primary healthcare professionals. The regional differences in our study are of interest for further analysis and likely relate to the environment in the different regions and the healthcare system. The study had certain strengths and limitations: it included more than 16 000 children with a thorough and standardized health examination from eight centres in Europe, where each centre included 1500 2000 children, allowing for assessment of differences among countries and cultures. The children were recruited through kindergartens or schools, where all parents were invited. Because the response rate was about 51%, a selection bias may be present with an over-representation of well-educated and healthinterested families (9). Responders were to a great extent mothers, limiting the possibility of studying the influence of parental gender. Although site visits were conducted for quality control and the field staff underwent central and local training sessions (16), differences by country resulting from parental interpretation and (mis)understanding of specific questions cannot be ruled out.

Conflict of interest statement

No conflict of interest was declared.

Acknowledgements
This work was done as a part of the IDEFICS study (http://www.idefics.eu). We gratefully acknowledge the financial support of the European Community within the sixth Research, Technological Development and Demonstration (RTD) framework programme under contract no. 016181, Food Quality and Safety projects in FP6 (FOOD). We are also grateful for support by grants from the Vstra Gtalandsregionen research funds and Forskningsrdet fr arbetsliv och socialvetenskap (FAS) and from the Nordic School of Public Health NHV. We thank the participating children and parents, and the local communities for their support. The contribution by each author was as follows: SR performed data analysis, data interpretation, literature search, generation of figures and tables and writing the manuscript; MN did data analysis, data interpretation and writing the manuscript; GE performed data interpretation and manuscript writing; KB participated in study design, data collection and manuscript writing; SDH participated in study design and data collection; JMF-A performed data collection, data analysis, data interpretation, literature search, generation of figures and manuscript writing; WG performed data interpretation and manuscript writing; YK participated in data collection; LAM contributed to study design, data collection, data analysis, data interpretation, generation of figures and manuscript writing; DM participated in study design and data collection; IP contributed to study design, data collection, data analysis, data interpretation and manuscript writing; LR participated in study design, especially the parental questionnaire, and manuscript writing; PR contributed to data collection, data interpretation and manuscript writing; TV

Conclusion
A significant proportion of parents in the total cohort either overestimated or underestimated their children's weight status when compared to their actual measured weight category. In general, parents considered their children to be healthy irrespective of their weight category. A seemingly irrational concern about

2012 The Authors Pediatric Obesity 2012 International Association for the Study of Obesity. Pediatric Obesity ,

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future underweight in children in the overweight and obesity categories strengthens the argument that parents need support from healthcare professionals for objective information about their children's weight status. The European regional differences with higher concern about overweight and obesity in Southern Europe and a more accurate weight perception in Central and Northern Europe may be studied further in relation to regional differences in the prevalence of overweight and obesity. We propose routine screening of children's height and weight to identify children with weight deviations and to help parents promote healthy habits in the family.

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participated in study design and data collection; IB helped with writing the manuscript and SM contributed to study design, data collection, data analysis, data interpretation, literature search, generation of figures and tables and writing the manuscript.

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