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The prevalence of obesity has more than doubled among US children and tripled among US adolescents during the past 30 years (1,2). Data from the National Health and Nutrition Examination Survey (NHANES) 2009–2010 showed that nearly one-third of children and adolescents living in the United States were overweight or obese (1).Obese children and adolescents are at increased risk for short-term health consequences (3), obesity in adulthood (4), and health problems in adulthood (5).

As the Health Belief Model suggests, to improve health, people need to be aware of the severity of their condition and acknowledge the benefits of taking steps to make positive changes in their health behavior (6–8). In childhood obesity prevention and reduction, children’s self-perceived weight status as well as parents’ perception of their children’s weight status may be important, because parents have considerable control over their children’s lives, including opportunities to offer obesity interventions (9,10). However, weight misperception, the discordance between an individual’s actual versus perceived weight status, has repeatedly been documented among overweight and obese people. Prior studies suggest that children and their parents often underestimate the child’s weight status (11–13).

Despite misperceptions of children’s weight status, few studies using nationally representative samples have examined the association between weight misperception among children, adolescents, or their parents and attempts at weight loss. Accurate weight perception would seem necessary to identify risks for obesity-related chronic diseases and health behaviors, and recognition of overweight status may motivate overweight children and adolescents to modify their adverse lifestyle practices.

The objective of this study was to describe estimates of weight misperception among a nationally representative sample of US children and adolescents aged 8 to 15 years and their parents. We also examined the extent to which accurate personal and parental weight perception was associated with self-reported attempted weight loss by children and adolescents. Data from the 2007–2008 and 2009–2010 National Health and Nutrition Examination Survey (NHANES) were used for this investigation.

To the best of our knowledge, this was the first study to assess the effect of a child’s personal weight misperception on self-reported attempted weight loss while also taking parental misperceptions of the child’s weight status into account. In this nationally representative survey of children and adolescents aged 8 to 15 years and their parents, the proportion of personal and parental weight misperception was substantial, particularly among overweight children and adolescents and their parents. Accurate personal, but not parental, weight perception was positively associated with self-reported attempted weight loss among overweight and obese children and adolescents. However, healthy weight children and adolescents who overestimated their weight status made unnecessary weight loss attempts.

Although accurate personal perception of being either overweight or obese has been linked to greater motivation to engage in healthy weight-related behaviors (13), increasing evidence suggests that actual and perceived weight are often not in agreement, and this discordance is more common among overweight and obese people. Data from US (13) and Canadian (19) studies found that overweight and obese youth were more likely to misperceive their actual weight. Where prior studies often collapsed overweight and obese into a single category of overweight (13,20), our study showed that personal misperception occurred more often when the child was overweight rather than obese. Further research is needed to determine what factors drive children’s perceptions of their weight and how best to maintain an optimal weight profile during the early, formative years of childhood.

Parents tend to be most influential in a child’s life and typically play a critical role in determining what food is available to their child as well as shaping eating behaviors (21). However, parents’ actions involving the child’s weight depend on their awareness of the child’s actual weight status (22). The published literature has shown an important disconnect between a child’s actual weight and parental perception of their child’s weight (23). Our results suggest that parents often do not perceive their child’s weight status accurately and that this misperception occurs most frequently when the child is overweight.

Accurate awareness of weight status is one of the motivators in weight loss attempts. In childhood obesity research, parents’ misperception of their child’s elevated weight status has been shown to be a barrier to their child’s participation in obesity prevention interventions (9). Data from the Youth Risk Behavior Surveillance System have shown that overweight adolescents in grades 9 through 12 with accurate weight perception were more likely to report engaging in positive weight-related behaviors than those who misperceived their weight status (13). An Australian study of adolescent students (grades 7–12) found that overweight and obese children who accurately perceived their weight status were more likely to try to lose weight and to be more physically active than those who misperceived their weight status (24). These prior studies, contrary to our study, did not examine the effect of a child’s personal weight perception while also taking parental weight perception into account. Our findings suggest that a child’s accurate weight perception was one of the major driving forces behind taking action to lose weight. In addition, although the child’s personal weight perception agreed with parental weight perception only 77% of the time, we did not observe a significant interaction between personal and parental weight misperception. These findings should be interpreted with appropriate caution, however, since we did not know if these children and adolescents actually engaged in weight loss activity as they reported and if they did so voluntarily.

Our findings indicate that unnecessary weight loss attempts occurred among healthy weight children and adolescents who overestimated their weight status. Although appropriate weight loss can decrease the risk for chronic disease in adulthood, overemphasis on thinness in childhood and adolescence may lead to unhealthy weight-loss practices and misperceptions (25). An ongoing concern remains that the preference for thinness in the mass media may have a negative influence in shaping children’s and adolescents’ concept of their ideal body image (25). Because NHANES does not collect information about the child’s body image, we were unable to examine the potentially important role of this factor in the present findings; however, several studies have shown that altered body image is associated with eating disorders, ineffective dieting, and low self-esteem among children and adolescents (26–28). Future studies are needed to determine why normal-weight children perceive themselves as being overweight.

Although it is unclear what factors may cause misperception of actual weight status, a prior study suggested that children may develop false perceptions of normal-weight status when they are frequently exposed to overweight and obese people in their home and school environments (19). A recent review suggested that parental weight misperception may be related to cultural beliefs about body size, lack of knowledge of the true definition of overweight, or unwillingness to accept that their child is overweight (29). Future studies examining factors contributing to weight misperception are needed to develop effective interventions to help children and parents accurately assess weight status. In addition, among children who accurately self-identified as being overweight, not all were actively engaged in weight loss, suggesting that weight misperception is only one of the contributors to weight control.

The strengths of this study include its population-based design and its contemporary sample of nationally representative children and adolescents. In addition, weight status based on measured height and weight has reduced the potential for reporting bias compared with studies that use self-reported data (30). Several limitations need to be acknowledged, however, when interpreting the present findings. First, NHANES data are cross-sectional, and our ability to infer causal pathways between weight misperception and attempted weight loss was limited. Second, we could not control for unmeasured, potentially confounding factors, such as child’s pubertal stage and psychosocial factors; siblings’ weight status; parent’s sex, BMI, and education level; and family history of obesity because this information was not captured in NHANES. Third, because measured weight status was based on the cutpoints of BMI percentiles, the misperception may relate to the child’s or parent’s inability to accurately assess the quantitative cutpoints. Fourth, although our findings indicate that accurate parental weight perception is not significantly associated with attempted weight loss reported by children and adolescents, parents were not directly asked about what they were doing about their child’s weight. Finally, attempted weight loss by children and adolescents was self-reported, which may be overreported because of social desirability bias. Future research on the validity of this measure is needed. In addition, participants who were trying to lose weight may not have been successful. This issue was not sufficiently captured in the NHANES data. Future longitudinal studies examining the effect of weight misperception on attempted weight loss and objectively measuring the success of weight loss are needed.

Our findings have important implications for childhood obesity prevention. Behavioral interventions for accurate weight perception are needed for children and parents, because intervention efforts related to weight loss may be ineffective if individuals do not recognize or acknowledge that they are overweight. Our findings indicate that one of the major driving forces behind taking action to lose weight comes from the child’s perception, which suggests the importance of intervening with the child directly. Health campaigns promoting weight loss among children who are overweight or obese and promoting healthy weight maintenance among children with a normal BMI need to take this notion into consideration.