Clinical Care/Education/Nutrition/Psychosocial Research
B R I E F
R E P O R T
Accuracy of Perceptions of Overweight and
Relation to Self-Care Behaviors Among
Adolescents With Type 2 Diabetes and
Their Parents
ASHELEY COCKRELL SKINNER, PHD1,2
MORRIS WEINBERGER, PHD1,3
SHELAGH MULVANEY, PHD4
DAVID SCHLUNDT, PHD4
RUSSELL L. ROTHMAN, MD, MPP4
OBJECTIVE — To examine how adolescents with type 2 diabetes and their parents/primary
caregivers perceive the adolescents’ weight and the relationship of those perceptions to diet and
exercise behaviors and perceived barriers to healthy behaviors.
RESEARCH DESIGN AND METHODS — Interviews were conducted with adolescents
and their parents about perceptions of the adolescents’ weight, diet, and exercise behaviors, as
well as barriers to engaging in healthy diet and exercise behaviors. Interviews were linked with
clinic records to provide BMI.
RESULTS — A total of 104 parent-adolescent dyads participated. Parents and adolescents
typically perceived the adolescents’ weight as less severe than it actually was. For parents and
adolescents, underestimating the adolescents ’ weight was associated with poorer diet behaviors
and more perceived barriers to following healthy diet or exercise behaviors.
CONCLUSIONS — Addressing misperceptions of weight by adolescents and their parents
may be an important first step to improving weight in these patients.
Diabetes Care 31:227–229, 2008
O
ver 80% of children with type 2 diabetes are overweight or at risk for
becoming overweight (1). Critical
to modifying diet and physical activity is
the recognition by overweight children
and their parents that the child is overweight and therefore at risk for serious
negative health consequences (2). Adolescents under physicians’ care for type 2
diabetes should be aware they areoverweight and understand the importance of
self-care behaviors to reduce weight and
prevent complications, as should their
parents. To determine whether weight
perceptions are related to self-care behaviors, we examined the associations be-
tween weight perceptions of adolescents
with type 2 diabetes and their parents,
and self-report of diet and exercise behaviors and perceived barriers to performing
these behaviors.
RESEARCH DESIGN AND
METHODS — Our sample consisted
of adolescents aged 12–20 years with type
2 diabetes who received care at the
Vanderbilt Eskind Pediatric Diabetes
Clinic and their parents/primary caregivers. Via telephone interview, parents provided information on demographics, the
adolescent’s diabetes regimen, perceptions of the adolescent’s weight, the ado-
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From 1Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, North
Carolina; the 2Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel
Hill, Chapel Hill, North Carolina; the 3Center for Health Services Research, Durham VA Medical Center,
Durham, North Carolina; and the 4Vanderbilt Diabetes Research and Training Center, Vanderbilt University
Medical Center, Nashville, Tennessee.
Address correspondence and reprint requests to Dr. Skinner, University of North Carolina at Chapel Hill,
CB 7411, Chapel Hill, NC 27599-7411. E-mail: asheley@unc.edu.
Received for publication 26 June 2007 and accepted in revised form 2 November 2007.
Published ahead of print at http://care.diabetesjournals.org on 13 November 2007. DOI: 10.2337/dc071214.
Abbreviations: CDC, Centers for Disease Control.
© 2008 by the American Diabetes Association.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby
marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
DIABETES CARE, VOLUME 31, NUMBER 2, FEBRUARY 2008
lescent’s self-care behaviors, and
perceptions of barriers to self-care. Adolescent telephone interviews included the
same questions, with additional questions
about perceived barriers to healthy diet
and exercise behaviors.
Weight perceptions were based on
parent and adolescent responses to the
following question: “Do you think [your
child’s/your] weight is very overweight,
slightly overweight, about right, slightly
thin, or very thin?” We calculated adolescents’ BMI using actual weight from medical records and categorized it using
current Centers for Disease Control
(CDC) recommendations (2,3).
We assessed both parents’ and adolescents’ reports of the adolescents’ diet
and exercise behaviors. For diet, adolescents reported frequency of consuming
sugary drinks, eating fast food, having unplanned snacks, and overeating; parents
reported only the first two. For exercise,
adolescents reported exercise frequency,
hours spent watching television, days taking physical education, and time spent in
physical education; parents reported only
exercise frequency. Responses were categorized by frequency (0 ⫽ never, 1 ⫽
once per week, 2 ⫽ two to three times per
week). Adolescents reported perceived
barriers to diet and exercise (0 ⫽ never,
1 ⫽ sometimes, 2 ⫽ always) using statements previously validated among adolescents and adults with diabetes (4 – 6). A
complete description of the methods is
published elsewhere (7).
For bivariate analyses, we used t (continuous variables) and ␹2 (categorical
variables) tests. We categorized weight
perceptions into four categories (very
overweight, slightly overweight, about
right, and slightly thin/thin) that were
consistent with the four CDC BMI categories for adolescents (overweight, at-risk
for overweight, normal weight, and underweight). We created summary variables of reported diet and exercise
behaviors by scoring each diet or exercise
frequency variable as above and summing
items to create separate diet and activity
scores for both parents and adolescents.
227
Weight perceptions and self-care behaviors
Table 1—Association between estimation of weight with self-reported diet and exercise behaviors and barriers
Parent
Underestimates
child’s weight
n
Good parent-reported behavior—
best quartile of scores (%)
Diet
Exercise
Good adolescent-reported
behavior—best quartile of
adherence scores (%)
Diet
Exercise
Report few self-care barriers (%)
To diet
To exercise
Child
Correct or overestimates
child’s weight
Underestimates
own weight
Correct or overestimates
own weight
68
41
59
50
22.1*
33.8
56.1
34.2
28.8
33.3
42.0
34.7
38.2
26.2†
43.9
46.3
30.5†
27.1‡
52.0
44.2
23.0‡
16.1*
38.5
40.0
20.3†
15.3*
41.5
39.5
Data are %. *P ⬍ 0.01, †P ⬍ 0.05, ‡P ⬍ 0.10, comparing those who underestimate severity to others.
The highest quartile on these summary
measures was considered “good” diet or
activity. Similarly, we summed each barrier to a diet and exercise subscale and
considered the lowest quartile to perceive
fewer barriers.
RESULTS — O f 1 3 9 a d o l e s c e n t parent pairs contacted, 104 (75%) participated. Parents were 85% mothers, 8.5%
fathers, and 6.5% other guardians. There
were no differences in responses for these
groups and they are therefore reported together as “parents.” The adolescents’
mean weight was 100.3 kg (220.7 lbs).
Most (69%) were female, and 47% were
African American. Based on CDC guidelines, 87% of adolescents were classified
as overweight, and an additional 5.9%
were at-risk for overweight. Mean A1C
levels were 7.7 ⫾ 2.6%. Most adolescents
were taking insulin, oral agents (typically
metformin), or both.
While 87% of children were overweight by CDC standards, only 41% of
parents and 35% of adolescents considered the adolescent “very overweight.”
Among parents who reported their child’s
weight as “about right,” 40% had children
whose BMI was ⱖ95th percentile; 55% of
adolescents who reported their weight as
“about right” had BMI ⱖ95th percentile.
Adolescents were more likely to underestimate their weight when their parents
also underestimated weight than when
parents accurately perceived weight
(66.2vs. 34.2%, P ⬍ 0.001).
Girls were more likely than boys to
underestimate the severity of their weight
(42.9 vs. 22.0%, P ⬍ 0.05), although par228
ents’ accuracy did not differ by their
child’s sex. There were also no differences
in the accuracy of weight perceptions by
race or insulin use for either parents or
adolescents. Parents and adolescents were
both more accurate in their perceptions
for adolescents ⬍13 and ⬎16 years; adolescents aged 13–16 years and their parents were the most inaccurate.
Compared with parents who either
correctly estimated or overestimated the
adolescents’ weight, those who underestimated their adolescents’ weight were
less likely to report good dietary behaviors (Table 1). Similarly, adolescents who
underestimated their weight were significantly less likely to report good diet behaviors. The pattern was similar, but
weaker, for physical activity behaviors.
Finally, adolescents who better estimated
the severity of their weight, and whose
parents better estimated the severity of
the adolescent’s weight, reported fewer
barriers to healthy diet and exercise
behaviors.
CONCLUSIONS — We found that
the poor recognition of overweight seen
among overweight adolescents (8 –14) is
also seen in adolescents with type 2 diabetes. What makes our findings particularly troublesome and important is that
we studied adolescents who should be
more cognizant of their weight status because they 1) have a diagnosis of type 2
diabetes, 2) are under physicians’ care,
and 3) are severely overweight (mean
BMI ⫽ 36.4 kg/m2).
There are some limitations to this
study are that. First, it was conducted at a
single academic medical center, and, second, although we have a relatively large
sample, we are limited in our ability to
analyze subgroup differences in the relationships between weight perceptions
and health behaviors.
Overweight adolescents under physician care for type 2 diabetes, as well as
their parents, failed to recognize the adolescents’ overweight status. Consistent
with health behavior models, failing to
recognize overweight was associated with
poorer diet and exercise behaviors and
more perceived barriers to performing
diet and exercise. Clinicians should recognize that even extremely overweight
children and their parents may not accurately perceive the presence of weight
problems, let alone the negative consequences of failing to make difficult lifestyle changes that result in weight loss.
Acknowledgments — R.R. was supported by
the Vanderbilt Physician Scientist Development Award and a National Institutes of
Health K23 Career Development Award (DK065294). A.C.S. was funded by an Agency for
Healthcare Research and Quality National Research Service Award (H-T32-HS00032–14).
M.W. is supported by a Department of Veterans Affairs Health Services Research and Development Service Senior Career Scientist
Award.
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