Diabetes Care Publish Ahead of Print, published online November 13, 2007
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 Rothman, MD MPP4
1
Health Policy and Administration, University of North Carolina at Chapel Hill
2
Cecil G. Sheps Center for Health Services Research,
University of North Carolina at Chapel Hill
3
Center for Health Services Research, Durham VAMC
4
Vanderbilt Diabetes Research and Training Center, Vanderbilt University Medical Center
Running title: Weight perceptions and self-care behaviors
Corresponding author: Dr. Skinner
Received for publication 26 June 2007 and accepted in revised form 2 November 2007.
Copyright American Diabetes Association, Inc., 2007
Weight perceptions and self-care behaviors
ABSTRACT
Objective: Examine how adolescents with type 2 diabetes and their parents/primary
caregivers perceive the adolescent’s 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 adolescent’s weight, diet and exercise behaviors, and
barriers to engaging in healthy diet and exercise behaviors. Interviews were linked with
clinic records to provide body mass index.
Results: 104 parent-adolescent dyads participated. Parents and adolescents typically
perceived the adolescent’s weight as less severe than it actually was. For parents and
adolescents, underestimating the adolescent’s 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.
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Weight perceptions and self-care behaviors
O
We assessed both parents’ and
adolescents’ reports of the adolescents’ diet
and exercise behaviors.
For diet,
adolescents reported the 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=1 time per week, 2=2-3 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 ttests (continuous variables) and χ2
(categorical variables). We categorized
weight perceptions into four categories
(very overweight, slightly overweight, about
right, and slightly thin/thin) that were
consistent with the 4 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.
The highest quartile on these summary
measures was considered “good” diet or
activity. Similarly, we summed each barrier
to diet and exercise subscale and considered
the lowest quartile to perceive fewer
barriers.
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 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, and their parents, should be
aware the child is overweight and the
importance of self-care behaviors to reduce
weight and prevent complications. In order
to determine whether weight perceptions are
related to self-care behaviors, we examined
the associations between 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 child’s weight,
the child’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: “Do you
think [your child’s/your] weight is very
overweight, slightly overweight, about
right, slightly thin, or very thin?” We
calculated adolescents’ body mass index
(BMI) using actual weight from medical
records and categorized it using current
CDC recommendations(2; 3).
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Weight perceptions and self-care behaviors
were less likely to report good dietary
behaviors (Table). 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 their
weight, reported fewer barriers to healthy
diet and exercise behaviors.
RESULTS
Of 139 adolescent–parent pairs
contacted, 104 (75%) participated. Parents
were 85% mothers, 8.5% fathers, 6.5%
other guardians. There were no differences
in responses for these groups, so they are
reported together as “parents”. The
adolescents’ mean weight was 100.3 kg
(220.7 pounds). 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
Hemoglobin 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 ≥95th percentile; 55% of adolescents
who reported their weight as “about right”
had BMI ≥95th percentile. Adolescents
were more likely to underestimate their
weight
when
their
parents
also
underestimated weight than when parents
accurately perceived weight (66.2% vs.
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), though parents’
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 younger
and older adolescents; adolescents aged 1316 years and their parents were the most
inaccurate.
Compared to parents who either
correctly estimated or overestimated the
adolescents’
weight,
those
who
underestimated their adolescents’ weight
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).
Limitations to this study are that: 1)
it was conducted at a single academic
medical center and, 2) 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
physicians care for type 2 diabetes and 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.
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Weight perceptions and self-care behaviors
Skinner was funded by an AHRQ National
Research
Service
Award
(#H-T32HS00032-14). Dr. Weinberger is supported
by a Department of Veterans Affairs
HSR&D Senior Career Scientist Award.
ACKNOWLEDGEMENTS
Dr. Rothman was supported by the
Vanderbilt Physician Scientist Development
Award and an NIH K23 Career
Development Award (DK065294).
Dr.
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Weight perceptions and self-care behaviors
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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=68)
Correct or
overestimates
child’s
weight
(n=41)
Child
Underestimates
own weight
(n=59)
Good parent-reported
behavior—best quartile of
scores (%)
Diet
22.1**
56.1
28.8
Exercise
33.8
34.2
33.3
Good adolescent-reported
behavior—best quartile of
adherence scores (%)
Diet
38.2
43.9
30.5*
Exercise
26.2*
46.3
27.1†
Report few self-care
barriers (%)
To diet
23.0†
38.5
20.3*
To exercise
16.1**
40.0
15.3**
†
p<0.10, *p<0.05, **p<0.01; comparing those who underestimate severity to others
7
Correct or
overestimates
own weight
(n=50)
42.0
34.7
52.0
44.2
41.5
39.5