Andrew R. Hansen

Change in Misperception of Child's Body Weight among Parents of American Preschool Children

BACKGROUND Little is known about parental recognition of their childs overweight status over time. The aim of this study was to examine the prevalence of parental misperceptions related to preschool childrens weight in the last two decades. METHODS Data come from the National Health and Nutrition Examination Survey from 1988 to 1994 (early survey; n=3839) and 2007 to 2012 (recent survey; n=3153). Parents were asked whether they considered their child, ages 2-5 years, to be overweight, underweight, or just about the right weight. We estimated the probability ratio (PR) between the two surveys for parents perceiving their overweight child as overweight. RESULTS Percentages of parents who inappropriately perceived their overweight child as just about the right weight was 96.6% and 94.9% for the early and recent survey, respectively. As high as 78.4% of parents perceived their obese child as just about the right weight in the recent survey. The probability of overweight/obese children being perceived as overweight in the early survey was 0.18 (95% confidence interval [CI]=0.14-0.22) and further lowered to 0.14 (95% CI=0.11-0.17) in the recent survey. After adjustment for sociodemographics and BMI z-scores of directly measured body weight, probability of being appropriately perceived by the parents declined by 30% between surveys (PR=0.70 [0.63, 0.78]). CONCLUSIONS There was a declining tendency among parents to perceive overweight children appropriately. Strategies are needed to explore how to encourage clinician discussions with parents about appropriate weight for their child and strengthen capacity for childhood obesity prevention.

Generational Shift in Parental Perceptions of Overweight Among School-Aged Children

BACKGROUND: Parental perceptions of child’s weight status may influence family readiness to foster healthy behaviors. This study investigated the generational shifting of parental perceptions about children’s weight. METHODS: Data were collected in the NHANES 1988–1994 (n = 2871) and 2005–2010 (n = 3202). Parents, mainly mothers, were asked whether they considered their child, ages 6 to 11 years, to be overweight, underweight, or just about the right weight. The Centers for Disease Control and Prevention 2000 growth chart was used for reference. We ran Poisson regression to estimate the probability ratio between the 2 surveys for parents perceiving their child as overweight after controlling for actual weight. RESULTS: The 10th percentile of BMI z scores for children who were parentally perceived as overweight shifted with statistical significance from 84th percentile of reference population in the early survey to 91st percentile of reference population in the recent survey (P < .05). The mean z score of children parentally perceived as overweight also increased between surveys with the largest increase among children from poor families (from 1.60 [SE: 0.20] to 1.98 [0.08], P < .05), followed by African Americans (from 1.65 [0.09] to 2.02 [0.05], P < .05). The probability of overweight/obese children being correctly perceived as overweight by the parents declined by 24% between surveys (probability ratio = 0.76 [95% confidence interval: 0.67–0.87]). CONCLUSIONS: Overweight/obese children were less likely to be perceived as overweight in the recent survey compared with peers of similar weight but surveyed 10+ years earlier. The declining tendency among parents to perceive overweight children appropriately may indicate a generational shift in social norms related to body weight.

Change in Percentages of Adults With Overweight or Obesity Trying to Lose Weight, 1988-2014

Socially acceptable body weight is increasing.1 If more individuals who are overweight or obese are satisfied with their weight, fewer might be motivated to lose unhealthy weight. This study assessed the trend in the percentage of adults who were overweight or obese and trying to lose weight during 3 periods from 1988 through 2014. We used data from the National Health and Nutrition Examination Survey (NHANES), an ongoing, stratified, multistage probability sample of the US noninstitutionalized population designed to represent the health and nutritional status of the general population. A strength of NHANES is that the sampling approaches, interviews, and physical examination methods are standardized across surveys and have been published extensively elsewhere.2 NHANES protocol was approved by the National Center for Health Statistics institutional review board, and written informed consent was obtained.2 The current analysis was categorized as exempt by the Georgia Southern University institutional review board.

Physical activity, screen time, and school absenteeism: self-reports from NHANES 2005–2008

Abstract Objective The purpose of this study was to examine how lifestyle behaviors in the context of physical activity levels and screen time are associated with school absenteeism. Methods We analyzed 2005–2008 NHANES data of proxy interviews for 1048 children aged 6–11 years and in-person self-reports of 1117 adolescents aged 12–18 years. Missing 10% of school days during the past school year was defined as severe school absenteeism (SSA). Results Watching TV ≥2 hours a day was significantly associated with SSA among both children (OR = 3.51 [1.03–12.0]) and adolescents (OR = 3.96 [1.84–8.52]) compared with their peers watching <2 hours a day. A U-shaped association was identified between the level of physical activity and SSA among children. Both inactive children (OR = 12.4 [1.43–108]) and highly active children (14.8 [2.82–77.7]) had higher odds of SSA compared with children with medium levels of physical activity. No associations were observed for either children 0.57 ([0.16–1.99]) or adolescents (0.94 [0.44–2.03]) using a computer ≥3 hours a day. Limitations Cross-sectional study involving self-reports. Transportation to and from school not included in physical activity assessment. Absenteeism was not validated with report cards. Unable to account for the absence type or frequency of illness or injury. No psychometric properties provided for subjective measures regarding participants’ attitudes and characteristic traits towards physical activity, TV viewing, and school attendance. Conclusions Excessive TV watching among children and adolescents, and inactivity and high activity levels (≥7 times per week) among children are independently associated with severe school absenteeism.

The Association between Arthritis and Depression Is Intensified by Excessive Body Weight: Findings from a US National Survey, 2005-2012

OBJECTIVE Obesity and arthritis are leading chronic conditions, but comorbidity of these conditions and their interaction leading to depression have not been fully investigated. The purpose of this study is to determine the degree to which excess body weight effect-modifies the relationship between arthritis and depressive symptoms. METHODS We used the data of 8677 men and 8820 women aged 20 or older, who completed a depression screening and general medical condition interview as a part of the National Health and Nutrition Examination Survey, 2005-2012. Depression was ascertained using the Patient Health Questionnaire-9 (PHQ-9); a PHQ-9 score of 15 or higher was defined as indicative of depression. RESULTS Arthritis was reported in 26.5% (SE=0.9) of men and 36.9% (SE=1.4) of women. The association between depression and arthritis was not significant among healthy weight women, but significant among overweight and obese women. The prevalence ratios (PRs) of depression among arthritis-free women were 1.00 (reference) for healthy weight, 1.43 (0.85-2.42) for overweight, and 1.99 (1.23-3.23) for obese women. For women with arthritis, the PRs were 1.16 (0.63-2.12) for healthy weight, 3.80 (2.24-6.45) for overweight and 3.73 (2.30-6.05) for obese women. The intensifying effect from excessive body weight on the association between arthritis and depression was less salient among men than women. CONCLUSIONS The association between arthritis and depression is intensified significantly by increased body weight, in particular, among women.

Striving to Meet Healthy People 2020 Objectives: Trend Analysis of Maternal Smoking:

Objectives: We examined trends in prevalence rates of smoking and smoking cessation during pregnancy among women in the United States to assess achievement of Healthy People 2020 prevention targets. Methods: We assessed the smoking habits of 30 667 mothers whose children were born between 1985 and 2014 and who were sampled by the National Health and Nutrition Examination Survey, 1999-2014. Sampled participants were children aged 0-15 at the time of interview; however, an adult proxy—usually the biological mother—responded on the child’s behalf and reported information about maternal tobacco use during pregnancy. We calculated prevalence rates, adjusted odds ratios (aORs), and predicted annual increase or decrease of smoking and quitting smoking during pregnancy, adjusting for mother’s age at delivery and income level and child’s race/ethnicity and sex. Results: The average annual prevalence of smoking at any time during pregnancy decreased from 25.7% (95% confidence interval [CI], 15.3%-36.0%) in 1985 to 10.1% (95% CI, 7.1%-13.0%) in 2014 (P < .001), and quitting smoking at any time during the index pregnancy increased from 36.6% (95% CI, 20.3%-52.9%) in 1985 to 54.9% (95% CI, 44.4%-65.4%) in 2008 (P = .002). The adjusted annual risk of smoking during pregnancy decreased significantly by 3% (aOR = 0.97; 95% CI, 0.95-0.98; P < .001). The prevalence rate of smoking in the year 2020 extrapolated from the current trend would be 6.1%. Conclusions: Smoking during pregnancy in the United States is declining. However, renewed public health measures are needed to achieve the Healthy People 2020 objectives of preventing smoking among pregnant women in the United States.

Racial Disparities in Emotional Distress among Cancer Survivors: Insights from the Health Information National Trends Survey (HINTS)

The purpose of this study was to examine the impact of race, cancer history, and their interaction on emotional distress among a nationally representative sample of US adults. Data utilized for this analysis were obtained from the first, second, and fourth iterations of the fourth cycle of the Health Information National Trends Survey (HINTS). The study sample included 3959, 3630, and 3677 respondents for the years 2011, 2012, and 2014, respectively, for a total sample size of 11,266. A multivariable ordered logistic regression model was used to assess the relationship between emotional distress, race, and cancer history. The effect of cancer history on emotional distress was found to be moderated by race. Specifically, emotional distress was significantly higher among African American cancer survivors. Factors found to be protective against emotional distress included healthy lifestyle, older age, and higher income. Factors associated with high levels of emotional distress included poor general health status, low self-efficacy, and being female. The authors recommend the design, advancement, and implementation of evidence-based culturally sensitive interventions aimed at effectively screening and managing psychological distress symptoms, particularly among African American long-term cancer survivor patient populations.

Preschool Children's Self-Reports of Fruit and Vegetable Knowledge, Preference, and Messages Encouraging Consumption

BACKGROUND Fruit and vegetable consumption (FVC) is associated with a reduced risk of diabetes, obesity, cancer, and cardiovascular disease. Only one third of children aged 4-8years consume the recommended 5 servings a day. Studies involving school-aged children (6-11 years) demonstrate that positive outcome expectancies can mediate FVC. There is a lack of similar studies involving preschool-aged (<5 years) children. The purpose of this study was to assess preschool childrens knowledge and preference of fruits and vegetables, messages they recall hearing related to FVC, and how they perceive these messages. METHODS Children (N = 192) were individually interviewed with a play-based picture card game followed by a mealtime environment reenactment open-ended interview. Fruit and vegetable messages were operationalized using Social Cognitive Theory (SCT). Descriptive statistics and associations are reported. RESULTS Each child recalled an average of 2.27 messages associated with FVC. Positive outcome expectancies, negative outcome expectancies, and prompts were most frequently recalled. Statistically significant differences in knowledge, preference, and messages were observed based on income. CONCLUSIONS Children as young as age 4 years understand positive outcome expectancies. Experimental trials are warranted to determine if tailored expectancy messages mediate FVC among preschool children.

Disease Intervention Specialist Education for the Future: An Analysis of Public Health Curricula:

Objectives: The objectives of this study were to (1) determine the degree of alignment between an existing public health curricula and disease intervention specialist (DIS) workforce training needs, (2) assess the appropriateness of public health education for DISs, and (3) identify existing curriculum gaps to inform future DIS training efforts. Methods: Using the iterative comparison analysis process of crosswalking, we compared DIS job tasks and knowledge competencies across a standard Council on Education for Public Health (CEPH)-accredited bachelor of science in public health (BSPH) and master of public health (MPH) program core curricula offered by the Georgia Southern University Jiann-Ping Hsu College of Public Health. Four researchers independently coded each DIS task and competency as addressed or not in the curriculum and then discussed all matches and non-matches between coders. Researchers consulted course instructors when necessary, and discussion between researchers continued until agreement was reached on coding. Results: The BSPH curriculum aligned with 75% of the DIS job tasks and 42% of the DIS knowledge competencies. The MPH core curriculum aligned with 55% of the job tasks and 40% of the DIS knowledge competencies. Seven job tasks and 9 knowledge competencies were considered unique to a DIS and would require on-the-job training. Conclusions: Findings suggest that an accredited public health academic program, grounded in CEPH competencies, could address multiple components of DIS educational preparation. Similar analyses should be conducted at other CEPH-accredited schools and programs of public health to account for variations in curriculum.

Actual body weight or perceived body weight? Comment on ‘childhood obesity and school absenteeism: a systematic review and meta‐analysis’

Dear Editor, With great enthusiasm, we have read the Journal article by An and colleagues examining the relationship between unhealthy body weight and school absenteeism among children and adolescents (1). We applaud the authors’ contributions to the ongoing efforts to quantitatively assess the biological and social impact of childhood obesity, and we certainly appreciate the authors’ selection of two studies from our group for reviewing and meta-analysing (2,3). However, we feel that our studies have been interpreted in a fashion different from what they were intended. The relevant issues may critically affect the estimates obtained by An et al. and hence raise a question on the validity of the conclusion from An’s review. An and his colleagues selected seven out of 13 studies for the meta-analyses. The two studies from our group (2,3) contributed approximately 20% of the weight to the overall meta-estimates. It is worth noting that the two studies were actually drawn from the same survey, that is, National Health and Nutrition Examination Survey, and for almost the same years (2003–2008 vs. 2005–2008). Therefore, the study populations from our two studies substantial overlapped, especially, for adolescents (12–18 vs. 12–19 years). Observing these two studies as separate ones for a metaanalysis may overweigh the contributions from the study populations in our reports, resulting in over or underestimation. More critically, our studies stratified paediatric populations by developmental stages (2,3), but An and his colleagues combined them (1). Starting with puberty, massive changes in children’s social behaviours and cognitive abilities are taking place. The evidence has emerged in recent years, showing strong modifying effects from the juvenile stage on the relationship between body weight and psychological well-being (4). Our earlier study reviewed by An et al. demonstrated a ‘dose–response’ effect of excessive body weight on school absenteeism among children, but not adolescents (2). The adjusted odds of severe school absenteeism were 2.27 (95% confidence interval = 0.64, 8.03) and 3.93 (CI = 1.55, 9.95), among overweight and obese children respectively compared with normal-weight peers. The corresponding estimates among adolescents were 1.33 (CI = 0.68, 2.59) and 1.26 (CI = 0.48, 3.23) among those with overweight and obese, respectively. We are puzzled by how and why An and his colleagues were able to reach an OR of 1.50 (CI = 0.32, 2.70) for the group with overweight and 2.24 (0.73, 6.82) for the group with obesity from our data with such poor uniformity. Echoing the findings from our earlier study that directly measured body weight was not associated with school absenteeism among adolescents (2), increasing numbers of studies found that among adolescents, it was perceived body weight or body image rather than objectively measured body weight that was associated with common psychological issues and behavioural problems, including general psychological disturbances (5–9), poor life-quality (10), harmful weight control behaviours (11), low self-esteem (12), depressed mood (13), suicidal behaviours (14,15) and school absenteeism (12) as well. Unlike young children, adolescents are especially susceptible to the fluidity of social norms and ideals of physical appearance perpetuated by culture and may be more sensitive to social stigma attached to obesity than their child counterparts. In a society that is characterized by contrasting reality, that is, an increasing average body size and a high social desirability of leanness for girls and muscularity for boys conveyed by the media, more adolescents are confronted with demands on their body shape that are desperately hard to meet, resulting in an increasing prevalence of psychological disturbances (4). Thus, it is plausible that culturally mediated body perception, body dysmorphic disorder or body dissatisfaction is a better predictor of psychological stress than measured body weight. Our recent study, also included in An et al.’s review, was designed and executed to test this hypothesis among nationally representative samples (3). It turned out that self-perceived overweight or obesity, in particularly the one not matching with actual body weight, is more detrimental to adolescents’ mental well-being than actual overweight or obesity. Healthy weight adolescents with erroneous self-perceptions of overweight had the highest risk of excessive school absenteeism compared with other groups. The adjusted prevalence ratios of excessive school absenteeism among healthy weight adolescents who erroneously perceived themselves as ‘overweight’ was 1.91 obesity reviews doi: 10.1111/obr.12651