Childhood overweight and obesity increased worldwide at the end of the 20th century,1 with the prevalence of childhood obesity in Spain jumping from 4.9% in 1984 to 13.9% in 2000.2 This trend was paralleled by an increase in the proportion of parents unable to recognize excess weight status in their children,3 reflecting the social normalization of obesity.4

From about 2000, childhood obesity prevalence began to stabilize in many countries.5,6 In Spain, the rate of increase slowed between 2001 and 2006 except among adolescents from a less privileged socioeconomic background.7 These developments were accompanied by increasing parental misperception of childhood weight status.3 Recent data for Spain are inconclusive. Compared with data from 2000,2 the results of a 2011 study indicated an overall stabilization except for a continuing increase in obesity among 6- to 9-year-olds girls.8 In contrast, a 2012 study detected a reduced prevalence among children aged between 8 and 13 years.9 To our knowledge, no study since 2006 has analyzed changes in parental misperception of childhood excess weight.

Factors associated with obesity include consumption of sugar-sweetened soft drinks, a high-energy diet lacking in fruit and vegetables,10,11 insufficient hours of sleep,12 and an excessively sedentary lifestyle.13,14 In Spain, a 1998 survey found that more than 40% of children and adolescents consumed below the recommended amount of fruit and vegetables,15 while other studies found that sugar intake among children accounted for 21% of total caloric intake (double the recommended amount)16 and that the consumption of sugar-sweetened soft drinks increased between 2001 and 2004.17 The proportion of 5- to 15-year-olds who slept less than 8h/d rose from 2.9% in 2001 to 4% in 2003,18 and the proportion watching television for more than 2h/d increased by 4% between 1997 and 2003.19,20

In the present study, we analyzed data from the Spanish National Health Surveys (Encuesta Nacional de Salud de España [ENSE]) for changes in childhood obesity in Spain between 2006 to 200721 and 2011 to 201222 and their relationship with diet, hours of sleep, sedentary activity, and parental misperception of childhood excess weight.

Sociodemographic characteristics of the samples are shown in Table 1. The prevalence of excess weight was 30.1% in 2006 to 2007 and 29.7% in 2011 to 2012 (P=.696). Obesity prevalence values for the same survey years were 9.6% and 9%, respectively (P=.485). No significant changes were detected in the prevalence of excess weight or obesity adjusted for age, sex, or family socioeconomic status (Table 2). In both survey years, excess weight and obesity were more prevalent among 5- to 9-year olds (P=.001 for both survey years). The relationship between family socioeconomic status and overall excess weight strengthened between the 2006-to-2007 and 2011-to-2012 surveys, but the same trend was not observed for obesity.

The proportion of parents failing to recognize childhood excess weight increased from 60.8% (95%CI, 58.1%-63.4%) in 2006 to 2007 to 71.4% (95%CI, 68.4%-74.4%) in 2011 to 2012 (P<.001) (Figure 1). This increase was observed in all subgroups except for children from a high or low socioeconomic background (Table 3). Misperception of obesity increased by 10% between 2006 to 2007 and 2011 to 2012 (P=.011). Stratification revealed increases in parental misperception in relation to 10- to 14-year-olds, boys, and a middle socioeconomic status, whereas misperception decreased among parents with high socioeconomic status. Parental misperception of both overall excess weight and obesity was highest in relation to 5 -to 9-year olds.

Figure.

Prevalence of childhood excess weight and obesity and the percentage of parents unable to recognize these characteristics in their children in 2006 to 2007 and 2011 to 2012.

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Daily consumption of fruit, vegetables, sweets, soft drinks, fast food, and snacks in 2006 to 2007 and 2011 to 2012 is shown in Table 4. These figures show an overall increase of 7.8% in vegetable consumption and decreases of 6.4% and 3.7% in the consumption of soft drinks and snacks, respectively. Stratification by socioeconomic status revealed that vegetable consumption increased most in children from a high socioeconomic status background and that consumption of soft drinks decreased most among children from families with a low socioeconomic status; children in this group also decreased their consumption of fast food and sweets. In 2011 to 2012, sweets consumption did not differ between socioeconomic groups.

In 2006 to 2007, 5- to 9-year-olds slept 9.67h/d (95%CI, 9.63-9.71) and in 2011 to 2012 children in the same age group slept 9.52h/d (95%CI, 9.47-9.57), a decrease of 9 min/d (P<.001). Children aged 10 to 14 years slept 8.94h/d in 2006 to 2007 (95%CI, 8.89-8.98) and 8.84h/d in 2011 to 2012 (95%CI, 8.78-8.88), a 6-minute decrease (P=.003). Adherence to sleep recommendations thus decreased by 5.9% among 5- to 9-year-olds and by 4.5% among 10- to 14-year-olds (Table 5). After adjustment for sex and family socioeconomic status, the sleep duration values for 2011 to 2012 represent a reduction of approximately 10% from those for 2006 to 2007.

In 2006 to 2007, Spanish 5- to 14-year-olds dedicated an average 2.4h/d (95%CI, 2.47-2.57) to sedentary activities. In 2011 to 2012, the figure was 2.5h/d (95%CI, 2.38-2.48), representing an increase of 5 min/d (P=.004). Adherence to recommendations for maximum sedentary time did not vary, remaining close to 50% (Table 5). In both survey years, a positive association was observed between adherence to recommendations and higher family socioeconomic status (data not shown in the tables).

The prevalence of excess weight and obesity among Spanish 5- to 14-year-olds was similar in 2006 to 2007 and 2011 to 2012, both overall and after adjustment for age, sex, and family socioeconomic status. However, the intersurvey period showed a marked increase in the proportion of parents unable to recognize excess weight in their children. There was an overall increase in the consumption of vegetables and a decrease in the consumption of soft drinks and snacks. Children from a low socioeconomic background consumed fewer sweets and less fast food. There was an overall reduction in sleep duration and an increase in the time dedicated to sedentary activities.

These data reveal a stabilization of the prevalence of childhood excess weight and obesity in Spain. The reported prevalence values are similar to those among children aged between 8 and 9 years in the 1998-to-2000 enKid study2 and the 2011 ALADINO study.8 The results presented here are the first to show a stabilization of excess weight prevalence among 10- to 14-year-olds. Despite this stabilization, Spanish rates of childhood excess weight and obesity are among the highest in the world.30 The results of the present analysis coincide with those of other studies showing an accentuation of the relationship between childhood excess weight and family socioeconomic status in 2011 to 201231 and a higher prevalence of excess weight and obesity in 5- to 9-year-olds.32

Up until 2006, parental misperception of childhood excess weight in Spain tracked the increases in childhood obesity.3 Our study shows that parental misperception in Spain has continued to grow despite the stabilization of childhood weight, and is now one of the highest in the world.4 Although parental misperception of excess weight may be skewed by erroneous estimates of children's weight, there was a similar increase in parental misperception of obesity, which has a lower risk of weight misclassification. Possible causes of parental misperception include comparison with other children who are more obese,33 fear of social stigmatization, and avoidance of guilt feelings.3 Other possible influences are the general increase in adult obesity and the associated social normalization of elevated body weight. As in other studies, misperception was highest among parents of younger children, for whom excess weight is widely accepted as a transitory characteristic that will disappear with growth.33 The increasing misperception of childhood weight is worrying because parents who do not detect weight problems in their children are unlikely to take steps to modify obesogenic habits.34,35 The exception to this trend was the decreased misperception of childhood obesity among parents with a high socioeconomic status, possibly reflecting a higher capacity to resist social pressures among people with greater wealth or a higher educational level.

There was an overall positive trend to 2011 to 2012 in the consumption of vegetables, soft drinks, and snacks; however, consumption of sweets, fast foods, and fruit did not change. Vegetable consumption increased most in children from a high socioeconomic background, whereas the largest reductions in soft drink, sweets, and fast food consumption were observed in children from a low socioeconomic background. In 2011 to 2012, sweets consumption did not differ according to family socioeconomic status. Consumption of fruit, vegetables, and soft drinks continues to show a relationship with socioeconomic status.36 Vegetable consumption remains below WHO recommendations,37 and the reduced soft drink consumption, while marked, is insufficient.38 Consumption of unhealthy foods remained highest among children from a low socioeconomic background. Fruit consumption, among the highest in Europe,39 did not change.

In 2011 to 2012, 5- to 9-year-olds slept 9 min/d less than the same age group in 2006 to 2007, whereas 10- to 14-year-olds slept 6 min/d less. These decreases translate into a drop in adherence to sleep recommendations of around 50%, in line with international studies.40 Adherence to recommendations for maximum sedentary time did not change, remaining slightly below 50%. These findings are concerning because habits established in childhood and adolescence set the pattern for adulthood. There is, moreover, an established inverse relationship among children between sleep duration and the time devoted to sedentary activities.41 Sedentary behavior among children is widespread throughout the world,42 and is a major health determinant, independently of the level of physical activity.13

The stabilization of childhood weight and the positive trend in the consumption of some foods come in the wake of the 2005 launch of the Spanish strategy on nutrition, physical activity, and obesity prevention (NAOS),43 and to some degree may reflect success of this strategy. However, a number of factors bring the effectiveness of the NAOS strategy into question; these include the discontinuation of some program activities,44,45 nonadherence to self-regulation agreements by the food and drink vending machine sector,46 the doubtful effectiveness of the PAOS self-regulation code governing food advertising directed at children,47 and the negative trends reported here in parental misperception, sleep duration, and sedentary activity. A possible alternative explanation for the observed changes is the effects of the economic crisis in Spain since 2008. Between 2006 and 2012, the price of food and nonalcoholic drinks increased by 12%,48 and 41% of Spaniards claimed to have adjusted their dietary habits in order to save money.49 These adjustments may have reduced the consumption of superfluous foods such as soft drinks and snacks and their replacement with other, healthier foods such as vegetables. This hypothesis is supported by the larger reduction in the consumption of these unhealthy foods among children from a low socioeconomic background. An earlier study attributed the major drop in body weight among Cubans during the 1991 to 1995 economic crisis to food shortages and an increase in manual labor.50

Despite the stabilization of childhood obesity in Spain between 2006 to 2007 and 2011 to 2012, its prevalence remains excessively high, especially among children from a less privileged background. During the intersurvey period, parental misperception of childhood excess weight grew alarmingly. The ENSE surveys reveal that Spanish children do not adhere to national and international recommendations on diet, sleep duration, or sedentary behavior.

Policy directed at improving childhood and adolescent health should include obesity awareness programs. These programs should be targeted at parents, who play a fundamental role in establishing healthy habits, and at families with a low socioeconomic status, among whom there is greater potential for improving health through changes to dietary, sleep, and sedentary habits.54,55

This project was financed by the Carlos III Institute of Health through the Fondo de Investigación en Salud (Project ENPY 1015/13).

None declared.