Perception of body size across weight categories and association with body size dissatisfaction:  A cross-sectional study among early primary school children

Perception of body size across weight categories and association with body size dissatisfaction: A cross-sectional study among early primary school children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perception of body size across weight categories and association with body size dissatisfaction: A cross-sectional study among early primary school children Tove L. Drilen, Trine T. Eik-Nes, Ellen M. I. Ersfjord, Christian A. Klöckner, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4450847/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Misperception of body size may affect children's health, however, associations with body size dissatisfaction among young children remain uncertain. Hence, this study aims to explore body size misperception (BSM) across weight categories and associations with body size dissatisfaction (BSD) in 8-9-year-old Norwegian children. Methods Using researcher-assisted interviews and figure rating scales, children's perceived current and ideal body size figures were assessed and compared with objectively measured body mass index (BMI) to evaluate three body image constructs: 1. body size dissatisfaction (perceived-ideal), 2. body size misperception (perceived-measured) and 3. discrepancy between objectively measured body size and the children's ideals (measured-ideal). The relationship between BSM and BSD was examined by multinomial logistic regression, adjusting for potential confounders (gender, BMI, socioeconomic status, ethnicity, and residency). Results The children's mean perceived body size figure (4.11) resembled their ideal figure (4.06) but was larger than their mean objectively measured figure (3.23). Most participants misperceived their body size, with a tendency to overestimate body size among children categorized as underweight or healthy weight. Children with overweight/obesity perceived their body size most precisely (30%), with higher odds of underestimating their body size (OR 13.17 [95% CI 3.88, 44.77]) compared to children in lower weight categories. No association was found between body size misperception and body size dissatisfaction for either underestimation or overestimation of body size figures. Conclusions Children categorized with underweight or overweight/obesity were likely to perceive a healthy body size figure, whereas the majority of children with healthy weight, overestimated their current body size. Children's perceived body size was in line with their ideal body size figure, but higher than the health professionals' reference categories for healthy weight. The longitudinal impact of body size misperception on children’s health should be further elucidated. Body image body size misperception body size dissatisfaction childhood obesity Figures Figure 1 Contribution to the literature Healthcare professionals communicating with children about weight-related health risks, should be aware that young children's perceptions of body size may be different from their actual and objectively measured body size. Public health care services detecting children at risk of underweight and obesity, should be cautious to aim for the correct perception of body size but focus on lifestyle changes for optimal health. Future height and weight screening programs should implement children's perspectives to ensure body satisfaction across all weight categories. 1. BACKGROUND Body image is a multidimensional concept encompassing the mental representation of one’s body size, shape, and form ( 1 ), and plays a crucial role in the psychological health and well-being of children and adolescents ( 2 ). Body image concern includes two main constructs: the attitudinal dimension of body size dissatisfaction (BSD) and the perceptual dimension of body size misperception (BSM). BSD refers to the negative subjective evaluation of one’s body size compared to ideal body size ( 1 ) and is a significant risk factor for eating disorders (ED) and poor mental health among children and adolescents ( 3 , 4 ). The construct BSM reflects one's ability to accurately perceive their current body size ( 5 , 6 ), however, its impact on children's health is not fully understood. It has been suggested that children can accurately estimate their body size from the age of 8 years ( 7 ), or even at preschool ( 8 ). Nevertheless, body size misperception (BSM) is commonly observed among children of both genders, across all body mass index (BMI) categories, and from different ethnic minorities and socioeconomic classes ( 5 , 9 , 10 ). A significant proportion of children with overweight and obesity underestimate their body size ( 5 ), along with their parents ( 11 ) and healthcare professionals ( 12 ). Conversely, difficulties in perceiving body size at the lower end of the weight spectrum have been observed ( 13 ). Thus, both underestimation and overestimation of children’s body size have been reported. Whereas the overestimation of underweight or normal weight categories may be associated with unhealthy weight-control behaviors and eating disorders ( 14 ), the underestimation of overweight status has been a proposed barrier to participation in lifestyle interventions with an increased risk of unintentional weight gain and childhood obesity ( 6 , 12 ). By contrast, recent studies suggest potential beneficial effects of BSM on children’s health and well-being ( 5 ). Among adolescents and young adults, the underestimation of overweight status has been associated with a lower risk of future weight gain ( 15 ), reduced likelihood of disordered eating behavior ( 16 ), less depressive symptoms ( 17 ) as well as better life satisfaction and mental health ( 18 ). In elementary school children, underestimation of overweight status has been linked to improved self-esteem ( 19 ) and stabilization or reduction of body weight ( 15 , 20 ). Hence, misperception of body size may potentially have both positive and negative implications on children’s health. It is crucial to acknowledge the spectrum of available methods used in body image research ( 21 ). In the assessment of BSM, verbal methods generally yield lower rates than visual methods ( 12 , 22 ), which may be explained by a refusal to identify oneself with negatively labeled responses such as “obese” or “underweight” ( 12 ). Visual figure rating scales (FRS) have exhibited good evidence of test-retest reliability ( 23 ), and are considered the most appropriate assessment tool for evaluating both body size misperception (BSM) and dissatisfaction (BSD) among young children ( 12 , 22 ), due to their visually engaging nature and inherent simplicity, independent of verbal skills. The two body image dimensions BSD and BSM have traditionally been analyzed separately, as two independent constructs ( 24 ), however, some recent evidence suggests that weight misperception may protect individuals with overweight and obesity against body dissatisfaction ( 17 , 25 , 26 ). As only a few studies have investigated the association between BSM and BSD among preadolescent children ( 8 , 27 – 29 ), this study aims to explore the prevalence of BSM across weight categories and its association with BSD in a sample of 8–9-year-old Norwegian school children. We hypothesized that the prevalence of BSM would vary across different weight categories, with underestimation of overweight status, and further that there would be a significant association between BSM and BSD, with a possible protective effect of BSM on BSD. 2. METHODS This cross-sectional study is part of a larger study investigating children's perspectives of school-based height and weight screening and body size dissatisfaction (BSD) among 8-9-year-old children (N = 209) from central Norway (Drilen et al, article in press). The assessments of body image in this study were conducted at the children's schools, using researcher-assisted interviews, from November 2021 to April 2022. 2.1 Recruitment and participants In this study, two rural and six urban schools with a geographical spread and diverse sociodemographic properties were recruited. Children received information about the study in the classroom from the main author (T.L.D.). Parents received oral and written study information from T.L.D. at a school meeting and through the school's digital communication platform. Information about the study was translated into three languages (English, Arabic, and Tigrinya) to promote study participation. Out of 310 eligible children, 226 children (72.9%) agreed to participate. Children who were absent on the day of data collection (n = 11), those who withdrew their assent (n = 2), and those with missing data (n = 4) were excluded, leaving a total of 209 children, which accounted for a participation rate of 67.4%. 2.2 Procedure The children were interviewed individually, in a private classroom, by experienced researchers and undergraduate students trained in the assessment of body image. Paper, colored pencils, and fidget toys were used to create a safe and child-friendly atmosphere. All children were initially informed about confidentiality and their right to withdraw at any time. The complete content of the interview is described elsewhere (Drilen et al, article in press). In this study, body image was assessed based on a child-friendly interview, earlier described by Birbeck and Drummond ( 30 ). Initially, each child was presented with nine validated ( 31 ) body silhouettes of their corresponding gender and hair color, ranging from underweight to severe obesity, but with equal height (Figure S1 A and S1B). The body silhouettes used were those adapted to 9-10-year-old children by Tiggemann and Pennington ( 32 ), based on Stunkard’s figure rating scales (FRS) for adults ( 33 ). To avoid potential bias, each silhouette was presented randomly for each child, on separate A4 sheets with numbers hidden on the back of the paper ( 34 ). Objectively measured body size and the children’s perceived and ideal body size figures were used to determine three constructs of body image: ( 1 ) Perceived-measured body size figure (body size misperception), ( 2 ) Perceived-ideal body size figure (body size dissatisfaction), and ( 3 ) Measured-ideal body size figure. The children were asked the following questions: 1. “Which of these images do you think looks mostly like you?” (Perceived body size) 2. “If I was Harry Potter or a magician, and I could change you into any of these figures, would you like me to change your figure into any of these images?” Those who did not indicate a desire for a different body size figure were categorized as “satisfied” with their current body size. Children who indicated a desire for a body size figure other than their perceived body figure were categorized as “dissatisfied” with their current figure and further asked the following questions: 3. “Which of these body images would you like me to change you into? Remember you may have to stay that way for a long time, so it needs to be a body figure that you really like” (Ideal body size). 4. “Can you tell me why you chose that body figure?” (Rationale for choice). 2.2.1 Anthropometrics and Demographics The school health nurse collected data regarding BMI, date of birth, and ethnicity. Children with at least one parent from a non-Western country of origin were denoted as non-Western ( 35 ). Socioeconomic status (SES) was categorized as low, medium or high, according to the proportion of children in persistently low-income households in each school region ( 36 ). 2.2.2 Body size misperception To assess body size misperception (BSM), BMI reference cut-offs were applied to the nine body silhouette figures. Stunkard's body silhouettes have previously been assigned BMI categories for both adults ( 37 ), and children ( 38 ). The BMI categories applied to the figures used in this study were based on a previous study with a similar sample ( 39 ), where body size Fig. 1 was categorized as underweight, Fig. 2–4 as normal weight, Fig. 5 as overweight, and Figs. 6–9 as obesity, for girls and boys, equally. Further, age- and gender-specific BMI cut-offs were assigned to each body silhouette figure, based on the international obesity task force (IOTF) BMI cut-off reference values for children (Figure S1 A and S1B). BSM was estimated as the discrepancy between the child's perceived body silhouette figure and the silhouette figure corresponding to the objectively measured BMI category. Negative scores indicated underestimation, positive scores indicated overestimation and no discrepancy indicated accurate perception of body size. 2.2.3 Body size dissatisfaction The discrepancy between the children's perceived and ideal body size figures was denoted as body size dissatisfaction (BSD) based on earlier methodology ( 28 ). Positive scores were interpreted and categorized as a desire to be thinner, negative scores as a desire to be larger, and no difference was categorized as body satisfaction, according to validated measures of body image ( 30 , 31 , 33 ). 2.2.4 Measured versus ideal body size Differences between a child’s objectively measured body size and the child’s perceived ideal body size figure were assessed as the discrepancy between measured and ideal body size figure. Positive scores indicated an ideal body size larger than their measured, negative scores indicated an ideal body size below their measured body size, and no difference indicated the child’s ideal body size concurrent with measured body size. 2.3 Statistical analyses IBM SPSS Version 29 was used for statistical analysis, with a statistical significance level defined by a p-value < 0.05. Due to a few children with obesity (n = 3), children in the overweight and obesity categories were merged. Moreover, the high and medium SES were merged in the statistical analysis and compared with low SES. Mean values for body sizes were estimated for the children’s measured, perceived current, and perceived ideal body size and compared across gender, BMI categories, SES, ethnicity, and residency. Paired samples t-tests were used to analyze differences between actual, perceived current, and ideal body size figures, whereas differences within gender, and demographic variables were analyzed using independent samples t-tests. A one-way ANOVA was used to study the difference between BMI categories (underweight, normal weight, and overweight/obesity) on actual, perceived current, and ideal body size. Children’s body size perception was estimated as either underestimation, accurate estimation, or overestimation, and presented as percentages and numbers, % (n = X). Differences in underestimation, accurate estimation, and overestimation of body size were analyzed separately, using Chi-square tests across gender, BMI categories, and demographic variables. Multinomial regression analyses were used to estimate the association between body size misperception (under- or overestimation), and body size dissatisfaction (BSD), adjusting for gender, BMI, SES, ethnicity, and residency. 3. RESULTS 3.1 Participant characteristics The study sample consisted of 209 children (51% boys) aged 7.9–9.3 years from central Norway and included 6.2% children with underweight (n = 13), 76.1% with average weight (n = 159), 16.3% with overweight (n = 34), and 1.4% with obesity (n = 3). Furthermore, 14% of the children had a non-western origin (n = 29), 14% went to schools in an area with low SES (n = 29), and 25% attended a rural school (n = 53). Demographic and anthropometric properties of non-participants (n = 84) and participants were similar, except for more children with a non-Western origin among non-participants, as described elsewhere (Drilen et al, article in press). 3.1 Body size perception Overall, the children's mean (M) perceived current figure (M = 4.11, SD = 0.86) did not differ significantly from their ideal body size figure (M = 4.06, SD = 1.10), but was significantly higher than their objectively measured body size figure (M = 3.23, SD 1.20; p < 0.01, 95% CI [0.70, 1.05]) (Table 1 ). No significant differences in objectively measured body sizes were found between genders, however, boys perceived their current body size to be significantly larger (M = 4.31, SD = 0.90) compared to girls (M = 3.90, SD = 0.76; p < 0.05, 95% CI [0.18, 0.63]). Furthermore, boys also perceived their ideal body size (M = 4.24, SD = 1.17) to be larger than the girls' (M = 3.86, SD = 1.00; p = 0.01, 95% CI [0.08, 0.68]). Children objectively categorized with overweight/obesity perceived their body size figures to be larger (M = 4.43, SD = 0.96) than their peers classified as normal weight (M = 4.04, SD = 0.80; p = 0.034, 95% CI [0.02, 0.75]). However, children’s ideal body size figures did not differ across weight categories (p = 0.149, 95% CI [0.00, 0.08]). Children from schools with lower SES desired a significantly larger ideal body size figure (M = 4.55, SD = 1.62) than those from areas with medium/high SES (M = 3.98, SD = 0.98; p = 0.009, 95% CI [0.15, 1.00]) (Table 1 ). Table 1 Mean values of measured, perceived, and ideal body size figures according to anthropometric and demographic characteristics of the participants. Mean (SD) Measured body size figure Perceived body size figure Ideal body size figure All children (n = 209) 3.23 (1.20) 4.11 (0.86) ᵃ 4.06 (1.10) ᵇ Gender Girls (n = 102) 3.26 (1.24) 3.90 (0.76) 3.86 (1.00) Boys (n = 107) 3.22 (1.17) 4.31 (0.90) *** 4.24 (1.17) * Assigned BMI category Underweight (n = 13) 1.00 (0.00) *** 4.18 (0.98) 4.18 (2.09) Average weight (n = 159) 2.97 (0.81) *** 4.03 (0.81) 3.98 (1.04) Overweight/obesity (n = 37) 5.08 (0.28) *** 4.41 (0.99) * 4.38 (0.99) SES Low (n = 29) 3.26 (1.19) 4.38 (0.94) 4.55 (1.62) ** Medium/high (n = 180) 3.07 (1.31) 4.07 (0.84) 3.98 (0.98) Ethnicity Non-Western (n = 29) 3.10 (1.42) 4.03 (0.94) 3.97 (1.32) Western (n = 180) 3.26 (1.17) 4.12 (0.84) 4.07 (1.07) Residence Rural (n = 53) 3.45 (1.23) 4.19 (0.74) 4.19 (0.90) Urban (n = 156) 3.16 (1.19) 4.08 (0.89) 4.01 (1.16) Results are presented as mean (SD). A paired samples t-test assessed the difference between the objectively measured, perceived current, and ideal body size. ᵃ Significant difference between measured and perceived body size. ᵇͨ Significant difference between measured and ideal body size. Independent samples t-tests (two-sided) were used to assess differences within gender and demographic variables. ANOVA was used to assess differences between weight categories. Level of significance: *** p < 0.001, ** p < 0.01 and * p < 0.05. BMI, body mass index; SD, standard deviation; SES, socioeconomic status. 3.2.1 Body size misperception The discrepancy scores between perceived and measured body size figures ranged from − 2 to + 5, as illustrated in Fig. 1 . Most children (78%) misperceived their current body size with at least one body size figure, as indicated by 64% overestimation and 14% underestimation of body size figure (Table 2 ), whereas 34% of the children misperceived their body size with at least 2 figure sizes (23% overestimation and 11% underestimation). According to weight categories, 35% misperceived at least one weight category above (n = 55) or below (n = 24) their measured BMI category (Table S1 ). Significantly more boys (71%) than girls (56%) overestimated their body size, and more girls (18%) than boys (11%) underestimated their body size figures. The majority (92%) of children with underweight overestimated their body size, and most (60%) of children categorized with overweight/obesity underestimated their body size figure. Lastly, most of the children categorized with average weight (74%) overestimated their current body figure (Table 2 ). Of the 22% who accurately estimated their body size, girls (27%) indicated a more accurate perception of their current body figure compared to boys (18%). Moreover, children categorized with overweight/obesity were more likely to be accurate in their perception of body size figures (30%) than children from both underweight (8%) and average weight (21%) categories (Table 2 ). 3.3 Body size dissatisfaction The discrepancy scores between the perceived current body size and the ideal body size varied from − 5 to + 4. A total of 23% of the children indicated a desire for another body size, by selecting an ideal body size figure with at least one body figure discrepancy above (9%) or below (14%) their perceived current body size figure. Only 7% of the children indicated a desire for more than one figure score above (n = 5) or below (n = 9) ideal body size (Fig. 1 ). No differences in BSD were observed between gender or BMI categories. Table 2 Body size perception based on the measured and perceived body size discrepancy. Correct estimation Underestimation Overestimation Total % (n = 209) 22.0% (n = 46) 14.4% (n = 30) 63.6% (n = 133) Gender (%) Girls (n = 102) 26.5% (n = 27) * 17.8% (n = 18) * 55.9% (n = 57) Boys (n = 107) 17.8% (n = 19) 11.2% (n = 12) 71.0% (n = 76) * BMI categories Underweight (n = 13) 0.0% (n = 0) NA 100.0% (n = 13) * Normal weight (n = 159) 21.3% (n = 34) 5.0% (n = 8) 73.8% (n = 117) * Overweight/Obesityᵃ (n = 37) 29.7% (n = 11) * 59.5% (n = 22) 10.8% (n = 4) * SES Low (n = 29) 13.8% (n = 4) 6.7% (n = 2) 79.3% (n = 23) Not low ᵇ (n = 180) 23.3% (n = 42) 15.6% (n = 28) 61.1% (n = 110) Ethnicity Western (n = 180) 21.1% (n = 38) 15.0% (n = 27) 63.9% (n = 115) Non-western (n = 29) 10.3% (n = 3) 27.6% (n = 8) 62.1% (n = 18) Residency Urban (n = 156) 20.5% (n = 32) 14.1% (n = 22) 65.4% (n = 102) Rural (n = 53) 26.4% (n = 14) 15.1% (n = 8) 58.5% (n = 31) The prevalence of BSM is presented as % (n = X) for categorical data. Pearson`s Chi-Square tests were used to analyze differences within gender, BMI categories, SES, ethnicity, and residency. ᵃ Overweight and obesity categories were merged. ᵇ Not low SES included both medium and high SES. Level of significance: * p < 0.05. BMI, body mass index; SES, socioeconomic status. 3.4 Measured versus ideal body size. The discrepancy scores between the objectively measured body size and the children's ideal body size ranged from − 8 to + 2. Most children (80%) indicated an ideal body size of at least one body size figure different from their objectively measured body size figure, with 60% indicating an ideal body size figure above the measured figure and 20% indicating an ideal body figure below their objectively measured body size (Fig. 1 ). Furthermore, 38% of the children desired an ideal body of at least 2 figures above (n = 66) or below (n = 13) their objectively measured body size figure. Boys' ideal body size was significantly larger and deviated more from their measured body size, as opposed to the girls. Further, significant differences were found across the BMI categories, with 91% of children with underweight and 69% of children with average weight perceiving an ideal body size above, and 62% of children living with overweight/obesity perceiving an ideal body size below their objectively measured body size figure (Table 3 ): Table 3 Mean distribution of three different dimensions of body image using figure rating scales. Mean (SD) Δ Perceived - Measured body size figure (BSM) Δ Perceived - Ideal body size figure (BSD) Δ Measured - Ideal body size figure All children (n = 209) 0.88 (1.31) 0.05 (0.92) -0.82 (1.56) Gender Girls (n = 102) 0.65 (1.29) 0.04 (0.82) -0.61 (1.52) Boys (n = 107) 1.10 (1.29) * 0.07 (1.00) -1.03 (1.58) * Measured BMI category Underweight (n = 13) 2.92 (1.26) * 0.00 (1.87) -2.92 (2.10) * Average weight (n = 159) 1.07 (0.99) * 0.06 (0.89) -1.01 (1.31) * Overweight/obesity (n = 37) -0.65 (0.98) * 0.05 (0.47) 0.70 (1.00) * SES Low (n = 29) 1.31 (1.26) -0.17 (1.42) -1.48 (2.10) Medium/high (n = 180) 0.81 (1.30) 0.09 (0.81) -0.72 (1.44) Ethnicity Non-Western (n = 29) 0.93 (1.07) 0.07 (1.13) -0.86 (1.71) Western (n = 180) 0.87 (1.34) 0.05 (0.88) -0.82 (1.54) Residence Rural (n = 53) 0.74 (1.27) 0.00 (0.68) -0.74 (1.47) Urban (n = 156) 0.93 (1.32) 0.07 (0.99) -0.85 (1.60) Results are presented as mean (SD) figure rating discrepancy. Independent samples t-tests (two-sided) were used for each dimension of body image to assess differences within gender and demographic variables. ANOVA was used to assess differences between BMI categories. Level of significance: * p < 0.05. BMI, body mass index; BSD, body size dissatisfaction; BSM, body size misperception; SES, socioeconomic status. 3.4 Association between BSM and BSD No significant association was observed between body size misperception (BSM) and body size dissatisfaction (BSD) for either underestimation (OR 1.78 [95%CI 0.45, 7.01]) or overestimation of body size figures (OR 1.03 [95%CI 0.44, 2.45]), after adjusting for gender, BMI, and demographic variables (Table 4 ). These findings were further substantiated by a sensitivity analysis utilizing discrepancy scores of +/-2 body size figures in the assessment of BSM. Table 4 Multinomial logistic regression analyses for the association between body size misperception and body dissatisfaction. Body size misperception (perceived – measured) Underestimation Overestimation Body size dissatisfaction (perceived-ideal body size) (Ref: No discrepancy) 1.78 [0.45, 7.01] 1.03 [0.44, 2.45] Gender (Ref: Girls) 0.52 [0.17, 1.64] 2.32 [1.11, 4.85] * BMI Underweight (Ref: average weight) BMI Overweight (Ref: average weight) N.A. - 13.17 *** [3.88, 44.77] 3.30 [0.40, 27.38] 0.07 *** [0.02, 0.26] SES (Ref: Not low) 4.83 [0.61, 38.11] 0.29 [0.07, 1.12] Ethnicity (Ref: Western) 1.62 [0.34, 7.75] 1.22 [0.45, 3.33] Residence (Ref: Urban) 2.27 [0.63, 8.16] 1.04 [0.45, 2.39] Results are presented as Odds ratio with a 95% Confidence Interval: OR [95% CI] Dependent variable: Body size misperception (underestimation and overestimation) compared to correct estimation. Independent variable: Body size dissatisfaction (reference: no BSD). Confounders: Gender (reference: girls), BMI underweight and overweight (ref average weight), SES (reference: med-high SES), ethnicity (reference: Western), and residence (reference: urban). Level of significance: * p < .05, ** p < 0.01 and *** p < .001. BSD, body size dissatisfaction; BMI, body mass index; SES, socioeconomic status. 4. DISCUSSION In this study, a high prevalence of body size misperception (BSM) was observed across all weight categories. Children classified as underweight or healthy weight showed a tendency to overestimate their body size, while those classified as overweight/obesity tended to underestimate their body size. Most children misperceived their current body size figure towards their ideal, indicating low rates of body size dissatisfaction (BSD). No significant association was found between BSM and BSD, irrespective of gender, BMI, and demographics, however, there was a significant disparity between children's perceived ideal and objectively measured body size. The high prevalence (78%) of BSM observed in our study aligns with several other studies with comparable age groups and similar methodologies ( 28 , 40 – 42 ), reinforcing that children of both genders, among all BMI categories, and across a range of demographics tend to misperceive their body size ( 5 ). The children categorized outside the healthy weight category perceived their body size to be healthy, reflected by persistent overestimation of underweight status and underestimation of overweight status. This finding is in line with several other studies among children ( 21 , 22 , 27 , 43 ), which may be due to children’s desire to be “normal” or “about right”, and their refusal to associate themselves with an undesirable or stigmatized body figure, such as “overweight” or “underweight” ( 12 ). However, most children with overweight/obesity in the present study indicated satisfaction with their body size, which may reflect a shift towards increased acceptance and satisfaction with having a larger body size ( 44 ). Furthermore, the increasing number of individuals with obesity in society ( 44 , 45 ), may lead to visual adaptation with children being more likely to underestimate their overweight status if they are surrounded by other people with higher BMI classifications ( 10 ). Thus, we cannot exclude the possibility that the children above healthy weight in our study were unaware of their overweight status and perceived to be average, which has been previously demonstrated ( 43 ). A notable finding of our study was the overall bias towards the overestimation of body size among children categorized with underweight and normal weight, contrasting most other studies reporting an overall underestimation of body size among young children ( 20 , 22 , 28 ). It has been suggested that studies using ascending figure rating scales (from thinness to obesity) might increase the likelihood of underestimating body size in children as they can visually compare themselves to the smaller figures on the scale ( 34 ). Interestingly, a study conducted in Brazil ( 40 ) presenting the FRSs in the same manner as in our study, with the silhouettes presented randomly on separate cards, also found an overestimation of body size, which agrees with perspectives from Gardner ( 7 ) and Ra ( 43 ) suggesting that young children have a general propensity to overestimate their body size ( 34 ). Furthermore, the higher number of figures used in ours and Costa’s study (9–11 figures), compared to others (3–7 figures), may have improved accuracy by increasing the likelihood of children identifying a figure that closely matched their actual body sizes. However, available literature on psychometric properties of figure rating scales among children is inconclusive ( 44 , 45 ) and it is uncertain whether randomly presented FRS and/or a higher range of body image figures affect rates and direction of BSM among children. Given that most children in our study indicated satisfaction with their body size, our findings are different from the overestimation commonly observed in individuals at risk of eating disorders ( 46 ). It may be that children's overestimation of body size is a normative phenomenon, explained by a tendency of children to perceive themselves with larger body size, including being more muscular or mature, as a more typical or desirable body size, possibly influenced by ideal body image norms, media, and peer comparisons ( 47 ). In our study, we found no significant association between BSD and BSM. This is in contrast with the positive associations found in studies among adults and adolescents, suggesting that BSM may either protect against BSD ( 48 ) or possibly reflect body satisfaction ( 26 ). The few studies that have investigated the association between BSM and BSD among young children are inconsistent, suggesting that BSM may be either predictive ( 27 , 49 ), protective ( 28 , 50 ), or unrelated to BSD ( 8 , 28 ). The lack of association between the two body image constructs found in our study is in line with a study among preschoolers ( 8 ) and the overall results among a sample of preadolescent children ( 28 ), and thus we cannot exclude the possibility that these two dimensions of body image are unrelated constructs. Hence, the association between BSD and BSM, and the impact on children’s health should be further elucidated in a larger sample, with subgroup analyses. This study highlights a significant disparity between children's perceived ideal body size and their objectively measured BMI, which may pose a dilemma for public healthcare professionals, who have the mandate to identify and address unhealthy weight deviations while safeguarding children from harm. Young children's perceptions of their body sizes may have important implications for health communication regarding weight category assessments, such as school-based height and weight screening programs and obesity prevention and treatment. Both parents, HCPs, and other relevant stakeholders should be aware of children's perceptions of their body sizes, their body size ideals, and whether there is a discrepancy between their perceived and measured weight status that may be related to health risks. According to recent literature ( 26 ), misperception of body size among children with obesity should not be corrected to ensure sufficient motivation for lifestyle changes, as the perception of overweight status may influence increased weight gain ( 18 ) and lower self-esteem ( 19 ), which may reduce children's overall health. Furthermore, the aim of interventions for children with weight deviations and in need of follow-up by the health care services, should not only include suggestions for lifestyle changes but also aim to improve mental health, including body satisfaction ( 2 ). 4.1 Strengths and limitations The main strength of the current study is the diverse sample of young elementary school children, with access to anthropometric and demographic data of non-participants, which can be generalized to represent children of central Norway. Further strengths are the use of objectively measured height and weight data. Moreover, the thorough face-to-face assessment of several constructs of body image using validated and child-friendly visual methods, with several efforts to reduce bias, may have strengthened the reliability of our findings. However, the current study should be interpreted with some limitations in mind. First, the figure rating scales used in this study only considered two dimensions of body size, such as being smaller or larger, with no option to indicate a more muscular body size. Second, the study was constrained by a small sample of children with obesity, precluding targeted analysis of this subgroup. 4.2 Conclusion Most children overestimated their current body size, without indicating a desire for another body size. A greater insight into the potential prospective implications of BSM on young children's health is needed. Future studies should aim to include a higher number of children, to enable comparison of subgroups with boys and girls across all weight categories, ethnicities, residency, and socioeconomic classes, preferably combining quantitative body image assessment with a more qualitative and explorative design. Abbreviations BMI Body mass index BMIz Body mass index z-score BSD Body size dissatisfaction BSM Body size misperception BSP Body size perception CI Confidence interval ED Eating disorder FRS Figure rating scale HCP Health care professional IOTF International Obesity Task Force M Mean SD Standard deviation SES Socioeconomic status Declarations Ethics approval and consent to participate The study was approved in 2021 by The Regional Committees for Medical and Health Research Ethics of Mid-Norway (no. 244609). Children's assents were collected in the classroom, whereas parental consent was either collected by teachers or digitally. Availability of data and materials The datasets used during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by a grant from The Norwegian Womens Health Association (Grant number: 40406) . Authors contributions T.L.D., R.A.Ø., T.T.E-N., and E.M.I.E. were responsible for the study design and planning of this study. T.L.D. had the main responsibility for data collection, data analysis, interpretation of the data, generation of figures, and writing the article. R.A.Ø. and T.T.E-N. contributed to the data collection. C.A.K. was responsible for the choice of statistical methods and assisted with the analysis and interpretation of the data. All authors reviewed the manuscript. Acknowledgments We acknowledge Betty Pettersen for her collaboration and organization of the study in the municipality of Trondheim, and the school principals, teachers, and healthcare nurses, who contributed to the organization of this project. Special gratitude to all the children who participated in the study, and to their parents for being positive to the research project. Thanks to the researchers who contributed to the data collection, and to the Norwegian Women’s Public Health Association for the funding. Author's information Tove L. Drilen, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Regional Centre for Obesity Research and Innovation, Post box 3250, Torgarden, 7006 Trondheim, Norway E-mail: [email protected] References Slade PD. What is body image? Behaviour research and therapy. 1994. Rodgers RF, Laveway K, Campos P, de Carvalho PHB. Body image as a global mental health concern. Cambridge Prisms: Global Mental Health. 2023;10:e9. Stice E, Shaw HE. Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. J Psychosom Res. 2002;53(5):985–93. Harriger JA, Thompson JK. Psychological consequences of obesity: Weight bias and body image in overweight and obese youth. Int Rev Psychiatry. 2012;24(3):247–53. Blanchet R, Kengneson C-C, Bodnaruc AM, Gunter A, Giroux I. Factors influencing parents’ and children’s misperception of children’s weight status: a systematic review of current research. Curr Obes Rep. 2019;8:373–412. Neves CM, Cipriani FM, Meireles JFF, Morgado FFR, Ferreira MEC. Body image in childhood: an integrative literature review. Revista Paulista de Pediatria. 2017;35:331–9. Gardner R. Measurement of perceptual body image. Encyclopedia body image Hum appearance. 2012;2:526–32. Tremblay L, Lovsin T, Zecevic C, Larivière M. Perceptions of self in 3–5-year-old children: A preliminary investigation into the early emergence of body dissatisfaction. Body image. 2011;8(3):287–92. Frayon S, Cherrier S, Cavaloc Y, Wattelez G, Touitou A, Zongo P, et al. Misperception of weight status in the pacific: preliminary findings in rural and urban 11-to 16-year-olds of New Caledonia. BMC Public Health. 2017;17:1–10. Robinson E. Overweight but unseen: a review of the underestimation of weight status and a visual normalization theory. Obes Rev. 2017;18(10):1200–9. Ramos Salas X, Buoncristiano M, Williams J, Kebbe M, Spinelli A, Nardone P, et al. Parental perceptions of children’s weight status in 22 countries: The WHO European childhood obesity surveillance initiative: COSI 2015/2017. Obes Facts. 2021;14(6):658–74. Alshahrani A, Shuweihdi F, Swift J, Avery A. Underestimation of overweight weight status in children and adolescents aged 0-19 years: A systematic review and meta‐analysis. Obes Sci Pract. 2021;7(6):760–96. Lundahl A, Kidwell KM, Nelson TD. Parental Misperceptions of Children's Underweight Status: A Meta-analysis. Ann Behav Med. 2014;48(2):184–93. Kinnear A, Withnell SJ, Witte TK, Smith AR, Szczyglowski K, Bodell LP. Weight misperception and its associations with eating disorder symptoms over the course of residential eating disorder treatment. Int J Eat Disord. 2021;54(10):1810–8. Haynes A, Kersbergen I, Sutin A, Daly M, Robinson E. A systematic review of the relationship between weight status perceptions and weight loss attempts, strategies, behaviours and outcomes. Obes Rev. 2018;19(3):347–63. Sonneville KR, Thurston IB, Milliren CE, Gooding HC, Richmond TK. Weight misperception among young adults with overweight/obesity associated with disordered eating behaviors. Int J Eat Disord. 2016;49(10):937–46. Thurston IB, Sonneville KR, Milliren CE, Kamody RC, Gooding HC, Richmond TK. Cross-sectional and prospective examination of weight misperception and depressive symptoms among youth with overweight and obesity. Prev Sci. 2017;18:152–63. Kvaløy K, Sandsgård-Hilmarsen E, Eik-Nes TT, Bratberg GH. Underestimation of Overweight and Health Beneficial Outcomes in Two Adolescent Cohorts in Norway–The HUNT Study. J Adolesc Health. 2021;69(1):82–9. Maximova K, Khan MK, Austin SB, Kirk SF, Veugelers PJ. The role of underestimating body size for self-esteem and self-efficacy among grade five children in Canada. Ann Epidemiol. 2015;25(10):753–9. Steinsbekk S, Klöckner CA, Fildes A, Kristoffersen P, Rognsås SL, Wichstrøm L. Body size estimation from early to middle childhood: stability of underestimation, BMI, and gender effects. Front Psychol. 2017;8:307082. Moeng-Mahlangu LT, Monyeki MA, Reilly JJ, McHiza ZJ, Moleah T, Loechl CU, et al. Level of agreement between objectively determined body composition and perceived body image in 6- to 8-year-old South African children: The Body Composition–Isotope Technique study. PLoS ONE. 2020;15(8):e0237399. Saxton J, Hill C, Chadwick P, Wardle J. Weight status and perceived body size in children. Arch Dis Child. 2009;94(12):944–9. Cash TF, Smolak L. Body image: A handbook of science. practice, and prevention: Guilford Press; 2011. Gardner RM, Friedman BN, Jackson NA. Methodological concerns when using silhouettes to measure body image. Percept Mot Skills. 1998;86(2):387–95. Nissen NK, Holm L. Literature review: perceptions and management of body size among normal weight and moderately overweight people. Obes Rev. 2015;16(2):150–60. Richmond TK, Sonneville KR, Milliren CE, Thurston IB. Unraveling the meaning of weight misperception in a sample of college students: Unaware or body satisfied? Body Image. 2022;43:87–94. Leppers I, Tiemeier H, Swanson SA, Verhulst FC, Jaddoe VW, Franco OH, et al. Agreement between weight status and perceived body size and the association with body size satisfaction in children. Obesity. 2017;25(11):1956–64. Bordeleau M, Leduc G, Blanchet C, Drapeau V, Alméras N. Body size misperception and dissatisfaction in elementary school children. Child Obes. 2021;17(7):467–75. León M-P, González-Martí I, Fernández-Bustos J-G, Contreras O. Perception of body size and dissatisfaction in children aged 3 to 6: A systematic review. anales de psicología. 2018;34(1):173. Birbeck D, Drummond M. Interviewing, and listening to the voices of, very young children on body image and perceptions of self. Early Child Dev Care. 2005;175(6):579–96. Tiggemann M, Wilson-Barrett E. Children's figure ratings: Relationship to self‐esteem and negative stereotyping. Int J Eat Disord. 1998;23(1):83–8. Tiggemann M, Pennington B. The development of gender differences in body-size dissatisfaction. Australian Psychol. 1990;25(3):306–13. Stunkard AJ, Sørensen TI, Hanis C, Teasdale TW, Chakraborty R, Schull WJ, et al. An adoption study of human obesity. N Engl J Med. 1986;314(4):193–8. Gardner RM, Brown DL. Body image assessment: A review of figural drawing scales. Pers Indiv Differ. 2010;48(2):107–11. Wissan ACC, Nag OS, Brys M, WorldAtlas. Reunion Technology Inc; 2021 [updated April 26, 2021. https://www.worldatlas.com/articles/list-of-western-countries.html . Heggstad IRL, Molden TH, Schistad S, Eiksund S, Gravaas BK et al. Living conditions and public health in Trondheim municipality. 2021. Bulik CM, Wade TD, Heath AC, Martin NG, Stunkard AJ, Eaves LJ. Relating body mass index to figural stimuli: population-based normative data for Caucasians. Int J Obes. 2001;25(10):1517–24. Cortés-Martínez G, Vallejo-de la Cruz NL, Pérez-Salgado D, Ortiz-Hernández L. Usefulness of body silhouettes to assess the nutritional status of school-age children and adolescents in Mexico City. Boletín Médico del Hosp Infantil de México. 2009;66(6):511–21. Sánchez GFL, Suárez AD, Smith L. Analysis of body image and obesity by Stunkard's silhouettes in 3-to 18-year-old Spanish children and adolescents. Anales de psicología. 2018;34(1):167–72. Costa LCF, Silva DAS, Almeida SS, Vasconcelos FdAGd. Association between inaccurate estimation of body size and obesity in schoolchildren. Trends psychiatry Psychother. 2015;37:220–6. Demir HP, Bayram HM. The Association between BMI and Body Weight Perception among Children in Turkey: A Cross-Sectional Study. Iran J Public Health. 2023;52(11):2372. Riahi R, Motlagh ME, Heshmat R, Qorbani M, Daniali SS, Kelishadi R. Body weight misperception and psychological distress among children and adolescents: The CASPIAN-V study. Osong Public Health Res Perspect. 2019;10(5):315. Plotas P, Tsekoura E, Souris E, Kantanis A, Kostopoulou E, Varvarigou A et al. Body-Size Misperception among Overweight Children and Adolescents in Greece: A Cross-Sectional Study. Nutrients. 2023;15(8). Burke MA, Heiland FW, Nadler CM. From overweight to about right: evidence of a generational shift in body weight norms. Obesity. 2010;18(6):1226–34. Lu H, Tarasenko YN, Asgari-Majd FC, Cottrell-Daniels C, Yan F, Zhang J. More overweight adolescents think they are just fine: generational shift in body weight perceptions among adolescents in the US. Am J Prev Med. 2015;49(5):670–7. Shin A, Nam CM. Weight perception and its association with socio-demographic and health-related factors among Korean adolescents. BMC Public Health. 2015;15:1–9. Roberts SR, Maheux AJ, Hunt RA, Ladd BA, Choukas-Bradley S. Incorporating social media and muscular ideal internalization into the tripartite influence model of body image: Towards a modern understanding of adolescent girls’ body dissatisfaction. Body image. 2022;41:239–47. Easton JF, Stephens CR, Sicilia HR. An analysis of real, self-perceived, and desired BMI: is there a need for regular screening to correct misperceptions and motivate weight reduction? Front public health. 2017;5:237776. Knowles G, Ling FCM, Thomas GN, Adab P, McManus AM. Body size dissatisfaction among young Chinese children in Hong Kong: a cross-sectional study. Public Health Nutr. 2015;18(6):1067–74. Veldhuis J, Te Poel F, Pepping R, Konijn EA, Spekman ML. Skinny is prettier and normal: I want to be normal—Perceived body image of non-Western ethnic minority children in the Netherlands. Body image. 2017;20:74–86. Additional Declarations No competing interests reported. Supplementary Files SupportingInformationToveLDrilenArchivesOfPublicHealth22.5.2024.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4450847","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":309308571,"identity":"17666e76-8db1-4dd1-8e90-fed8bff317a2","order_by":0,"name":"Tove L. Drilen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYNCCAgbGBmbmBgaGCiIU84BJA5AWRqCWMwwSJGgBozYitNiz9xg+AGqR3d7O2Pi4cN6dOnOJBLYHH/DZwnPG2ACoxXjOYcZm45nbnklYzkhgN5yBT4tEWpoEUEviDGbGNmnebYclDG4ksEnz4NeS/gOqpf037xyitCQfY4DZwszbQIyWM4cPSyQYSBgDtTRL8xw7LLnhzMM2SXx+YW9vbPzwocJGdgb/4YOfeWoO8xscTz4mgS/EwCABNTZAcToKRsEoGAWjgCIAAAwoQiIu1+JIAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Tove","middleName":"L.","lastName":"Drilen","suffix":""},{"id":309308572,"identity":"d3c2ec57-a4a4-4ad4-ba74-47059e7efc26","order_by":1,"name":"Trine T. Eik-Nes","email":"","orcid":"","institution":"Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Trine","middleName":"T.","lastName":"Eik-Nes","suffix":""},{"id":309308573,"identity":"fb389675-ca77-4a62-bd80-82526288eb6f","order_by":2,"name":"Ellen M. I. Ersfjord","email":"","orcid":"","institution":"Department of Health and Nursing Sciences, University of Agder","correspondingAuthor":false,"prefix":"","firstName":"Ellen","middleName":"M. I.","lastName":"Ersfjord","suffix":""},{"id":309308574,"identity":"794c1bb8-7fa8-488e-aeba-f66b79af20b8","order_by":3,"name":"Christian A. Klöckner","email":"","orcid":"","institution":"Department of Psychology, Norwegian University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"A.","lastName":"Klöckner","suffix":""},{"id":309308575,"identity":"c5d6a82d-1287-4813-a909-dd788a97d4d3","order_by":4,"name":"Rønnaug A. Ødegård","email":"","orcid":"","institution":"Centre of Obesity Research (ObeCe), St. Olav’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Rønnaug","middleName":"A.","lastName":"Ødegård","suffix":""}],"badges":[],"createdAt":"2024-05-20 19:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4450847/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4450847/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57954676,"identity":"52c6f753-2192-4151-9703-9dfe59382050","added_by":"auto","created_at":"2024-06-07 23:17:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76591,"visible":true,"origin":"","legend":"\u003cp\u003eThe distribution of three body image dimensions.\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4450847/v1/e8c4e1981b32e8c2b5dec6ad.png"},{"id":60815292,"identity":"0e295f28-2010-49a7-ae2f-f1fc004188d9","added_by":"auto","created_at":"2024-07-22 11:47:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1040808,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4450847/v1/6780ca20-a89b-4605-a103-7e52df921e36.pdf"},{"id":57954677,"identity":"b868798e-62b1-4ed0-99c3-eca7ce599ee6","added_by":"auto","created_at":"2024-06-07 23:17:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":285959,"visible":true,"origin":"","legend":"","description":"","filename":"SupportingInformationToveLDrilenArchivesOfPublicHealth22.5.2024.docx","url":"https://assets-eu.researchsquare.com/files/rs-4450847/v1/121d029409a94744518025d5.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perception of body size across weight categories and association with body size dissatisfaction: A cross-sectional study among early primary school children","fulltext":[{"header":"Contribution to the literature","content":"\u003cul\u003e\n \u003cli\u003eHealthcare professionals communicating with children about weight-related health risks, should be aware that young children\u0026apos;s perceptions of body size may be different from their actual and objectively measured body size.\u003c/li\u003e\n \u003cli\u003ePublic health care services detecting children at risk of underweight and obesity, should be cautious to aim for the correct perception of body size but focus on lifestyle changes for optimal health.\u003c/li\u003e\n \u003cli\u003eFuture height and weight screening programs should implement children\u0026apos;s perspectives to ensure body satisfaction across all weight categories.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. BACKGROUND","content":"\u003cp\u003eBody image is a multidimensional concept encompassing the mental representation of one\u0026rsquo;s body size, shape, and form (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), and plays a crucial role in the psychological health and well-being of children and adolescents (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Body image concern includes two main constructs: the attitudinal dimension of body size dissatisfaction (BSD) and the perceptual dimension of body size misperception (BSM). BSD refers to the negative subjective evaluation of one\u0026rsquo;s body size compared to ideal body size (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and is a significant risk factor for eating disorders (ED) and poor mental health among children and adolescents (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The construct BSM reflects one's ability to accurately perceive their current body size (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), however, its impact on children's health is not fully understood.\u003c/p\u003e \u003cp\u003eIt has been suggested that children can accurately estimate their body size from the age of 8 years (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), or even at preschool (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Nevertheless, body size misperception (BSM) is commonly observed among children of both genders, across all body mass index (BMI) categories, and from different ethnic minorities and socioeconomic classes (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). A significant proportion of children with overweight and obesity underestimate their body size (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), along with their parents (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) and healthcare professionals (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Conversely, difficulties in perceiving body size at the lower end of the weight spectrum have been observed (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Thus, both underestimation and overestimation of children\u0026rsquo;s body size have been reported.\u003c/p\u003e \u003cp\u003eWhereas the overestimation of underweight or normal weight categories may be associated with unhealthy weight-control behaviors and eating disorders (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), the underestimation of overweight status has been a proposed barrier to participation in lifestyle interventions with an increased risk of unintentional weight gain and childhood obesity (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). By contrast, recent studies suggest potential beneficial effects of BSM on children\u0026rsquo;s health and well-being (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Among adolescents and young adults, the underestimation of overweight status has been associated with a lower risk of future weight gain (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), reduced likelihood of disordered eating behavior (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), less depressive symptoms (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) as well as better life satisfaction and mental health (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In elementary school children, underestimation of overweight status has been linked to improved self-esteem (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and stabilization or reduction of body weight (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Hence, misperception of body size may potentially have both positive and negative implications on children\u0026rsquo;s health.\u003c/p\u003e \u003cp\u003eIt is crucial to acknowledge the spectrum of available methods used in body image research (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In the assessment of BSM, verbal methods generally yield lower rates than visual methods (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), which may be explained by a refusal to identify oneself with negatively labeled responses such as \u0026ldquo;obese\u0026rdquo; or \u0026ldquo;underweight\u0026rdquo; (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Visual figure rating scales (FRS) have exhibited good evidence of test-retest reliability (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), and are considered the most appropriate assessment tool for evaluating both body size misperception (BSM) and dissatisfaction (BSD) among young children (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), due to their visually engaging nature and inherent simplicity, independent of verbal skills.\u003c/p\u003e \u003cp\u003eThe two body image dimensions BSD and BSM have traditionally been analyzed separately, as two independent constructs (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), however, some recent evidence suggests that weight misperception may protect individuals with overweight and obesity against body dissatisfaction (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). As only a few studies have investigated the association between BSM and BSD among preadolescent children (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), this study aims to explore the prevalence of BSM across weight categories and its association with BSD in a sample of 8\u0026ndash;9-year-old Norwegian school children. We hypothesized that the prevalence of BSM would vary across different weight categories, with underestimation of overweight status, and further that there would be a significant association between BSM and BSD, with a possible protective effect of BSM on BSD.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cp\u003eThis cross-sectional study is part of a larger study investigating children's perspectives of school-based height and weight screening and body size dissatisfaction (BSD) among 8-9-year-old children (N\u0026thinsp;=\u0026thinsp;209) from central Norway (Drilen et al, article in press). The assessments of body image in this study were conducted at the children's schools, using researcher-assisted interviews, from November 2021 to April 2022.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Recruitment and participants\u003c/h2\u003e \u003cp\u003eIn this study, two rural and six urban schools with a geographical spread and diverse sociodemographic properties were recruited. Children received information about the study in the classroom from the main author (T.L.D.). Parents received oral and written study information from T.L.D. at a school meeting and through the school's digital communication platform. Information about the study was translated into three languages (English, Arabic, and Tigrinya) to promote study participation. Out of 310 eligible children, 226 children (72.9%) agreed to participate. Children who were absent on the day of data collection (n\u0026thinsp;=\u0026thinsp;11), those who withdrew their assent (n\u0026thinsp;=\u0026thinsp;2), and those with missing data (n\u0026thinsp;=\u0026thinsp;4) were excluded, leaving a total of 209 children, which accounted for a participation rate of 67.4%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Procedure\u003c/h2\u003e \u003cp\u003eThe children were interviewed individually, in a private classroom, by experienced researchers and undergraduate students trained in the assessment of body image. Paper, colored pencils, and fidget toys were used to create a safe and child-friendly atmosphere. All children were initially informed about confidentiality and their right to withdraw at any time. The complete content of the interview is described elsewhere (Drilen et al, article in press). In this study, body image was assessed based on a child-friendly interview, earlier described by Birbeck and Drummond (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Initially, each child was presented with nine validated (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) body silhouettes of their corresponding gender and hair color, ranging from underweight to severe obesity, but with equal height (Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003eA and S1B). The body silhouettes used were those adapted to 9-10-year-old children by Tiggemann and Pennington (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), based on Stunkard\u0026rsquo;s figure rating scales (FRS) for adults (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). To avoid potential bias, each silhouette was presented randomly for each child, on separate A4 sheets with numbers hidden on the back of the paper (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Objectively measured body size and the children\u0026rsquo;s perceived and ideal body size figures were used to determine three constructs of body image: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Perceived-measured body size figure (body size misperception), (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Perceived-ideal body size figure (body size dissatisfaction), and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Measured-ideal body size figure. The children were asked the following questions:\u003c/p\u003e \u003c/div\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cem\u003e1. \u0026ldquo;Which of these images do you think looks mostly like you?\u0026rdquo;\u003c/em\u003e (Perceived body size)\u003c/div\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e2. \u0026ldquo;If I was Harry Potter or a magician, and I could change you into any of these figures, would you like me to change your figure into any of these images?\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eThose who did not indicate a desire for a different body size figure were categorized as \u0026ldquo;satisfied\u0026rdquo; with their current body size. Children who indicated a desire for a body size figure other than their perceived body figure were categorized as \u0026ldquo;dissatisfied\u0026rdquo; with their current figure and further asked the following questions:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e3. \u0026ldquo;Which of these body images would you like me to change you into? Remember you may have to stay that way for a long time, so it needs to be a body figure that you really like\u0026rdquo;\u003c/em\u003e (Ideal body size).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cem\u003e4. \u0026ldquo;Can you tell me why you chose that body figure?\u0026rdquo;\u003c/em\u003e (Rationale for choice).\u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.2.1 Anthropometrics and Demographics\u003c/h2\u003e \u003cp\u003eThe school health nurse collected data regarding BMI, date of birth, and ethnicity. Children with at least one parent from a non-Western country of origin were denoted as non-Western (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Socioeconomic status (SES) was categorized as low, medium or high, according to the proportion of children in persistently low-income households in each school region (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Body size misperception\u003c/h2\u003e \u003cp\u003eTo assess body size misperception (BSM), BMI reference cut-offs were applied to the nine body silhouette figures. Stunkard's body silhouettes have previously been assigned BMI categories for both adults (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), and children (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). The BMI categories applied to the figures used in this study were based on a previous study with a similar sample (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), where body size Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e was categorized as underweight, Fig.\u0026nbsp;2\u0026ndash;4 as normal weight, Fig.\u0026nbsp;5 as overweight, and Figs.\u0026nbsp;6\u0026ndash;9 as obesity, for girls and boys, equally. Further, age- and gender-specific BMI cut-offs were assigned to each body silhouette figure, based on the international obesity task force (IOTF) BMI cut-off reference values for children (Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003eA and S1B).\u003c/p\u003e \u003cp\u003eBSM was estimated as the discrepancy between the child's perceived body silhouette figure and the silhouette figure corresponding to the objectively measured BMI category. Negative scores indicated underestimation, positive scores indicated overestimation and no discrepancy indicated accurate perception of body size.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Body size dissatisfaction\u003c/h2\u003e \u003cp\u003eThe discrepancy between the children's perceived and ideal body size figures was denoted as body size dissatisfaction (BSD) based on earlier methodology (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Positive scores were interpreted and categorized as a desire to be thinner, negative scores as a desire to be larger, and no difference was categorized as body satisfaction, according to validated measures of body image (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.2.4 Measured versus ideal body size\u003c/h2\u003e \u003cp\u003eDifferences between a child\u0026rsquo;s objectively measured body size and the child\u0026rsquo;s perceived ideal body size figure were assessed as the discrepancy between measured and ideal body size figure. Positive scores indicated an ideal body size larger than their measured, negative scores indicated an ideal body size below their measured body size, and no difference indicated the child\u0026rsquo;s ideal body size concurrent with measured body size.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analyses\u003c/h2\u003e \u003cp\u003eIBM SPSS Version 29 was used for statistical analysis, with a statistical significance level defined by a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Due to a few children with obesity (n\u0026thinsp;=\u0026thinsp;3), children in the overweight and obesity categories were merged. Moreover, the high and medium SES were merged in the statistical analysis and compared with low SES. Mean values for body sizes were estimated for the children\u0026rsquo;s measured, perceived current, and perceived ideal body size and compared across gender, BMI categories, SES, ethnicity, and residency. Paired samples t-tests were used to analyze differences between actual, perceived current, and ideal body size figures, whereas differences within gender, and demographic variables were analyzed using independent samples t-tests. A one-way ANOVA was used to study the difference between BMI categories (underweight, normal weight, and overweight/obesity) on actual, perceived current, and ideal body size.\u003c/p\u003e \u003cp\u003eChildren\u0026rsquo;s body size perception was estimated as either underestimation, accurate estimation, or overestimation, and presented as percentages and numbers, % (n\u0026thinsp;=\u0026thinsp;X). Differences in underestimation, accurate estimation, and overestimation of body size were analyzed separately, using Chi-square tests across gender, BMI categories, and demographic variables. Multinomial regression analyses were used to estimate the association between body size misperception (under- or overestimation), and body size dissatisfaction (BSD), adjusting for gender, BMI, SES, ethnicity, and residency.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant characteristics\u003c/h2\u003e \u003cp\u003eThe study sample consisted of 209 children (51% boys) aged 7.9\u0026ndash;9.3 years from central Norway and included 6.2% children with underweight (n\u0026thinsp;=\u0026thinsp;13), 76.1% with average weight (n\u0026thinsp;=\u0026thinsp;159), 16.3% with overweight (n\u0026thinsp;=\u0026thinsp;34), and 1.4% with obesity (n\u0026thinsp;=\u0026thinsp;3). Furthermore, 14% of the children had a non-western origin (n\u0026thinsp;=\u0026thinsp;29), 14% went to schools in an area with low SES (n\u0026thinsp;=\u0026thinsp;29), and 25% attended a rural school (n\u0026thinsp;=\u0026thinsp;53). Demographic and anthropometric properties of non-participants (n\u0026thinsp;=\u0026thinsp;84) and participants were similar, except for more children with a non-Western origin among non-participants, as described elsewhere (Drilen et al, article in press).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Body size perception\u003c/h2\u003e \u003cp\u003eOverall, the children's mean (M) perceived current figure (M\u0026thinsp;=\u0026thinsp;4.11, SD\u0026thinsp;=\u0026thinsp;0.86) did not differ significantly from their ideal body size figure (M\u0026thinsp;=\u0026thinsp;4.06, SD\u0026thinsp;=\u0026thinsp;1.10), but was significantly higher than their objectively measured body size figure (M\u0026thinsp;=\u0026thinsp;3.23, SD 1.20; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, 95% CI [0.70, 1.05]) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNo significant differences in objectively measured body sizes were found between genders, however, boys perceived their current body size to be significantly larger (M\u0026thinsp;=\u0026thinsp;4.31, SD\u0026thinsp;=\u0026thinsp;0.90) compared to girls (M\u0026thinsp;=\u0026thinsp;3.90, SD\u0026thinsp;=\u0026thinsp;0.76; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, 95% CI [0.18, 0.63]). Furthermore, boys also perceived their ideal body size (M\u0026thinsp;=\u0026thinsp;4.24, SD\u0026thinsp;=\u0026thinsp;1.17) to be larger than the girls' (M\u0026thinsp;=\u0026thinsp;3.86, SD\u0026thinsp;=\u0026thinsp;1.00; p\u0026thinsp;=\u0026thinsp;0.01, 95% CI [0.08, 0.68]). Children objectively categorized with overweight/obesity perceived their body size figures to be larger (M\u0026thinsp;=\u0026thinsp;4.43, SD\u0026thinsp;=\u0026thinsp;0.96) than their peers classified as normal weight (M\u0026thinsp;=\u0026thinsp;4.04, SD\u0026thinsp;=\u0026thinsp;0.80; p\u0026thinsp;=\u0026thinsp;0.034, 95% CI [0.02, 0.75]). However, children\u0026rsquo;s ideal body size figures did not differ across weight categories (p\u0026thinsp;=\u0026thinsp;0.149, 95% CI [0.00, 0.08]). Children from schools with lower SES desired a significantly larger ideal body size figure (M\u0026thinsp;=\u0026thinsp;4.55, SD\u0026thinsp;=\u0026thinsp;1.62) than those from areas with medium/high SES (M\u0026thinsp;=\u0026thinsp;3.98, SD\u0026thinsp;=\u0026thinsp;0.98; p\u0026thinsp;=\u0026thinsp;0.009, 95% CI [0.15, 1.00]) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean values of measured, perceived, and ideal body size figures according to anthropometric and demographic characteristics of the participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeasured\u003c/p\u003e \u003cp\u003ebody size figure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerceived\u003c/p\u003e \u003cp\u003ebody size figure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIdeal\u003c/p\u003e \u003cp\u003ebody size figure\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAll children\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;209)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.23 (1.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.11 (0.86) ᵃ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.06 (1.10) ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGirls (n\u0026thinsp;=\u0026thinsp;102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.26 (1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.90 (0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.86 (1.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoys (n\u0026thinsp;=\u0026thinsp;107)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.22 (1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.31 (0.90) ***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.24 (1.17) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAssigned BMI category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderweight (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.00) ***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.18 (0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.18 (2.09)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage weight (n\u0026thinsp;=\u0026thinsp;159)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.97 (0.81) ***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.03 (0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.98 (1.04)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight/obesity (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.08 (0.28) ***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.41 (0.99) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.38 (0.99)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.26 (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.38 (0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.55 (1.62) **\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium/high (n\u0026thinsp;=\u0026thinsp;180)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.07 (1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.07 (0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.98 (0.98)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Western (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.10 (1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.03 (0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.97 (1.32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWestern (n\u0026thinsp;=\u0026thinsp;180)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.26 (1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.12 (0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.07 (1.07)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural (n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.45 (1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.19 (0.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.19 (0.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban (n\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.16 (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.08 (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.01 (1.16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eResults are presented as mean (SD). A paired samples t-test assessed the difference between the objectively measured, perceived current, and ideal body size.\u003c/p\u003e \u003cp\u003eᵃ Significant difference between measured and perceived body size.\u003c/p\u003e \u003cp\u003eᵇͨ Significant difference between measured and ideal body size.\u003c/p\u003e \u003cp\u003eIndependent samples t-tests (two-sided) were used to assess differences within gender and demographic variables. ANOVA was used to assess differences between weight categories.\u003c/p\u003e \u003cp\u003eLevel of significance: *** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 and * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eBMI, body mass index; SD, standard deviation; SES, socioeconomic status.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Body size misperception\u003c/h2\u003e \u003cp\u003eThe discrepancy scores between perceived and measured body size figures ranged from \u0026minus;\u0026thinsp;2 to +\u0026thinsp;5, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most children (78%) misperceived their current body size with at least one body size figure, as indicated by 64% overestimation and 14% underestimation of body size figure (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), whereas 34% of the children misperceived their body size with at least 2 figure sizes (23% overestimation and 11% underestimation). According to weight categories, 35% misperceived at least one weight category above (n\u0026thinsp;=\u0026thinsp;55) or below (n\u0026thinsp;=\u0026thinsp;24) their measured BMI category (Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSignificantly more boys (71%) than girls (56%) overestimated their body size, and more girls (18%) than boys (11%) underestimated their body size figures. The majority (92%) of children with underweight overestimated their body size, and most (60%) of children categorized with overweight/obesity underestimated their body size figure. Lastly, most of the children categorized with average weight (74%) overestimated their current body figure (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Of the 22% who accurately estimated their body size, girls (27%) indicated a more accurate perception of their current body figure compared to boys (18%). Moreover, children categorized with overweight/obesity were more likely to be accurate in their perception of body size figures (30%) than children from both underweight (8%) and average weight (21%) categories (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Body size dissatisfaction\u003c/h2\u003e \u003cp\u003eThe discrepancy scores between the perceived current body size and the ideal body size varied from \u0026minus;\u0026thinsp;5 to +\u0026thinsp;4. A total of 23% of the children indicated a desire for another body size, by selecting an ideal body size figure with at least one body figure discrepancy above (9%) or below (14%) their perceived current body size figure. Only 7% of the children indicated a desire for more than one figure score above (n\u0026thinsp;=\u0026thinsp;5) or below (n\u0026thinsp;=\u0026thinsp;9) ideal body size (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No differences in BSD were observed between gender or BMI categories.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBody size perception based on the measured and perceived body size discrepancy.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrect estimation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderestimation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOverestimation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal %\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;209)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.0% (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.4% (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.6% (n\u0026thinsp;=\u0026thinsp;133)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGirls (n\u0026thinsp;=\u0026thinsp;102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.5% (n\u0026thinsp;=\u0026thinsp;27) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.8% (n\u0026thinsp;=\u0026thinsp;18) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.9% (n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoys (n\u0026thinsp;=\u0026thinsp;107)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.8% (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.2% (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71.0% (n\u0026thinsp;=\u0026thinsp;76) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI categories\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderweight (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0% (n\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0% (n\u0026thinsp;=\u0026thinsp;13) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal weight (n\u0026thinsp;=\u0026thinsp;159)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.3% (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0% (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73.8% (n\u0026thinsp;=\u0026thinsp;117) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight/Obesityᵃ (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.7% (n\u0026thinsp;=\u0026thinsp;11) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.5% (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.8% (n\u0026thinsp;=\u0026thinsp;4) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.8% (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7% (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79.3% (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot low ᵇ (n\u0026thinsp;=\u0026thinsp;180)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.3% (n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.6% (n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.1% (n\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWestern (n\u0026thinsp;=\u0026thinsp;180)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.1% (n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0% (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.9% (n\u0026thinsp;=\u0026thinsp;115)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-western (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.3% (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.6% (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62.1% (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban (n\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.5% (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1% (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65.4% (n\u0026thinsp;=\u0026thinsp;102)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural (n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.4% (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.1% (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58.5% (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eThe prevalence of BSM is presented as % (n\u0026thinsp;=\u0026thinsp;X) for categorical data. Pearson`s Chi-Square tests were used to analyze differences within gender, BMI categories, SES, ethnicity, and residency.\u003c/p\u003e \u003cp\u003eᵃ Overweight and obesity categories were merged.\u003c/p\u003e \u003cp\u003eᵇ Not low SES included both medium and high SES.\u003c/p\u003e \u003cp\u003eLevel of significance: * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eBMI, body mass index; SES, socioeconomic status.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Measured versus ideal body size.\u003c/h2\u003e \u003cp\u003eThe discrepancy scores between the objectively measured body size and the children's ideal body size ranged from \u0026minus;\u0026thinsp;8 to +\u0026thinsp;2. Most children (80%) indicated an ideal body size of at least one body size figure different from their objectively measured body size figure, with 60% indicating an ideal body size figure above the measured figure and 20% indicating an ideal body figure below their objectively measured body size (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Furthermore, 38% of the children desired an ideal body of at least 2 figures above (n\u0026thinsp;=\u0026thinsp;66) or below (n\u0026thinsp;=\u0026thinsp;13) their objectively measured body size figure.\u003c/p\u003e \u003cp\u003eBoys' ideal body size was significantly larger and deviated more from their measured body size, as opposed to the girls. Further, significant differences were found across the BMI categories, with 91% of children with underweight and 69% of children with average weight perceiving an ideal body size above, and 62% of children living with overweight/obesity perceiving an ideal body size below their objectively measured body size figure (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean distribution of three different dimensions of body image using figure rating scales.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eΔ Perceived - Measured\u003c/p\u003e \u003cp\u003ebody size figure\u003c/p\u003e \u003cp\u003e(BSM)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eΔ Perceived - Ideal\u003c/p\u003e \u003cp\u003ebody size figure (BSD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eΔ Measured -\u003c/p\u003e \u003cp\u003eIdeal\u003c/p\u003e \u003cp\u003ebody size figure\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAll children\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;209)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.88 (1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05 (0.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.82 (1.56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGirls (n\u0026thinsp;=\u0026thinsp;102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.65 (1.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.04 (0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.61 (1.52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoys (n\u0026thinsp;=\u0026thinsp;107)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.10 (1.29) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.07 (1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.03 (1.58) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMeasured BMI category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderweight (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.92 (1.26) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00 (1.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.92 (2.10) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage weight (n\u0026thinsp;=\u0026thinsp;159)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.07 (0.99) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.06 (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.01 (1.31) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight/obesity (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.65 (0.98) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05 (0.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.70 (1.00) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.31 (1.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.17 (1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.48 (2.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium/high (n\u0026thinsp;=\u0026thinsp;180)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.81 (1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.09 (0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.72 (1.44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Western (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.93 (1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.07 (1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.86 (1.71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWestern (n\u0026thinsp;=\u0026thinsp;180)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87 (1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.82 (1.54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural (n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.74 (1.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00 (0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.74 (1.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban (n\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.93 (1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.07 (0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.85 (1.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eResults are presented as mean (SD) figure rating discrepancy. Independent samples t-tests (two-sided) were used for each dimension of body image to assess differences within gender and demographic variables. ANOVA was used to assess differences between BMI categories.\u003c/p\u003e \u003cp\u003eLevel of significance: * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eBMI, body mass index; BSD, body size dissatisfaction; BSM, body size misperception; SES, socioeconomic status.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Association between BSM and BSD\u003c/h2\u003e \u003cp\u003eNo significant association was observed between body size misperception (BSM) and body size dissatisfaction (BSD) for either underestimation (OR 1.78 [95%CI 0.45, 7.01]) or overestimation of body size figures (OR 1.03 [95%CI 0.44, 2.45]), after adjusting for gender, BMI, and demographic variables (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). These findings were further substantiated by a sensitivity analysis utilizing discrepancy scores of +/-2 body size figures in the assessment of BSM.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultinomial logistic regression analyses for the association between body size misperception and body dissatisfaction.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eBody size misperception (perceived \u0026ndash; measured)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUnderestimation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eOverestimation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody size dissatisfaction\u003c/b\u003e (perceived-ideal body size)\u003c/p\u003e \u003cp\u003e(Ref: No discrepancy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003cp\u003e[0.45, 7.01]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003cp\u003e[0.44, 2.45]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003e(Ref: Girls)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003cp\u003e[0.17, 1.64]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.32\u003c/b\u003e\u003c/p\u003e \u003cp\u003e[1.11, 4.85] *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI Underweight\u003c/p\u003e \u003cp\u003e(Ref: average weight)\u003c/p\u003e \u003cp\u003eBMI Overweight\u003c/p\u003e \u003cp\u003e(Ref: average weight)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN.A.\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e\u003cb\u003e13.17\u003c/b\u003e ***\u003c/p\u003e \u003cp\u003e[3.88, 44.77]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.30\u003c/p\u003e \u003cp\u003e[0.40, 27.38]\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.07\u003c/b\u003e ***\u003c/p\u003e \u003cp\u003e[0.02, 0.26]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSES\u003c/p\u003e \u003cp\u003e(Ref: Not low)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.83\u003c/p\u003e \u003cp\u003e[0.61, 38.11]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003cp\u003e[0.07, 1.12]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003cp\u003e(Ref: Western)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.62\u003c/p\u003e \u003cp\u003e[0.34, 7.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003cp\u003e[0.45, 3.33]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003cp\u003e(Ref: Urban)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.27\u003c/p\u003e \u003cp\u003e[0.63, 8.16]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003cp\u003e[0.45, 2.39]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eResults are presented as Odds ratio with a 95% Confidence Interval: OR [95% CI]\u003c/p\u003e \u003cp\u003eDependent variable: Body size misperception (underestimation and overestimation) compared to correct estimation.\u003c/p\u003e \u003cp\u003eIndependent variable: Body size dissatisfaction (reference: no BSD).\u003c/p\u003e \u003cp\u003eConfounders: Gender (reference: girls), BMI underweight and overweight (ref average weight), SES (reference: med-high SES), ethnicity (reference: Western), and residence (reference: urban).\u003c/p\u003e \u003cp\u003eLevel of significance: * p\u0026thinsp;\u0026lt;\u0026thinsp;.05, ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 and *** p\u0026thinsp;\u0026lt;\u0026thinsp;.001.\u003c/p\u003e \u003cp\u003eBSD, body size dissatisfaction; BMI, body mass index; SES, socioeconomic status.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eIn this study, a high prevalence of body size misperception (BSM) was observed across all weight categories. Children classified as underweight or healthy weight showed a tendency to overestimate their body size, while those classified as overweight/obesity tended to underestimate their body size. Most children misperceived their current body size figure towards their ideal, indicating low rates of body size dissatisfaction (BSD). No significant association was found between BSM and BSD, irrespective of gender, BMI, and demographics, however, there was a significant disparity between children's perceived ideal and objectively measured body size.\u003c/p\u003e \u003cp\u003eThe high prevalence (78%) of BSM observed in our study aligns with several other studies with comparable age groups and similar methodologies (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), reinforcing that children of both genders, among all BMI categories, and across a range of demographics tend to misperceive their body size (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The children categorized outside the healthy weight category perceived their body size to be healthy, reflected by persistent overestimation of underweight status and underestimation of overweight status. This finding is in line with several other studies among children (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), which may be due to children\u0026rsquo;s desire to be \u0026ldquo;normal\u0026rdquo; or \u0026ldquo;about right\u0026rdquo;, and their refusal to associate themselves with an undesirable or stigmatized body figure, such as \u0026ldquo;overweight\u0026rdquo; or \u0026ldquo;underweight\u0026rdquo; (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, most children with overweight/obesity in the present study indicated satisfaction with their body size, which may reflect a shift towards increased acceptance and satisfaction with having a larger body size (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Furthermore, the increasing number of individuals with obesity in society (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), may lead to visual adaptation with children being more likely to underestimate their overweight status if they are surrounded by other people with higher BMI classifications (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Thus, we cannot exclude the possibility that the children above healthy weight in our study were unaware of their overweight status and perceived to be average, which has been previously demonstrated (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA notable finding of our study was the overall bias towards the overestimation of body size among children categorized with underweight and normal weight, contrasting most other studies reporting an overall underestimation of body size among young children (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). It has been suggested that studies using ascending figure rating scales (from thinness to obesity) might increase the likelihood of underestimating body size in children as they can visually compare themselves to the smaller figures on the scale (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Interestingly, a study conducted in Brazil (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) presenting the FRSs in the same manner as in our study, with the silhouettes presented randomly on separate cards, also found an overestimation of body size, which agrees with perspectives from Gardner (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and Ra (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) suggesting that young children have a general propensity to overestimate their body size (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Furthermore, the higher number of figures used in ours and Costa\u0026rsquo;s study (9\u0026ndash;11 figures), compared to others (3\u0026ndash;7 figures), may have improved accuracy by increasing the likelihood of children identifying a figure that closely matched their actual body sizes. However, available literature on psychometric properties of figure rating scales among children is inconclusive (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) and it is uncertain whether randomly presented FRS and/or a higher range of body image figures affect rates and direction of BSM among children.\u003c/p\u003e \u003cp\u003eGiven that most children in our study indicated satisfaction with their body size, our findings are different from the overestimation commonly observed in individuals at risk of eating disorders (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). It may be that children's overestimation of body size is a normative phenomenon, explained by a tendency of children to perceive themselves with larger body size, including being more muscular or mature, as a more typical or desirable body size, possibly influenced by ideal body image norms, media, and peer comparisons (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, we found no significant association between BSD and BSM. This is in contrast with the positive associations found in studies among adults and adolescents, suggesting that BSM may either protect against BSD (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) or possibly reflect body satisfaction (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The few studies that have investigated the association between BSM and BSD among young children are inconsistent, suggesting that BSM may be either predictive (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e), protective (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), or unrelated to BSD (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The lack of association between the two body image constructs found in our study is in line with a study among preschoolers (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and the overall results among a sample of preadolescent children (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), and thus we cannot exclude the possibility that these two dimensions of body image are unrelated constructs. Hence, the association between BSD and BSM, and the impact on children\u0026rsquo;s health should be further elucidated in a larger sample, with subgroup analyses.\u003c/p\u003e \u003cp\u003eThis study highlights a significant disparity between children's perceived ideal body size and their objectively measured BMI, which may pose a dilemma for public healthcare professionals, who have the mandate to identify and address unhealthy weight deviations while safeguarding children from harm. Young children's perceptions of their body sizes may have important implications for health communication regarding weight category assessments, such as school-based height and weight screening programs and obesity prevention and treatment. Both parents, HCPs, and other relevant stakeholders should be aware of children's perceptions of their body sizes, their body size ideals, and whether there is a discrepancy between their perceived and measured weight status that may be related to health risks. According to recent literature (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), misperception of body size among children with obesity should not be corrected to ensure sufficient motivation for lifestyle changes, as the perception of overweight status may influence increased weight gain (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and lower self-esteem (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), which may reduce children's overall health. Furthermore, the aim of interventions for children with weight deviations and in need of follow-up by the health care services, should not only include suggestions for lifestyle changes but also aim to improve mental health, including body satisfaction (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Strengths and limitations\u003c/h2\u003e \u003cp\u003eThe main strength of the current study is the diverse sample of young elementary school children, with access to anthropometric and demographic data of non-participants, which can be generalized to represent children of central Norway. Further strengths are the use of objectively measured height and weight data. Moreover, the thorough face-to-face assessment of several constructs of body image using validated and child-friendly visual methods, with several efforts to reduce bias, may have strengthened the reliability of our findings. However, the current study should be interpreted with some limitations in mind. First, the figure rating scales used in this study only considered two dimensions of body size, such as being smaller or larger, with no option to indicate a more muscular body size. Second, the study was constrained by a small sample of children with obesity, precluding targeted analysis of this subgroup.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Conclusion\u003c/h2\u003e \u003cp\u003eMost children overestimated their current body size, without indicating a desire for another body size. A greater insight into the potential prospective implications of BSM on young children's health is needed. Future studies should aim to include a higher number of children, to enable comparison of subgroups with boys and girls across all weight categories, ethnicities, residency, and socioeconomic classes, preferably combining quantitative body image assessment with a more qualitative and explorative design.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eBMI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Body mass index\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMIz\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Body mass index z-score\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBSD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Body size dissatisfaction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBSM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Body size misperception\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBSP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Body size perception\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Confidence interval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eED\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Eating disorder\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFRS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Figure rating scale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Health care professional\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIOTF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;International Obesity Task Force\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Mean\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Standard deviation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSES \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Socioeconomic status\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved in 2021 by The Regional Committees for Medical and Health Research Ethics of Mid-Norway (no. 244609). Children\u0026apos;s assents were collected in the classroom, whereas parental consent was either collected by teachers or digitally.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a grant from The Norwegian Womens Health Association (Grant number: 40406)\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT.L.D., R.A.\u0026Oslash;., T.T.E-N., and E.M.I.E. were responsible for the study design and planning of this study. T.L.D. had the main responsibility for data collection, data analysis, interpretation of the data, generation of figures, and writing the article. R.A.\u0026Oslash;. and T.T.E-N. contributed to the data collection. C.A.K. was responsible for the choice of statistical methods and assisted with the analysis and interpretation of the data. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge Betty Pettersen for her collaboration and organization of the study in the municipality of Trondheim, and the school principals, teachers, and healthcare nurses, who contributed to the organization of this project. Special gratitude to all the children who participated in the study, and to their parents for being positive to the research project. Thanks to the researchers who contributed to the data collection, and to the Norwegian Women\u0026rsquo;s Public Health Association for the funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026apos;s information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTove L. Drilen, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Regional Centre for Obesity Research and Innovation, Post box 3250, Torgarden, 7006 Trondheim, Norway\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eE-mail: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSlade PD. What is body image? Behaviour research and therapy. 1994.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodgers RF, Laveway K, Campos P, de Carvalho PHB. Body image as a global mental health concern. Cambridge Prisms: Global Mental Health. 2023;10:e9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStice E, Shaw HE. Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. J Psychosom Res. 2002;53(5):985\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarriger JA, Thompson JK. Psychological consequences of obesity: Weight bias and body image in overweight and obese youth. Int Rev Psychiatry. 2012;24(3):247\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlanchet R, Kengneson C-C, Bodnaruc AM, Gunter A, Giroux I. Factors influencing parents\u0026rsquo; and children\u0026rsquo;s misperception of children\u0026rsquo;s weight status: a systematic review of current research. Curr Obes Rep. 2019;8:373\u0026ndash;412.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeves CM, Cipriani FM, Meireles JFF, Morgado FFR, Ferreira MEC. Body image in childhood: an integrative literature review. Revista Paulista de Pediatria. 2017;35:331\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGardner R. Measurement of perceptual body image. Encyclopedia body image Hum appearance. 2012;2:526\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTremblay L, Lovsin T, Zecevic C, Larivi\u0026egrave;re M. Perceptions of self in 3\u0026ndash;5-year-old children: A preliminary investigation into the early emergence of body dissatisfaction. Body image. 2011;8(3):287\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrayon S, Cherrier S, Cavaloc Y, Wattelez G, Touitou A, Zongo P, et al. Misperception of weight status in the pacific: preliminary findings in rural and urban 11-to 16-year-olds of New Caledonia. BMC Public Health. 2017;17:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobinson E. Overweight but unseen: a review of the underestimation of weight status and a visual normalization theory. Obes Rev. 2017;18(10):1200\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamos Salas X, Buoncristiano M, Williams J, Kebbe M, Spinelli A, Nardone P, et al. Parental perceptions of children\u0026rsquo;s weight status in 22 countries: The WHO European childhood obesity surveillance initiative: COSI 2015/2017. Obes Facts. 2021;14(6):658\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlshahrani A, Shuweihdi F, Swift J, Avery A. Underestimation of overweight weight status in children and adolescents aged 0-19 years: A systematic review and meta‐analysis. Obes Sci Pract. 2021;7(6):760\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLundahl A, Kidwell KM, Nelson TD. Parental Misperceptions of Children's Underweight Status: A Meta-analysis. Ann Behav Med. 2014;48(2):184\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKinnear A, Withnell SJ, Witte TK, Smith AR, Szczyglowski K, Bodell LP. Weight misperception and its associations with eating disorder symptoms over the course of residential eating disorder treatment. Int J Eat Disord. 2021;54(10):1810\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaynes A, Kersbergen I, Sutin A, Daly M, Robinson E. A systematic review of the relationship between weight status perceptions and weight loss attempts, strategies, behaviours and outcomes. Obes Rev. 2018;19(3):347\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSonneville KR, Thurston IB, Milliren CE, Gooding HC, Richmond TK. Weight misperception among young adults with overweight/obesity associated with disordered eating behaviors. Int J Eat Disord. 2016;49(10):937\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThurston IB, Sonneville KR, Milliren CE, Kamody RC, Gooding HC, Richmond TK. Cross-sectional and prospective examination of weight misperception and depressive symptoms among youth with overweight and obesity. Prev Sci. 2017;18:152\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKval\u0026oslash;y K, Sandsg\u0026aring;rd-Hilmarsen E, Eik-Nes TT, Bratberg GH. Underestimation of Overweight and Health Beneficial Outcomes in Two Adolescent Cohorts in Norway\u0026ndash;The HUNT Study. J Adolesc Health. 2021;69(1):82\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaximova K, Khan MK, Austin SB, Kirk SF, Veugelers PJ. The role of underestimating body size for self-esteem and self-efficacy among grade five children in Canada. Ann Epidemiol. 2015;25(10):753\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteinsbekk S, Kl\u0026ouml;ckner CA, Fildes A, Kristoffersen P, Rogns\u0026aring;s SL, Wichstr\u0026oslash;m L. Body size estimation from early to middle childhood: stability of underestimation, BMI, and gender effects. Front Psychol. 2017;8:307082.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoeng-Mahlangu LT, Monyeki MA, Reilly JJ, McHiza ZJ, Moleah T, Loechl CU, et al. Level of agreement between objectively determined body composition and perceived body image in 6- to 8-year-old South African children: The Body Composition\u0026ndash;Isotope Technique study. PLoS ONE. 2020;15(8):e0237399.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaxton J, Hill C, Chadwick P, Wardle J. Weight status and perceived body size in children. Arch Dis Child. 2009;94(12):944\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCash TF, Smolak L. Body image: A handbook of science. practice, and prevention: Guilford Press; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGardner RM, Friedman BN, Jackson NA. Methodological concerns when using silhouettes to measure body image. Percept Mot Skills. 1998;86(2):387\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNissen NK, Holm L. Literature review: perceptions and management of body size among normal weight and moderately overweight people. Obes Rev. 2015;16(2):150\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichmond TK, Sonneville KR, Milliren CE, Thurston IB. Unraveling the meaning of weight misperception in a sample of college students: Unaware or body satisfied? Body Image. 2022;43:87\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeppers I, Tiemeier H, Swanson SA, Verhulst FC, Jaddoe VW, Franco OH, et al. Agreement between weight status and perceived body size and the association with body size satisfaction in children. Obesity. 2017;25(11):1956\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBordeleau M, Leduc G, Blanchet C, Drapeau V, Alm\u0026eacute;ras N. Body size misperception and dissatisfaction in elementary school children. Child Obes. 2021;17(7):467\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLe\u0026oacute;n M-P, Gonz\u0026aacute;lez-Mart\u0026iacute; I, Fern\u0026aacute;ndez-Bustos J-G, Contreras O. Perception of body size and dissatisfaction in children aged 3 to 6: A systematic review. anales de psicolog\u0026iacute;a. 2018;34(1):173.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBirbeck D, Drummond M. Interviewing, and listening to the voices of, very young children on body image and perceptions of self. Early Child Dev Care. 2005;175(6):579\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiggemann M, Wilson-Barrett E. Children's figure ratings: Relationship to self‐esteem and negative stereotyping. Int J Eat Disord. 1998;23(1):83\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiggemann M, Pennington B. The development of gender differences in body-size dissatisfaction. Australian Psychol. 1990;25(3):306\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStunkard AJ, S\u0026oslash;rensen TI, Hanis C, Teasdale TW, Chakraborty R, Schull WJ, et al. An adoption study of human obesity. N Engl J Med. 1986;314(4):193\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGardner RM, Brown DL. Body image assessment: A review of figural drawing scales. Pers Indiv Differ. 2010;48(2):107\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWissan ACC, Nag OS, Brys M, WorldAtlas. Reunion Technology Inc; 2021 [updated April 26, 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.worldatlas.com/articles/list-of-western-countries.html\u003c/span\u003e\u003cspan address=\"https://www.worldatlas.com/articles/list-of-western-countries.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeggstad IRL, Molden TH, Schistad S, Eiksund S, Gravaas BK et al. Living conditions and public health in Trondheim municipality. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBulik CM, Wade TD, Heath AC, Martin NG, Stunkard AJ, Eaves LJ. Relating body mass index to figural stimuli: population-based normative data for Caucasians. Int J Obes. 2001;25(10):1517\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCort\u0026eacute;s-Mart\u0026iacute;nez G, Vallejo-de la Cruz NL, P\u0026eacute;rez-Salgado D, Ortiz-Hern\u0026aacute;ndez L. Usefulness of body silhouettes to assess the nutritional status of school-age children and adolescents in Mexico City. Bolet\u0026iacute;n M\u0026eacute;dico del Hosp Infantil de M\u0026eacute;xico. 2009;66(6):511\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026aacute;nchez GFL, Su\u0026aacute;rez AD, Smith L. Analysis of body image and obesity by Stunkard's silhouettes in 3-to 18-year-old Spanish children and adolescents. Anales de psicolog\u0026iacute;a. 2018;34(1):167\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCosta LCF, Silva DAS, Almeida SS, Vasconcelos FdAGd. Association between inaccurate estimation of body size and obesity in schoolchildren. Trends psychiatry Psychother. 2015;37:220\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemir HP, Bayram HM. The Association between BMI and Body Weight Perception among Children in Turkey: A Cross-Sectional Study. Iran J Public Health. 2023;52(11):2372.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiahi R, Motlagh ME, Heshmat R, Qorbani M, Daniali SS, Kelishadi R. Body weight misperception and psychological distress among children and adolescents: The CASPIAN-V study. Osong Public Health Res Perspect. 2019;10(5):315.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlotas P, Tsekoura E, Souris E, Kantanis A, Kostopoulou E, Varvarigou A et al. Body-Size Misperception among Overweight Children and Adolescents in Greece: A Cross-Sectional Study. Nutrients. 2023;15(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurke MA, Heiland FW, Nadler CM. From overweight to about right: evidence of a generational shift in body weight norms. Obesity. 2010;18(6):1226\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu H, Tarasenko YN, Asgari-Majd FC, Cottrell-Daniels C, Yan F, Zhang J. More overweight adolescents think they are just fine: generational shift in body weight perceptions among adolescents in the US. Am J Prev Med. 2015;49(5):670\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShin A, Nam CM. Weight perception and its association with socio-demographic and health-related factors among Korean adolescents. BMC Public Health. 2015;15:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoberts SR, Maheux AJ, Hunt RA, Ladd BA, Choukas-Bradley S. Incorporating social media and muscular ideal internalization into the tripartite influence model of body image: Towards a modern understanding of adolescent girls\u0026rsquo; body dissatisfaction. Body image. 2022;41:239\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEaston JF, Stephens CR, Sicilia HR. An analysis of real, self-perceived, and desired BMI: is there a need for regular screening to correct misperceptions and motivate weight reduction? Front public health. 2017;5:237776.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnowles G, Ling FCM, Thomas GN, Adab P, McManus AM. Body size dissatisfaction among young Chinese children in Hong Kong: a cross-sectional study. Public Health Nutr. 2015;18(6):1067\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeldhuis J, Te Poel F, Pepping R, Konijn EA, Spekman ML. Skinny is prettier and normal: I want to be normal\u0026mdash;Perceived body image of non-Western ethnic minority children in the Netherlands. Body image. 2017;20:74\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Body image, body size misperception, body size dissatisfaction, childhood obesity","lastPublishedDoi":"10.21203/rs.3.rs-4450847/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4450847/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMisperception of body size may affect children's health, however, associations with body size dissatisfaction among young children remain uncertain. Hence, this study aims to explore body size misperception (BSM) across weight categories and associations with body size dissatisfaction (BSD) in 8-9-year-old Norwegian children.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUsing researcher-assisted interviews and figure rating scales, children's perceived current and ideal body size figures were assessed and compared with objectively measured body mass index (BMI) to evaluate three body image constructs: 1. body size dissatisfaction (perceived-ideal), 2. body size misperception (perceived-measured) and 3. discrepancy between objectively measured body size and the children's ideals (measured-ideal). The relationship between BSM and BSD was examined by multinomial logistic regression, adjusting for potential confounders (gender, BMI, socioeconomic status, ethnicity, and residency).\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe children's mean perceived body size figure (4.11) resembled their ideal figure (4.06) but was larger than their mean objectively measured figure (3.23). Most participants misperceived their body size, with a tendency to overestimate body size among children categorized as underweight or healthy weight. Children with overweight/obesity perceived their body size most precisely (30%), with higher odds of underestimating their body size (OR 13.17 [95% CI 3.88, 44.77]) compared to children in lower weight categories. No association was found between body size misperception and body size dissatisfaction for either underestimation or overestimation of body size figures.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eChildren categorized with underweight or overweight/obesity were likely to perceive a healthy body size figure, whereas the majority of children with healthy weight, overestimated their current body size. Children's perceived body size was in line with their ideal body size figure, but higher than the health professionals' reference categories for healthy weight. The longitudinal impact of body size misperception on children\u0026rsquo;s health should be further elucidated.\u003c/p\u003e","manuscriptTitle":"Perception of body size across weight categories and association with body size dissatisfaction: A cross-sectional study among early primary school children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-07 23:17:04","doi":"10.21203/rs.3.rs-4450847/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bdc311ab-1bc1-4880-9a19-708dc001d766","owner":[],"postedDate":"June 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-22T11:39:07+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-07 23:17:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4450847","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4450847","identity":"rs-4450847","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}