To the best of our knowledge, this is the first study on the differences between child-reported and the parent-reported PedsQL item scores for obese children from a community-based sample. Moreover, regression analyses stratified by gender and grade were examined for a more complete understanding of the relationship between QoL and being obese. One study  indicates that, based on the PedsQL domain score, the parents of obese children overrated their children’s physical ability, were unaware of their children’s emotions, and were unaware of the extent to which these results are reflected in specific behaviors (e.g., hard to run; feel sad or blue). Our data extend these findings to specific difficulties that obese boys and obese girls respectively faced and how their parents perceived these difficulties.
Our finding that the parents of obese children tended to overestimate their children’s QoL contradicts the results of published clinical studies [11–16], but agrees with published community-based studies [10, 19]. One possible reason is that the parents of obese children from a community-based sample have different perspectives from the parents of obese children from a clinically based sample. Parents of children with illnesses tend to rate their children’s QoL lower than their children do, because the parents recognize and possibly overestimate the effects of the illnesses once they are brought to medical attention and verified by physicians . Thus, the parents of obese children from a community-based sample may overestimate their children’s QoL because they are unaware of their children’s obesity-induced problems.
To probe this issue, we examined the differences in item scores between child-reported and parent-reported PedsQL. Our findings indicated that parents were not aware of their obese children’s low level of athletic ability, such as running and playing sports [2, 36], their physical pain, their emotional problems , their trouble sleeping, and their social difficulties (viz., being teased and having difficulty physically keeping up with their peers ). However, parents gave their obese children a lower score on item P6 (Hard to do chores) than their children did. This finding agrees with our previous study  on healthy children, and suggests that parents may rate item P6 lower than their children do because parents evaluate their children’s ability to follow orders to do housework rather than their ability to actually do the chores.
Moreover, we examined the effect of basic demography. A surprising result indicated that family income was a potential explanatory factor for these differences: the QoLs of obese children whose parents earned a higher income were likely to be overrated than those of obese children whose parents earned a lower income. This finding suggests that healthcare providers should consider family income when addressing child–parent agreement on QoL. However, our results cannot explain the relationship between family income and child-reported and parent-reported differences. Additional studies on this issue are needed to understand what factors might mediate the relationship between family income and child-reported and parent-reported differences.
Furthermore, after potential confounders had been controlled for, we found that 3rd- and 4th-grade obese boys had several physical and emotional difficulties, and that 5th- and 6th-grade obese girls had some social difficulties. These findings are in accord with Steinsbekk et al. , who reported that the elevated levels of psychopathology in obese children contributed to their impaired parent-reported QoL. Traditionally, boys are expected to be muscular, independent, and tough [38–40]. However, because obese boys are substantially overweight, they generally do not have strong bodies (“are not muscular”) or minds (“are not independent and tough”) [2, 3], which probably affects how they rate their physical and emotional functioning. Likewise, girls need friends to share their emotions and to play group-oriented roles [38, 40]. However, obese girls are generally not welcomed by their peers, and are teased about their weight during puberty [3, 41, 42]. Thus, obese girls may feel frustrated by social interaction. This information is helpful for healthcare providers who plan intervention programs tailored to the children’s needs. For example, physical training and emotional support are important for obese 3rd- and 4th-grade boys, and social interaction groups for obese 5th- and 6th-grade girls.
Of these specific difficulties, we found that parents overestimated their obese boys’ athletic ability, such as running, and were unaware of their sad moods and sleeping problems. In addition, parents were unaware of their obese girls’ relationships with peers. Because most parents in Taiwan work full-time, they have little time to spend with their children ; therefore, they may not detect some warning signs from their children. The difficulties that community-based obese children face are usually not as serious as those faced by clinically based obese children, but they may merely be the beginning of their problems because of their obesity. Prepubescent and pubescent children between 8 and 12 years old are at a critical stage of development; therefore, parents’ understanding, support, and guidance are crucial for establishing a stronger basis for future development and fostering a better QoL. Hence, we suggest that the parents of obese children, especially of 3rd- and 4th-grade obese boys and of 5th- and 6th-grade obese girls, become more aware of their children’s difficulties and provide support to help them deal with these difficulties.
Shaya et al.  report that many studies on obese children have examined the intervention effects of losing or controlling weight. However, in addition to these objectively measured health indices, child-reported and parent-reported assessments of QoL are also important indicators of children’s well-being. We therefore suggest another direction for healthcare providers: address the child–parent incongruence. It is essential for healthcare providers to help parents of obese children understand the QoL problems that their children face. We suggest that parents of 3rd- and 4th-grade obese boys focus on their children’s physical and emotional performances, while parents of 5th- and 6th-grade obese girls focus on their children’s social performance. We expect that if parents understand their children’s difficulties, they will be more likely to care about and deal with their children’s obesity-related problems.
Another implication of our findings is related to using parent-proxy questionnaires. We found that parent-reported QoL differed from child-reported QoL. Therefore, we suggest that healthcare providers need to be careful when interpreting parent-reported QoL, especially for those from community-based samples.
The current study analyzed the same data our previous study  did. Therefore, we summarize the differences between them as follows: (1) our previous study focused on QoL domain scores. In contrast, the current study analyzed QoL item scores, which provide health professionals more specific and concrete information about QoL; (2) the current study analyzed the relationship between weight status and each specific QoL difficulty that obese children had, which is not reported in the previous study; (3) the current study separately analyzed QoL across gender and grade in school. Thus, it provides healthcare professionals clear guidelines for therapeutic intervention. Had we merely pooled all the participants together for an analysis, as was done in the previous study, we would know only that obese children have a lower QoL than do normal-weight children. Therefore, our findings in this current study seem to be more clinically useful; (4) the current study found that family income was correlated with the QoL rating difference between obese children and their parents, which the previous study did not examine.