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To assess the level of agreement between body size self-perception and actual body size determined by body mass index (BMI) z-score and body fatness measured by the deuterium dilution method (DDM) in South African children aged 6–8 years. A cross-sectional sample of 202 children (83 boys and 119 girls) aged 6–8 years from the Body Composition–Isotope Technique study (BC–IT) was taken. Subjective measures of body image (silhouettes) were compared with the objective measures of BMI z-score and body fatness measured by the DDM. The World Health Organization BMI z-scores were used to classify the children as underweight, normal, overweight, or obese. DDM-measured fatness was classified based on the McCarthy centile curves set at 2nd, 85th and 95th in conjunction with fatness cut-off points of 25% in boys and 30% in girls. Data were analyzed using SPSS v26. Of 202 children, 32.2%, 55.1%, 8.8%, and 2.4% perceived their body size as underweight, normal, overweight, and obese, respectively. Based on BMI z-score, 18.8%, 72.8%, 6.9%, and 1.5% were classified as underweight, normal, overweight, and obese, respectively. Body fatness measurement showed that 2.5%, 48.0%, 21.8%, and 29.7% were underweight, normal weight, overweight, and obese, respectively. The application of silhouettes and BMI z-scores resulted in either overestimation or underestimation of own body size. Overall, the levels of agreements (kappa, κ) between body size perception, body fatness, and BMI for age respectively, were small (κ = 0.083, p = 0.053 and κ = 0.154, p<0.001). Level of agreement between body size perception, body fatness, and BMI z-score was poor. The use of silhouettes made children either overestimate their own body size while being underweight or underestimate their own body size while being overweight or obese. Given the potential health implications associated with misclassification of body size during childhood, correct self-assessment of body size is important, and may be key to the adoption of weight control strategies directed at curbing the escalating obesity epidemic in the country. Scalable measures to allow for more accurate self-assessment are urgently needed–one approach is behavior change communication at all levels.

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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