INTRODUCTION: Parents can act as important agents of change and support for healthy childhood growth and development. Studies have found that parents may not be able to accurately perceive their child's weight status. The purpose of this study was to measure parental perceptions of their child's weight status and to identify predictors of potential parental misperceptions. METHODS: We used data from the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative and 22 countries. Parents were asked to identify their perceptions of their children's weight status as "underweight," "normal weight," "a little overweight," or "extremely overweight." We categorized children's (6-9 years; n = 124,296) body mass index (BMI) as BMI-for-age Z-scores based on the 2007 WHO-recommended growth references. For each country included in the analysis and pooled estimates (country level), we calculated the distribution of children according to the WHO weight status classification, distribution by parental perception of child's weight status, percentages of accurate, overestimating, or underestimating perceptions, misclassification levels, and predictors of parental misperceptions using a multilevel logistic regression analysis that included only children with overweight (including obesity). Statistical analyses were performed using Stata version 15 1. RESULTS: Overall, 64.1% of parents categorized their child's weight status accurately relative to the WHO growth charts. However, parents were more likely to underestimate their child's weight if the child had overweight (82.3%) or obesity (93.8%). Parents were more likely to underestimate their child's weight if the child was male (adjusted OR [adjOR]: 1.41; 95% confidence intervals [CI]: 1.28-1.55); the parent had a lower educational level (adjOR: 1.41; 95% CI: 1.26-1.57); the father was asked rather than the mother (adjOR: 1.14; 95% CI: 0.98-1.33); and the family lived in a rural area (adjOR: 1.10; 95% CI: 0.99-1.24). Overall, parents' BMI was not strongly associated with the underestimation of children's weight status, but there was a stronger association in some countries. DISCUSSION/CONCLUSION: Our study supplements the current literature on factors that influence parental perceptions of their child's weight status. Public health interventions aimed at promoting healthy childhood growth and development should consider parents' knowledge and perceptions, as well as the sociocultural contexts in which children and families live.

Centre for Disease Prevention and Control Riga Latvia

Centre for Exercise Nutrition and Health Sciences University of Bristol Bristol United Kingdom

Centre for Health Promotion Bishkek Kyrgyzstan

Danish Health Authority Copenhagen Denmark

Department for Organization of Health Services to Children Mothers Adolescents and Family Planning Ministry of Health and Social Protection of the Population Dushanbe Tajikistan

Department of Cardiology Institute of Mother and Child Warsaw Poland

Department of Pediatrics Paracelsus Medical University Salzburg Austria

Department of Preventive Medicine Lithuanian University of Health Sciences Kaunas Lithuania

Department of Public Health and Management University of Medicine and Pharmacy Carol Davila Romania Bucharest Romania

Department of Social and Policy Sciences University of Bath Bath United Kingdom

European Association for the Study of Obesity Teddington United Kingdom

European Association for the Study of Obesity United Kingdom and Obesity Prevention and Care Program Contrepoids Service of Endocrinology Diabetology and Therapeutic Education Department of Medicine University Hospitals of Geneva and University of Geneva Geneva Switzerland

Faculty for Sport and Physical Education University of Montenegro Niksic Montenegro

Faculty of Sport and PE University of Novi Sad Novi Sad Serbia

Faculty of Sport University of Ljubjana Ljubjana Slovenia

Hungarian School Sport Federation Budapest Hungary

Institute of Pediatric Endocrinology Endocrine Research Centre Moscow Russian Federation

Institute of Public Health Podgorica Montenegro

Institute of Public Health Tirana Albania

Internal Diseases Department of the Scientific Clinical Centre of Mother and Child Health Ashgabat Turkmenistan

Istituto per la Sicurezza Sociale Cailungo San Marino

Istituto Superiore di Sanità Rome Italy

Ministry of Health Public Health General Directorate Ankara Turkey

National Center for Disease Control and Public Health of Georgia Tbilisi Georgia

National Center of Public Health and Analyses Ministry of Health Sofia Bulgaria

National Center of Public Health of the Ministry of Health of the Republic of Kazakhstan Nur Sultan Kazakhstan

National Institute for Health and Welfare Helsinki Finland

National Institute of Health Dr Ricardo Jorge 1 P Lisbon Portugal

National Institute of Public Health Oslo Norway

National Institute of Public Health University of Southern Denmark Odense Denmark

National Nutrition Surveillance Centre University College Dublin Dublin Ireland

Obesity Management Centre Institute of Endocrinology Prague Czechia

Observatory of Nutrition and Study of Obesity Spanish Agency for Food Safety and Nutrition Ministry of Health Madrid Spain

Pennington Biomedical Research Center Baton Rouge Louisiana USA

Primary Health Care Ministry of Health Floriana Malta

Public Health Agency of Sweden Solna Sweden

School for Health in Europé Ministry of Health Tashkent Uzbekistan

University of Zagreb School of Medicine Croatian Institute of Public Health Zagreb Croatia

WHO European Office for Prevention and Control of NCDs Country Health Programmes WHO Regional Office for Europe Copenhagen Denmark

WHO European Office for the Prevention and Control of Noncommunicable Diseases Moscow Russian Federation

World Health Organization Country Office Dushanbe Tajikistan

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