previous decades have seen a significant rise in the global prevalence of childhood obesity . in saudi arabia , the prevalence of overweight and obesity in school - aged children is estimated at 23% and 9% , respectively . the hypothesis is that deteriorating nutritional intake and declining levels of physical activity are the underlying causes of childhood obesity . the proposal in the kingdom is that a comprehensive intervention to be undertaken to address childhood obesity should include educational programs for parents and children in schools . it is believed that with the cooperation of the children and parents this rise in the prevalence of obesity could be slowed or even stabilized . the initial step to address childhood obesity in saudi arabia is the recognition of the problem . globally , it has been shown that in certain ethnic groups , < 50% of parents recognize their child 's overweight status . it is likely that the gulf region is one area where correct identification of childhood obesity by parents is quite poor . studies in saudi arabia , kuwait , and the united arab emirates have all shown that there were significant differences between parents perceptions of weight compared to measured weight . the inaccurate parental perception was associated with being female , older age , less education , and children with higher body mass index ( bmi ) . misclassification was higher in parents of overweight / obese children compared to those parents with normal weight children . parental perception of a child 's weight status is critical to addressing the health problem of childhood obesity , and this is a relatively new area of research in saudi arabia . therefore , the objectives of this study were : ( 1 ) to determine the percentage of parents who misclassified their overweight / obese children as having normal weight , and ( 2 ) to determine whether the misclassification is higher among parents with overweight / obese children than in parents of children with normal weight . the schools from two cities ( with the largest populations ) in the al - qassim province , buraidah , and unaizah , were selected . an updated list of all public primary schools was used in the sampling frame : 34 schools were randomly selected from a total of 340 schools ( 29 for buraidah and 5 for unaizah according to the proportion of the population ) . thereafter , a class list was created for each of the targeted grades ( from grades i - iv ) in the selected schools . all students in the selected classes were invited to participate ( 1000 , with an average 25 students per class ) . those who were present at the time of data collection and voluntarily consented were recruited . the students were given a form and a questionnaire to be taken to their parents at home . the form had a brief description of the study , an invitation for participation , informed consent , and a request to complete the accompanying questionnaire , which included questions about their sociodemographic characteristics and dietary , physical , and disease - related information of their children . the students were asked to return the completed questionnaires to the school social workers . after giving consent , the inclusion criteria of children in this study were : saudi nationality and aged between 6 and 10 years . the exclusion criteria were : being disabled ( physically or mentally ) , a diagnosis of chronic disease , psychiatric illness , or immune - compromised disorder . a total of 874 children ( male : 618 ; female : 256 ) provided anthropometric measurements , and 601 of them returned the questionnaire completed by their parents . although the number of boys and girls in saudi primary schools are comparable , the low involvement of girls in this study was because of the low response from their parents . approximately , 30% of the parents of the female students did not return the questionnaire . height and weight were measured following the standard protocol ( e.g. , bare feet and light clothes ) , using a digital scale ( ultra - precision digital personal scale , michealth db-2201 , tokyo , japan ) and the scales were recalibrated after each measurement . body mass index ( bmi ) was calculated as weight ( in kg ) divided by height ( in square meters ) . the questionnaire included information about sociodemographics : ( a ) parent 's age , education , occupation , residence , family size , and socioeconomic status , ( b ) children 's age and gender and ( c ) two questions to assess parent 's perception of the child 's weight ( 1 . do you think that your child is obese ?  and 2 .  is the child 's weight normal ?  ) . the questionnaire was piloted on a small group of students before it was administered in the study . the study protocol was approved by the ethical review committee at qassim university college of medicine . prevalence of overweight and obesity were calculated according to body mass index cut - off values . using chi - square tests , we tested whether misclassification of the status of the child 's weight by parents differed significantly between normal , overweight , and obese children . the schools from two cities ( with the largest populations ) in the al - qassim province , buraidah , and unaizah , were selected . an updated list of all public primary schools was used in the sampling frame : 34 schools were randomly selected from a total of 340 schools ( 29 for buraidah and 5 for unaizah according to the proportion of the population ) . thereafter , a class list was created for each of the targeted grades ( from grades i - iv ) in the selected schools . all students in the selected classes were invited to participate ( 1000 , with an average 25 students per class ) . those who were present at the time of data collection and voluntarily consented were recruited . the students were given a form and a questionnaire to be taken to their parents at home . the form had a brief description of the study , an invitation for participation , informed consent , and a request to complete the accompanying questionnaire , which included questions about their sociodemographic characteristics and dietary , physical , and disease - related information of their children . the students were asked to return the completed questionnaires to the school social workers . after giving consent , the inclusion criteria of children in this study were : saudi nationality and aged between 6 and 10 years . the exclusion criteria were : being disabled ( physically or mentally ) , a diagnosis of chronic disease , psychiatric illness , or immune - compromised disorder . a total of 874 children ( male : 618 ; female : 256 ) provided anthropometric measurements , and 601 of them returned the questionnaire completed by their parents . although the number of boys and girls in saudi primary schools are comparable , the low involvement of girls in this study was because of the low response from their parents . approximately , 30% of the parents of the female students did not return the questionnaire . height and weight were measured following the standard protocol ( e.g. , bare feet and light clothes ) , using a digital scale ( ultra - precision digital personal scale , michealth db-2201 , tokyo , japan ) and the scales were recalibrated after each measurement . body mass index ( bmi ) was calculated as weight ( in kg ) divided by height ( in square meters ) . the questionnaire included information about sociodemographics : ( a ) parent 's age , education , occupation , residence , family size , and socioeconomic status , ( b ) children 's age and gender and ( c ) two questions to assess parent 's perception of the child 's weight ( 1 . do you think that your child is obese ?  and 2 .  is the child 's weight normal ?  ) . the questionnaire was piloted on a small group of students before it was administered in the study . the study protocol was approved by the ethical review committee at qassim university college of medicine . prevalence of overweight and obesity were calculated according to body mass index cut - off values . we examined the association between overweight and obesity with selected sociodemographic characteristics . using chi - square tests , we tested whether misclassification of the status of the child 's weight by parents differed significantly between normal , overweight , and obese children . of the 874 children invited to participate , 601 ( 69% ) returned the questionnaires which were filled by either of their parents . of the sample , 69% were boys and 31% were girls ; their mean age was 8.4  1.3 years . on average , girls had a significantly higher body mass index ( bmi ) than boys ( 18.1 vs. 16.0 kg / m ) . accordingly , the prevalence of overweight and obesity in girls ( 17.9% and 14.1% ) was higher than in boys ( 10.3% and 7.2% ) . combined data for overweight / obese prevalence were significantly higher in girls than in boys ( 32.1% vs. 17.5% , p < 0.0001 ) . table 1 shows an unclear relationship between parental education and economic status with the child 's overweight / obese status . for example , parents with lower education had a slightly higher percentage of obese children , but parents with secondary and higher education had a higher percentage of overweight children . a similar pattern appeared for socioeconomic status : parents of low socioeconomic status had more obese children ( 9.7% ) , and those of high socioeconomic status had more overweight children ( 20.4% ) . families with less than five members had a lower percentage of overweight and obese ( 9.3% and 5.6% ) children than larger families . families that had other obese family members were more likely to have overweight ( 21.3% ) and obese ( 23.8% ) children compared to families with normal weight . parental reporting on the child 's dietary habits and activity were not correlated with the child 's weight status , neither were the dietary habits or the child 's activities measured directly . sociodemographic characteristics of school children by their measured weight status , al qassim , saudi arabia ( n=601 ) parents reported on whether their child had normal weight . of the 76 overweight children , of the 56 obese children , 64.3% of parents misclassified the child 's weight status . misclassification  identifying an overweight or obese child as normal weight  was significantly higher among parents with overweight and obese children than parents with normal children ( p = 0.001 ) [ figure 1 ] . parental perception of weight compared with measured weight status among school - children from al - qassim , saudi arabia the main finding of the study was that a high percentage of parents misclassified the status of their child 's weight . these findings suggest a much higher prevalence of parent misclassification compared to earlier studies . since the methods of this study were similar to earlier studies , it is possible that this phenomenon may be regional . it has been shown that overall adult and child obesity is higher in the qassim region than in other regions of saudi arabia . however , our study findings are similar to earlier studies , which showed that most parents underestimated the child 's weight and infrequently identified normal weight children as overweight . further , we found that a significantly higher proportion of parents with overweight and obese children misclassified their child 's weight status than parents of children with normal weight . this finding indicates that parents are unaware of the signs and/or cut - off values for childhood obesity . earlier studies in other regions have suggested that normal weight children are perceived as too thin or even malnourished , and a more plump physical appearance is considered healthy . in addition , there could be some gender differences related to this misperception , but these hypotheses have not yet been adequately explored , and we had no evidence of any difference in our study . this study has identified a critical component for addressing the public health problem of childhood obesity in saudi arabia . parents level of awareness and understanding of childhood obesity with its negative health impact must be improved . parents have a great deal of influence on the dietary habits of their children and opportunities for activity . further , they are role models for their children with respect to health and proper health behaviors . our study showed that families that had other obese family members were more likely to have overweight and obese children compared to families with normal weight children . these findings corroborate previous research that showed the status of parental weight as a strong predictor of the status of child 's weight and the child 's weight gain . as stated by others , successful management of childhood obesity requires an understanding of the history , religion , culture and family and social networks of the people concerned . the findings indicate the importance of childhood obesity as a health issue in saudi arabia , and demand for more intervention - based studies , which could generate evidence - based programs to reduce the costs and burden of childhood obesity and its complications . this study has some methodological limitations : ( 1 ) physical activity levels were not measured objectively , and we had no information on the exact dietary intake or portion sizes . however , questionnaires are common , low - cost methods , particularly in large epidemiological studies . ( 2 ) data on parental height and weight were not taken and therefore we could not examine the associations between parent obesity and child obesity . ( 3 ) in our sample , the number of girls enrolled was lower than boys ; hence , we could not test gender differences in obesity or parental misclassification with adequate power . saudi parents with overweight and obese children do not appreciate the status of their child 's weight . widespread public health campaigns and programs are needed either through the schools or via the ministry of health to address childhood obesity in saudi arabia .
background and objectives : although the prevalence of childhood obesity has increased significantly in saudi arabia , parents are unable to appreciate obesity in their child . 
 the objective of the study was to identify the percentage of parents who misclassify the status of child 's weight , and determine whether there is a difference between those parents whose children are overweight and obese and those with children of normal weight.materials and methods : this cross - sectional study included 601 children aged 6 - 10 years . 
 the children were recruited from the primary schools located in al - qassim , saudi arabia . 
 the body mass index of the children was assessed in the school , and their parents responded to a self - administered questionnaire which contained questions on parental perception of the children 's weight / obesity status . 
 data were entered and analyzed using spss.results:parents with overweight / obese children had significantly more misclassification than those with normal weight children . 
 ninety percent of parents of the 81 overweight children misclassified and reported that their child had normal weight , while 65% of parents of the 61 obese children , misclassified the child 's weight status.conclusions:the level of misclassification of children 's weight status by parents is high . 
 saudi parents with overweight and obese children do not recognize their child 's weight status . 
 parents awareness of childhood obesity and its negative health impact needs to be improved .