ABSTRACT
Purpose
To explore the association between parental and child correct cognitions of the child's weight and child weight loss willingness and behaviours.
Methods
Data from the 2007–2020 NHANES database were used, focusing on overweight children aged 8–15 years with age‐ and sex‐specific BMI ≥ the 85th percentile. Both parental and child correct cognitions of the child's weight were assessed by comparing subjective questionnaires with objective BMI measurements. Multivariable logistic regression was conducted. Path analysis was employed to confirm the effect of child correct cognition on the relationship between parental correct cognition and child weight loss willingness and behaviour.
Results
A total of 1383 overweight children were included. Parental correct cognition was independently associated with both child correct cognition and child weight loss willingness, but not with child weight loss frequency. Path analysis further demonstrated that child correct cognitions were linked to the relationship of parental correct cognitions on child weight loss willingness, establishing a significant path: ‘Parental correct cognitions → Child correct cognitions → Child weight loss willingness → Child weight loss behaviour’.
Conclusion
Among overweight children, parental correct cognitions of the child's weight do not directly relate to children's willingness. Instead, they were indirectly associated with child weight loss willingness and behaviour by shaping child correct cognitions of weight. This finding suggests that family weight management interventions should focus not only on parental correct cognitions but also on helping children establish objective correct cognitions of weight.
Keywords: overweight children, parental cognition, weight loss behaviour, weight loss willingness
1. Introduction
Overweight and obesity in children and adolescents have emerged as a significant global public health concern [1]. Worldwide, the rates of childhood obesity are on the rise. According to a World Health Organisation report, in 2022, more than 390 million children and adolescents aged 5–19 were classified as overweight. Additionally, forecasts suggest that by 2050, about one‐third of adolescents will be affected by obesity [2, 3]. Childhood overweight often persists into adulthood. This not only heightens early health risks like type 2 diabetes, cardiovascular disease, and metabolic syndrome but also leads to long‐term adverse effects on mental health and social adaptation [4]. Therefore, early intervention and management of childhood overweight and obesity are essential.
In the realm of managing childhood weight, the family environment plays a decisive role. Research indicates that parents constitute a crucial target group for implementing obesity prevention interventions in young children [5]. Current medical practices integrate family‐focused therapies and motivational interviewing into intervention plans [6]. The family environment, particularly maternal responses to a child's weight, occupies a central position in intervention strategy design. As primary shapers of children's health cognitions and key enforcers of behaviour management, parental cognition of their child's weight status constitutes an essential step in preventing overweight and initiating early obesity treatment [7]. However, parents frequently underestimate their child's weight status [8]. A mother's inability to accurately assess her child's weight can delay timely intervention and sustain unhealthy behaviours [9]. Research indicates that children often view weight management as a personal responsibility. Children should actively change behaviours to improve health upon being diagnosed as overweight, while the family should provide support and participate throughout the process [10]. Yet, in practice, direct conversations between parents and children about weight are rare, and the child's perspective is frequently overlooked [11]. Existing research predominantly examines isolated associations between parental correct cognitions or child correct cognitions and health behaviours. However, the underlying path associated with this relationship remains unclear. According to Social Cognitive Theory, an individual's cognition and behaviour do not develop in a vacuum. Instead, they are gradually internalised through observing and imitating the behaviours and attitudes of ‘significant others’ (particularly parents) [12]. This implies that children's perceptions of their own weight and subsequent behavioural responses may be significantly influenced by parental attitudes. Concurrently, the Theory of Planned Behaviour asserts that an individual's behavioural intention constitutes the most direct predictor of their actual actions [13]. Integrating these two theoretical perspectives suggests a potential sequential path: parental correct cognitions of a child's weight first influence the child correct cognitions of weight, subsequently shaping their weight loss willingness, and ultimately driving weight loss behaviour. This chain‐‘parental correct cognition → child correct cognition → child weight loss willingness → child weight loss behaviour’‐reveals how parental correct cognitions relate to child correct cognitions and subsequent weight‐loss behaviour. To date, no study has systematically empirically tested and quantitatively validated this path using a nationally representative sample.
To address this knowledge gap, this study systematically examines the relationship between parental correct cognitions and overweight child correct cognitions using nationally representative data from the National Health and Nutrition Examination Survey (NHANES). It specifically examines the role of child correct cognitions in the path connecting parental correct cognitions to child weight loss willingness and behaviours. Validating this mechanism not only enhances theoretical understanding of how the parental correct cognitions impact children's health behaviours but also provides essential scientific evidence for designing future family‐based, more targeted childhood weight management interventions.
2. Methods
2.1. Study Design and Data Source
This study was a cross‐sectional investigation utilising data from the 2007–2020 NHANES database (Available at: http://www.cdc.gov/nhanes). NHANES employed a multistage probability sampling design to collect data through structured household interviews, physical examinations at mobile centres, and laboratory tests. This encompasses demographic information, dietary records, examination findings, laboratory results, questionnaire responses, and restricted‐access data [14]. NHANES received approval from the National Centre for Health Statistics Ethics Review Committee, with all participants providing written informed consent. The need for ethical approval was waived due to the study's exclusive use of publicly accessible data.
2.2. Study Population
Overweight children were assessed based on age‐ and sex‐specific BMI values calculated from height and weight data directly measured during NHANES physical examinations. The US Centres for Disease Control and Prevention guidelines define overweight as having a BMI at or above the 85th percentile for age‐ and sex‐specific BMI values, while obesity is defined as a BMI at or above the 95th percentile [15]. Given the small number of children with obesity, for ease of analysis, this study included all children with a BMI at or above the 85th percentile for age‐ and sex‐specific BMI values in the analysis, without further stratification by severity of weight status.
The study's objective was to explore the relationship between parental and child weight‐related cognitions and child weight loss willingness and behaviours. The inclusion criteria explicitly specify an age range of 8–15 years (based on the NHANES database, which contains complete weight and related cognitive data only for this age group), and require the availability of complete BMI data, parental weight‐related cognitions data, and the child weight‐related cognitions data (n = 10 122). Table 1 presents age‐ and sex‐specific BMI for children aged 8–15 years. After excluding participants with missing BMI data (n = 557), those with underweight or normal weight based on age‐ and sex‐specific BMI values (n = 8116), those with missing parental weight‐related cognition data (n = 3), and those with missing child weight‐related cognition data (n = 63), a total of 1383 overweight children were ultimately included in the analysis. Figure 1 illustrates the participant inclusion process.
TABLE 1.
Age‐ and sex‐specific BMI for children aged 8–15 years.
| Age (years) | BMI for males (kg/m2) | BMI for females (kg/m2) | ||
|---|---|---|---|---|
| 5th percentile | 85th percentile | 5th percentile | 85th percentile | |
| 8 | 14.085 | 22.235 | 13.810 | 22.925 |
| 9 | 14.325 | 23.570 | 14.360 | 24.010 |
| 10 | 14.700 | 25.200 | 14.200 | 24.444 |
| 11 | 15.200 | 26.400 | 15.220 | 27.088 |
| 12 | 15.300 | 27.500 | 15.700 | 28.000 |
| 13 | 16.162 | 27.910 | 16.308 | 28.865 |
| 14 | 16.570 | 28.900 | 17.597 | 29.990 |
| 15 | 17.104 | 29.800 | 18.142 | 31.476 |
FIGURE 1.
Flowchart for the inclusion of overweight children aged 8–15 years.
2.3. The Definition of Correct Cognition
This study extracted parental correct cognitions of children's weight and child correct cognitions of weight from the questionnaire section of the NHANES database. Parents were asked: ‘How do you consider your child's weight?’ and children were asked: ‘How do you consider your weight?’ Both questions provided three identical response options: ‘overweight’, ‘underweight’, and ‘normal weight’.
The concept of ‘parental/child correct cognition’ in this study specifically refers to the accuracy of weight cognition, namely, whether assessments of weight status align with objective measurement results. It does not encompass broader related concepts such as general awareness of weight, level of concern, motivation, or willingness to change. The operational definition is as follows: subjective responses from parents and children are compared against the child's age‐ and sex‐specific BMI classification based on objective measurements. Respondents are categorised accordingly into three groups: ‘underestimation’, ‘correct cognition’, and ‘overestimation’. It should be clarified that all samples exhibiting ‘incorrect cognition’ in this study fall within the ‘underestimation’ category. If parental assessments of their child's weight align with objective BMI classification results, this is defined as ‘parental correct cognition’; similarly, if a child's self‐assessment of their weight corresponds with objective BMI classification results, this is termed ‘child correct cognition’.
2.4. Child Weight Loss Willingness and Behaviour
Child weight loss willingness and behaviour were defined based on two self‐reported indicators from the NHANES database. Child weight loss willingness was measured using the following question: ‘Which of the following are you trying to do about your weight? lose weight, gain weight, stay the same weight, or not try to do anything about your weight?’ Respondents selecting ‘lose weight’ were coded as having a willingness to lose weight. Child weight loss behaviour was measured using the following question: ‘In the past year, how often have you tried to lose weight?’ This indicator reflects the number of behavioural attempts made by children to lose weight over the preceding 12 months.
2.5. Collected Variables
We systematically reviewed potential influencing factors from previous relevant studies [16, 17, 18, 19], simultaneously collecting data based on availability within the NHANES database. This study collected demographic characteristics, medical conditions, dietary intake, and child weight loss‐related variables, specifically including: (1) Demographic and socio‐economic characteristics: gender, children's age, education level, race, and family income to poverty ratio (PIR). (2) Medical and health information: birth weight, health insurance, and healthcare services received times over the past year. (3) Dietary intake: energy, protein, carbohydrate, total sugars, dietary fibre, total fat, total saturated fatty acids (SFAs), total monounsaturated fatty acids (MUFAs), total polyunsaturated fatty acids (PUFAs), and cholesterol. (4) Relevant health information: whether a doctor had informed parents of their child's overweight status (abbreviated as child overweight told by the doctor) and maternal pregnancy details (mother's age at childbirth and mother smoked during pregnancy).
2.6. Statistical Analysis
All statistical analyses were performed using SPSS (version 26.0) and R (version 4.2.1) software. A two‐tailed p < 0.05 was considered statistically significant. Continuous variables were described by median (quartiles), while categorical variables were presented as frequency (percentage). The Mann–Whitney U test was used for comparing continuous variables between groups, and the chi‐square test was applied for categorical variables. Logistic regression analysis was employed to investigate associations between the parental correct cognition and the overweight child correct cognitions, willingness, and behaviours regarding weight management. Due to missing values in variables exhibiting statistically significant intergroup differences at baseline (p < 0.05) (e.g., PIR, mother's age at childbirth, and child overweight told by the doctor), we first employed simple mode imputation for rapid analysis to mitigate the impact of missing data. Given that missingness may be random and mode imputation could introduce bias, we subsequently employed multiple imputation for validation. This preliminary examination sought to determine whether the initial findings were merely an artefact attributable to the specific imputation method selected.
Based on the multiple imputed data, Spearman's correlation analysis was used to evaluate inter‐variable relationships. Multicollinearity was examined, with a variance inflation factor (VIF) > 10 indicating collinearity. Path analysis was employed to investigate the role of child correct cognition in the relationship between parental correct cognition and child weight loss willingness and behaviours, with results reported as standardised regression coefficients (β) and corresponding p‐values. All covariates (PIR, mother's age at childbirth, and child overweight told by the doctor) are treated as exogenous variables, simultaneously pointing to each endogenous variable (parental correct cognition, child correct cognition, and child weight loss willingness/behaviour). We employed the maximum‐likelihood for model estimation. Model fit was assessed using the following indices: relative chi‐square test [Chi‐square minimum/degrees of freedom (CMIN/DF) < 2, p > 0.05], Goodness‐of‐Fit Index (GFI) > 0.900, Root Mean Square Error of Approximation (RMSEA) < 0.060, Root Mean Square Residual (RMR) < 0.050, Comparative Fit Index (CFI) > 0.950, Normed Fit Index (NFI) > 0.950 [20].
3. Results
3.1. The Baseline Information
Table 2 presents the baseline characteristics of the 1383 overweight children aged 8–15 years who participated in this study, along with comparative results of parental correct versus incorrect cognitions. The median age of these 1383 overweight children was 11 years, with an almost equal distribution between genders (50.832% male vs. 49.168% female). Among parents, 76.428% held correct cognitions regarding their child's overweight status. Comparing baseline data between parents with correct versus incorrect cognitions of their child's weight revealed no significant differences in the children's medical conditions or dietary intake (p > 0.05). However, the group with correct cognitions exhibited higher PIR (1.290 vs. 1.150), mother's age at childbirth (26.000 vs. 24.000), child overweight told by the doctor (66.350% vs. 24.847%), child correct cognition (65.752% vs. 38.344%), child weight loss willingness (87.985% vs. 79.448%), and child weight loss frequency (p < 0.05).
TABLE 2.
Basic information on overweight children aged 8–15.
| Variables | Missing (%) | Total (n = 1383) | Parental correct cognition | p | |
|---|---|---|---|---|---|
| No (n = 326) | Yes (n = 1057) | ||||
| Gender, n (%) | 0 (0.000) | 0.395 | |||
| Male | 703 (50.832) | 159 (48.773) | 544 (51.466) | ||
| Female | 680 (49.168) | 167 (51.227) | 513 (48.534) | ||
| Race, n (%) | 0 (0.000) | 0.477 | |||
| Hispance | 498 (36.009) | 112 (34.356) | 386 (36.518) | ||
| Other | 885 (63.991) | 214 (65.644) | 671 (63.482) | ||
| Health insurance, n (%) | 201 (14.534) | 0.297 | |||
| Yes | 1065 (90.102) | 254 (88.502) | 811 (90.615) | ||
| No | 117 (9.898) | 33 (11.498) | 84 (9.385) | ||
| Healthcare services received times over the past year, n (%) | 1 (0.072) | 0.256 | |||
| 0 | 185 (13.386) | 41 (12.577) | 144 (13.636) | ||
| 1 ~ 3 | 868 (62.808) | 217 (66.564) | 651 (61.648) | ||
| ≥ 4 | 329 (23.806) | 68 (20.859) | 261 (24.716) | ||
| Education level, n (%) | 366 (26.464) | 0.77 | |||
| Primary school | 716 (70.403) | 163 (71.179) | 553 (70.178) | ||
| > Primary school | 301 (29.597) | 66 (28.821) | 235 (29.822) | ||
| Mother smoked during pregnancy, n (%) | 15 (1.085) | 0.081 | |||
| No | 1158 (84.649) | 279 (87.736) | 879 (83.714) | ||
| Yes | 210 (15.351) | 39 (12.264) | 171 (16.286) | ||
| Child overweight told by the doctor, n (%) | 5 (0.362) | < 0.001 | |||
| No | 599 (43.469) | 245 (75.153) | 354 (33.650) | ||
| Yes | 779 (56.531) | 81 (24.847) | 698 (66.350) | ||
| Child correct cognition, n (%) | 0 (0.000) | < 0.001 | |||
| No | 563 (40.709) | 201 (61.656) | 362 (34.248) | ||
| Yes | 820 (59.291) | 125 (38.344) | 695 (65.752) | ||
| Child weight loss willingness, n (%) | 0 (0.000) | < 0.001 | |||
| No | 194 (14.027) | 67 (20.552) | 127 (12.015) | ||
| Yes | 1189 (85.973) | 259 (79.448) | 930 (87.985) | ||
| Child weight loss frequency, n (%) | 0 (0.000) | 0.024 | |||
| None | 115 (8.315) | 39 (11.963) | 76 (7.190) | ||
| Occasionally | 821 (59.364) | 185 (56.748) | 636 (60.170) | ||
| Frequently | 447 (32.321) | 102 (31.288) | 345 (32.640) | ||
| Children's age, years | 0 (0.000) | 11.000 [9.000, 13.000] | 11.000 [9.000, 13.000] | 11.000 [9.000, 13.000] | 0.312 |
| PIR | 125 (9.038) | 1.260 [0.780, 2.330] | 1.150 [0.700, 1.980] | 1.290 [0.810, 2.370] | 0.012 |
| Mother's age at childbirth, years | 17 (1.229) | 25.000 [21.000, 31.000] | 24.000 [20.000, 30.000] | 26.000 [21.000, 31.000] | 0.001 |
| Birth weight, pounds | 27 (1.952) | 7.000 [6.000, 8.000] | 7.000 [6.000, 8.000] | 7.000 [6.000, 8.000] | 0.471 |
| Energy, kcal | 284 (20.535) | 1717.000 [1234.000, 2177.000] | 1783.000 [1239.000, 2311.000] | 1696.000 [1236.000, 2145.000] | 0.189 |
| Protein, g | 284 (20.535) | 64.650 [45.620, 85.870] | 66.940 [44.350, 93.420] | 63.940 [46.110, 84.100] | 0.285 |
| Carbohydrate, g | 284 (20.535) | 216.940 [156.090, 281.690] | 228.050 [158.080, 298.530] | 215.870 [156.090, 277.910] | 0.137 |
| Total sugars, g | 284 (20.535) | 92.080 [59.430, 130.670] | 89.920 [60.770, 136.030] | 92.350 [59.400, 125.850] | 0.481 |
| Dietary fibre, g | 284 (20.535) | 12.200 [8.400, 17.000] | 12.200 [8.300, 17.700] | 12.200 [8.600, 16.800] | 0.728 |
| Total fat, g | 284 (20.535) | 62.880 [41.400, 87.080] | 64.220 [41.550, 94.740] | 62.150 [41.450, 84.850] | 0.290 |
| SFAs, g | 284 (20.535) | 20.540 [13.710, 30.510] | 21.500 [13.510, 31.610] | 20.350 [13.780, 29.972] | 0.484 |
| MUFAs, g | 284 (20.535) | 21.310 [13.670, 30.030] | 22.260 [13.306, 31.760] | 21.000 [13.910, 29.650] | 0.367 |
| PUFAs, g | 284 (20.535) | 12.900 [8.200, 19.320] | 14.040 [7.940, 19.883] | 12.630 [8.316, 19.000] | 0.316 |
| Cholesterol, mg | 284 (20.535) | 171.000 [105.000, 285.000] | 175.000 [105.000, 284.000] | 169.000 [105.000, 283.000] | 0.695 |
Abbreviations: MUFAs, total monounsaturated fatty acids; PIR, income to poverty ratio; PUFAs, total polyunsaturated fatty acids; SFAs, total saturated fatty acids.
3.2. Association Between Parental Correct Cognition and Overweight Child Correct Cognition, Willingness, and Behaviour
Baseline data revealed differences in the correct cognition, willingness, and behaviour of overweight children associated with parental correct cognition. Multivariable logistic results indicated that parental correct cognitions were primarily associated with child correct cognitions (OR = 2.585, 95% CI: 1.935–3.464, p < 0.001) (Figure 2A). Its association with child weight loss willingness was borderline significant (OR = 1.435, 95% CI: 0.957–2.095, p = 0.064), suggesting a potential trend towards association (Figure 2B). However, parental correct cognition was not associated with the child weight loss frequency (OR = 0.965, 95% CI: 0.725–1.285, p = 0.807) (Figure 2C).
FIGURE 2.
Relationship between parental correct cognition and child correct cognition (A), child weight loss willingness (B), and child weight loss frequency (C). Abbreviations: CI, confidence interval; OR, odds ratio; PIR, income to poverty ratio.
Analysis based on mode imputation revealed that the association between parental correct cognition and child correct cognition persisted and remained robust (OR = 2.446, 95% CI: 1.861–3.221, p < 0.001), while the effect on the child weight loss frequency remained non‐significant (OR = 0.981, 95% CI: 0.748–1.286, p = 0.889). Notably, after mode imputation, parental correct cognition was significantly linked to child weight loss willingness (OR = 1.531, 95% CI: 1.070–2.179, p = 0.019), suggesting that missing value handling may have affected the estimation of this specific association (Table 3). We further validated changes in results before and after imputation through multiple imputation. Analysis based on multiple imputation revealed that parental correct cognition remained strongly associated with child correct cognition (OR = 2.446, 95% CI: 1.861–3.223, p < 0.001). However, no association was found with the child weight loss frequency (OR = 0.980, 95% CI: 0.747–1.285, p = 0.882). Parental correct cognition was associated with the child weight loss willingness, with multiple imputation confirming the statistical significance of this association (OR = 1.522, 95% CI: 1.065–2.164, p = 0.020) (Table 3). In summary, parental correct cognition was independently associated with both child correct cognition and their weight loss willingness, but not with the weight loss frequency.
TABLE 3.
Relationship between parental correct cognition and child correct cognition, child weight loss willingness, and child weight loss frequency after imputation.
| After mode imputation | After multiple imputation | |
|---|---|---|
| OR (95% CI) | OR (95% CI) | |
| Child correct cognition | ||
| PIR | 1.044 (0.971–1.123) | 1.031 (0.942–1.130) |
| Mother's age at childbirth | 1.012 (0.994–1.030) | 1.013 (0.995–1.031) |
| Child overweight told by the doctor (reference = No) | 1.731 (1.367–2.193)*** | 1.738 (1.372–2.203)*** |
| Parental correct cognition (reference = No) | 2.446 (1.861–3.221)*** | 2.446 (1.861–3.223)*** |
| Child weight loss willingness | ||
| PIR | 0.877 (0.798–0.966)** | 0.926 (0.822–1.047) |
| Mother's age at childbirth | 0.995 (0.971–1.020) | 0.993 (0.969–1.019) |
| Child overweight told by the doctor (reference = No) | 1.847 (1.326–2.580)*** | 1.826 (1.311–2.549)*** |
| Parental correct cognition (reference = No) | 1.531 (1.070–2.179)* | 1.522 (1.065–2.164)* |
| Child weight loss frequency | ||
| PIR | 0.997 (0.931–1.067) | 1.004 (0.921–1.093) |
| Mother's age at childbirth | 0.984 (0.967–1.001) | 0.984 (0.967–1.001) |
| Child overweight told by the doctor (reference = No) | 1.711 (1.359–2.155)*** | 1.718 (1.363–2.164)*** |
| Parental correct cognition (reference = No) | 0.981 (0.748–1.286) | 0.980 (0.747–1.285) |
Abbreviations: CI, confidence interval; OR, odds ratio; PIR, income to poverty ratio.
p < 0.05.
p < 0.01.
p < 0.001.
3.3. The Potential Role of Child Correct Cognitions in the Relationship Between Parental Correct Cognitions and Child Weight Loss Willingness and Behaviours
Spearman correlation analysis showed that the child correct cognition was associated with their weight loss willingness and child weight loss frequency. The child weight loss willingness related to the child weight loss frequency (Figure 3). Additionally, there was no significant multicollinearity among the four variables (all VIF < 10, Table 4). Consequently, we further combined parental and child correct cognitions to jointly analyse their impact on child weight loss willingness. Multivariable regression analysis revealed that, after adjusting for other variables, only the child correct cognition (OR = 2.469, 95% CI: 1.787–3.430, p < 0.001) and the children's overweight told by the doctor (OR = 1.635, 95% CI: 1.167–2.296, p = 0.004) were independently associated with the child weight loss willingness. Parental correct cognition (OR = 1.273, 95% CI: 0.882–1.826, p = 0.193) was not associated with child weight loss willingness (Table 5). Meanwhile, multivariable logistic results suggested that child weight loss willingness (OR = 9.313, 95% CI: 6.436–13.478, p < 0.001) and child overweight told by the doctor (OR = 1.509, 95% CI: 1.194–1.907, p = 0.001) were linked to the child weight loss frequency, while child correct cognition was not (Table 6).
FIGURE 3.
Correlation between parental correct cognition, child correct cognition, child weight loss willingness, and child weight loss frequency.
TABLE 4.
Results of multicollinearity analysis.
| Variables | VIF |
|---|---|
| Child weight loss willingness | 1.167 |
| Child weight loss frequency | 1.142 |
| Child correct cognition | 1.091 |
| Parental correct cognition | 1.064 |
Abbreviation: VIF, variance inflation factor.
TABLE 5.
Factors influencing child weight loss willingness.
| Variables | OR (95% CI) | p |
|---|---|---|
| PIR | 0.924 (0.819–1.046) | 0.204 |
| Mother's age at childbirth | 0.990 (0.965–1.015) | 0.424 |
| Child overweight told by the doctor (reference = No) | 1.635 (1.167–2.296) | 0.004 |
| Parental correct cognition (reference = No) | 1.273 (0.882–1.826) | 0.193 |
| Child correct cognition (reference = No) | 2.469 (1.787–3.430) | < 0.001 |
Abbreviations: CI, confidence interval; OR, odds ratio; PIR, income to poverty ratio.
TABLE 6.
Factors influencing child weight loss frequency.
| Variables | OR (95% CI) | p |
|---|---|---|
| PIR | 1.019 (0.935–1.111) | 0.665 |
| Mother's age at childbirth | 0.984 (0.967–1.002) | 0.075 |
| Child weight loss willingness (reference = No) | 9.313 (6.436–13.478) | < 0.001 |
| Parental correct cognition (reference = No) | 0.820 (0.622–1.082) | 0.160 |
| Child correct cognition (reference = No) | 1.244 (0.990–1.565) | 0.061 |
| Child overweight told by the doctor (reference = No) | 1.509 (1.194–1.907) | 0.001 |
Abbreviations: CI, confidence interval; OR, odds ratio; PIR, income to poverty ratio.
Within the path model, a total of 16 paths were established (Figure 4). The path model fitted well (Table 7). Path analysis results revealed that PIR (β = 0.062), mother's age at childbirth (β = 0.079), and child overweight told by the doctor (β = 0.357) were directly associated with parental correct cognitions (all p < 0.05). Beyond influencing parental cognition, child overweight told by the doctor also directly affected child cognition (β = 0.138), child weight loss willingness (β = 0.090) and behaviour (β = 0.090) (all p < 0.05). Parental correct cognitions were associated with child correct cognitions (β = 0.197) but showed no direct link to child weight loss willingness. Furthermore, child correct cognitions (β = 0.169) were directly associated with their willingness to lose weight, which in turn related to their weight loss behaviour (β = 0.331) (p < 0.001). The path ‘parental correct cognition → child correct cognition → child weight loss willingness → child weight loss behaviour’ was statistically significant (Figure 4). This finding corroborated the multivariable logistic regression result, indicating that the effect of parental correct cognition disappeared after controlling for child correct cognition.
FIGURE 4.
Path analysis visualisation.
TABLE 7.
Structural model fit indices.
| Index | CMIN/DF | GFI | RMSEA | RMR | CFI | NFI |
|---|---|---|---|---|---|---|
| Ideal | < 2 | > 0.900 | < 0.060 | < 0.050 | > 0.950 | > 0.950 |
| Measurement model fitting result | 1.735 | 0.994 | 0.024 | 0.034 | 0.997 | 0.994 |
Abbreviations: CFI, Comparative Fit Index; CMIN, Chi‐square minimum; DF, Degrees of freedom; GFI, Goodness‐of‐Fit Index; NFI, Normed fit index; RMR, Root mean square residual; RMSEA, Root mean square error of approximation.
4. Discussion
This study, based on nationally representative data from the NHANES, systematically examined the paths through which parental correct cognition is associated with overweight child weight loss willingness and behaviours regarding weight management. Results indicated that parental correct cognitions of their child's weight did not directly relate to the child weight loss willingness. Instead, this effect operated through the key path of ‘shaping the child correct cognition of weight’, forming a clear path: ‘parental correct cognition → child correct cognition → child weight loss willingness → child weight loss behaviour’. This finding offered a novel mechanistic perspective on how familial factors were associated with children's health behaviours.
Research indicates that parents may lack sufficient awareness and accurate understanding of their children's overweight or obesity condition. For example, some mothers assess their child's weight based solely on activity levels, eating habits, or appetite, unaware that the child is already considered overweight [21]. Other parents, although concerned about their child's weight, fear the stigma of labelling them as ‘obese’ [22] and avoid discussing weight issues with their child [23]. Parents' misperception of their child's weight status often delays or hinders necessary interventions, potentially preventing them from actively encouraging lifestyle changes to prevent obesity [24, 25]. However, children and adolescents are more open to interventions when parents and families accurately perceive weight issues [26]. Family support, particularly from parents, plays a crucial role in the lives of children and adolescents. Children and adolescents rely on parents to alter the home environment and provide resources to facilitate change. Parental attitudes may either promote or hinder behavioural change. For instance, parental denial of the potential adverse health effects of their child's overweight status or underestimation of their child's weight may constitute barriers to guiding them towards intervention [27, 28]. Our study confirmed the association between parental correct cognition and child correct cognition. Parents are essential stakeholders in their children's health and development [29]. As primary influencers of their children's health perceptions, parents' attitudes and evaluations serve as critical reference points for children's self‐concept development [7]. When parents objectively recognise their child's overweight status, they are more likely to convey weight‐related concerns through family communication and daily environments, thereby prompting children to develop corresponding self‐evaluations.
The core finding of this study was the crucial role of child correct cognition—that is, correct cognition served as the key internal psychological factor underpinning the formation of healthy behavioural intentions (such as weight loss willingness) and subsequent action. In the multivariable regression analysis, when both parental correct cognition and child correct cognition variables were included simultaneously, the direct effect of parental correct cognition on child weight loss willingness disappeared, whereas the effect of child correct cognition on child weight loss willingness remained significant. This clearly indicates that the positive relationship of parental correct cognition must be channelled through the child's own internal cognitive restructuring to translate into behavioural willingness. This outcome aligns strongly with behavioural change theories (such as the health belief model), which posit that an individual's behavioural intent fundamentally depends on their cognition and assessment of their own health status [30, 31, 32]. In other words, if parents unilaterally decide their child needs to lose weight without the child's own agreement, effective behavioural change motivation is unlikely to be stimulated.
Previous research indicates that healthcare barriers and facilitators for childhood obesity involve multiple levels—children, parents, and professionals—such as a lack of problem awareness or self‐efficacy [33]. The path analysis results of this study further identified the crucial role of ‘physician communication’ as an external information source. As an authoritative health information provider, physicians' communication not only directly reinforces parental correct cognitions of their child's weight but also directly relates children's correct cognition and weight loss willingness. This indicated that in childhood obesity interventions, healthcare professionals' explicit diagnosis and effective communication represent a vital intervention entry point, capable of simultaneously exerting positive effects across multiple levels of the family cognitive system.
Many current family‐based intervention programmes focus on educating parents to recognise childhood obesity and learn management skills. However, when targeting school‐age children and adolescents, these programmes may fail to sufficiently incorporate the children's own cognition, preferences, and communication styles, thereby overlooking their agency in family weight management [11]. Our research strongly advocated that future intervention designs should undergo a paradigm shift from ‘parent education’ to ‘family empowerment’. Specifically, programmes should be structured to simultaneously assist parents and children in establishing objective, consistent weight cognitions. By fostering constructive parent–child dialogue on weight health, parental correct cognition can be effectively internalised by children, ultimately activating autonomous behavioural change. From a public health perspective, given the high prevalence of overweight and obesity among children, even a modest effect size could yield substantial population‐attributable risk reduction if implemented at the community level. From an intervention practice standpoint, should this effect size correspond to easily implementable, low‐cost interventions (such as modifying parental communication styles), then even with limited individual effects, its scalability and cost‐effectiveness in real‐world settings may confer substantial practical value.
This study also has several limitations. Firstly, the cross‐sectional design does not allow for establishing causal relationships between variables; although path analysis was based on theoretical constructs, the direction of causality needs further validation through longitudinal research. Secondly, all variables were self‐reported, which may introduce social desirability bias. Thirdly, the study did not include potential mediating or moderating variables such as the quality of the parent–child relationship or family communication patterns, which could complicate the paths from cognition to behaviour. Finally, owing to sample size constraints, this study combined individuals with overweight and obesity in its analysis, potentially masking risks of heterogeneity. Future research is advised to expand sample sizes and recruit more children with obesity to conduct stratified analyses. Furthermore, future research could use longitudinal designs and include more comprehensive family process variables to better understand this complex mechanism.
5. Conclusion
Child correct cognition of weight acts as a crucial psychological link connecting parental effect to behavioural intent in managing overweight children's weight. This study reveals the behavioural path characteristics of childhood overweight interventions, suggesting that clinical efforts may shift focus from solely correcting parental perceptions to direct attention on the child. Findings indicate no direct correlation between parental accurate perceptions and children's weight‐loss behaviours; conversely, children's own weight perceptions demonstrate a stronger association with their willingness to lose weight.
Author Contributions
Y.H. and Q.Z. contributed to the conception and design. Y.H., Q.Z. and H.C. contributed to the collection and assembly of data. Y.H., J.S. and S.S. analysed and interpreted the data. All authors wrote and approved the final manuscript.
Funding
The authors have nothing to report.
Ethics Statement
The Ethics Committee of Longyan First Hospital deemed that this research is based on open‐source data, so the need for ethics approval was waived.
Consent
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgements
The authors have nothing to report.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.