Parental Knowledge, Attitudes, Practices, and Feeding Behaviors in Relation to Childhood BMI Among Families Attending Primary Healthcare Centers in Riyadh, Saudi Arabia

Parental Knowledge, Attitudes, Practices, and Feeding Behaviors in Relation to Childhood BMI Among Families Attending Primary Healthcare Centers in Riyadh, Saudi Arabia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Parental Knowledge, Attitudes, Practices, and Feeding Behaviors in Relation to Childhood BMI Among Families Attending Primary Healthcare Centers in Riyadh, Saudi Arabia Norah Abdullah Alshahrani, Mashaer Mohamed Elamin Swarelzahab, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9232977/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Childhood obesity is a growing public health concern in Saudi Arabia, with parental knowledge, attitudes, practices (KAP), and feeding behaviors playing a central role in shaping children’s weight outcomes. This study examined the associations between parental KAP, child feeding behaviors, demographic characteristics, and child BMI among families attending primary healthcare centers in Riyadh, Saudi Arabia. Methods A cross-sectional study was conducted among parents of children aged 6–12 years attending primary healthcare centers. Data were collected using validated KAP scales and selected Child Feeding Questionnaire (CFQ) subscales. Child BMI percentiles were calculated using clinically verified anthropometric data. Due to non-normal BMI distribution, nonparametric statistical tests were applied. Results A total of 457 parents participated. Significant associations were found between child BMI and parental knowledge (p < .001), attitudes (p < .001), practices (p = .006), and CFQ feeding behaviors (p < .001). Higher BMI was observed among boys and children of older parents. Lower parental education and smaller family size were also associated with higher BMI. Conclusion Parental behavioral factors and feeding styles were significantly associated with child BMI. Although higher parental awareness was linked to healthier weight outcomes, knowledge did not consistently translate into practice. Findings support the need for family-centered, behavior-focused interventions within primary healthcare settings. Health educators should emphasize balanced feeding practices, practical behavior-change strategies, and regular parental follow-up to translate awareness into sustainable healthy routines. Introduction Childhood obesity has emerged as one of the most pressing global public health challenges of the 21st century. According to the World Health Organization, the prevalence of overweight and obesity among children has risen dramatically over the past four decades, placing millions at increased risk of chronic diseases such as diabetes, cardiovascular disorders, and metabolic dysfunction [ 1 ]. Studies conducted in Saudi Arabia have also documented rising obesity trends among children [ 2 , 3 ]. Beyond physical consequences, childhood obesity negatively affects psychological well-being, academic performance, and overall quality of life. Evidence shows that affected children may have significant impairments in social functioning and emotional health [ 4 ]. In Saudi Arabia, the burden of childhood obesity has escalated to alarming levels. National and multicenter studies have reported a substantial rise in overweight and obesity among school-aged children and adolescents, with recent research indicating rates ranging between 20% and 30% across different regions of the Kingdom [ 2 , 3 , 8 ]. Children’s weight trajectories and susceptibility to obesity is greatly influenced by parenting styles, feeding practices, nutrition knowledge, and health attitudes [ 9 – 14 ]. The family environment forms the foundation of children’s behaviors; thus, parents' beliefs and actions can either promote healthy patterns or increase obesity risk. Studies have shown that parents with higher nutrition literacy and health awareness tend to adopt more structured, consistent feeding and activity routines that protect against excessive weight gain [ 10 – 12 ]. Conversely, permissive feeding, excessive restriction, or limited parental supervision have been associated with unhealthy weight outcomes [ 9 , 13 ]. In the Saudi context, the trends reflect broader lifestyle transitions, including increased consumption of high-calorie foods, reduced physical activity, prolonged screen time, and significant environmental shifts [ 7 ]. Cultural beliefs and family norms further shape parental practices. Some families continue to perceive a “chubby child” as healthy or believe that larger body size represents prosperity and good care [ 15 ]. Such cultural perceptions may delay recognition of weight problems or reduce parents’ motivation to seek early weight management [ 15 , 16 ]. The Saudi Ministry of Health has highlighted childhood obesity as a national priority, emphasizing the need for early detection, prevention, and interventions tailored to family and community contexts [ 7 ]. Despite the growing number of studies on childhood obesity in Saudi Arabia, limited research has examined the combined influence of parental demographics, feeding styles, and behavioral determinants on children's weight status [ 5 , 6 ]. Given the central role that parental involvement plays in childhood obesity prevention, this study aims to assess parental knowledge, attitudes, practices, and child feeding behaviors and examine their association with children’s weight outcomes among families attending primary healthcare centers in Riyadh. By identifying familial behavioral and demographic predictors of childhood obesity, this research seeks to provide actionable insights to support family-centered obesity prevention strategies and inform primary healthcare interventions in Saudi Arabia. Methods Study Design and Setting This study employed a descriptive cross-sectional design to examine the associations between parental knowledge, attitudes, practices (KAP), child feeding behaviors, and children's BMI percentile. The study was conducted across 37 primary healthcare centers (PHCCs) within the First Health Cluster in Riyadh, Saudi Arabia. The data collection took place over a one-month period (September 2025 – October 2025). PHCCs were selected because they provide routine pediatric care, growth monitoring, and health education, making them an appropriate setting for investigating parental determinants of child weight status. Study Participants The study population included parents or legal guardians of children aged 6–12 years attending the four selected PHCCs during the data collection period. All parents present during clinic operating hours were invited to participate. A total of 477 questionnaires were distributed; after screening for completeness and consistency, 457 valid responses were retained for final analysis. Inclusion criteria: • being a parent/guardian of a child aged 6–12 years, • child having documented anthropometric measurements, • ability to complete the questionnaire independently. Sampling The minimum required sample size was calculated using Cochran’s formula, assuming a 50% expected prevalence, 95% confidence level, and 5% margin of error, yielding a target of 460 participants [ 20 ]. A convenience sampling approach was used, where eligible parents visiting the selected PHCCs during the study period were invited to participate. Data were collected using a structured, self-administered questionnaire adapted from validated tools, including the Knowledge, Attitudes, and Practices (KAP) framework and selected subscales from the Child Feeding Questionnaire (CFQ) [ 22 ]. The final questionnaire, administered in Arabic, consisted of five sections. The sociodemographic section included 11 items assessing parental age, gender, education, income, number of children, and child characteristics such as age, gender, height, weight, BMI, and physician diagnosis of overweight or obesity. Parental knowledge was measured using eight statements related to nutrition, obesity risk factors, and lifestyle behaviors, with response options of “True,” “False,” or “I don’t know.” Attitudes were assessed using six items rated on a five-point Likert scale ranging from “strongly agree” to “strongly disagree.” Parental practices were evaluated using ten items rated on a five-point frequency scale ranging from “always” to “never,” addressing feeding behaviors, dietary routines, and physical activity-related practices. Child feeding behaviors were measured using eight items from three CFQ subscales perceived responsibility, concern about child weight, and pressure to eat each rated on a five-point Likert scale. Score computations followed standardized procedures. Knowledge items were coded as 1 for correct answers and 0 for incorrect or “I don’t know” responses (score range: 0–8). Attitude items were coded from 1 to 5, with higher values indicating more positive attitudes (score range: 6–30). Practice items were coded from 1 to 5, with reverse scoring applied for negatively worded items, yielding a total score range of 10–50. CFQ subscale items were scored from 1 to 5 according to standardized scoring guidelines, with higher scores reflecting greater expression of the corresponding feeding behavior. Child BMI Measurement and Verification Child anthropometric data (height and weight) were obtained from the most recent documented measurements in the electronic medical records of primary healthcare centers. To ensure accuracy, the research team verified all child measurements through two official systems used in Saudi PHCCs: the SANED system and the Raqeem electronic health platform. Parents who were unsure about their child’s latest measurements were encouraged to confirm them with the attending physician. BMI was calculated using the standard formula: BMI = weight (kg) / height (m²) [ 23 ]. BMI data were then converted to BMI z-scores, accounting for sex and age at assessment, using the 2007 national growth charts for the Saudi children and adolescents reference population, as this reference is more suitable for children in Saudi Arabia. Obesity status was then categorized using percentile (centile) cut-offs: underweight (3rd centile or below), normal weight (above the 3rd centile to below the 85th centile), overweight (85th centile to less than the 95th centile), and obesity (95th centile or above). Data Analysis Statistical analyses were performed using IBM SPSS version 26. Data were first screened for missing values, outliers, and distribution patterns. Descriptive statistics, including frequencies, percentages, medians, and interquartile ranges, were used to summarize participant characteristics. Initial screening indicated that BMI percentile data were negatively skewed (skewness = -1.306), with clear deviation from normality on histogram inspection. Because parametric tests such as t-tests and ANOVA require normally distributed data, nonparametric tests including the Spearman’s Rank Correlation, Mann-Whitney U test, and Kruskal-Wallis test were selected as the most appropriate analytical methods. A significance level of p < 0.05 was used for all analyses. Participant Characteristics A total of 457 parents of children aged 6–12 years were included in the final analysis. The majority of respondents were mothers (75.5%), with fathers representing 24.5%. The median parental age was 37 years (IQR: 31–42). Nearly half of the parents held a university-level education (46.4%), followed by 29.1% with secondary education and 9.8% with only primary education. Household income varied among study participants, with 36.1% reporting an income above 10,000 SAR. Regarding the children, 52.5% were males and 47.5% were females. According to parents, 36.1% (n = 165) of the children had been previously diagnosed as overweight or obese by a physician. Based on Saudi percentile references, 34.1% of the children were within the normal BMI percentile range, 14.9% were overweight, and 49.5% were obese, and the remaining 1.5% were underweight. Participant characteristics are shown in Table 1 (Appendix B) Reliability of Study Instruments All study scales demonstrated strong internal reliability. Cronbach’s alpha values were as follows: Knowledge (α = 0.82) Attitudes (α = 0.86) Practices (α = 0.79) CFQ subscales (α = 0.83–0.88) These values indicate high internal consistency and validate the appropriateness of the KAP and CFQ tools for this population. Child BMI Percentile Distribution Children’s BMI percentiles ranged from 0 to 100, with a median of 94 and a negatively skewed distribution (skewness = -1.306). Due to non-normality, nonparametric testing methods were used for group comparisons. BMI percentile descriptive statistics are shown in Table 2 (Appendix B). Associations Between Parental KAP and Child BMI Significant differences in child BMI were observed across all parental KAP domains using the Spearman’s Rank Correlation: Parental attitudes: (ρ = − 0.290, p < .001) Parental knowledge: (ρ = − 0.253, p < .001) Parental practices: (ρ = − 0.129, p = .006) Children whose parents had higher knowledge, and more positive attitudes had significantly lower BMI values. Parental practices also showed a significant association, though with a smaller effect size. The results of the nonparametric tests for parental KAP domains and child BMI are summarized in Table 3 (Appendix B). Associations Between CFQ Feeding Behaviors and Child BMI Child feeding behaviors, measured by the CFQ, showed significant differences across BMI groups: CFQ feeding subscales: (ρ = − 0.260, p < .001) Children exposed to either highly restrictive or permissive feeding behaviors showed higher BMI values, indicating a nonlinear association. These results are shown in Table 3 (Appendix B). Associations Between Demographic Factors and Child BMI Significant associations were found between BMI percentile and several demographic variables: Child age: No significant difference ( ρ = 0.048, p = .303) Child gender: Boys had higher BMI than girls (U = 21,869.50, p = .008) Number of children: Smaller families showed higher child BMI (ρ = 0.113, p < .015) Parental age: Older parents had children with higher BMI (ρ = 0.444, p < .001) Parental education: Lower education was associated with higher BMI (H = 20.917, p < .001) Parental gender: No significant difference (p = .141) Household income: Not significantly associated (p = .798) Physician diagnosis of obesity: Parents of obese children were significantly older (U = 19,710, p = .001) These associations are shown in Table 3 (Appendix B). Associations Between Parental Age and KAP/CFQ Parental age was significantly associated with all behavioral domains: Knowledge ρ= − 0.229, p < .001 Attitudes ρ= − 0.185, p < .001 Practices ρ= − 0.224, p < .001 CFQ feeding behaviors ρ= − 0.213, p < .001 Older parents demonstrated higher knowledge, more positive attitudes, healthier practices, and stronger feeding behavior awareness despite having children with higher BMI. These results are summarized in Table 3 (Appendix B). Discussion This study aimed to examine the associations between parental knowledge, attitudes, practices (KAP), child feeding behaviors (CFQ), and children’s BMI among families attending primary healthcare centers in Riyadh. The findings reveal significant relationships between parental behavioral domains, demographic characteristics, and childhood BMI, highlighting the central role of parents in shaping children’s nutritional habits and weight outcomes. Parental KAP and Its Association with Child BMI The study found strong and significant associations between parental knowledge, attitudes, and practices with children’s BMI. Higher parental knowledge and more positive attitudes were associated with lower BMI among children. These findings are consistent with previous Saudi and international research indicating that knowledgeable parents are better equipped to recognize obesity risk factors, implement healthier dietary habits, regulate portion sizes, and promote physical activity at home. Studies conducted in Saudi Arabia have emphasized that parental awareness is often one of the strongest predictors of healthy weight maintenance in children [ 5 , 8 , 12 ]. Although parental practices also showed a significant relationship with child BMI, the effect size was smaller compared to knowledge and attitudes. This pattern suggests that high awareness does not always translate into consistent behavior, which aligns with previous research demonstrating that parents may face practical, cultural, or environmental barriers that impede the implementation of healthy routines. For example, busy schedules, cultural norms surrounding food generosity, and reliance on convenience foods may weaken the link between knowledge and actual practices. [ 11 , 15 ]. CFQ Feeding Behaviors and Nonlinear Associations with BMI Findings from the CFQ subscales revealed a significant nonlinear relationship with child BMI. Children exposed to either highly restrictive feeding or highly permissive feeding behaviors demonstrated higher BMI levels. Moderate feeding practices were more strongly associated with normal BMI ranges. These findings are in line with global evidence indicating that excessive restriction may trigger overeating or food preoccupation, while permissive feeding reduces dietary structure and increases the availability of energy-dense foods [ 9 , 13 ]. Previous research conducted in Saudi families has similarly reported that parents who apply inconsistent feeding strategies either too lenient or too strict end to have children at higher risk of obesity [ 15 ]. Therefore, balanced feeding strategies that combine monitoring, structure, and age-appropriate autonomy appear to be more effective. Child Demographic Factors and BMI The study demonstrated that child age had no association with BMI levels. Although, multiple national and global reports illustrate rising obesity rates during late childhood and early adolescence. This developmental stage is characterized by decreased physical activity, increased screen time, and greater exposure to calorie-dense foods [ 1 – 3 ]. Additionally, boys showed significantly higher BMI levels than girls. This finding aligns with regional literature reporting that boys in the Middle East tend to have higher obesity prevalence compared to girls, potentially due to differences in physical activity patterns, lifestyle habits, and family expectations [ 19 ]. Parental Demographics, Family Structure, and BMI Parental age was significantly associated with higher child BMI. Older parents were found to have children with higher BMI, despite scoring higher on knowledge, attitudes, practices, and CFQ awareness. This paradox may be due to lifestyle constraints, reduced parental availability, and increased sedentary routines in older households, as reported in prior studies [ 10 , 17 ]. Parental education level was also a major predictor of child BMI, with lower educational attainment associated with higher obesity risk. This aligns with evidence that higher education enhances health literacy, nutritional awareness, and the ability to incorporate healthier behaviors into daily family routines [ 16 , 21 ]. Family structure further influenced child BMI. Children from smaller families had higher BMI values, a pattern consistent with research showing that parents with fewer children may indulge more in food or provide larger portion sizes, whereas larger families tend to maintain more structured meal routines and shared physical activities [ 18 ]. Physician Diagnosis and Parental Response Approximately one-third of the children in this study had been diagnosed as overweight or obese by a physician. Parents of these children were significantly older, which supports the argument that parental age plays a role in weight-related outcomes. The fact that this diagnosis did not translate into improved practices suggests a possible gap in follow-up, counseling, health communication, or parental readiness to implement behavioral changes. Interpretation and Integration of Findings Overall, the study highlights that childhood obesity is influenced by a combination of: Parental knowledge and attitudes Feeding styles Household structure Socio-demographic context The findings suggest that although many parents demonstrate high levels of knowledge and awareness about healthy nutrition and obesity risks, they do not consistently apply this knowledge in their daily routines with their children. This gap between awareness and actual behavior indicates that knowledge alone is not enough to influence child weight outcomes. Effective, structured, and ongoing behavior-change support from primary healthcare centers such as counseling, follow-up, and practical guidance is necessary to help parents translate awareness into sustainable healthy practices. Comparison with Previous Literature The findings of this study are consistent with several studies conducted across Saudi Arabia, including work in Jeddah, Riyadh, and the Eastern Province, all of which emphasize the critical impact of parental behaviors on children’s weight trajectories [ 5 , 8 , 15 ]. International research similarly identifies parental modeling, feeding routines, and household food environments as the strongest predictors of childhood obesity [ 9 – 14 ]. Translation to Health Education Practice The findings of this study provide important implications for health education practice within primary healthcare settings. Although parents demonstrated relatively high levels of knowledge and awareness regarding childhood obesity, this awareness did not consistently translate into healthy feeding practices and daily routines. This gap highlights the need for health education interventions that move beyond information provision toward practical behavior-change strategies. Health educators working in primary healthcare centers should adopt structured, parent-focused counseling approaches that emphasize balanced feeding practices, portion control, reduction of screen time, and the incorporation of daily physical activity into family routines. Brief, repeated counseling sessions and simple educational tools—such as cue cards, goal-setting checklists, or visual reminders—may enhance parental engagement and improve adherence to healthy behaviors. Targeted interventions should prioritize older parents, families with fewer children, and parents with lower educational attainment, as these groups were associated with higher child BMI in this study. Integrating health education strategies into routine pediatric visits offers a sustainable opportunity to support long-term healthy weight behaviors and prevent childhood obesity within the Saudi primary healthcare context. Strengths and Limitations Strengths This study has several notable strengths. First, it included a relatively large and diverse sample (N = 457) of parents attending primary healthcare centers in Riyadh, which enhances the representativeness of the findings. Second, the study used validated instruments including the Knowledge, Attitudes, and Practices (KAP) scales and the Child Feeding Questionnaire (CFQ), with high internal reliability demonstrated by Cronbach’s alpha coefficients ranging from 0.79 to 0.88. Third, a key methodological strength of this study is the use of clinically verified anthropometric data. Child height and weight measurements were obtained from official electronic medical records and cross-checked using two national systems SANED and Raqeem ensuring high measurement accuracy and minimizing recall or reporting bias. This strengthens the validity of BMI calculations and enhances confidence in the weight-status classifications used in the analysis. Additionally, BMI percentiles were derived using the Saudi National Growth Charts for age and sex, providing an additional layer of validation for the accuracy and clinical relevance of the weight-status assessments. Fourth, the study provides a comprehensive analysis by integrating parental behavioral factors (KAP and CFQ), demographic characteristics, and child BMI outcomes, allowing for a multidimensional understanding of factors influencing childhood obesity. Additionally, the use of appropriate nonparametric statistical tests ensured valid analysis despite the skewed distribution of BMI, strengthening the methodological rigor. Finally, this study addresses a critical public health issue in Saudi Arabia and contributes new insights that can inform family-centered obesity prevention strategies within primary care settings. Limitations Despite its strengths, this study has limitations that should be considered when interpreting the findings. The cross-sectional design prevents establishing causal relationships between parental behaviors and child BMI; therefore, associations observed cannot determine directionality. Second, the reliance on self-reported data, particularly regarding parental practices, knowledge, and feeding behaviors, may introduce response or social desirability bias. Third, the sample was drawn exclusively from public primary healthcare centers in Riyadh, which may limit the generalizability of the results to families attending private healthcare centers or living in other regions of Saudi Arabia. Additionally, although validated instruments were used, the subdivision of KAP and CFQ into multiple scoring categories may have introduced variability across groups. Finally, certain contextual factors such as physical activity environments, household food availability, and screen-time patterns were not measured directly, which may have influenced children’s BMI outcomes. Conclusion This study highlights the significant influence of parental knowledge, attitudes, practices, and feeding behaviors on children’s BMI among families attending primary healthcare centers in Riyadh. The findings demonstrate that higher parental awareness particularly in knowledge and attitudes is associated with healthier child weight, yet awareness alone does not guarantee healthy practices within the home. Feeding behaviors characterized by extreme restriction or excessive permissiveness were linked to higher BMI, emphasizing the importance of balanced, structured approaches to child feeding. Child demographic factors, mainly gender, showed strong associations with BMI, consistent with national and international trends. Additionally, parental age, education level, and family size played important roles in shaping weight-related outcomes. Despite older parents demonstrating higher awareness, their children exhibited higher BMI values, highlighting a gap between knowledge and implementation. Overall, childhood obesity in this population appears to be driven by a complex interplay of parental behaviors, demographic influences, and developmental factors. These results underscore the need for family-centered, behavior-focused interventions within primary healthcare settings to support sustainable, healthy lifestyle practices among children Abbreviations KAP: Parental knowledge, attitudes, practices CFQ: Child Feeding Questionnaire PHCCs: Primary healthcare centers Declarations Ethical Approval and Consent to Participation This study complied with the Declaration of Helsinki guidelines and all practices involving study participants were approved by the Ethical Committee of King Saud Medical City under Riyadh’s First Health Cluster (Approval Number H1QI-14-Aug25-04). Participation was voluntary, and electronic informed consent was obtained from all participating parents or legal guardians, who completed the questionnaire during their clinic visit. Children under the age of 16 did not directly participate in the study, however their BMI measurement was recorded as part of routine clinical care. Parental consent included permission to use their child’s clinical data for research purposes. No identifying information was collected, and participant confidentiality was fully maintained throughout the study . Funding No funding was received for this study. Availability of data and materials Data and materials can be requested from the corresponding author when applicable. Conflict of Interest The authors declare that there is no conflict of interest. Consent for publication Not applicable. Authors’ Contributions N.A. contributed to formation, design of the study, drafting, and manuscript writing. H.A. lead the data analysis, interpretation, and revision of the study. M.S., S.A., A.H., A.A., F.A., S.G., F.A., and H. A. contributed to data acquisition, collection and cleaning. S. A., F.A., and T.A. revised and supervised the work. All authors reviewed and finalized the manuscript. Acknowledgements We extend our deepest thanks and gratitude to Dr. Najla Altigani for her guidance through the writing of this manuscript. References World Health Organization. (2024). Obesity and overweight . https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight Al-Mohaimeed AA, et al. Prevalence of overweight and obesity among Saudi children. J Family Community Med. 2021;28(2):80–6. AlEnazi TH, et al. A multicenter study on childhood obesity in Saudi Arabia. J Obes Public Health. 2023;5(3):122–30. Schwimmer JB, et al. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289(14):1813–9. Al-Hussaini A, et al. Parental knowledge and practices related to childhood obesity prevention: A cross-sectional study in Saudi Arabia. BMC Pediatr. 2021;21(1):1–9. https://doi.org/10.1186/s12887-021-02619-4 . Al-Ghamdi SH. Impact of health education on parental practices in Riyadh. Int J Pediatr. 2022;10(4):215–23. Ministry of Health, Saudi Arabia. (2022). National Obesity Control Program Annual Report . Adam M, et al. National prevalence of childhood obesity in Saudi Arabia: A systematic review. Saudi Med J. 2024;45(1):10–8. Birch LL, Davison KK. Family environmental factors influencing the developing behavioral controls of food intake and childhood overweight. Pediatr Clin North Am. 2001;48(4):893–907. Golan M, Crow S. Targeting parents exclusively in the treatment of childhood obesity: Long-term results. Obes Res. 2004;12(2):357–61. Rhee KE, et al. Factors associated with parental readiness to make changes for overweight children. Pediatrics. 2005;116(1):e94–101. Faith MS, et al. Family-based behavioral treatment for childhood obesity: Evidence for efficacy and new directions. Pediatrics. 2012;130(2):S146–52. Ventura AK, Birch LL. Does parenting affect children’s eating and weight status? Int J Behav Nutr Phys Activity. 2008;5:15. Johnson SL, Birch LL. Parents’ and children’s adiposity and eating style. Pediatrics. 1994;94(5):653–61. Almutairi AF. Cultural beliefs and childhood obesity in Saudi Arabia: A qualitative study. Child Care Health Dev. 2022;48(2):221–8. Al-Qahtani MM. Effectiveness of school-based nutrition education interventions in Saudi Arabia. J Nutr Educ Behav. 2020;52(3):303–10. Kitzmann KM, et al. Interventions for children with overweight and obesity: A systematic review. Pediatrics. 2010;125(2):e396–418. Economos CD, et al. A community intervention reduces BMI z-score in children: Shape Up Somerville first year results. Obesity. 2007;15(5):1325–36. Alruwaili M, et al. Prevalence and factors associated with childhood obesity in the MENA region: A systematic review. Int J Pediatr Obes. 2024;19(2):100–12. https://doi.org/10.1016/j.ijpo.2024.100112 . Cochran WG. Sampling techniques. 3rd ed. Wiley; 1977. Contento IR. Nutrition education: Linking research, theory, and practice. Jones & Bartlett Learning; 2007. Birch LL, et al. Confirmatory factor analysis of the Child Feeding Questionnaire: A measure of parental attitudes, beliefs, and practices about child feeding and obesity proneness. Appetite. 2001;36(3):201–10. Centers for Disease Control and Prevention. (2022). BMI percentile calculator for child and teen: Results . https://www.cdc.gov/healthyweight/bmi/calculator.html Additional Declarations No competing interests reported. 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Health","correspondingAuthor":false,"prefix":"","firstName":"Faisal","middleName":"","lastName":"Alruhaimi","suffix":""},{"id":633484225,"identity":"8283d906-f71b-456e-ba8a-7782ec212519","order_by":11,"name":"Talal Saeed Alqahtani","email":"","orcid":"","institution":"Riyadh First Health Cluster Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Talal","middleName":"Saeed","lastName":"Alqahtani","suffix":""},{"id":633484226,"identity":"27473d6b-31ea-4f45-b2a7-b10557cbd557","order_by":12,"name":"Hadeel Adel AlSulimani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIiWNgGAWjYBACgwMMBgwMBQwyDAzMDQeAAjz8IOGEAkJaDBh4GBgYIVokG0BaDIjUAhMBkXi0HD+88cEHAzse+RmJjYdu1NyRMT6/OvHDAwMGeX6xA1i12J9JKzacYZDMY3AjseFwzrFnPGY33m6WADrMcObsBBwOyzGT5jFg5jGQAGlhOwzUcnYDSEuCwW0cWs6/Mf/9x6Ae5DCgln+HeYxnnN38A6+WGzlmzAwGh3kYQA7LbTvMY8Dfuw2/LTeeFUv2GBznMTjzEKil7zCPxA3ebRYJBhK4/XI+eeOHHxXVcvLtyYc/53w7bM/ff3bzzR8VNvL80ti1YAESYJUSxCoHAf4DpKgeBaNgFIyCEQAAt0hofLFH7tYAAAAASUVORK5CYII=","orcid":"","institution":"Riyadh First Health Cluster Ministry of Health","correspondingAuthor":true,"prefix":"","firstName":"Hadeel","middleName":"Adel","lastName":"AlSulimani","suffix":""}],"badges":[],"createdAt":"2026-03-26 10:40:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9232977/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9232977/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108494065,"identity":"025674c0-bfd3-4182-a326-1d8e66f99300","added_by":"auto","created_at":"2026-05-05 10:02:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":227543,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9232977/v1/5e5d538b-ae66-48bf-9053-a078971b9808.pdf"},{"id":108458241,"identity":"f77fec97-125c-41c6-aad7-0480ea882d92","added_by":"auto","created_at":"2026-05-04 23:18:29","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":27372,"visible":true,"origin":"","legend":"","description":"","filename":"Appendixtables.docx","url":"https://assets-eu.researchsquare.com/files/rs-9232977/v1/c2014e671ebb57817fb0f11f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Parental Knowledge, Attitudes, Practices, and Feeding Behaviors in Relation to Childhood BMI Among Families Attending Primary Healthcare Centers in Riyadh, Saudi Arabia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChildhood obesity has emerged as one of the most pressing global public health challenges of the 21st century. According to the World Health Organization, the prevalence of overweight and obesity among children has risen dramatically over the past four decades, placing millions at increased risk of chronic diseases such as diabetes, cardiovascular disorders, and metabolic dysfunction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Studies conducted in Saudi Arabia have also documented rising obesity trends among children [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Beyond physical consequences, childhood obesity negatively affects psychological well-being, academic performance, and overall quality of life. Evidence shows that affected children may have significant impairments in social functioning and emotional health [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Saudi Arabia, the burden of childhood obesity has escalated to alarming levels. National and multicenter studies have reported a substantial rise in overweight and obesity among school-aged children and adolescents, with recent research indicating rates ranging between 20% and 30% across different regions of the Kingdom [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChildren\u0026rsquo;s weight trajectories and susceptibility to obesity is greatly influenced by parenting styles, feeding practices, nutrition knowledge, and health attitudes [\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The family environment forms the foundation of children\u0026rsquo;s behaviors; thus, parents' beliefs and actions can either promote healthy patterns or increase obesity risk. Studies have shown that parents with higher nutrition literacy and health awareness tend to adopt more structured, consistent feeding and activity routines that protect against excessive weight gain [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Conversely, permissive feeding, excessive restriction, or limited parental supervision have been associated with unhealthy weight outcomes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the Saudi context, the trends reflect broader lifestyle transitions, including increased consumption of high-calorie foods, reduced physical activity, prolonged screen time, and significant environmental shifts [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Cultural beliefs and family norms further shape parental practices. Some families continue to perceive a \u0026ldquo;chubby child\u0026rdquo; as healthy or believe that larger body size represents prosperity and good care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Such cultural perceptions may delay recognition of weight problems or reduce parents\u0026rsquo; motivation to seek early weight management [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Saudi Ministry of Health has highlighted childhood obesity as a national priority, emphasizing the need for early detection, prevention, and interventions tailored to family and community contexts [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Despite the growing number of studies on childhood obesity in Saudi Arabia, limited research has examined the combined influence of parental demographics, feeding styles, and behavioral determinants on children's weight status [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Given the central role that parental involvement plays in childhood obesity prevention, this study aims to assess parental knowledge, attitudes, practices, and child feeding behaviors and examine their association with children\u0026rsquo;s weight outcomes among families attending primary healthcare centers in Riyadh.\u003c/p\u003e \u003cp\u003eBy identifying familial behavioral and demographic predictors of childhood obesity, this research seeks to provide actionable insights to support family-centered obesity prevention strategies and inform primary healthcare interventions in Saudi Arabia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis study employed a descriptive cross-sectional design to examine the associations between parental knowledge, attitudes, practices (KAP), child feeding behaviors, and children's BMI percentile. The study was conducted across 37 primary healthcare centers (PHCCs) within the First Health Cluster in Riyadh, Saudi Arabia. The data collection took place over a one-month period (September 2025 \u0026ndash; October 2025). PHCCs were selected because they provide routine pediatric care, growth monitoring, and health education, making them an appropriate setting for investigating parental determinants of child weight status.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Participants\u003c/h3\u003e\n\u003cp\u003eThe study population included parents or legal guardians of children aged 6\u0026ndash;12 years attending the four selected PHCCs during the data collection period. All parents present during clinic operating hours were invited to participate.\u003c/p\u003e \u003cp\u003eA total of 477 questionnaires were distributed; after screening for completeness and consistency, 457 valid responses were retained for final analysis.\u003c/p\u003e \u003cp\u003eInclusion criteria:\u003c/p\u003e \u003cp\u003e\u0026bull; being a parent/guardian of a child aged 6\u0026ndash;12 years,\u003c/p\u003e\n\u003cp\u003e\u0026bull; child having documented anthropometric measurements,\u003c/p\u003e\n\u003cp\u003e\u0026bull; ability to complete the questionnaire independently.\u003c/p\u003e\n\u003ch3\u003eSampling\u003c/h3\u003e\n\u003cp\u003eThe minimum required sample size was calculated using Cochran\u0026rsquo;s formula, assuming a 50% expected prevalence, 95% confidence level, and 5% margin of error, yielding a target of 460 participants [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA convenience sampling approach was used, where eligible parents visiting the selected PHCCs during the study period were invited to participate.\u003c/p\u003e \u003cp\u003eData were collected using a structured, self-administered questionnaire adapted from validated tools, including the Knowledge, Attitudes, and Practices (KAP) framework and selected subscales from the Child Feeding Questionnaire (CFQ) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The final questionnaire, administered in Arabic, consisted of five sections. The sociodemographic section included 11 items assessing parental age, gender, education, income, number of children, and child characteristics such as age, gender, height, weight, BMI, and physician diagnosis of overweight or obesity. Parental knowledge was measured using eight statements related to nutrition, obesity risk factors, and lifestyle behaviors, with response options of \u0026ldquo;True,\u0026rdquo; \u0026ldquo;False,\u0026rdquo; or \u0026ldquo;I don\u0026rsquo;t know.\u0026rdquo; Attitudes were assessed using six items rated on a five-point Likert scale ranging from \u0026ldquo;strongly agree\u0026rdquo; to \u0026ldquo;strongly disagree.\u0026rdquo; Parental practices were evaluated using ten items rated on a five-point frequency scale ranging from \u0026ldquo;always\u0026rdquo; to \u0026ldquo;never,\u0026rdquo; addressing feeding behaviors, dietary routines, and physical activity-related practices. Child feeding behaviors were measured using eight items from three CFQ subscales perceived responsibility, concern about child weight, and pressure to eat each rated on a five-point Likert scale.\u003c/p\u003e \u003cp\u003eScore computations followed standardized procedures. Knowledge items were coded as 1 for correct answers and 0 for incorrect or \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo; responses (score range: 0\u0026ndash;8). Attitude items were coded from 1 to 5, with higher values indicating more positive attitudes (score range: 6\u0026ndash;30). Practice items were coded from 1 to 5, with reverse scoring applied for negatively worded items, yielding a total score range of 10\u0026ndash;50. CFQ subscale items were scored from 1 to 5 according to standardized scoring guidelines, with higher scores reflecting greater expression of the corresponding feeding behavior.\u003c/p\u003e\n\u003ch3\u003eChild BMI Measurement and Verification\u003c/h3\u003e\n\u003cp\u003eChild anthropometric data (height and weight) were obtained from the most recent documented measurements in the electronic medical records of primary healthcare centers. To ensure accuracy, the research team verified all child measurements through two official systems used in Saudi PHCCs: the SANED system and the Raqeem electronic health platform. Parents who were unsure about their child\u0026rsquo;s latest measurements were encouraged to confirm them with the attending physician. BMI was calculated using the standard formula: BMI\u0026thinsp;=\u0026thinsp;weight (kg) / height (m\u0026sup2;) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. BMI data were then converted to BMI z-scores, accounting for sex and age at assessment, using the 2007 national growth charts for the Saudi children and adolescents reference population, as this reference is more suitable for children in Saudi Arabia. Obesity status was then categorized using percentile (centile) cut-offs: underweight (3rd centile or below), normal weight (above the 3rd centile to below the 85th centile), overweight (85th centile to less than the 95th centile), and obesity (95th centile or above).\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS version 26. Data were first screened for missing values, outliers, and distribution patterns. Descriptive statistics, including frequencies, percentages, medians, and interquartile ranges, were used to summarize participant characteristics. Initial screening indicated that BMI percentile data were negatively skewed (skewness = -1.306), with clear deviation from normality on histogram inspection. Because parametric tests such as t-tests and ANOVA require normally distributed data, nonparametric tests including the Spearman\u0026rsquo;s Rank Correlation, Mann-Whitney U test, and Kruskal-Wallis test were selected as the most appropriate analytical methods. A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was used for all analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e \u003cp\u003eA total of 457 parents of children aged 6\u0026ndash;12 years were included in the final analysis. The majority of respondents were mothers (75.5%), with fathers representing 24.5%. The median parental age was 37 years (IQR: 31\u0026ndash;42). Nearly half of the parents held a university-level education (46.4%), followed by 29.1% with secondary education and 9.8% with only primary education. Household income varied among study participants, with 36.1% reporting an income above 10,000 SAR.\u003c/p\u003e \u003cp\u003eRegarding the children, 52.5% were males and 47.5% were females. According to parents, 36.1% (n\u0026thinsp;=\u0026thinsp;165) of the children had been previously diagnosed as overweight or obese by a physician.\u003c/p\u003e \u003cp\u003eBased on Saudi percentile references, 34.1% of the children were within the normal BMI percentile range, 14.9% were overweight, and 49.5% were obese, and the remaining 1.5% were underweight. \u003cb\u003eParticipant characteristics are shown in Table\u0026nbsp;1 (Appendix B)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eReliability of Study Instruments\u003c/h3\u003e\n\u003cp\u003eAll study scales demonstrated strong internal reliability. Cronbach\u0026rsquo;s alpha values were as follows:\u003c/p\u003e \u003cp\u003eKnowledge (α\u0026thinsp;=\u0026thinsp;0.82)\u003c/p\u003e \u003cp\u003eAttitudes (α\u0026thinsp;=\u0026thinsp;0.86)\u003c/p\u003e \u003cp\u003ePractices (α\u0026thinsp;=\u0026thinsp;0.79)\u003c/p\u003e \u003cp\u003eCFQ subscales (α\u0026thinsp;=\u0026thinsp;0.83\u0026ndash;0.88)\u003c/p\u003e \u003cp\u003eThese values indicate high internal consistency and validate the appropriateness of the KAP and CFQ tools for this population.\u003c/p\u003e\n\u003ch3\u003eChild BMI Percentile Distribution\u003c/h3\u003e\n\u003cp\u003eChildren\u0026rsquo;s BMI percentiles ranged from 0 to 100, with a median of 94 and a negatively skewed distribution (skewness = -1.306). Due to non-normality, nonparametric testing methods were used for group comparisons.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBMI percentile descriptive statistics are shown in Table\u0026nbsp;2 (Appendix B).\u003c/b\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAssociations Between Parental KAP and Child BMI\u003c/h2\u003e \u003cp\u003eSignificant differences in child BMI were observed across all parental KAP domains using the Spearman\u0026rsquo;s Rank Correlation:\u003c/p\u003e \u003cp\u003eParental attitudes: (ρ = \u0026minus;\u0026thinsp;0.290, p \u0026lt; .001)\u003c/p\u003e \u003cp\u003eParental knowledge: (ρ = \u0026minus;\u0026thinsp;0.253, p \u0026lt; .001)\u003c/p\u003e \u003cp\u003eParental practices: (ρ = \u0026minus;\u0026thinsp;0.129, p = .006)\u003c/p\u003e \u003cp\u003eChildren whose parents had higher knowledge, and more positive attitudes had significantly lower BMI values. Parental practices also showed a significant association, though with a smaller effect size.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe results of the nonparametric tests for parental KAP domains and child BMI are summarized in Table\u0026nbsp;3 (Appendix B).\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAssociations Between CFQ Feeding Behaviors and Child BMI\u003c/h2\u003e \u003cp\u003eChild feeding behaviors, measured by the CFQ, showed significant differences across BMI groups: CFQ feeding subscales: (ρ = \u0026minus;\u0026thinsp;0.260, p \u0026lt; .001)\u003c/p\u003e \u003cp\u003eChildren exposed to either highly restrictive or permissive feeding behaviors showed higher BMI values, indicating a nonlinear association.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThese results are shown in Table\u0026nbsp;3 (Appendix B).\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAssociations Between Demographic Factors and Child BMI\u003c/h2\u003e \u003cp\u003eSignificant associations were found between BMI percentile and several demographic variables:\u003c/p\u003e \u003cp\u003eChild age: No significant difference ( ρ\u0026thinsp;=\u0026thinsp;0.048, p = .303)\u003c/p\u003e \u003cp\u003eChild gender: Boys had higher BMI than girls (U\u0026thinsp;=\u0026thinsp;21,869.50, p = .008)\u003c/p\u003e \u003cp\u003eNumber of children: Smaller families showed higher child BMI (ρ\u0026thinsp;=\u0026thinsp;0.113, p \u0026lt; .015)\u003c/p\u003e \u003cp\u003eParental age: Older parents had children with higher BMI (ρ\u0026thinsp;=\u0026thinsp;0.444, p \u0026lt; .001)\u003c/p\u003e \u003cp\u003eParental education: Lower education was associated with higher BMI (H\u0026thinsp;=\u0026thinsp;20.917, p \u0026lt; .001)\u003c/p\u003e \u003cp\u003eParental gender: No significant difference (p = .141)\u003c/p\u003e \u003cp\u003eHousehold income: Not significantly associated (p = .798)\u003c/p\u003e \u003cp\u003ePhysician diagnosis of obesity: Parents of obese children were significantly older (U\u0026thinsp;=\u0026thinsp;19,710, p = .001)\u003c/p\u003e \u003cp\u003e \u003cb\u003eThese associations are shown in Table\u0026nbsp;3 (Appendix B).\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAssociations Between Parental Age and KAP/CFQ\u003c/h2\u003e \u003cp\u003eParental age was significantly associated with all behavioral domains:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eKnowledge\u003c/strong\u003e \u003cp\u003eρ= \u0026minus;\u0026thinsp;0.229, p \u0026lt; .001\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAttitudes\u003c/strong\u003e \u003cp\u003eρ= \u0026minus;\u0026thinsp;0.185, p \u0026lt; .001\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePractices\u003c/strong\u003e \u003cp\u003eρ= \u0026minus;\u0026thinsp;0.224, p \u0026lt; .001\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCFQ feeding behaviors\u003c/strong\u003e \u003cp\u003eρ= \u0026minus;\u0026thinsp;0.213, p \u0026lt; .001\u003c/p\u003e \u003c/p\u003e \u003cp\u003eOlder parents demonstrated higher knowledge, more positive attitudes, healthier practices, and stronger feeding behavior awareness despite having children with higher BMI.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThese results are summarized in Table\u0026nbsp;3 (Appendix B).\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to examine the associations between parental knowledge, attitudes, practices (KAP), child feeding behaviors (CFQ), and children\u0026rsquo;s BMI among families attending primary healthcare centers in Riyadh. The findings reveal significant relationships between parental behavioral domains, demographic characteristics, and childhood BMI, highlighting the central role of parents in shaping children\u0026rsquo;s nutritional habits and weight outcomes.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eParental KAP and Its Association with Child BMI\u003c/h2\u003e \u003cp\u003eThe study found strong and significant associations between parental knowledge, attitudes, and practices with children\u0026rsquo;s BMI. Higher parental knowledge and more positive attitudes were associated with lower BMI among children. These findings are consistent with previous Saudi and international research indicating that knowledgeable parents are better equipped to recognize obesity risk factors, implement healthier dietary habits, regulate portion sizes, and promote physical activity at home. Studies conducted in Saudi Arabia have emphasized that parental awareness is often one of the strongest predictors of healthy weight maintenance in children [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough parental practices also showed a significant relationship with child BMI, the effect size was smaller compared to knowledge and attitudes. This pattern suggests that high awareness does not always translate into consistent behavior, which aligns with previous research demonstrating that parents may face practical, cultural, or environmental barriers that impede the implementation of healthy routines. For example, busy schedules, cultural norms surrounding food generosity, and reliance on convenience foods may weaken the link between knowledge and actual practices. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCFQ Feeding Behaviors and Nonlinear Associations with BMI\u003c/h2\u003e \u003cp\u003eFindings from the CFQ subscales revealed a significant nonlinear relationship with child BMI. Children exposed to either highly restrictive feeding or highly permissive feeding behaviors demonstrated higher BMI levels. Moderate feeding practices were more strongly associated with normal BMI ranges. These findings are in line with global evidence indicating that excessive restriction may trigger overeating or food preoccupation, while permissive feeding reduces dietary structure and increases the availability of energy-dense foods [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious research conducted in Saudi families has similarly reported that parents who apply inconsistent feeding strategies either too lenient or too strict end to have children at higher risk of obesity [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, balanced feeding strategies that combine monitoring, structure, and age-appropriate autonomy appear to be more effective.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eChild Demographic Factors and BMI\u003c/h2\u003e \u003cp\u003eThe study demonstrated that child age had no association with BMI levels. Although, multiple national and global reports illustrate rising obesity rates during late childhood and early adolescence. This developmental stage is characterized by decreased physical activity, increased screen time, and greater exposure to calorie-dense foods [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, boys showed significantly higher BMI levels than girls. This finding aligns with regional literature reporting that boys in the Middle East tend to have higher obesity prevalence compared to girls, potentially due to differences in physical activity patterns, lifestyle habits, and family expectations [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eParental Demographics, Family Structure, and BMI\u003c/h2\u003e \u003cp\u003eParental age was significantly associated with higher child BMI. Older parents were found to have children with higher BMI, despite scoring higher on knowledge, attitudes, practices, and CFQ awareness. This paradox may be due to lifestyle constraints, reduced parental availability, and increased sedentary routines in older households, as reported in prior studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParental education level was also a major predictor of child BMI, with lower educational attainment associated with higher obesity risk. This aligns with evidence that higher education enhances health literacy, nutritional awareness, and the ability to incorporate healthier behaviors into daily family routines [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFamily structure further influenced child BMI. Children from smaller families had higher BMI values, a pattern consistent with research showing that parents with fewer children may indulge more in food or provide larger portion sizes, whereas larger families tend to maintain more structured meal routines and shared physical activities [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003ePhysician Diagnosis and Parental Response\u003c/h2\u003e \u003cp\u003eApproximately one-third of the children in this study had been diagnosed as overweight or obese by a physician. Parents of these children were significantly older, which supports the argument that parental age plays a role in weight-related outcomes. The fact that this diagnosis did not translate into improved practices suggests a possible gap in follow-up, counseling, health communication, or parental readiness to implement behavioral changes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation and Integration of Findings\u003c/h2\u003e \u003cp\u003eOverall, the study highlights that childhood obesity is influenced by a combination of:\u003c/p\u003e \u003cp\u003eParental knowledge and attitudes\u003c/p\u003e \u003cp\u003eFeeding styles\u003c/p\u003e \u003cp\u003eHousehold structure\u003c/p\u003e \u003cp\u003eSocio-demographic context\u003c/p\u003e \u003cp\u003eThe findings suggest that although many parents demonstrate high levels of knowledge and awareness about healthy nutrition and obesity risks, they do not consistently apply this knowledge in their daily routines with their children. This gap between awareness and actual behavior indicates that knowledge alone is not enough to influence child weight outcomes. Effective, structured, and ongoing behavior-change support from primary healthcare centers such as counseling, follow-up, and practical guidance is necessary to help parents translate awareness into sustainable healthy practices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eComparison with Previous Literature\u003c/h2\u003e \u003cp\u003eThe findings of this study are consistent with several studies conducted across Saudi Arabia, including work in Jeddah, Riyadh, and the Eastern Province, all of which emphasize the critical impact of parental behaviors on children\u0026rsquo;s weight trajectories [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. International research similarly identifies parental modeling, feeding routines, and household food environments as the strongest predictors of childhood obesity [\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eTranslation to Health Education Practice\u003c/h2\u003e \u003cp\u003eThe findings of this study provide important implications for health education practice within primary healthcare settings. Although parents demonstrated relatively high levels of knowledge and awareness regarding childhood obesity, this awareness did not consistently translate into healthy feeding practices and daily routines. This gap highlights the need for health education interventions that move beyond information provision toward practical behavior-change strategies.\u003c/p\u003e \u003cp\u003eHealth educators working in primary healthcare centers should adopt structured, parent-focused counseling approaches that emphasize balanced feeding practices, portion control, reduction of screen time, and the incorporation of daily physical activity into family routines. Brief, repeated counseling sessions and simple educational tools\u0026mdash;such as cue cards, goal-setting checklists, or visual reminders\u0026mdash;may enhance parental engagement and improve adherence to healthy behaviors.\u003c/p\u003e \u003cp\u003eTargeted interventions should prioritize older parents, families with fewer children, and parents with lower educational attainment, as these groups were associated with higher child BMI in this study. Integrating health education strategies into routine pediatric visits offers a sustainable opportunity to support long-term healthy weight behaviors and prevent childhood obesity within the Saudi primary healthcare context.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eStrengths\u003c/h2\u003e \u003cp\u003eThis study has several notable strengths. First, it included a relatively large and diverse sample (N\u0026thinsp;=\u0026thinsp;457) of parents attending primary healthcare centers in Riyadh, which enhances the representativeness of the findings. Second, the study used validated instruments including the Knowledge, Attitudes, and Practices (KAP) scales and the Child Feeding Questionnaire (CFQ), with high internal reliability demonstrated by Cronbach\u0026rsquo;s alpha coefficients ranging from 0.79 to 0.88.\u003c/p\u003e \u003cp\u003eThird, a key methodological strength of this study is the use of clinically verified anthropometric data. Child height and weight measurements were obtained from official electronic medical records and cross-checked using two national systems SANED and Raqeem ensuring high measurement accuracy and minimizing recall or reporting bias. This strengthens the validity of BMI calculations and enhances confidence in the weight-status classifications used in the analysis. Additionally, BMI percentiles were derived using the Saudi National Growth Charts for age and sex, providing an additional layer of validation for the accuracy and clinical relevance of the weight-status assessments.\u003c/p\u003e \u003cp\u003eFourth, the study provides a comprehensive analysis by integrating parental behavioral factors (KAP and CFQ), demographic characteristics, and child BMI outcomes, allowing for a multidimensional understanding of factors influencing childhood obesity.\u003c/p\u003e \u003cp\u003eAdditionally, the use of appropriate nonparametric statistical tests ensured valid analysis despite the skewed distribution of BMI, strengthening the methodological rigor.\u003c/p\u003e \u003cp\u003e Finally, this study addresses a critical public health issue in Saudi Arabia and contributes new insights that can inform family-centered obesity prevention strategies within primary care settings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eDespite its strengths, this study has limitations that should be considered when interpreting the findings. The cross-sectional design prevents establishing causal relationships between parental behaviors and child BMI; therefore, associations observed cannot determine directionality.\u003c/p\u003e \u003cp\u003eSecond, the reliance on self-reported data, particularly regarding parental practices, knowledge, and feeding behaviors, may introduce response or social desirability bias.\u003c/p\u003e \u003cp\u003eThird, the sample was drawn exclusively from public primary healthcare centers in Riyadh, which may limit the generalizability of the results to families attending private healthcare centers or living in other regions of Saudi Arabia.\u003c/p\u003e \u003cp\u003eAdditionally, although validated instruments were used, the subdivision of KAP and CFQ into multiple scoring categories may have introduced variability across groups.\u003c/p\u003e \u003cp\u003eFinally, certain contextual factors such as physical activity environments, household food availability, and screen-time patterns were not measured directly, which may have influenced children\u0026rsquo;s BMI outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the significant influence of parental knowledge, attitudes, practices, and feeding behaviors on children\u0026rsquo;s BMI among families attending primary healthcare centers in Riyadh. The findings demonstrate that higher parental awareness particularly in knowledge and attitudes is associated with healthier child weight, yet awareness alone does not guarantee healthy practices within the home. Feeding behaviors characterized by extreme restriction or excessive permissiveness were linked to higher BMI, emphasizing the importance of balanced, structured approaches to child feeding.\u003c/p\u003e \u003cp\u003eChild demographic factors, mainly gender, showed strong associations with BMI, consistent with national and international trends. Additionally, parental age, education level, and family size played important roles in shaping weight-related outcomes. Despite older parents demonstrating higher awareness, their children exhibited higher BMI values, highlighting a gap between knowledge and implementation.\u003c/p\u003e \u003cp\u003eOverall, childhood obesity in this population appears to be driven by a complex interplay of parental behaviors, demographic influences, and developmental factors. These results underscore the need for family-centered, behavior-focused interventions within primary healthcare settings to support sustainable, healthy lifestyle practices among children\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eKAP: Parental knowledge, attitudes, practices\u003c/p\u003e\n\u003cp\u003eCFQ: Child Feeding Questionnaire\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePHCCs: Primary healthcare centers\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis study complied with the Declaration of Helsinki guidelines and all practices involving study participants were approved by the Ethical Committee of\u0026nbsp;King Saud Medical City under Riyadh\u0026rsquo;s First Health Cluster (Approval Number\u0026nbsp;H1QI-14-Aug25-04). Participation was voluntary, and electronic informed consent was obtained from all participating parents or legal guardians, who completed the questionnaire during their clinic visit. Children under the age of 16 did not directly participate in the study, however their BMI measurement was recorded as part of routine clinical care. Parental consent included permission to use their child\u0026rsquo;s clinical data for research purposes. \u0026nbsp;No identifying information was collected, and participant confidentiality was fully maintained throughout the study\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData and materials can be requested from the corresponding author when applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN.A. contributed to formation, design of the study, drafting, and manuscript writing. H.A. lead the data analysis, interpretation, and revision of the study. M.S., S.A., A.H., A.A., F.A., S.G., F.A., and H. A. contributed to data acquisition, collection and cleaning. S. A., F.A., and T.A. revised and supervised the work. All authors reviewed and finalized the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our deepest thanks and gratitude to Dr. Najla Altigani for her guidance through the writing of this manuscript.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. (2024). \u003cem\u003eObesity and overweight\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Mohaimeed AA, et al. Prevalence of overweight and obesity among Saudi children. J Family Community Med. 2021;28(2):80\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlEnazi TH, et al. A multicenter study on childhood obesity in Saudi Arabia. J Obes Public Health. 2023;5(3):122\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwimmer JB, et al. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289(14):1813\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Hussaini A, et al. Parental knowledge and practices related to childhood obesity prevention: A cross-sectional study in Saudi Arabia. BMC Pediatr. 2021;21(1):1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12887-021-02619-4\u003c/span\u003e\u003cspan address=\"10.1186/s12887-021-02619-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Ghamdi SH. Impact of health education on parental practices in Riyadh. Int J Pediatr. 2022;10(4):215\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health, Saudi Arabia. (2022). \u003cem\u003eNational Obesity Control Program Annual Report\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdam M, et al. National prevalence of childhood obesity in Saudi Arabia: A systematic review. Saudi Med J. 2024;45(1):10\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBirch LL, Davison KK. Family environmental factors influencing the developing behavioral controls of food intake and childhood overweight. Pediatr Clin North Am. 2001;48(4):893\u0026ndash;907.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGolan M, Crow S. Targeting parents exclusively in the treatment of childhood obesity: Long-term results. Obes Res. 2004;12(2):357\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRhee KE, et al. Factors associated with parental readiness to make changes for overweight children. Pediatrics. 2005;116(1):e94\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaith MS, et al. Family-based behavioral treatment for childhood obesity: Evidence for efficacy and new directions. Pediatrics. 2012;130(2):S146\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVentura AK, Birch LL. Does parenting affect children\u0026rsquo;s eating and weight status? Int J Behav Nutr Phys Activity. 2008;5:15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson SL, Birch LL. Parents\u0026rsquo; and children\u0026rsquo;s adiposity and eating style. Pediatrics. 1994;94(5):653\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlmutairi AF. Cultural beliefs and childhood obesity in Saudi Arabia: A qualitative study. Child Care Health Dev. 2022;48(2):221\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Qahtani MM. Effectiveness of school-based nutrition education interventions in Saudi Arabia. J Nutr Educ Behav. 2020;52(3):303\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKitzmann KM, et al. Interventions for children with overweight and obesity: A systematic review. Pediatrics. 2010;125(2):e396\u0026ndash;418.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEconomos CD, et al. A community intervention reduces BMI z-score in children: Shape Up Somerville first year results. Obesity. 2007;15(5):1325\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlruwaili M, et al. Prevalence and factors associated with childhood obesity in the MENA region: A systematic review. Int J Pediatr Obes. 2024;19(2):100\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijpo.2024.100112\u003c/span\u003e\u003cspan address=\"10.1016/j.ijpo.2024.100112\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCochran WG. Sampling techniques. 3rd ed. Wiley; 1977.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eContento IR. Nutrition education: Linking research, theory, and practice. Jones \u0026amp; Bartlett Learning; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBirch LL, et al. Confirmatory factor analysis of the Child Feeding Questionnaire: A measure of parental attitudes, beliefs, and practices about child feeding and obesity proneness. Appetite. 2001;36(3):201\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. (2022). \u003cem\u003eBMI percentile calculator for child and teen: Results\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/healthyweight/bmi/calculator.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/healthyweight/bmi/calculator.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9232977/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9232977/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChildhood obesity is a growing public health concern in Saudi Arabia, with parental knowledge, attitudes, practices (KAP), and feeding behaviors playing a central role in shaping children\u0026rsquo;s weight outcomes. This study examined the associations between parental KAP, child feeding behaviors, demographic characteristics, and child BMI among families attending primary healthcare centers in Riyadh, Saudi Arabia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A cross-sectional study was conducted among parents of children aged 6\u0026ndash;12 years attending primary healthcare centers. Data were collected using validated KAP scales and selected Child Feeding Questionnaire (CFQ) subscales. Child BMI percentiles were calculated using clinically verified anthropometric data. Due to non-normal BMI distribution, nonparametric statistical tests were applied.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 457 parents participated. Significant associations were found between child BMI and parental knowledge (p \u0026lt; .001), attitudes (p \u0026lt; .001), practices (p = .006), and CFQ feeding behaviors (p \u0026lt; .001). Higher BMI was observed among boys and children of older parents. Lower parental education and smaller family size were also associated with higher BMI.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eParental behavioral factors and feeding styles were significantly associated with child BMI. Although higher parental awareness was linked to healthier weight outcomes, knowledge did not consistently translate into practice. Findings support the need for family-centered, behavior-focused interventions within primary healthcare settings. Health educators should emphasize balanced feeding practices, practical behavior-change strategies, and regular parental follow-up to translate awareness into sustainable healthy routines.\u003c/p\u003e","manuscriptTitle":"Parental Knowledge, Attitudes, Practices, and Feeding Behaviors in Relation to Childhood BMI Among Families Attending Primary Healthcare Centers in Riyadh, Saudi Arabia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 23:18:25","doi":"10.21203/rs.3.rs-9232977/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-14T19:26:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109405935590230856067913846553689381804","date":"2026-05-10T10:29:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"93613406313581316212234553227628499175","date":"2026-05-05T08:41:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T15:03:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326376156618138208913691334925900995142","date":"2026-04-23T05:55:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-23T00:56:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-16T23:47:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-08T10:49:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-08T09:29:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-04-08T08:36:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a1781e2c-839c-4325-a174-67434bb839b9","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-14T19:26:32+00:00","index":66,"fulltext":""},{"type":"reviewerAgreed","content":"109405935590230856067913846553689381804","date":"2026-05-10T10:29:32+00:00","index":65,"fulltext":""},{"type":"reviewerAgreed","content":"93613406313581316212234553227628499175","date":"2026-05-05T08:41:14+00:00","index":61,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T15:03:30+00:00","index":48,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T23:18:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 23:18:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9232977","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9232977","identity":"rs-9232977","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}