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Received: 23 December 2025

Revised: 11 January 2026

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Published: 22 January 2026

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Article

Parental Mental Health, Feeding Practices, and

Sociodemographic Factors as Determinants of Childhood

Obesity in Greece

Vlasia Stymfaliadi 1, Yannis Manios 2, Odysseas Androutsos 3, Maria Michou 1, Eleni Angelopoulou 4,

Xanthi Tigani 1, Panagiotis Pipelias 1, Styliani Katsouli 1and Christina Kanaka-Gantenbein 1,4,*

1Postgraduate Course “Science of Stress and Health Promotion”, Medical School, National and Kapodistrian

University of Athens (NKUA), 11527 Athens, Greece; vstymf@gmail.com (V.S.);

mariamixou@hotmail.com (M.M.); xanthitig@med.uoa.gr (X.T.); panospt@med.uoa.gr (P.P.);

stellakatsouli13@gmail.com (S.K.)

2Department of Nutrition and Dietetics, Harokopio University of Athens, 17676 Athens, Greece;

manios@hua.gr

3Laboratory of Nutrition & Clinical Dietetics, Department of Dietetics and Nutrition, School of Physical

Education, Sport and Dietetics, University of Thessaly, 42132 Trikala, Greece; oandroutsos@uth.gr

4First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens,

“Aghia Soﬁa” Children’s Hospital, 11527 Athens, Greece; elen.angel@yahoo.gr

*Correspondence: ckanaka@med.uoa.gr or chriskan@med.uoa.gr

Abstract

Background/Objectives: Childhood obesity remains a major public health issue, particu-

larly in Mediterranean countries such as Greece. Although parental inﬂuences on children’s

weight have been extensively studied, fewer studies have jointly examined parental mental

health, feeding practices, sociodemographic factors, and biological stress markers. This

study aimed to investigate associations between psychological status, educational level,

feeding behaviors, and children’s Body Mass Index (BMI) in a Greek sample. A pilot assess-

ment of salivary cortisol was included in evaluating its feasibility as an objective biomarker

of parental stress. Subjects and Methods: A total of 103 parent–child dyads participated in

this cross-sectional study. Children’s BMI was classiﬁed using World Health Organization

(WHO) growth standards. Parental stress, anxiety, and depressive symptoms were assessed

using the Perceived Stress Scale-14 (PSS-14) and the Depression Anxiety Stress Scale-21

(DASS-21) questionnaires. Feeding practices were evaluated with the Comprehensive

Feeding Practices Questionnaire (CFPQ). Statistical analyses included Pearson correlations,

independent samples t-tests, one-way ANOVA, Mann–Whitney U, and Kruskal–Wallis

tests. A subsample provided saliva samples for cortisol analysis to assess feasibility and

explore the potential associations with parental stress indicators. Results: Parental BMI

showed a strong positive association with child BMI (p= 0.002). Higher parental anxiety

(p= 0.002) and depression (p= 0.009) were also associated with increased child BMI. Re-

strictive (p< 0.001) and emotion-driven (p< 0.001) feeding practices were associated with

higher child BMI, whereas monitoring (p= 0.013) and health-promoting feeding practices

(p= 0.001) appeared protective. Lower parental education was related to a higher BMI in

both parents (p= 0.001) and children (p= 0.002) and to more frequent use of restrictive

feeding strategies (p= 0.001). WHO charts identiﬁed a greater proportion of children

as overweight or obese compared with the Centers for Disease Control and Prevention

(CDC) criteria. The analysis showed statistically signiﬁcant differences between the two

classiﬁcation systems (

χ2

(4) = 159.704, p< 0.001), indicating that BMI categorization varies

considerably depending on the reference system used. No signiﬁcant associations were

observed with residential environment or salivary cortisol, likely due to the limited size

Nutrients 2026,18, 364 https://doi.org/10.3390/nu18020364

Nutrients 2026,18, 364 2 of 18

of the pilot biomarker subsample. Conclusions: The ﬁndings highlight the combined

effect of parental mental health status, educational level, and feeding practices on child

BMI within the Greek context. The preliminary inclusion of a biological stress marker

provides added value to the existing research in this area. These results underscore the

importance of prevention strategies that promote parental psychological wellbeing and

responsive feeding practices while addressing socioeconomic disparities to reduce the

childhood obesity risk.

Keywords: childhood obesity; parental stress; feeding practices; body mass index (BMI);

psychosocial determinants; salivary cortisol; World Health Organization (WHO); Greece

1. Introduction

Childhood obesity has emerged as one of the most urgent global public health chal-

lenges, with long-term consequences for children’s physical, psychological, and metabolic

health [

]. According to the World Health Organization (WHO), the worldwide prevalence

of overweight and obesity among children and adolescents has dramatically risen in recent

years, affecting millions of youths across low-, middle-, and high-income countries [

–

Europe has experienced similar upward trajectories, with Southern European countries

reporting the highest burden [

]. Greece consistently ranks among the countries with the

highest prevalence of childhood overweight and obesity, with national surveillance systems

indicating persistently elevated rates that render effective, targeted, evidence-based public

health approaches of utmost importance.

Children’s eating behaviors and weight evolution are shaped largely within the family

environment, where parental roles, household dynamics, and dietary routines exert profound

influence [

]. Parental feeding practices—defined as the strategies parents use to manage,

guide, or regulate their child’s eating—represent a key component of this environment [

These practices are not simply behaviorally driven; they are strongly shaped by parental

psychology, stress levels, cultural expectations, and socioeconomic pressures [

–

]. Accumu-

lating evidence suggests that parental stress plays a key role in modulating feeding behaviors,

often in ways that may compromise children’s ability to self-regulate intake and maintain a

healthy weight [

–

]. Stress can arise from multiple adversities, including financial strain,

professional demands, caregiving burdens, family conflict, and limited social support, all of

which may modify the consistency, responsiveness, and emotional status of parents’ feeding

interactions with their children [14].

Research has shown that higher levels of parental stress are associated with less struc-

tured and less responsive feeding practices, such as increased pressure to eat, inconsistent

limit setting, emotional feeding, greater use of food as reward or comfort, and reduced

monitoring of unhealthy foods [

–

]. These non-responsive practices have been linked

to disinhibited eating, emotional overeating, and diminished satiety responsiveness in

children, thereby contributing to excess weight gain over time [

–

]. Conversely, re-

sponsive feeding—characterized by supportive guidance, modeling healthy choices, and

providing autonomy—has been consistently associated with healthier dietary habits and

more optimal weight trajectories during childhood [22–24].

Stress is a complex biopsychosocial process involving neuroendocrine, cognitive,

emotional, and behavioral pathways [

]. Central to the biological stress response is the

activation of the hypothalamic–pituitary–adrenal (HPA) axis, which leads to the release

of glucocorticoids, primarily cortisol [

]. Chronic or dysregulated cortisol secretion

has been associated with altered appetite control, preferences for energy-dense foods,

https://doi.org/10.3390/nu18020364

Nutrients 2026,18, 364 3 of 18

increased reward-driven eating, abdominal adiposity, reduced physical activity, sleep

disturbances, and disruptions in metabolic homeostasis—pathways all implicated in obesity

development [

–

]. Stress-related physiological changes can also affect gastrointestinal

function, systemic inﬂammation, and energy balance, further supporting the link between

chronic stress exposure and weight gain in both adults and children [31–33].

Within the family context, parental stress has both direct and indirect implications for

children’s health. Increased parental stress can amplify children’s own physiological and

emotional reactivity, diminish parental emotional availability, reduce positive communica-

tion, increase irritability or inconsistency in parenting, and contribute to more conﬂictual

or chaotic home environments [

–

]. These conditions may limit opportunities for struc-

tured family meals, reduce shared physical activity, increase children’s sedentary screen

time, and weaken routines that support healthy behaviors [

–

]. Parental stress may

further aggravate parental mental health, including symptoms of anxiety and depression,

which may provoke difﬁculties in maintaining supportive feeding practices or establish-

ing predictable household routines [

]. Co-parenting quality further moderates

these processes, with supportive and cooperative parenting acting as a buffer against

stress-related disruptions in family functioning [43].

Given these complex interactions, parental feeding practices represent a critical mech-

anism linking stress to children’s dietary behaviors and weight outcomes. The Comprehen-

sive Feeding Practices Questionnaire (CFPQ) and similar validated tools have been widely

used to assess the multidimensional aspects of feeding, including positive practices (e.g.,

monitoring, modeling, healthy-eating guidance) and maladaptive strategies (e.g., pressure

to eat, restriction, emotional feeding, food reward) [

–

]. Evidence consistently indicates

that responsive and autonomy-supportive feeding promotes healthier eating behaviors and

sustainable self-regulation of energy intake among children [

–

]. In contrast, coercive or

emotionally driven practices may undermine children’s satiety cues, promote overeating,

and contribute to unhealthy weight gain [50–52].

In parallel with these family-level dynamics, epidemiological evidence underscores

the growing global and national burden of childhood obesity. Worldwide, the prevalence

of overweight and obesity among school-aged children has increased more than eight-fold

from 1975 to 2016, with substantial rises across regions regardless of economic develop-

ment [

–

]. Socioeconomic inequalities further exacerbate these trends, as children from

disadvantaged households face disproportionate exposure to obesogenic environments,

reduced access to healthy foods, and greater psychosocial stress [

–

]. In Greece, national

surveys such as the World Health Organization (WHO) European Childhood Obesity

Surveillance Initiative (COSI) and the Greek Examination of Cohorts (GRECO) Study have

consistently reported overweight and obesity rates exceeding 35–40% among primary

school children, among the highest in Europe [

]. These alarming trends reﬂect the

interplay between biological predispositions, obesogenic environments, family behaviors,

sociocultural norms, and psychosocial determinants including parental stress and mental

health [61–63].

In the Greek context, childhood obesity is closely linked to family-centered lifestyles,

strong parental involvement in child feeding, and sociocultural norms that emphasize

shared meals and caregiving roles. At the same time, prolonged economic strain and

social stressors in recent decades may further inﬂuence psychological wellbeing and feed-

ing behaviors, highlighting the importance of examining these associations within a na-

tional framework.

Despite extensive research linking stress, mental health, and obesity, fewer studies

have thoroughly examined how parental psychological functioning interacts with feed-

ing practices, sociodemographic characteristics, and children’s anthropometric outcomes

https://doi.org/10.3390/nu18020364

Nutrients 2026,18, 364 4 of 18

within the same analytical framework [

–

]. Even fewer studies have explored these

relationships in Mediterranean populations, where traditional dietary habits coexist with

rapid lifestyle changes, high obesity prevalence, and unique familial caregiving dynam-

ics [

]. The integration of biological stress markers, such as salivary cortisol, into

family-based pediatric obesity research remains limited, although such biomarkers pro-

vide valuable objective insight into the physiological stress pathways that may inﬂuence

parenting behavior and child health [69,70].

Although childhood obesity has been extensively studied, existing research has pre-

dominantly examined parental psychological factors, feeding practices, and sociodemo-

graphic characteristics as separate determinants of child weight outcomes. Fewer studies

have approached these domains in an integrated manner, particularly within Mediterranean

populations, where cultural, familial, and social contexts may shape parental behaviors

differently. Moreover, evidence remains limited regarding the concurrent consideration of

behavioral and biological indicators of stress in relation to childhood obesity.

The present study addresses these gaps by investigating the associations among parental

stress, parental mental health, feeding practices, and children’s weight status in a Greek sample

of parent–child dyads. By incorporating both psychosocial assessments and a preliminary

biological measure of parental stress (salivary cortisol), this research offers an integrated

examination of the behavioral, psychological, and physiological pathways that may contribute

to childhood obesity within contemporary Mediterranean contexts [

]. Understanding

these interconnected determinants is essential for informing family-centered interventions

and public health strategies aimed at mitigating the childhood obesity epidemic.

Based on the existing evidence, it was hypothesized that higher levels of parental

stress and poorer parental mental health would be associated with less responsive feeding

practices and higher child Body Mass Index. In addition, maladaptive feeding practices

were expected to be positively associated with children’s weight status. These hypotheses

were examined within the context of relevant sociodemographic characteristics.

2. Subjects and Methods

2.1. Study Design and Ethical Approval

This cross-sectional study was conducted between 2024 and 2025 in community set-

tings in the regions of Attica and Corinthia, as well as at the Pediatric Obesity Clinic of the

First Department of Pediatrics, Medical School of the National and Kapodistrian Univer-

sity of Athens (NKUA), at “Aghia Soﬁa” Children’s Hospital, Athens, Greece. The study

adhered to the ethical standards described in the Declaration of Helsinki.

The study protocol was approved by the Scientiﬁc Committee of the “Aghia Soﬁa”

Children’s Hospital (initial approval: protocol no. 19998/05.08.2024, approved on

11 October 2024; protocol amendment: protocol no. 13710/05.06.2025, approved on 17

June 2025). Written informed consent was obtained from all participating parents or legal

guardians prior to data collection.

2.2. Procedure

Parents were invited to participate either in community settings or during visits to the

Pediatric Obesity Clinic. After receiving standardized information about the study aims and

procedures, written informed consent was obtained from all participating parents or legal

guardians. Parents completed paper-based questionnaires, including a sociodemographic

form and validated instruments assessing perceived stress, mental health, and feeding

practices (approximately 20 min). Children’s anthropometric data were recorded as part

of the study assessment. In a pilot subsample, salivary cortisol samples were collected

https://doi.org/10.3390/nu18020364

Nutrients 2026,18, 364 5 of 18

following standardized instructions and analyzed in the afﬁliated laboratory. All data were

coded and handled conﬁdentially in accordance with ethical and data protection principles.

All psychometric instruments used in this study (PSS-14, DASS-21, and CFPQ) were

administered in their ofﬁcially translated and validated Greek versions. Prior to data col-

lection, written permission was obtained from the respective developers and/or copyright

holders of each instrument.

2.3. Participants

The study included 103 parent–child dyads, consisting of 23 father–child dyads and

80 mother–child dyads, with children aged 2–12 years. Participants were recruited either

during clinic visits or through community outreach.

Inclusion Criteria

•Parents of children aged 2–12 years.

•

Group A: Children with normal weight (5th–85th percentile) or underweight

(<5th percentile).

•

Group B: Children with overweight (>85th percentile), obesity (>95th percentile), or

severe obesity based on age- and sex-speciﬁc BMI percentiles.

Exclusion Criteria

•

Secondary causes of obesity (e.g., endocrine disorders such as Cushing syndrome or

growth hormone deﬁciency).

•

Genetic syndromes associated with abnormal weight (e.g., Down syndrome, Prader–

Willi syndrome, etc.).

•Chronic diseases or severe emotional/behavioral disorders.

Participant Flow

A total of 130 parents were approached; after applying inclusion and exclusion criteria,

103 dyads were included in the ﬁnal analysis.

Anthropometric Measurements

Child height and weight were obtained either by trained clinical staff at the Pediatric

Obesity Clinic or parent-reported for community participants following standardized

written instructions.

BMI was calculated as weight (kg)/height (m2).

•

For ages 2–5 years, BMI-for-age z-scores were computed using the WHO child growth

standards (2006) [73] and WHO Anthro software (version 3.2.2) [74].

•

For ages 5–12 years, BMI-for-age z-scores were computed using the WHO growth

reference (2007) [75] and WHO AnthroPlus software (version 1.0.4) [76].

For cross-method comparability, BMI categories were additionally veriﬁed using the

CDC Child and Teen BMI Calculator [77].

2.4. Measures

Sociodemographic Questionnaire

A structured questionnaire was used to collect information on parental sex, age,

education, occupation, BMI, residence, and child characteristics (age, sex, height, weight,

health history).

Perceived Stress Scale (PSS-14)

Parental perceived stress was assessed using the Greek-validated version of the Per-

ceived Stress Scale-14 (PSS-14) [

], originally developed by Cohen et al. [

], a 14-item

measure evaluating the frequency of stress-related thoughts and feelings on a 0–4 Likert

scale, yielding total scores from 0 to 56. Higher total scores indicate higher perceived stress.

Depression Anxiety Stress Scale (DASS-21)

https://doi.org/10.3390/nu18020364

Nutrients 2026,18, 364 6 of 18

The Greek-validated Depression Anxiety Stress Scale-21 (DASS-21) [

], originally

developed by Lovibond et al. [

], was used to assess symptoms of depression, anxiety,

and stress. The scale includes 21 items rated on a 0–3 Likert scale and produces three 7-item

subscale scores. Separate scores were calculated for each subscale (Depression, Anxiety,

and Stress), with higher scores indicating greater symptom severity.

Comprehensive Feeding Practices Questionnaire (CFPQ)

Parent feeding practices were measured using the Greek-validated Comprehensive

Feeding Practices Questionnaire (CFPQ) [

], originally developed by Musher-Eizenman

et al. [17], consisting of 42 items across six factors:

1. Healthy Eating Guidance (14 items);

2. Emotion Regulation/Food as Reward (6 items);

3. Monitoring (4 items);

4. Child Control (5 items);

5. Pressure (3 items);

6. Restriction (10 items).

Subscale scores were calculated by summing item responses within each factor, with

higher scores reﬂecting greater use of the corresponding feeding practice.

Pilot Salivary Cortisol Assessment

A subsample of 13 parents provided four salivary cortisol samples (awakening,

+30–45 min, evening, midnight) collected using Salivette

(Sarstedt, Nümbrecht, Ger-

many) devices. Samples were centrifuged, stored at

−

◦

C, and analyzed in batch

using a validated immunoassay at the Clinical and Translational Endocrinology Labo-

ratory, “Aghia Sofia” Children’s Hospital. This assessment served as a feasibility pilot

to explore the biological markers of parental stress.

2.5. Statistical Analysis

Quantitative variables are presented as means

standard deviation or medians

(interquartile range), depending on distribution. Categorical variables are presented as

frequencies (%). Normality was assessed using the Kolmogorov–Smirnov test. Group

comparisons were conducted using independent sample t-tests and one-way ANOVA

for normally distributed variables, and Mann–Whitney U and Kruskal–Wallis tests for

non-normally distributed variables.

Associations between continuous variables were examined using Pearson correlation

coefﬁcients. Chi-square tests were used to compare BMI classiﬁcation between WHO and

CDC criteria. The signiﬁcance level was set at p< 0.05. Analyses were performed using

IBM SPSS Statistics, version 29.

3. Results

3.1. Participants’ Characteristics

Table 1presents the demographic and psychological characteristics of the 103 par-

ticipating parent–child dyads. Most parents were women (77.7%), married (88.3%), and

residents of urban areas (67.0%). Regarding parental weight status, 5.8% of parents were

underweight, 40.8% had normal weight, while 35.9% were overweight and 17.5% were

classiﬁed as obese. The educational level was relatively high, with more than 70% of

parents having completed higher or postgraduate education.

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Table 1. Demographic characteristics and psychological status of parents (n= 103).

Variable Category n(%)

Parental sex Male 23 (22.3)

Female 80 (77.7)

Parental BMI category Underweight (<18.5) 6 (5.8)

Normal weight (18.5–24.9) 42 (40.8)

Overweight (25.0–29.9) 37 (35.9)

Obese (≥30.0) 18 (17.5)

Residence Urban area (Athens) 69 (67.0)

Non-urban area (Corinthia) 34 (33.0)

Marital status Single/divorced/widowed 12 (11.7)

Married 91 (88.3)

Educational level High school or lower 13 (12.6)

Vocational/technical training 16 (15.5)

University degree 34 (33.0)

Master’s degree 30 (29.1)

Doctoral degree 10 (9.7)

Occupation Other occupation 17 (16.5)

Public sector employee 26 (25.2)

Private sector employee 41 (39.8)

Self-employed 19 (18.4)

Child sex Boy 46 (44.7)

Girl 57 (55.3)

Child BMI (WHO) Underweight

(−3SD ≤Z < −2SD) 5 (4.9)

Normal weight

(−1SD ≤Z≤+1SD) 50 (48.5)

Overweight (+1SD < Z < +2SD) 18 (17.5)

Obese (+2SD ≤Z≤+3SD) 11 (10.7)

Severely obese (Z > +3SD) 19 (18.4)

Child BMI (CDC) Underweight 9 (8.7)

Normal weight 49 (47.6)

Overweight 16 (15.5)

Obese 14 (13.6)

Severely obese 15 (14.6)

Parental stress (DASS-21

Stress subscale) Normal (0–14) 71 (68.9)

Mild (15–18) 12 (11.7)

Moderate (19–25) 12 (11.7)

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Nutrients 2026,18, 364 8 of 18

Table 1. Cont.

Variable Category n(%)

Severe (26–33) 6 (5.8)

Extreme (34+) 2 (1.9)

Parental anxiety

(DASS-21 Anxiety

subscale)

Normal (0–7) 75 (72.8)

Mild (8–9) 6 (5.8)

Moderate (10–14) 8 (7.8)

Severe (15–19) 6 (5.8)

Extreme (20+) 8 (7.8)

Parental depression

(DASS-21 Depression

subscale)

Normal (0–9) 78 (75.7)

Mild (10–13) 10 (9.7)

Moderate (14–20) 10 (9.7)

Severe (21–27) 3 (2.9)

Extreme (28+) 2 (1.9)

Note: BMI = Body Mass Index; WHO = World Health Organization; CDC = Centers for Disease Control and

Prevention; DASS-21 = Depression Anxiety Stress Scale-21.

Among the children, 55.3% were girls and 44.7% boys. According to the World Health

Organization (WHO) growth standards [

], 4.9% of children were classiﬁed as under-

weight, 48.5% had normal weight, 17.5% were overweight, 10.7% were obese, and 18.4%

were classiﬁed as severely obese. Similar distributions were observed using the Centers for

Disease Control and Prevention (CDC) criteria. Regarding parental psychological status

assessed with the Depression Anxiety Stress Scale-21 (DASS-21), the majority of parents

reported scores within the normal range for stress (68.9%), anxiety (72.8%), and depression

(75.7%). The prevalence of severe or very severe symptomatology was low across all three

subscales, remaining below 8% for each domain.

3.2. Correlations Between Parental Factors and Child BMI

Table 2summarizes the correlations between parental characteristics and children’s

BMI (WHO classiﬁcation). Parental BMI showed a signiﬁcant positive association with

child BMI (r = 0.304, p= 0.002), indicating that higher parental weight status was correlated

with higher child BMI values.

Child BMI was also positively associated with parental anxiety (r = 0.297, p= 0.002)

and depression (r = 0.255, p= 0.009), suggesting that parental psychological distress may

play a role in children’s weight trajectory.

Regarding feeding practices (CFPQ; Comprehensive Feeding Practices Questionnaire),

restrictive strategies (r = 0.558, p< 0.001), emotional feeding/food as reward (r = 0.466,

p< 0.001), and child control (r = 0.278, p= 0.004) were positively associated with higher

child BMI. Conversely, monitoring (r =

−

0.244, p= 0.013), pressure to eat (r =

−

0.204,

p= 0.039), and healthy eating guidance (r =

−

0.318, p= 0.001) were negatively associated

with child BMI.

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Nutrients 2026,18, 364 9 of 18

Table 2. Correlations between parental variables and child Body Mass Index (BMI) based on World

Health Organization (WHO) standards (n= 103).

Variable r p

Parental BMI 0.304 0.002 **

Perceived parental stress (PSS-14) 0.076 0.444

Parental stress (DASS-21 Stress subscale) 0.046 0.646

Parental anxiety (DASS-21 Anxiety subscale) 0.297 0.002 **

Parental depression (DASS-21 Depression subscale) 0.255 0.009 **

Monitoring (CFPQ subscale) −0.244 0.013 *

Child control (CFPQ subscale) 0.278 0.004 **

Emotional feeding/food as reward (CFPQ subscale) 0.466 0.000 **

Pressure to eat (CFPQ subscale) −0.204 0.039 *

Restriction (CFPQ subscale) 0.558 0.000 **

Healthy eating guidance (CFPQ subscale) −0.318 0.001 **

Cortisol AUCg (salivary) 0.168 0.584

Cortisol AUCi (salivary) −0.163 0.594

Note: * p< 0.05; ** p< 0.01. Pearson correlation coefﬁcients were used. CFPQ = Comprehensive Feeding

Practices Questionnaire.

No signiﬁcant correlations were found between child BMI and salivary cortisol indices

(AUCg, AUCi).

3.3. Associations Between Parental BMI, Psychological Factors, and Feeding Practices

Table 3displays the relationship between parental BMI, psychological status, and

feeding practices. Higher parental BMI was associated with greater perceived stress

(r = 0.196, p= 0.048), anxiety (r = 0.352, p< 0.001), depression (r = 0.262, p= 0.008), and

more restrictive feeding (r = 0.310, p= 0.001).

Table 3. Correlations between parental psychological factors and child feeding practices (n= 103).

Variable 1 Variable 2 r p

Parental BMI Perceived parental

stress (PSS-14) 0.196 0.048 *

Parental BMI

Parental anxiety

(DASS-21 Anxiety

subscale)

0.352 0.000 **

Parental BMI

Parental depression

(DASS-21 Depression

subscale)

0.262 0.008 **

Parental BMI Restriction (CFPQ) 0.310 0.001 **

Parental stress (DASS-21

Stress subscale) Child control (CFPQ) 0.218 0.027 *

Parental anxiety (DASS-21

Anxiety subscale)

Emotional

feeding/food as

reward (CFPQ)

0.307 0.002 **

Parental anxiety (DASS-21

Anxiety subscale) Restriction (CFPQ) 0.218 0.027 *

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Nutrients 2026,18, 364 10 of 18

Table 3. Cont.

Variable 1 Variable 2 r p

Parental depression (DASS-21

Depression subscale) Monitoring (CFPQ) −0.215 0.029 *

Parental depression (DASS-21

Depression subscale)

Emotional

feeding/Food as

reward (CFPQ)

0.199 0.044 *

Parental depression (DASS-21

Depression subscale)

Healthy eating

guidance (CFPQ) −0.331 0.001 **

Note: * p< 0.05; ** p< 0.01. Pearson correlation coefﬁcients were used. CFPQ = Comprehensive Feeding

Practices Questionnaire.

Parental stress (DASS-21) was positively correlated with child control feeding prac-

tices (r = 0.218, p= 0.027). Parental anxiety was associated with both emotional feeding

(r = 0.307, p= 0.002) and restriction (r = 0.218, p= 0.027). Depression correlated negatively

with monitoring (r =

−

0.215, p= 0.029) and healthy eating guidance (r =

−

0.331, p= 0.001)

and positively with emotional feeding (r = 0.199, p= 0.044).

3.4. Differences by Parental Education Level

As shown in Table 4, parental education was significantly related to parental BMI

(p= 0.001), child BMI (p= 0.002), and restrictive feeding practices (p= 0.001). Parents with

lower educational attainment (high school graduates, graduates from technical schools) had

higher BMI (p= 0.001), children with higher BMI (p= 0.002), and used more restrictive feeding

practices (p= 0.001) compared with parents holding postgraduate or doctoral degrees.

Table 4. Differences in parental education level across parental and child outcomes (n= 103).

Education Level Parental BMI

(Mean ±SD)

Child BMI WHO

(Mean ±SD)

Food Restriction

(CFPQ) (Mean ±SD)

Perceived Parental

Stress (PSS-14)

(Mean ±SD)

High school or lower

(n= 13) 29.04 ±6.72 †,ˆ 19.19 ±4.41 †,ˆ 31.08 ±5.77 †,ˆ 25.62 ±5.68

Vocational/technical

training (n= 16) 28.94 ±6.77 #,< 22.83 ±6.30 #,< 34.94 ±8.58 #,< 28.75 ±8.61

University

degree—TEI/AEI

(n= 34)

25.53 ±4.80 20.20 ±5.52 28.53 ±9.76 22.65 ±8.47

Master’s degree

(n= 30) 24.52 ±5.10 ˆ,< 16.99 ±2.92 ˆ,< 25.13 ±7.58 ˆ,< 22.30 ±5.96

Doctoral degree

(n= 10) 21.91 ±4.25 †,# 16.42 ±4.14 †,# 20.30 ±7.15 †,# 22.20 ±8.55

p-value (Signiﬁcance) 0.001 ** 0.002 ** 0.001 ** 0.05 *

Note: * p< 0.05; ** p< 0.01. One-way ANOVA and Kruskal–Wallis with post hoc pairwise comparisons were

conducted to assess differences across education groups. Symbols denote statistically signiﬁcant pairwise

differences:

†

signiﬁcantly different from High school or lower, # signiﬁcantly different from IEK, ˆ signiﬁcantly

different from University degree, < signiﬁcantly different from Doctoral degree.

3.5. Differences by Parental Gender

Table 5presents comparisons between mothers and fathers. Mann–Whitney U tests

were used due to non-normal variable distributions. Fathers had signiﬁcantly higher BMIs

than mothers (p= 0.006). Mothers reported signiﬁcantly greater monitoring of their child’s

eating (p= 0.020). No signiﬁcant gender differences were observed for stress, anxiety,

depression, or most feeding practice subscales.

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Nutrients 2026,18, 364 11 of 18

Table 5. Differences in parental variables according to parental sex (n= 103).

Variable Men

(Median, IQR)

Women

(Median, IQR)

(Two-Tailed)

Parental BMI 28 (4) 25 (4) 0.006 *

Child BMI (WHO) 49 (8) 53 (6) 0.587

Perceived parental stress (PSS-14) 24 (8) 24 (6) 0.651

Parental stress

(DASS-21 Stress subscale) 50 (8) 53 (7) 0.721

Parental anxiety

(DASS-21 Anxiety subscale) 48 (8) 53 (8) 0.438

Parental depression (DASS-21

Depression subscale) 48 (7) 53 (6) 0.511

Monitoring (CFPQ) 15 (3) 17 (4) 0.020 *

Child control (CFPQ) 49 (6) 53 (6) 0.535

Emotional feeding/food as reward

(CFPQ) 57 (7) 51 (7) 0.402

Pressure to eat (CFPQ) 62 (7) 49 (8) 0.059

Healthy eating guidance (CFPQ) 44 (8) 54 (8) 0.155

Note: * p< 0.05. Differences were assessed using the independent samples t-test and Mann–Whitney U test

(two-tailed). CFPQ = Comprehensive Feeding Practices Questionnaire; BMI = Body Mass Index.

3.6. Differences by Child Gender

According to Table 6, parents of boys had signiﬁcantly higher BMIs than parents of

girls (p= 0.006). Parents of girls demonstrated higher monitoring of their children’s dietary

behaviors (p= 0.020). All other variables, including child BMI, parental stress, anxiety, and

depression, did not signiﬁcantly differ between boys and girls.

Table 6. Comparison of boys and girls on key variables (n= 103).

Variable Boys

(Median, IQR)

Girls

(Median, IQR)

Child BMI (WHO) 16.2 (2.5) 15.7 (2.6) 0.152

Parental BMI 28 (4.7) 25 (6.7) 0.006 *

Perceived parental stress (PSS-14) 24 (12) 24 (12) 0.651

Parental stress

(DASS-21 Stress subscale) 50 (10) 53 (8) 0.721

Parental anxiety

(DASS-21 Anxiety subscale) 48 (11) 53 (9) 0.438

Parental depression (DASS-21

Depression subscale) 48 (9) 53 (8) 0.511

Monitoring (CFPQ) 15 (3) 17 (3) 0.020 *

Child control (CFPQ) 49 (7) 53 (6) 0.535

Emotional feeding/food as reward

(CFPQ) 57 (10) 51 (7) 0.402

Pressure to eat (CFPQ) 62 (7) 49 (7) 0.059

Healthy eating guidance (CFPQ) 44 (7) 54 (7) 0.155

Note: * p< 0.05. Comparisons were performed using the independent samples t-tests and Mann–Whitney U test

(two-tailed). CFPQ = Comprehensive Feeding Practices Questionnaire; BMI = Body Mass Index.

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Nutrients 2026,18, 364 12 of 18

3.7. Comparison Between WHO and CDC BMI Classiﬁcation

Table 7compares BMI categorization based on WHO versus CDC criteria for

94 children. Of the initial 103 participants, 94 were included because the “underweight”

category contained a limited number of cases and was excluded from statistical analysis.

WHO identiﬁed a slightly higher proportion of overweight and obese children compared

with CDC charts. The analysis showed statistically signiﬁcant differences between the two

classiﬁcation systems (

χ2

(4) = 159.704, p< 0.001), indicating that BMI categorization varies

considerably depending on the reference system used.

Table 7. Comparison of child BMI classiﬁcation based on WHO and CDC standards.

BMI Category WHO n(%) CDC n(%)

Normal weight 46 (48.9) 49 (52.1)

Overweight 18 (19.1) 16 (17.0)

Obese 30 (31.9) 29 (30.9)

Total 94 (100) 94 (100)

Note: Data are presented as absolute numbers (n) and percentages (%). BMI categories were deﬁned using World

Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) growth standards.

4. Discussion

This study examined the associations between parental psychological functioning,

feeding practices, sociodemographic characteristics, and children’s BMI in a Greek sample

of 103 parent–child pairs. Moreover, a pilot study that included 13 parents, investigating

the use of salivary cortisol as a biological stress marker, was also conducted in a small

number of participants. Overall, the ﬁndings support the multifactorial nature of childhood

obesity and highlight the central role of the family environment, particularly parental

mental health and feeding practices, in shaping children’s weight outcomes [61–63].

Consistent with the extensive international evidence, parental BMI was strongly as-

sociated with child BMI, reinforcing the well-established intergenerational transmission

of obesity risk. This link reﬂects both shared genetic predispositions and shared behav-

ioral and environmental factors within families [

]. Notably, parental anxiety and

depression were also positively related to child BMI. These results suggest that beyond

behavioral modeling, the emotional milieu of the household may inﬂuence children’s eating

patterns and weight status. Previous studies have reported similar associations, indicating

that psychological distress can disrupt the parental capacity for consistent and responsive

feeding practices and may contribute to unstructured food environments [1,11,12].

Feeding practices demonstrated clear and meaningful associations with children’s

BMI. Restrictive feeding, emotional feeding, and greater child control were positively

associated with higher child BMI, whereas monitoring and healthy eating guidance were

inversely associated. These ﬁndings align with previous research showing that restrictive

and emotionally driven strategies may undermine children’s ability to self-regulate food

intake, increase the desirability of high-fat, high-calorie foods, or encourage maladaptive

emotional eating behaviors [

]. In contrast, responsive practices—such as encourag-

ing healthy eating and monitoring unhealthy food intake—have been linked to healthier

dietary patterns and lower obesity risk [

]. Notably, the observed patterns also

mirror cultural dynamics in Mediterranean settings, where food is often intertwined with

emotional expression, reward, and parental care [53,67,68].

Educational level emerged as a strong determinant of parental and child weight status

as well as feeding practices. Parents with lower educational attainment exhibited higher

BMIs, had children with higher BMIs, and used more restrictive feeding practices. These

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Nutrients 2026,18, 364 13 of 18

gradients have already been documented in numerous European cohorts and reﬂect broader

socioeconomic inequalities regarding access to health information, nutrition literacy, and

lifestyle opportunities [

–

]. In Greece, where disparities in health literacy remain

prominent, these results underscore the relevance of social determinants in shaping obesity

risk [7,59,60].

The comparison between the WHO and CDC classiﬁcation systems revealed that

WHO charts identiﬁed a greater proportion of children as overweight or obese. This is

consistent with the existing literature reporting the higher sensitivity of WHO references,

which are based on optimal growth standards rather than population-based norms [

For clinical and public health practices, this ﬁnding highlights the importance of selecting a

classiﬁcation system aligned with the aims of screening and early identiﬁcation of at-risk

pediatric populations.

No signiﬁcant associations were detected between salivary cortisol indices and psy-

chological or behavioral variables. This is likely attributable to the limited number of

samples obtained during the pilot phase, which severely constrained the statistical power.

However, the successful implementation of the saliva collection protocol supports the

feasibility of this research approach in future obesity studies. Incorporating biological

stress markers may be particularly valuable in stress-related obesity research, providing

a measurable biological marker to assess the impact of stress on human behavior and its

consequences [69,70].

Overall, the ﬁndings point to the importance of addressing parental mental health in

the context of childhood obesity prevention frameworks. Interventions that support parents

in managing their own stress, enhancing emotional wellbeing, and adopting responsive

feeding practices may yield substantial beneﬁts for children’s weight trajectories [

Health promotion programs in Greece should consider integrating parental psychosocial

support with traditional nutritional guidance, particularly among families with lower

educational attainment [

–

]. Future research should expand biomarker assessment,

incorporate qualitative approaches to capture cultural nuances in feeding practices, and

adopt longitudinal designs to disentangle causal mechanisms. By capturing the interplay

between psychological, behavioral, and social determinants, this study contributes to a

more comprehensive understanding of childhood obesity within the Greek context.

5. Strengths and Limitations

5.1. Strengths

This study simultaneously examined parental mental health, feeding practices, and

sociodemographic factors in relation to childhood BMI, offering a comprehensive biopsy-

chosocial perspective rarely addressed in Greek populations. The use of validated Greek

versions of all psychometric tools (PSS-14, DASS-21, CFPQ), standardized anthropometric

methods, and WHO/CDC growth references strengthens the robustness of the ﬁndings. An

additional strength is the pilot inclusion of salivary cortisol, which, although exploratory,

demonstrates the feasibility of integrating biological stress markers in family-based obe-

sity research.

5.2. Limitations

The cross-sectional design limits the assessment of causal inferences and the

sample—although diverse—was not nationally representative. Self-reported psychologi-

cal and behavioral measures may be influenced by reporting bias. The relatively small

biomarker subsample in the pilot study assessing salivary cortisol as a stress biomarker

limited the extraction of meaningful results. Finally, parental measurements collected at

home for part of the sample may have introduced measurement variability.

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Nutrients 2026,18, 364 14 of 18

In addition, the analyses were restricted to bivariate associations. Although multi-

variable models could further clarify independent predictors of child BMI, the present

study was designed as an exploratory investigation focusing on the initial relationships

between parental psychological factors, feeding practices, and child weight status. Future

studies with larger samples and longitudinal designs should incorporate multivariable

analytical approaches.

6. Conclusions

This study highlights the multifactorial nature of childhood obesity, demonstrating

that parental mental health, educational level, and feeding practices jointly inﬂuence

children’s BMI. Higher parental anxiety, depression, and restrictive or emotion-driven

feeding behaviors were associated with increased child BMI, whereas monitoring and

health-oriented guidance appeared protective. These ﬁndings underscore the need for

family-centered prevention strategies that support parental psychological wellbeing and

promote responsive, non-restrictive feeding approaches. Although the exploratory salivary

cortisol sub-study did not yield signiﬁcant associations, its feasibility suggests potential

value for future biomarker-driven research. Further longitudinal and large-scale stud-

ies are required to clarify the causal pathways and inform more targeted public health

interventions in Greece and comparable settings.

Author Contributions: Conceptualization, V.S. and C.K.-G.; methodology, V.S., M.M., E.A. and X.T.;

formal analysis, V.S. and M.M.; investigation, V.S.; resources, C.K.-G.; data curation, V.S. and M.M.;

writing—original draft preparation, V.S.; writing—review and editing, Y.M., O.A., M.M., E.A., X.T.,

P.P., S.K. and C.K.-G.; visualization, V.S.; supervision, C.K.-G.; project administration, C.K.-G. All

authors have read and agreed to the published version of the manuscript.

Funding: This study received no external funding and was conducted as part of the requirements for

the MSc program “Science of Stress and Health Promotion” at the National and Kapodistrian University

of Athens.

Institutional Review Board Statement: The study was conducted in accordance with the Declaration

of Helsinki and has been approved by the Scientiﬁc Council and the Ethics and Deontology Committee

of “Aghia Soﬁa” Children’s Hospital, Athens, Greece. The initial protocol was approved on 11 October

2024 (approval number: 19998/05.08.2024) and subsequently amended and approved on 17 June

2025 (approval number: 13710/05.06.2025).

Informed Consent Statement: Written informed consent was obtained from all parents or legal

guardians involved in the study. All participants were fully informed about the study procedures,

objectives, conﬁdentiality measures, and their right to withdraw at any time without consequences.

Data Availability Statement: The data supporting the ﬁndings of this study are not publicly available

due to ethical and privacy restrictions involving minors. De-identiﬁed datasets may be provided

by the corresponding author upon reasonable request and subject to approval by the institutional

ethics committee.

Acknowledgments: The ﬁrst author, V. Stymfaliadi, would like to express her heartfelt gratitude to

her family for their continuous support during the preparation of this manuscript.

Conﬂicts of Interest: The authors declare no conﬂicts of interest.

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Parental Mental Health, Feeding Practices, and Sociodemographic Factors as Determinants of Childhood Obesity in Greece PDF Free Download

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