<sec>
<title>Objectives</title>
<p>Misperception of weight status is a risk factor that affects psychological health. The aim of this study was to evaluate the association between weight misperception patterns and psychological distress among Iranian children and adolescents.</p></sec>
<sec>
<title>Methods</title>
<p>This was a cross-sectional nationwide study where data was collected from 14,440 students, aged 7–18 years who participated in the national school-based surveillance program (CASPIAN-V). The students’ weight perception and psychological distress were assessed by validated questionnaires. Weight misperception was classified as misperception of being either underweight or overweight with respect to actual weight.</p></sec>
<sec>
<title>Results</title>
<p>The rate of weight misperception in all study participants was 59.1%. In groups with a perception of being underweight or overweight, the risks of worthlessness, being worried, experiencing aggression, insomnia, or depression, were significantly higher than groups with an accurate weight perception (<italic>p</italic> < 0.05). The risk of anxiety in girls of normal weight who perceived themselves as underweight, decreased by 57% compared to girls with an accurate weight perception (OR: 0.43; 95% CI, 0.28–0.66).</p></sec>
<sec>
<title>Conclusion</title>
<p>Weight misperception is highly prevalent among Iranian children and adolescents and is associated with their psychological health status. Appropriate education intervention needs to be developed to improve the children and adolescents’ perception of their body weight status.</p></sec>
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