The current study aimed at examining a conceptual model of direct and indirect relations of maternal emotional states with BMI and HRQoL in their children. Our results indicate that while maternal emotional states could directly affect HRQoL in both genders, they were associated with weight status only in girls. Interestingly in both genders, weight status was not associated with HRQoL, which is why its mediating role in the association between maternal emotional states and offspring HRQoL was not confirmed. In addition, among maternal characteristics which have been considered as influential factors in the initial hypothesized model, level of education directly affected mothers’ emotional states in both genders and HRQoL only in boys.
The current findings regarding the negative relationship between maternal emotional states and HRQol in children are consistent with data reported by previous studies [31, 41, 42]. Maternal depression and stress are accompanied by inappropriate parenting practices and reduced warmth and sensitivity in interactions with children which lead to delays in achieving developmental milestones and poor self-regulation and executive performance in children, and as a result, problems in their overall functioning [42, 43]. In addition, anxious mothers via transference of negative emotional and thinking patterns to their children and lack of providing motivational environment in family, reduce their children’s self-efficacy and success in future experiences .
Our results showed that maternal emotional states were associated with higher BMI levels in girls but not in boys. Several studies have reported the relationship between maternal emotional problems and child overweight [28, 30, 45]; however, only one study has explicitly investigated this relationship in a sex-specific pattern, focusing on maternal depression ,and reported findings consistent with those of ours, which found a significant association between maternal depression and higher BMI only in girls; low levels of physical activity in girls mediated this relationship . Existing literature shows that mothers with emotional problems are more likely to have unhealthy weight-related behaviors  and regarding same-gender role modeling, the impact of maternal lifestyle on daughters is greater than that on sons, resulting in higher levels of girl’s BMI [47-49].
In the present study, neither in girls nor in boys, no relationship was observed between weight status and HRQoL, findings that contradict our initial assumption regarding the mediating role of BMI in the association between maternal emotional states and HRQoL in their children. Data available on the relationship between weight status and HRQoL in children is controversial. Several studies showed negative associations between children’s weight status and HRQoL [9, 10], as demonstrated by the Tsiros et al. systematic review conducted on 22 studies, revealing an inverse linear relationship between children's BMI and HRQoL for both pediatric self-reports and parent proxy-reports . Further evidence indicates Iranian children with higher BMI are more likely to report poorer HRQoL . However, consistent with current results, two other studies from Kuwait and Fiji found no strong association between children weight and HRQoL [12, 51]; both reported that HRQoL scores in children with overweight/obesity did not differ significantly with corresponding values in their normal weight counterparts.
Our findings regarding the negative relationship between maternal education and HRQol in boys, but not in girls, are difficult to compare with those of other studies because there is no gender-specific study comparing this relationship; however, contrary to our results, several studies have documented the positive relationship between maternal education and children’s HRQoL worldwide [52, 53] and in Iran . It seems highly educated mothers who cannot work because of child care, have more parenting stress and experience less satisfaction with their mothering roles  which, considering the emerging sexuality in early adolescence and increasing complexity in opposite-sex relationships in the family, maternal stress has stronger effects on the son’s functioning . However, regarding the inconsistency of our findings with previous studies, more research is needed to clarify the relationship between the education of mothers and HRQoL in children. On the other hand, in our study, maternal education had a positive association with HRQoL in both genders through maternal emotional states, results consistent with those of previous studies [57-59]. Mothers with lower levels of education are more likely to suffer from depression, use negative and harsh parental practices which adversely affect children’s mental wellbeing and their ability to learn [57, 59]. Also, given that education is one of the indicators of socioeconomic status, mothers who are less educated have limited access to social support and childcare services and experience excessive parenting stress, which can impede their ability to adequately meet the needs of children . Also, in this study, the HRQoL declined with increasing age of children, results consistent with existing literature [61, 62]. As age increases, around puberty, physical and hormonal changes occur that reduce psychological balance . Also, because of the formation of new values and norms in adolescence, teenagers seeking their new identity, encounter social insecurities, moral contradictions and ambiguity in the future which may ultimately impair their subjective well-being .
This study is one of the first efforts to explore the direct and indirect effects of maternal emotional states on children’s weight status and HRQoL using a structural equation modeling approach. Its findings also add important information to the literature available regarding the gender differences in the mentioned associations. However, certain limitations also need to be considered. First, the cross-sectional nature of this study did not allow us to derive causal relationships between studied variables. This study was conducted on an urban population of Tehran, which may limit the generalizability of current findings to rural and sub-urban populations. Finally, considering other influential factors including parents’ relationship quality and children’s coping strategies can provide a more accurate picture of the association between mothers’ emotional states and their children's weight status and HRQoL.
In conclusion, our results highlight the impact of maternal emotional state on subjective health status of children in both genders irrespective of their BMI. Further research is definitely required to confirm our gender-specific findings.