a case study of childhood obesity

• Open access
• Published: 25 November 2019

The epidemiological burden of obesity in childhood: a worldwide epidemic requiring urgent action

• Mariachiara Di Cesare 1 ,
• Maroje Sorić 2 , 3 ,
• Pascal Bovet 4 , 5 ,
• J Jaime Miranda 6 ,
• Zulfiqar Bhutta 7 ,
• Gretchen A Stevens 8 , 9 ,
• Avula Laxmaiah 10 ,
• Andre-Pascal Kengne 11 &
• James Bentham 12  

BMC Medicine volume  17 , Article number:  212 ( 2019 ) Cite this article

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In recent decades, the prevalence of obesity in children has increased dramatically. This worldwide epidemic has important consequences, including psychiatric, psychological and psychosocial disorders in childhood and increased risk of developing non-communicable diseases (NCDs) later in life. Treatment of obesity is difficult and children with excess weight are likely to become adults with obesity. These trends have led member states of the World Health Organization (WHO) to endorse a target of no increase in obesity in childhood by 2025.

Estimates of overweight in children aged under 5 years are available jointly from the United Nations Children’s Fund (UNICEF), WHO and the World Bank. The Institute for Health Metrics and Evaluation (IHME) has published country-level estimates of obesity in children aged 2–4 years. For children aged 5–19 years, obesity estimates are available from the NCD Risk Factor Collaboration. The global prevalence of overweight in children aged 5 years or under has increased modestly, but with heterogeneous trends in low and middle-income regions, while the prevalence of obesity in children aged 2–4 years has increased moderately. In 1975, obesity in children aged 5–19 years was relatively rare, but was much more common in 2016.

Conclusions

It is recognised that the key drivers of this epidemic form an obesogenic environment, which includes changing food systems and reduced physical activity. Although cost-effective interventions such as WHO ‘best buys’ have been identified, political will and implementation have so far been limited. There is therefore a need to implement effective programmes and policies in multiple sectors to address overnutrition, undernutrition, mobility and physical activity. To be successful, the obesity epidemic must be a political priority, with these issues addressed both locally and globally. Work by governments, civil society, private corporations and other key stakeholders must be coordinated.

Peer Review reports

Excess weight during childhood and adolescence remains one of the most important issues in global health, despite emerging as a concern several decades ago [ 1 , 2 ]. Recent estimates suggest that 40 million children under the age of 5 years and more than 330 million children and adolescents aged 5–19 years were overweight or obese in 2016 [ 3 ]. Given the global emergency posed by excess weight in children, member states of the World Health Organization (WHO) endorsed “no increase in childhood overweight by 2025” as one of the six global nutrition targets in the ‘Comprehensive Implementation Plan for Maternal, Infant and Young Child Nutrition’ [ 4 ]. This is consistent with the same target for obesity and diabetes between 2010 and 2025 in the ‘WHO Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020’ [ 5 , 6 ].

Overweight or obesity during childhood has important short-term and long-term consequences. In the short term, children who are overweight or obese are more likely to suffer from psychological comorbidities such as depression, anxiety, low self-esteem, a series of emotional and behavioural disorders [ 7 , 8 ], asthma [ 9 ], low-grade systemic inflammation [ 10 , 11 ], liver complications [ 12 , 13 ], and musculoskeletal problems, especially in the lower extremities [ 14 ]. Children who are overweight and obese also have more metabolic and cardiovascular risk factors [ 15 , 16 ], such as high blood pressure [ 17 ], dyslipidaemia [ 18 ], type 2 diabetes [ 19 ] and other abnormalities of the cardiovascular system [ 20 ]. In the long term, overweight or obesity during childhood increases the risk of developing cardiovascular diseases, diabetes, some cancers, and musculoskeletal disorders in adulthood, which can lead to disability [ 21 ] and premature death [ 22 , 23 , 24 ]. In addition, the treatment of obesity in adulthood is difficult [ 25 ], with evidence suggesting that around three-quarters of children who are overweight or obese carry this status into adulthood [ 26 ]. Strong persistence of overweight status and low efficacy of available treatments highlight the need to prevent overweight and obesity at the earliest possible stage of life.

It is recognised that weight gain is partly caused by elevated energy intake, which often includes a disproportionate amount of refined carbohydrates and/or processed foods (increasing insulin release and fat storage), and decreased physical activity [ 27 ]. Weight gain is also promoted by environmental, behavioural, biological, and genetic factors, whose interactions have driven the current levels of worldwide obesity. Maternal health status during pregnancy, an obese intrauterine environment [ 28 ] and rapid changes in weight status during infancy [ 29 ] are other factors contributing to obesity in children. Moreover, the expanding ‘obesogenic’ environment increases the propensity of children to consume foods and beverages that are high in calories, energy-dense, or low in nutrients, as well as promoting sedentary lifestyles through reductions in opportunities for active mobility in daily lives [ 30 ]. Key drivers of the rapidly increasing worldwide occurrence of obesity and diabetes across populations are the globalised market and commercial interests that favour the production and distribution of inexpensive, energy-dense foods and beverages and limited political will to address the economic causes of the obesity epidemic [ 3 ], which include a strong association with socioeconomic inequalities [ 31 , 32 ]. In high-income settings, higher prevalence of obesity is observed in disadvantaged and marginalised communities than in groups with higher socioeconomic status [ 33 , 34 , 35 ]. In contrast, higher prevalence of obesity is seen in groups with higher socioeconomic status in some, but not all, low and middle-income settings [ 31 ].

Over the past decade, genome-wide association studies have been used to identify genetic markers that increase predisposition to weight gain, with the goal of explaining the biological mechanisms leading to obesity. For example, the FTO gene is recognised as being key to the regulation of energy intake, with variants predisposing individuals to greater caloric intake and reduced feelings of satiety [ 36 ]. Genetic and epigenetic factors also produce heterogeneity in obesity phenotypes across populations, including characteristic metabolic profiles and greater central body adiposity in south Asians [ 37 ]. However, groups with almost identical genotypes can have very different obesity phenotypes, as shown by the large differences in prevalence between Samoa and American Samoa [ 38 ]. In addition, obesity-associated genes cannot explain the rapid onset and scale of the current obesity epidemic, even if genetic predisposition makes some individuals more susceptible to the obesogenic environment [ 39 ].

Finally, obesity in childhood has important economic and social costs, with increased burdens on health systems as well as later reduced economic productivity [ 40 , 41 , 42 , 43 ]. For example, in the USA, the estimated direct medical cost over the lifetime of a 10-year-old child with obesity, compared with a similar child with normal weight and allowing for weight gain in adulthood, is between US$12,660 and US$19,630 [ 44 ].

Over the past decade, there has been a global effort to provide reliable and detailed estimates of the worldwide epidemic of excess weight in children and adolescents. Here, we aim to provide a comprehensive description of this work, presenting global, regional and national trends based on the most up-to-date information available. To do so, we use data from the United Nations Children’s Fund (UNICEF)/WHO/World Bank Joint Child Malnutrition Estimates [ 45 ], the Institute for Health Metrics and Evaluation (IHME) Global Burden of Disease Study [ 46 ] and the Non-Communicable Disease (NCD) Risk Factor Collaboration (NCD-RisC) [ 47 ] (see Table  1 ). It should be noted that there are two definitions of obesity in childhood: the International Obesity Taskforce (IOTF) definition [ 48 ] and one based on the WHO growth reference curve [ 49 ]. They have different age-specific cut-offs and can therefore give different obesity estimates for a given set of data. In the following, estimates published by IHME use the IOTF definition, while estimates published by UNICEF/WHO/World Bank and NCD-RisC use the WHO growth reference. Readers interested in the differences in statistical models and regional definitions in these studies are referred to the original papers.

Children aged 5 years or under

Global and regional trends in overweight.

The most recent estimates of trends in overweight for children under the age of 5 years were published jointly by UNICEF, WHO and the World Bank in April 2019 [ 45 ]. Globally, the prevalence of overweight rose modestly, from 4.8% in 1990 to 5.9% in 2018, but with estimates for low and middle-income United Nations regions showing heterogeneous trends. Estimates were not published for high-income regions.

Table  2 presents results by region. In Africa as a whole, overweight prevalence changed little between 1990 and 2018. However, prevalence increased in Northern and Southern Africa, and also rose modestly in Middle Africa. This was offset by decreases in overweight prevalence in Eastern and Western Africa. Overweight prevalence in Asia rose, with increases in every region except Eastern Asia, where overweight prevalence remained almost unchanged. In Latin America and the Caribbean, overweight prevalence increased, including a moderate increase in the Caribbean and small increases in Central and South America. Finally, the overweight epidemic in Oceania (excluding Australia and New Zealand) became much more severe, with a three-fold increase in prevalence.

Trends in obesity prevalence

Obesity trends in children aged 2–4 years are available from IHME for the period 1980–2015 [ 46 ] and are the only source of comparable country-level information for children under the age of 5 years. National-level estimates for 1980 and 2015 are shown in Figs.  1 and 2 , respectively.

Obesity prevalence for girls and boys aged 2–4 years in 1980, by country. Estimates of obesity prevalence in ( a ) girls and ( b ) boys aged 2–4 years were published by the Institute for Health Metrics and Evaluation using the International Obesity Taskforce growth reference [ 46 ] (see Table  1 )

Obesity prevalence for girls and boys aged 2–4 years in 2015, by country. Estimates of obesity prevalence in ( a ) girls and ( b ) boys aged 2–4 years were published by the Institute for Health Metrics and Evaluation using the International Obesity Taskforce growth reference [ 46 ] (see Table  1 )

At the global level between 1980 and 2015, the prevalence of obesity increased from 3.9 to 7.2% in boys and from 3.7 to 6.4% in girls aged 2–4 years. In 2015, by far the highest levels of obesity were in American Samoa, where around 50% of girls and boys in this age group were obese. More than one in three girls were obese in Kiribati and more than one in four in Samoa and Kuwait. For boys, the second highest prevalence of obesity in this age group was in Kuwait, followed by Qatar and Kiribati. For girls, the lowest prevalence of obesity was seen in North Korea, followed by Eritrea, Bangladesh and Burundi. In boys, the lowest prevalence was in Eritrea, followed by North Korea, Burundi and Bangladesh.

Table  3 presents estimates by region. As shown in Figs. 1 and 2 , patterns are heterogeneous in sub-Saharan Africa. In 1980, obesity was most common in girls and boys in South Africa and least common in girls and boys in Mali. By 2015, the country with the highest prevalence of obesity in girls was Equatorial Guinea, followed by Djibouti, Zambia and South Africa. Countries with the highest prevalence of obesity in boys were also Equatorial Guinea, followed by Zambia, Djibouti and South Africa. In contrast, less than 2% of girls in Eritrea and Burundi and less than 1% of boys in Eritrea were obese.

In south Asia in 1980, the prevalence of obesity was highest in girls and boys in Afghanistan and lowest in girls and boys in Nepal (Fig.  1 ). By 2015, the highest prevalence of obesity was seen in Bhutan and the lowest in Bangladesh for both sexes (Fig.  2 ). In 1980 in East and Southeast Asia, obesity prevalence was highest in girls in Malaysia and boys in Taiwan and was lowest in girls in the Philippines and boys in Vietnam. In 2015, the highest levels of obesity in girls were seen in Malaysia, followed by Thailand and China, while in boys, the highest obesity was also seen in Malaysia, followed by Taiwan and Thailand. North Korea had the lowest level of obesity for both sexes.

Obesity prevalence in children aged 2–4 years was heterogeneous in Oceania. In 1980, while almost half of girls and boys in American Samoa were obese, this was the case for fewer than 1 in 20 girls in Papua New Guinea and boys in Fiji. In 2015, obesity ranged from approximately 50% in American Samoa to around 5% in Papua New Guinea in both sexes.

In Latin America and the Caribbean in 1980, the highest levels of obesity were seen in girls in Uruguay and boys in Chile. The lowest levels of obesity were seen in girls in Colombia and boys in Honduras. By 2015, the highest levels of obesity were seen in Puerto Rico for both girls and boys. For girls, the next highest levels of obesity were seen in Dominica and Uruguay, while for boys, Puerto Rico was followed by Chile and Barbados. The lowest prevalence of obesity was seen in Haiti and Colombia for both boys and girls.

In the Middle East in 1980, the highest levels of obesity were seen in girls in Kuwait and boys in Qatar, while the lowest levels were seen in girls in Iran and boys in Yemen. By 2015, the highest levels of obesity were seen in girls in Kuwait, Saudi Arabia and Qatar and in boys, in Kuwait, Qatar and Oman. This contrasted with girls in Jordan and boys in Yemen, for whom obesity rates were lowest. In North Africa in 1980, the highest prevalence of obesity was seen in girls and boys in Libya and the lowest prevalence was in girls and boys in Algeria. By 2015, the highest obesity prevalence was seen in girls and boys in Egypt, while the lowest level was in Tunisia for both sexes.

In high-income countries, obesity prevalence increased between 1980 and 2015 (Figs.  1 and 2 ). In high-income Western countries in 1980, the highest obesity prevalence was in girls in Andorra and boys in Spain, with the lowest levels of obesity in girls in Switzerland and boys in the Netherlands. In 2015, the highest levels of obesity in girls were still in Andorra, followed by Malta, Greece and Portugal. In boys, the highest levels were in Luxembourg, Andorra, Canada and Malta. The lowest levels were in girls and boys in Switzerland. In high-income Asia-Pacific, the highest obesity prevalence in 1980 was seen in girls and boys in Singapore and the lowest in girls and boys in Japan. By 2015, obesity prevalence exceeded 10% in boys and 6% in girls in Singapore and South Korea. In contrast, obesity prevalence was less than 3% in girls and boys in Japan.

In Central and Eastern Europe in 1980, the highest obesity prevalence was seen in girls in Albania and boys in Bulgaria, with the lowest in girls and boys in Ukraine. In 2015, obesity was particularly high in girls in Albania, followed by Montenegro, Bosnia and Herzegovina and Russia. Albania also had the highest prevalence of obesity in boys, followed by Montenegro, Russia and Bosnia and Herzegovina. Obesity prevalence was lowest in girls in Ukraine, followed by Moldova, while in boys, the lowest obesity was in Moldova, followed by Ukraine. In Central Asia in 1980, obesity was most common in girls and boys in Uzbekistan and least common in girls and boys in Kazakhstan. In 2015, the prevalence of obesity was highest in girls in Georgia and boys in Azerbaijan and lowest in both sexes in Kyrgyzstan.

The number of children aged 2–4 years with obesity was also published by IHME for the period 1980–2015 [ 46 ]. The division of these children by country in 1980 and 2015 is shown in Figs.  3 and 4 , respectively. In 1980, the country with the largest number of girls with obesity was India, followed by China, Russia and the USA. India, China and Russia also had the largest number of boys with obesity, followed by Mexico. By 2015, China had the largest number of girls with obesity, followed by India, the USA and Brazil. The largest number of boys with obesity was in China, followed by India, Brazil and the USA.

Division of the number of girls and boys aged 2–4 years with obesity in 1980, by country. Estimates of obesity in ( a ) girls and ( b ) boys were published by the Institute for Health Metrics using the International Obesity Taskforce growth reference [ 46 ] (see Table  1 )

Division of the number of girls and boys aged 2–4 years with obesity in 2015, by country. Estimates of obesity in ( a ) girls and ( b ) boys were published by the Institute for Health Metrics using the International Obesity Taskforce growth reference [ 46 ] (see Table  1 )

Children and adolescents aged 5–19 years

Worldwide trends in obesity.

NCD-RisC holds the largest global database on obesity in children and adolescents aged 5–19 [ 50 ]. The most recent estimates, published in 2017, were based on 2416 measured data sources [ 47 ]. They showed that between 1975 and 2016, obesity prevalence increased from 0.7 to 5.6% in girls and from 0.9 to 7.8% in boys. However, the global increase in obesity masked heterogeneous trends at national level, as shown in Figs.  5 and 6 .

Obesity prevalence for girls and boys aged 5–19 years in 1975, by country. Estimates of obesity in ( a ) girls and ( b ) boys were published by the Non-Communicable Diseases Risk Factor Collaboration (NCD-RisC) using the World Health Organization growth reference [ 47 ] (see Table  1 )

Obesity prevalence for girls and boys aged 5–19 years in 2016, by country. Estimates of obesity in ( a ) girls and ( b ) boys were published by the Non-Communicable Diseases Risk Factor Collaboration (NCD-RisC) using the World Health Organization growth reference [ 47 ] (see Table  1 )

Obesity trends by region

Table  4 presents results by region. As shown in Fig.  5 , obesity was rare across the world in 1975, but particularly so in sub-Saharan Africa, with an estimated prevalence of 0.1% for girls and 0.0% for boys. An obesity prevalence greater than 0.5% was observed only in Djibouti and Seychelles for girls and in Seychelles for boys. By 2016, an obesity prevalence of greater than 5% was seen in 10 countries for girls and two for boys (Fig.  6 ). Six of the seven countries with the highest rates of obesity in girls were in southern Africa, with South Africa having the highest prevalence and Burkina Faso the lowest prevalence. For boys, Seychelles had the highest prevalence, followed by South Africa and with Uganda having the lowest prevalence.

South Asia also had extremely low levels of obesity in 1975, estimated at 0.0% for both girls and boys and reaching a maximum of 0.1% for boys in Pakistan. However, obesity was less rare by 2016, with Afghanistan for girls and Bhutan, Pakistan and Bangladesh for boys having a prevalence of obesity of greater than 3%. More heterogeneous trends were observed in East and Southeast Asia. In 1975, obesity in boys and girls was most common in Hong Kong, but the prevalence of obesity was less than 2% elsewhere in the region. In 2016, the highest level of obesity in girls was seen in Malaysia and the lowest in Cambodia. For boys, the prevalence of obesity was highest in Brunei Darussalam and lowest in Vietnam. Meanwhile, in high-income countries in Asia-Pacific in 1975, obesity prevalence was highest in Singapore for girls and boys. By 2016, the highest prevalence of obesity was in South Korea and the lowest in Japan for both sexes.

In 1975, obesity levels were low in Latin America and the Caribbean (Fig.  5 ). Obesity was most common in Bermuda, followed by Argentina and Uruguay for both sexes. By 2016, the prevalence of obesity had become more heterogeneous. For girls, the highest levels of obesity were seen in Puerto Rico, Bermuda and the Bahamas, while for boys the highest levels were seen in Bermuda, Argentina and Puerto Rico. Obesity prevalence was lowest in Colombia for girls and boys, followed by Peru and Haiti for girls and Saint Lucia and Peru for boys.

Heterogeneous trends were observed across North Africa, the Middle East and Central Asia. In 1975, obesity prevalence was highest in girls and boys in Kuwait. By 2016, obesity prevalence was highest in Kuwait and Egypt for girls and in Kuwait and Qatar for boys. Meanwhile, obesity prevalence was lowest in both sexes in Tajikistan.

There were heterogeneous patterns of obesity in high-income Western countries in both 1975 and 2016. In 1975, the highest level of obesity was in Malta for girls and boys, followed by the USA, Andorra and Israel for girls and Andorra, Israel and the USA for boys. Meanwhile, the prevalence of obesity was below 2% in eight countries for girls and in five countries for boys. By 2016, the highest levels of obesity were observed mostly in English-speaking and Mediterranean countries. The USA had the highest prevalence of obesity for girls and boys, followed by New Zealand. Switzerland had the lowest obesity prevalence among girls and boys.

In 1975, for both sexes, obesity prevalence was less than 2% in every country in Central and Eastern Europe (Fig.  5 ). By 2016, the prevalence of obesity had exceeded 13% in boys and 7% in girls in Croatia, Hungary and Bulgaria. Obesity prevalence was lowest among boys in Moldova, followed by Bosnia and Herzegovina and the three Baltic states. For girls, Moldova, Russia and Estonia had the lowest prevalence of obesity.

Obesity was uncommon in children and adolescents aged 5–19 years in Oceania in 1975, with prevalence exceeding 5% only in girls and boys in Nauru and in girls in Palau. By 2016, the 13 countries with the highest obesity rates for girls and the eight countries with the highest obesity rates for boys were all in Oceania; more than 30% of girls and boys in Nauru, the Cook Islands and Palau were obese. However, there was a contrast between patterns in Melanesia, and Polynesia and Micronesia, with obesity prevalence lower in all countries in Melanesia.

Changes in obesity at national level

Between 1980 and 2015, obesity prevalence in every country increased for both sexes, but there was wide variation in the extent of increase. Proportional increases per decade are shown in Fig.  7 . For girls, the largest increase in obesity prevalence over time was in Botswana, where obesity increased more than seven-fold per decade, followed by Lesotho and Cambodia, where prevalence increased more than six-fold per decade. In contrast, obesity prevalence only increased by about 10% per decade in Singapore and Belgium. For boys, the proportional increases were even greater, reaching a peak in Botswana, where obesity increased more than ten-fold per decade. Again, the increase in Singapore was only approximately 10% per decade.

Proportional increase in obesity for girls and boys aged 5–19 years, between 1975 and 2016. Estimates of obesity for (A) girls and (B) boys were published by the Non-Communicable Diseases Risk Factor Collaboration (NCD-RisC) using the World Health Organization growth reference [ 47 ] (see Table  1 )

Numbers of children and adolescents with obesity

In 1975, there were 5 million girls and 6 million boys aged 5–19 with obesity across the world. The division of these children by country is shown in Fig.  8 . In 1975, the USA had the highest number of obese boys and girls aged 5–19, followed by Italy, Mexico and Germany for girls and China, Italy and Mexico for boys. By 2016, the number of children and adolescents aged 5–19 with obesity had increased to 50 million girls and 75 million boys. As shown in Fig.  9 , China had the most obese boys and girls, followed by the USA and India.

Division of the number of girls and boys aged 5–19 years with obesity in 1975, by country. Estimates of obesity for ( a ) girls and ( b ) boys were published by the Non-Communicable Diseases Risk Factor Collaboration (NCD-RisC) using the World Health Organization growth reference [ 47 ] (see Table  1 )

Division of the number of girls and boys aged 5–19 years with obesity in 2016, by country. Estimates of obesity for ( a ) girls and ( b ) boys were published by the Non-Communicable Diseases Risk Factor Collaboration (NCD-RisC) using the World Health Organization growth reference [ 47 ] (see Table  1 )

Gender comparison

There are clear regional differences in the relationship between obesity level and sex, as shown in Figs.  10 and 11 . In 2016, the prevalence of obesity was higher in girls than boys in most countries in sub-Saharan Africa and Oceania, as well as in some other middle-income countries. In contrast, obesity was more common in boys than girls in all high-income countries, and all countries in East and Southeast Asia. Figure  11 shows the absolute numbers of girls and boys with obesity by country; again, clear regional patterns can be seen. In 2016, there were more girls than boys with obesity in almost all countries in sub-Saharan Africa and in a few other countries, but across the rest of the world, there were more boys than girls with obesity. Substantial differences in the numbers of boys and girls in the general populations of some countries can partly explain this finding. For example, in both China and India in 2016, there were 19 million more 5–19 year-old boys than girls.

Comparison of obesity prevalence in girls and boys aged 5–19 years in 1975 and 2016. Estimates of obesity in ( a ) 1975 and ( b ) 2016 were published by the Non-Communicable Diseases Risk Factor Collaboration (NCD-RisC) using the World Health Organization growth reference [ 47 ] (see Table  1 )

Comparison of the number of girls and boys aged 5–19 years with obesity in 1975 and 2016. Estimates of obesity for ( a ) 1975 and ( b ) 2016 were published by the Non-Communicable Diseases Risk Factor Collaboration (NCD-RisC) using the World Health Organization growth reference [ 47 ] (see Table  1 )

Over the past four decades, obesity in children of all ages has increased worldwide, as it has for adults [ 47 ]. However, obesity appears to have increased more rapidly in 5–19 year olds than in younger children, with an eight-fold increase between 1975 and 2016. This contrasts with an approximate doubling in obesity rates in children aged 2–4 years between 1980 and 2015, albeit using metrics that are not directly comparable. There is heterogeneity in the levels and trends in obesity prevalence between regions and countries, depending on the stage of the global obesity epidemic they are experiencing. In particular, there has been some flattening of trends, especially among those with high socioeconomic status in high-income countries [ 51 ].

The need for high-quality and comparable data is recognised as a key component for monitoring malnutrition [ 3 ]. Data from pooled analyses allow examination of change over time and the use of standardised, comparable metrics allows trends to be benchmarked across countries. Here, we have used data from three different sources, covering different ages and countries. This limits their comparability [ 45 , 46 , 47 ] and, in particular, there is less standardised and comparable country-level information for children under the age of 5 years [ 45 ]. Equally, although national trends are of great interest, it is known that they mask subnational heterogeneity. Collection of disaggregated data at the subnational level and across specific groups of the population is therefore essential to identify groups that are at risk of malnutrition and to ensure progress in meeting global targets [ 3 ].

Despite overall increases in the prevalence of obesity in childhood, different forms of malnutrition coexist at global, national and subnational levels. Increases in obesity are linked to a reduction in the prevalence of children of normal weight, without there necessarily being decreases in the prevalence of children who are underweight. At a global level, the prevalence of underweight among children aged 5–19 years has remained unchanged over the past four decades [ 47 ]. Similar observations have been made in individual countries. For example, in Seychelles, only children in the upper percentiles of body mass index (BMI) have increased in weight, with little or no increase observed among those with median and low BMI [ 52 ]. More studies are needed to describe the shift in distribution of BMI over time in populations, e.g. estimates of the whole distribution to examine whether increases in BMI have occurred in all children or only in subgroups.

It is recognised that the main drivers of the current obesity epidemic are related to changing food systems and reduced physical activity [ 53 , 54 , 55 ], with two key features. Firstly, there is increased availability of generally inexpensive, energy-dense and ultra-processed foods and beverages. The globalisation of food supply means that it is often economically more profitable to produce and market processed, energy-dense foods than fresh ones. Recent results from the Global Burden of Disease study show that consumption of healthy foods is suboptimal, whereas that of unhealthy options exceeds recommended levels [ 46 ]. Secondly, there have been increases in the number of people with sedentary lifestyles, with high levels of physical inactivity among children [ 56 ]. As children transition through childhood and adolescence, susceptibility to the food and physical environments increases. Increasingly, children can choose the foods they eat and how much exercise they do and this has a strong impact on current and future behaviour [ 57 , 58 , 59 , 60 ]. This may, in part, explain the rapid increase in the prevalence of obesity in this group. Further investigation is required to explain the more rapid increase in obesity in boys, including studies of whether they are more susceptible to obesogenic pressures.

The need to improve the food environment requires governments, international organisations and other key stakeholders, including civil society and the private sector at local and global levels, to address global and local commercial determinants of obesity, including production and marketing of unhealthy, energy-dense foods and to improve availability and affordability of unprocessed healthy foods. Equally, healthy diets must be integrated with food systems in a sustainable way, such that long-term health benefits are possible [ 61 ]. A constructive dialogue with the food industry and effective regulations are needed to improve the availability of healthy foods and reduce that of unhealthy options, including prevention of unethical marketing of unhealthy foods aimed at low-income countries and other vulnerable members of the global population. The paradigm of energy imbalance (increased energy intake not balanced by energy consumption) is often used by the food industry to weaken policies aimed at tackling the use of energy-dense foods; i.e., it is argued that adequate levels of physical activity can compensate for this imbalance. Given the scale of the obesity epidemic, this argument must be viewed with scepticism. In the same vein, city and urban planners must rethink their role in society, given that current physical environments substantially restrict mobility patterns. As sedentarism becomes more common and future jobs require less activity, our children will amass a substantial cumulative burden of inactivity that will become difficult to reverse.

The effectiveness of interventions aimed at children who are overweight and obese has been widely studied [ 62 , 63 , 64 , 65 ]. Most interventions have targeted behavioural changes, mainly in terms of nutrition and physical activity. There is evidence that some of these interventions have been effective in schools [ 66 , 67 ]. In particular, promotion of physical activity in school-based settings may be beneficial given adequate resources [ 68 ], as well as being an important component of effective overweight prevention strategies in children [ 66 ]. Efforts to promote active mobility, such as cycling lanes, are being implemented in many cities in high-income countries – and, increasingly in low or middle-income countries, including the cities adhering to the Agita Mundo Network in Latin America [ 69 ]. Recently, declines in the level of obesity among pre-school-age children have been observed in New Zealand [ 70 ], Leeds (UK) [ 71 , 72 ] and Amsterdam (the Netherlands) [ 73 ]. These declines are associated with interventions aimed at supporting families and communities by creating a healthier food environment and supporting families to enforce healthy habits in children with an approach of shared responsibilities among multiple actors. This may have important implications for future trends of obesity in childhood. However, caution in causal interpretation is necessary and more evidence is needed to establish that the implemented interventions are, in fact, responsible for the observed declines in obesity in childhood [ 70 , 71 ]. Equally, data and evidence on the effectiveness of community-based approaches are limited compared to school-based programmes [ 74 , 75 ]. Discussions about the role of community knowledge, attitudes and awareness towards obesity in accepting policy-level solutions continue, but data supporting such evidence are lacking or show unsuccessful examples [ 76 , 77 ].

Despite this work, the effects of traditional behavioural change interventions will be too small to relieve the global burden of obesity in childhood – at least in the short to medium-term [ 53 ]. Community-wide approaches matched with changes in government policies related to food reformulation, advertising and affordability are therefore also required. Policies that can achieve such changes include, among others, excise tax on beverages containing sugar, subsidies or alleviation of trade tax for producing and distributing fruit and vegetables, regulations on food labelling, restrictions on advertising of unhealthy foods and beverages, and incentives or regulations to catalyse reformulation of processed foods toward healthier composition. Other policies include giving vouchers to mothers in the USA with low incomes to purchase fruits and vegetables, low-fat or skimmed milk and whole-grain instead of refined-grain products, among other changes. This has been shown to reduce obesity rates among children aged 2–4 years [ 78 ]. However, high levels of heterogeneity in policy are observed across countries, with low and middle-income countries relying more on such approaches (and implementing them earlier) than high-income countries. For example, Mexico was one of the first countries to implement a sugar-sweetened beverage tax; 2 years after implementation, consumption had decreased by 8.2% [ 79 ]. In 2014, Chile started to implement a series of policies aimed at reducing obesity. Tax on beverages with high sugar content was increased from 13 to 18%, while tax on drinks with low or no sugar content was reduced from 13 to 10%. In 2016, a labelling system using black octagons on packaging was introduced for food and beverages that are high in sugar, calories, sodium and saturated fats. In addition, foods and beverages with such labels have been banned from schools, while marketing of these products to children under the age of 14 years is no longer allowed [ 80 , 81 ]. Initial results suggest a positive impact on knowledge and awareness, reductions in consumption of unhealthy foods and a positive response from the food industry. In turn, the food industry is decreasing the amount of sugar and sodium in some food categories.

The heterogeneity in levels of obesity across the world also has important implications for global targets and goals. It is necessary to aim only for “no increase in obesity by 2025” in those regions and countries in which a clear upward trend in obesity is observed. However, much stronger political action is needed in those regions and countries where the prevalence of obesity has plateaued at high levels, to raise the priority of multi-sectoral interventions to address obesity and other chronic conditions. In general, there is a need to examine how different policy agendas [ 5 , 6 , 82 , 83 , 84 ] can be integrated and strengthened to promote healthy nutrition and regular physical activity, including preventing overweight among children, while also continuing to implement interventions against undernutrition. This will require additional efforts that should not overlook low and middle-income countries simply because some have moderate levels of obesity and high levels of undernutrition.

Tackling the obesity epidemic in children will require integrated efforts across multiple sectors to provide equitable access to economic resources, education, healthy food and urban environments and to universal health coverage. Most importantly, bolder political will and accountability is needed from actors including government, civil society, academia, the private sector and other key stakeholders, to spearhead efforts to promote production of and access to a healthier environment for all.

Availability of data and materials

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Abbreviations

Institute for Health Metrics

International Obesity Taskforce

Non-communicable disease

World Health Organization

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Mariachiara Di Cesare

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Di Cesare, M., Sorić, M., Bovet, P. et al. The epidemiological burden of obesity in childhood: a worldwide epidemic requiring urgent action. BMC Med 17 , 212 (2019). https://doi.org/10.1186/s12916-019-1449-8

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The Childhood Obesity Data Initiative: A Case Study in Implementing Clinical-Community Infrastructure Enhancements to Support Health Services Research and Public Health

Affiliation.

• 1 Obesity Prevention and Control Branch, Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion (Drs King and Goodman and Mss Harrison and Sucosky), and Center for Surveillance Epidemiology and Laboratory Services (Ms Garret), Centers for Disease Control and Prevention, Atlanta, Georgia; Health Technical Center, The MITRE Corporation, McLean, Virginia (Drs Heisey-Grove and Mork and Messrs Gregorowicz, Chudnov, and Jellison); Denver Public Health, Denver, Colorado (Dr Scott); Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado (Dr Daley); University of Colorado Department of Pediatrics and Children's Hospital Colorado, Aurora, Colorado (Dr Haemer); Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts (Dr Block); Louisiana Public Health Institute, New Orleans, Louisiana (Dr Carton); McKing Consulting Corporation, Atlanta, Georgia (Dr Porter); Public Health Informatics Institute, Decatur, Georgia (Dr Kraus); and Duke University School of Medicine, Durham, North Carolina (Dr Armstrong).
• PMID: 34446638
• PMCID: PMC8781217
• DOI: 10.1097/PHH.0000000000001419

Context: We describe a participatory framework that enhanced and implemented innovative changes to an existing distributed health data network (DHDN) infrastructure to support linkage across sectors and systems. Our processes and lessons learned provide a potential framework for other multidisciplinary infrastructure development projects that engage in a participatory decision-making process.

Program: The Childhood Obesity Data Initiative (CODI) provides a potential framework for local and national stakeholders with public health, clinical, health services research, community intervention, and information technology expertise to collaboratively develop a DHDN infrastructure that enhances data capacity for patient-centered outcomes research and public health surveillance. CODI utilizes a participatory approach to guide decision making among clinical and community partners.

Implementation: CODI's multidisciplinary group of public health and clinical scientists and information technology experts collectively defined key components of CODI's infrastructure and selected and enhanced existing tools and data models. We conducted a pilot implementation with 3 health care systems and 2 community partners in the greater Denver Metro Area during 2018-2020.

Evaluation: We developed an evaluation plan based primarily on the Good Evaluation Practice in Health Informatics guideline. An independent third party implemented the evaluation plan for the CODI development phase by conducting interviews to identify lessons learned from the participatory decision-making processes.

Discussion: We demonstrate the feasibility of rapid innovation based upon an iterative and collaborative process and existing infrastructure. Collaborative engagement of stakeholders early and iteratively was critical to ensure a common understanding of the research and project objectives, current state of technological capacity, intended use, and the desired future state of CODI architecture. Integration of community partners' data with clinical data may require the use of a trusted third party's infrastructure. Lessons learned from our process may help others develop or improve similar DHDNs.

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The Measures Registry User Guides include several examples or case studies for each of the four domains. These case studies are listed in the table below. For ease of use, we have grouped the project designs for the case studies into three categories—intervention, epidemiology, and surveillance. However, these types of projects can be characterized in other ways, as well, as detailed in the framework for individual physical activity .

The user guide authors described various approaches in their case studies. For consistency across the four domains, we applied three major steps to these approaches—background, considerations, and measure selection.

Readers will note that the case studies differ in one important aspect. The food environment and physical activity environment user guides mention specific measures that were considered and then selected to meet the needs of the specific projects described in the case studies. In contrast, the case studies for the individual diet and individual physical activity domains describe measures in a more generic way.

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Childhood obesity treatment: case studies

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Family-Based Interventions in the Prevention and Management of Childhood Overweight and Obesity: An International Review of Best Practices, and a Review of current Irish Interventions

The aim of this review is "to identify current family-based practice internationally for the prevention and treatment of childhood overweight and obesity and to examine current Irish Programmes so that best practice recommendations can be drawn up."

Cost-effectiveness of intensive inpatient treatment for severely obese children and adolescents in the Netherlands; a randomized controlled trials (HELIOS)

This paper presents "the design of a randomized controlled trial comparing the cost-effectiveness of two itnensive one-year inpatient treatments to each other and to usual are for severely obese children and adolescents." 

Family-based behavioural treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial

The objective of this randomised controlled trial was "to examine the acceptability and effectiveness of 'family-based behavioural treatment' (FBBT) for childhood obesity in an ethnically and social diverse sample of families in a UK National Health Service (NHS) setting."  

Reducing childhood obesity in Poland by effective policies

The purpose of this report was "to faciliate the development of an action plan and implementation of the strategy dimensions around childhood obesity by providing evidence-based policy options adapted to the national context."  https://www.who.int/europe/publications/i/item/WHO-EURO-2017-2977-42735-59610

The Malaysian Childhood Obesity Treatment Trial (MASCOT)

The primary aim of the study is "to describe a behavioural family-centred, group-based treatment programme for childhood obesity in Malaysia - the MASCOT." 

Process evaluation of an up-scaled community-based child obesity treatment program: NSW Go4Fun®

This paper "describes the up-scaling of Go4Fun in New South Wales and the characteristics of the population it has reached and retained since inception in 2009,including characteristics of children who completed and did not copmlete the programme."  

Randomized Controlled Trial of the MEND Program: A Family-Based Community Intervention for Childhood Obesity

The objective of this study was to evaluate the effectiveness of the Mind, Exercise, Nutrition, Do it (MEND) Programme. 

Assessing the short-term outcomes of a community-based intervention for overweight and obese children: the MEND 5-7 programme

The aim of this study was "to report outcomes from the UK service level delivery of MEND 5-7." 

Effectiveness of a Multi-Component Intervention for Overweight and Obese Children (Nereu Program): A Randomized Controlled Trial

The objective of this study was "to evaluate the effectiveness of the Nereu Program in improving anthropometric parameters, physical activity and sedentary behaviours, and dietary intake." 

Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity: a prospective five-year Swedish nationwide study (AMOS)

The objective of this study was "to report outcomes over 5 years in adolescents follow Roux-en-Y gastric bypass (RYGB) or conservative treatment in a Swedish nationwide prospective non-randomised controlled study, with an additional matched adult comparison group undergoing RYGB."

Mapping the health system response to childhood obesity in the WHO European Region. An overview and country perspectives

This project aimed "to assess the response of health care delivery systems in 19 countries in the WHO European Region to the childhood obesity epidemic." 

An Integrated Clinic-Community Partnership for Child Obesity Treatment: A Randomized Pilot Trial  

This study aims “to describe the implementation of an integrated clinic-community partnership for child obesity treatment and [...] to evaluate the effectiveness of integrated treatment on child BMI and health outcomes” in a lower-income area. Enrolled children were between 5 and 11 years of age, over the 95th percentile for BMI, and referred to clinic by their paediatrician.

Adapting Pediatric Obesity Treatment Delivery for Low-Income Families: A Public–Private Partnership

The aim of this study was to “evaluate the feasibility of delivering a paediatric weight management intervention adapted for low-income families.” 

Challenges and results of a school-based intervention to manage excess weight among school children in Tunisia 2012-2014

This study intended to “demonstrate the feasibility and effectiveness of a school-based weight management program based on healthy lifestyle promotion for obese and overweight adolescents in Sousse, Tunisia.” 

The Effect of a Multidisciplinary Lifestyle Intervention on Obesity Status, Body Composition, Physical Fitness, and Cardiometabolic Risk Markers in Children and Adolescents with Obesity

The aim of this study was to develop a “moderate-intensity multidisciplinary lifestyle intervention program” to treat obesity in the “real world” and evaluate its effectiveness through anthropometric measures. 

The GReat-Child™ Trial: A Quasi-Experimental Intervention on Whole Grains with Healthy Balanced Diet to Manage Childhood Obesity in Kuala Lumpur, Malaysia

Scientists designed the GReat-Child™ trial to determine if increasing whole grain consumption could effectively impact health parameters in Malaysian children. 

Impact of readiness to change behaviour on the effects of a multidisciplinary intervention in obese Brazilian children and adolescents

This study examined how the success of a multifaceted obesity treatment was related to a child’s willingness to alter their lifestyle using Stages of Readiness for Behavior Change (SRBC). 

Sacbe, a Comprehensive Intervention to Decrease Body Mass Index in Children with Adiposity: A Pilot Study

The aim of this study was to “to achieve a higher percentage of success in lowering the BMI z-score in children with adiposity and their parents through a pilot program "Sacbe" based on HLS, sensitive to the sociocultural context previously explored and with the active participation of parents.” 

A Novel Home-Based Intervention for Child and Adolescent Obesity: The Results of the Whānau Pakari Randomized Controlled Trial

The aim of this study was to “report 12‐month outcomes from a multidisciplinary child obesity intervention program, targeting high‐risk groups” in New Zealand. 

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Reducing risk of childhood obesity in the wake of covid-19

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• Alexandra Chung , research fellow 1 2 ,
• Louise Tully , PhD scholar 3 ,
• Sarah Czernin , research assistant 4 ,
• Rachel Thompson , policy adviser 5 ,
• Athar Mansoor , PhD candidate in public policy 6 ,
• Steven L Gortmaker , professor of the practice of health sociology 7
• 1 Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
• 2 Global Obesity Centre (GLOBE), Institute for Health Transformation, Deakin University, Australia
• 3 Obesity Research and Care Group, School of Physiotherapy, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
• 4 Austrian Academic Institute for Clinical Nutrition, Vienna, Austria
• 5 World Obesity Federation, London, UK
• 6 Division of Public Policy, Hong Kong University of Science and Technology, Hong Kong
• 7 Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Boston, MA, USA
• Correspondence to: A Chung alexandra.chung{at}monash.edu

Alexandra Chung and colleagues call for governments to prioritise child obesity as they implement measures to recover from the pandemic

The swift and necessary public health response to the covid-19 pandemic has had detrimental consequences for the prevention and management of childhood obesity, a concern critically in need of public health action. Although children are not as severely affected by covid-19 as adults—experiencing fewer or no symptoms—the public health response to mitigate its spread has exacerbated several risk factors for childhood obesity. Extended lockdowns and social distancing measures have increased children’s exposure to obesogenic environments and disrupted their participation in health promoting behaviours. 1

Childhood obesity affects an estimated 50 million girls and 74 million boys worldwide. 2 These children are at greater risk of developing related functional, metabolic, and psychological conditions; experiencing pervasive weight bias and stigma; and having greater healthcare costs. Childhood obesity is strongly correlated with risk of adult obesity and poor health, with considerable social and economic consequences. 3 4 Despite efforts, no country is on track to meet the targets set out by the World Health Organization’s Commission on Ending Childhood Obesity (ECHO). 5

All children have a right to healthcare, yet the evidence is clear that current obesogenic environments are detrimental to health, violating the UN Convention on the Rights of the Child, to which many countries are signatories. 6 Furthermore, childhood obesity is greater among poorer children, and trends continue to rise among marginalised and deprived populations, and those in low and middle income countries. 2 The impact of covid-19 might exacerbate these inequities, with data from the United States indicating widening racial, ethnic, and neighbourhood socioeconomic differences in childhood obesity rates since its onset. 7

As we look towards recovery from covid-19, we have the chance to build back better, with the opportunity for increased focus on the role of public health and prevention to protect and promote the health of populations. With the public health response to covid-19 exacerbating risk factors for childhood obesity, there is an increased urgency for evidence based action.

We highlight the effect of the public health response to covid-19 on risk factors for childhood obesity and discuss evidence based action across three key areas: providing healthy food and physical activity environments for preschool and school age children; reducing children’s exposure to unhealthy food marketing; and imposing an effective tax on sugar sweetened beverages. These actions are outlined in WHO commission’s recommendations to prevent the development of obesity among infants, children, and adolescents. 5 International evidence suggests that they are effective, equitable, and cost effective in improving diets and thus reducing obesity among children. 8 9 Although much of the evidence to date is drawn from high income countries, these approaches have been identified as double duty actions, simultaneously dealing with the common drivers of overweight, obesity, and undernutrition across countries of all levels of development. 10

Healthy school food and physical activity environments

As part of government efforts to reduce the spread of covid-19, schools and early childhood education and care settings have sometimes been closed for long periods. More than one year into the pandemic, school closures continue for millions of children worldwide. 11 As a consequence, many schools have turned to home learning, with reduced opportunities for physical activity and a reliance on screens for education and communication. 12 13 14 Excess sedentary time and inadequate physical activity are known risk factors for the development of childhood obesity.

School closures have also reduced the availability of nutritious foods. Data from the US indicate that many children rely on food provided by school and nurseries for up to two thirds of daily dietary needs. 15 Without these programmes during school closures or holidays, children miss a vital source of nutrition for healthy growth and development and are at increased risk of food insecurity and health inequities.

Fast food chains have indicated their willingness to replace missed meals during school closures. For example, in the United Kingdom McDonald’s announced it would provide one million free meals during the October school holidays. 16 The provision of school meals by the fast food industry is not a suitable alternative to government policy and might increase children’s consumption of unhealthy food and beverages.

Recognising that covid-19 restrictions differ between countries and have been periodically lifted and reinstated, early childhood and school settings have a dual role: to help children to eat well and be physically active at home; and as children return to campus, provide nutritious food and drinks and physical education curriculums. Box 1 provides a case study of a US school food policy.

Case study—the Healthy, Hunger-Free Kids Act

The Healthy, Hunger-Free Kids Act of 2010 improved nutrition standards for meals and beverages provided through the US National School Lunch, Breakfast, and Smart Snacks Programs, reaching 50 million children across 99 000 schools. This policy, championed by first lady Michelle Obama, improved the nutritional quality of school meals and was associated with substantial reductions in obesity rates among children from low income households. 17 Findings indicate that improved nutrition standards in school meal programmes are likely to equitably improve children’s diet related health.

Marketing of unhealthy foods and non-alcoholic beverages to children

A further consequence of covid-19 restrictions has been an increased reliance on digital platforms for children’s learning and communication. Screen time increases exposure to unhealthy food and beverage marketing. Evidence consistently shows that marketing unhealthy foods and beverages impairs children’s dietary preferences and consumption. 18 Research from many countries has also found that children from minority and socioeconomically disadvantaged backgrounds are disproportionately exposed to such marketing. 19

Despite this, or perhaps because of it, food and beverage industries have seized the opportunity to turn covid-19 into a new marketing strategy, with stay at home messaging and the promotion of home delivery or drive through services prominent features of advertising. 20 Industries also promoted their donations of fast food and confectionery to frontline workers throughout the pandemic. These strategies show opportunism by an industry that that cannot self-regulate effectively and places profits ahead of public health.

Actions by the food and beverage industry pose key challenges to government policies to restrict marketing of unhealthy food and beverages to children. 21 Policy development and its introduction require strong political will. Guidance has been outlined by WHO, including recommendations for regulation that restricts all forms of marketing of unhealthy food and beverages. 22 Box 2 provides examples from the UK.

Case study: London public transport ban on unhealthy food advertising

A ban on unhealthy food advertising across London's public transport network was implemented in February 2019. The advertising policy restricts the promotion of food and non-alcoholic drinks that are high in fat, salt, or sugar on all services operated or regulated by Transport for London, reducing public exposure to marketing of unhealthy food. Factors deemed critical to the successful adoption of this policy include strong political will from the mayor of London; effective government partnerships between the Greater London Authority and Transport for London; support from London boroughs; policy alignment with local government policies on sugar reduction and healthier foods; and integration of the advertising policy within the broader London food strategy. 23

In June 2021, the UK prime minister announced plans for a ban on advertising of food and drinks that are high in fat, salt, or sugar across all forms of digital media and before 9 pm on television. The ban is due to come into effect in 2023. 24

Tax on sugar sweetened beverages

In many regions, covid-19 has changed the way people eat. Parents are reporting changes in their children’s dietary behaviour, including more frequent snacking, the use of food for pleasure and comfort, and increased consumption of unhealthy food and sugary drinks. 14 25 Parents are also reporting enhanced levels of covid-19 related stress, and this has been associated with children’s intake of unhealthy snacks. 26 Meanwhile, household budgets are under pressure from rising unemployment and economic recession. 27 These factors might increase the appeal of low cost, shelf stable, processed food and beverages. For socially and economically vulnerable families, the economic and employment effects of covid-19 will probably be more severe and lasting. 28

A tax on sugar sweetened beverages is an effective public health intervention that can improve health equity. Evidence strongly suggests that reductions in consumption of sugar sweetened beverages will lead to reduced excess weight gain and reduced obesity. 29 Evidence also indicates that a tax on these beverages is an equitable intervention, with health benefits reported to be either similar or greater for those at socioeconomic disadvantage. 30 Real world evaluations have shown that an excise tax on sugar sweetened beverages is effective in reducing both purchase and consumption. 31 A recent meta-analysis of such taxes across the Americas records these effects. 32 Data from the UK show that taxes incentivise industry to reduce sugar content through reformulation. 33 34 Studies indicate that excise taxes on sugar sweetened beverages are cost effective, saving more money in future healthcare expenses than the projected cost of implementation. 8 35 Revenue generated by the tax can also be spent on public health.

As the number of jurisdictions introducing taxes on such beverages grows, evidence of their effect becomes increasingly available ( box 3 ). The dominant challenge is opposition from the beverage industry. To overcome this requires robust design of a tax that is relevant to the local context, underpinned by evidence of local consumption of sugar sweetened beverages and associated health effects; the likely effect of the tax, including across socioeconomic groups; and projected use of revenue. 37

Case studies

Uk soft drinks industry levy.

In the UK, a two tier soft drink levy was announced in March 2016 and introduced in April 2018. The initiative was explicitly designed to incentivise product reformulation, with the levy targeted towards soft drink manufacturers rather than consumers. Drinks with ≥8 g sugar/100 mL (high tier) are taxed at £0.24/L and drinks with ≥5 to <8 g sugar/100 mL (low tier) are taxed at £0.18/L. Drinks with <5 g sugar/100 mL are not taxed.

Evaluations found that the volume of drinks purchased, and sugar content in drinks decreased after implementation of the levy for high and low tier drink categories. Purchase of untaxed drinks, however, increased. For all soft drink categories combined, the overall volume purchased remained unchanged, but the amount of sugar purchased decreased by 30 g per household per week. 33

Mexico excise tax on sugar sweetened beverages

In Mexico, an excise tax of 1 peso per litre on sugar sweetened beverages was introduced in January 2014. During the two years after its introduction, evaluation of household purchases showed an average decline of 7.6% for taxed beverages and a 2.1% increase in purchases of untaxed beverages. Reductions in purchases of taxed beverages were seen for households across all socioeconomic levels but were greatest among lowest socioeconomic households. 36

The tax on sugar sweetened beverages in Mexico is projected to prevent 239 900 instances of obesity, of which almost 40% would be among children. Furthermore, the tax is estimated to save $3.98 (£2.88; €3.37) in healthcare costs for each dollar spent on implementation. Modelling suggests that doubling the tax to 2 pesos per litre would nearly double the health benefits and cost savings. 35

The covid-19 pandemic has shown that governments can act swiftly to protect health and healthcare services. Leaders worldwide have gone to unprecedented lengths in the interest of public health during the covid-19 crisis, restricting societies in ways never witnessed by this generation. As a result, risk factors for the development and progression of childhood obesity have been exacerbated. As societies build back from covid-19, it is time to focus on childhood obesity risk factors amplified by the response, and to leverage growing support for public health action to promote population health. Priorities for action include promoting healthy school food and physical activity environments; reducing children’s exposure to unhealthy food marketing; and imposing taxes on sugar sweetened beverages. These actions are successful, cost effective, can improve health equity, and contribute to a comprehensive approach to prevention of childhood obesity. The covid-19 pandemic presents an opportunity for governments worldwide to prioritise action as we rebuild economies and public health systems to deal with the problem of childhood obesity effectively and equitably.

Key messages

The public health response to covid-19 has exacerbated risk factors for the development and progression of childhood obesity

An opportunity exists to leverage the global attention brought about by covid-19 for public health action to improve population health

Action to reduce childhood obesity must be equitable, evidence based, and government led

Priorities include promotion of healthy school food and physical activity environments, reducing exposure to unhealthy food marketing, and taxation of sugar sweetened beverages

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Contributors and sources: All authors are fellows of the Salzburg Global Seminar Health and Health Care Innovation programme, “Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems,” convened in Salzburg, Austria on 14-19 December 2019. This article stems from discussions that began during our deliberations and interactions in Austria and have continued to evolve in the context of the covid-19 global pandemic. All authors worked together to conceptualise this article. AC and LT drafted the article and all authors contributed to revisions and approved the final version of the manuscript. AC is the guarantor.

Provenance and peer review: Commissioned; externally peer reviewed.

This article is part of a series from the Salzburg Global Seminar on building healthy communities: healthy children, healthy weight. Open access fees were funded by the Robert Wood Johnson Foundation. The BMJ peer reviewed, edited, and made the decision to publish the article with no involvement from the foundation.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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• Research article
• Open access
• Published: 30 November 2020

Impact of a community-based pilot intervention to tackle childhood obesity: a ‘whole-system approach’ case study

• E. W. Gadsby   ORCID: orcid.org/0000-0002-4151-5911 1 ,
• S. Hotham 1 ,
• T. Eida 1 ,
• C. Lawrence 2 &
• R. Merritt 1  

BMC Public Health volume  20 , Article number:  1818 ( 2020 ) Cite this article

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Go-Golborne was a three-year pilot programme to test an innovative, community-based ‘whole system’ approach to preventing overweight in children in Golborne ward, London. Whilst there is a growing interest in local whole systems approaches to obesity, understandings of what they look like in practice are newly emerging. Go-Golborne was designed, implemented and evaluated within this context.

The evaluation used a case-study design and theory of change approach to assess the effectiveness of the intervention. Height/weight measurements of children in the six participating primary schools were recorded annually for 4 years. For behavioural outcomes, children aged six-11 completed four annual on-line surveys (total 4331 responses). Parents were surveyed in year one and year four (177 responses). Three focus group discussions were held with children aged 10–11 ( N  = 21); interviews were conducted with parents ( N  = 11), and school representatives ( N  = 4). Stakeholders were surveyed twice (37 responses), and interviews were conducted with key stakeholders ( N  = 11). An extensive range of programme documents were reviewed and additional process data was collected from the programme team. The RE-AIM framework was used to synthesise findings and examine public health impact.

Go-Golborne reached a diverse range of partners across Golborne. Events were attended by over 3360 local children and families and all six primary schools in the ward actively engaged in activities. The proportion of children in the above healthy weight categories remained stable over time. A number of changes in home, school and neighbourhood environments to support healthy behaviour change were evidenced. There was some qualitative evidence of positive changes in children’s behaviours, though significant or sustained changes were not evidenced by the quantitative data.

Conclusions

Go-Golborne helped stakeholders and parents to develop a shared commitment to improving healthy weight in children, to identify barriers to a healthy lifestyle, and to start to make changes in their services/behaviours. The campaigns and changes made at micro-level appeared to be insufficient, in the face of counteracting forces and personal factors, to achieve significant behaviour change within 3 years. This highlights the need for local initiatives to be reinforced by supporting action at regional, national and global levels.

Peer Review reports

The Go-Golborne intervention was developed by the Royal Borough of Kensington and Chelsea’s (RBKC) public health team to promote healthy lifestyles amongst children and families, as part of a broader programme to tackle childhood obesity. A third of year six children across RBKC are overweight or obese, and prevalence is above the London and national averages in several of the most deprived wards [ 1 , 2 ]. Variations in prevalence are strongly linked to income and socio-economic status; higher rates of obesity tend to be concentrated in areas with high levels of deprivation. The RBKC council chose to pilot a targeted approach to identifying and addressing barriers to a healthy lifestyle at a community level within Golborne ward: an area with a diverse population and relatively high deprivation and obesity prevalence. There were around 900 children living in the ward, and over 1700 children attending six local schools [ 2 ].

There is a great deal of literature on behaviour modification or lifestyle change in the prevention and management of childhood obesity, influenced by several different theories, concepts and accounts of behaviour and behaviour change. Evidence of effectiveness for behavioural interventions has been mixed with small, short term effects on weight loss and Body Mass Index (BMI) [ 3 , 4 ]. However research has highlighted key behaviour change techniques that are most likely to promote positive changes (e.g. provide information on the consequences of behaviour and environmental restructuring) [ 5 ]. Health behaviours are influenced by a range of socio-economic, cultural and environmental conditions, social and community networks and individual factors such as age and sex. Therefore, a combination of interventions that tackle population, community and individual-level factors are needed to help people change their behaviour in the longer term [ 6 ]. Systematic reviews of interventions and clinical guidelines indicate that successful interventions are complex and multi-component - aimed at changing both physical (or sedentary) activity and diet or healthy eating, and comprise multiple, potentially interacting methods of changing behaviour [ 3 , 7 , 8 , 9 , 10 ]. In general, interventions which involve the whole community in complex interventions that target environments and upstream determinants appear to be more effective than those which simply target children [ 9 ].

The increased recognition of the complexity of obesity causation and prevention, and a frustration with the lack of success of efforts over the last few decades, has led to a growing interest in whole systems approaches (WSAs) [ 11 , 12 ]. In theory, WSAs draw on understandings of complexity science and of complex adaptive systems that help to explain particular problematic situations and identify ways in which they might be improved. However, what is meant by a whole system is interpreted in different ways. In practice, they are often described in terms of ‘big picture’ thinking, where efforts are made to link together actions in a coordinated and integrated effort, across multiple sectors, to bring about change [ 13 ]. According to Public Health England, “a local whole systems approach responds to complexity through an ongoing, dynamic and flexible way of working … stakeholders agree actions and decide as a network how to work together in an integrated way to bring about sustainable, long-term systems change” (p.17) [ 12 ]. Whilst community-based and local WSAs to health and wellbeing are not the same thing, they share many common features, such as community engagement, long-term commitment, a focus on relationships and networks and dynamic understandings of causes and effects [ 14 ].

There is a paucity of evidence on the effectiveness of community-wide programmes displaying features of a WSA to prevent obesity. A systematic review of population-based whole-of-community obesity prevention interventions published in 2014 identified eight trials, none of which were undertaken in the UK [ 15 ]. The review suggested that such interventions can be effective in achieving modest reductions in population weight gain among children, but there is a paucity of evidence, particularly for the UK context. Since that review, there have been important additions to the evidence base, particularly from Australia where experiences in implementing community-based childhood obesity prevention projects in different contexts and communities found that the effectiveness of intervention strategies is dependent on individual and community factors. This reinforces the call for a systems approach whereby existing systems are modified [ 16 ]. The language, theory and practice of WSAs – certainly within the public health field - is still young. Understandings of how best to apply systems thinking and what a WSA to obesity looks like in practice are newly emerging [ 12 ] and there is little knowledge yet of what is most likely to work.

Go-Golborne was designed in 2014 and implemented over 3 years (2015–2018). It sought to engage all those with a role in shaping the environments in which children live, learn and play in Golborne. The programme team described it as a WSA in that it combined “‘bottom-up’ community empowerment actions with ‘top-down’ interventions in a single initiative” and aimed to “use and optimize existing systems, build on local assets, connect multiple stakeholders, synchronize ongoing activities across multiple settings and stimulate further actions” (p.110) [ 17 ]. Its methodology and design are detailed in a separate paper [ 17 ], but it was informed by the best practice principles for community-based obesity prevention developed in Australia [ 18 ], the World Health Organisation Good Practice Appraisal Tool [ 19 ] and the EPODE approach to childhood obesity prevention [ 20 ]. The PESTEL framework (distinguishing political, economic, sociocultural, technological and physical and legal environments) was used to explore and describe the influences that hinder or support the adoption of healthy lifestyles in the community. From this, and through stakeholder engagement, a programme plan was developed that included: social marketing campaigns every 6 months, covering specific nutrition and physical activity themes; training and development opportunities for people working with children and families; the distribution and promotion of consistent messages on nutrition and physical activity; environmental improvements, working with council departments, local agencies and other stakeholders such as local retailers; and community development activities, including a grant scheme for each theme, local events and other ad hoc support. The high-level programme theory was that by engaging the whole community and stakeholders within the ward and across the council in a geographically-focused initiative, locally appropriate and co-developed activities would be designed and delivered to raise awareness and understanding of the issues, and encourage and support behaviour change amongst children and their families (see Theory of Change, Fig.  1 ).

Theory of Change Diagram

Researchers at the University of Kent were commissioned to design and conduct a robust research evaluation (from May 2015 to April 2019). This paper provides a summary of the overarching findings. A thorough analysis of the quantitative data, and a more detailed report of the process evaluation findings will be available in separate articles (in progress).

The evaluation was designed to answer questions associated with process, outcomes, and implications for future programmes and policy. It took a theory of change approach [ 21 , 22 , 23 , 24 ], which clarified the programme’s aims, objectives and outcomes and articulated the assumptions underlying the programme’s design (see Logic Model, Fig.  2 ). Data collection, management and analysis was guided by the RE-AIM framework [ 25 ], which focuses on essential programme elements (reach, efficacy, adoption, implementation, and maintenance) that can improve the sustainable adoption and implementation of evidence-based interventions.

Logic Model of Go Golborne Programme

Data was collected and analysed to measure programme reach, assess implementation fidelity, and examine programme context, from: eight steering group meetings; ten stakeholder group meetings; event log forms (completed by the programme team); progress reports; eight newsletters; three in-depth interviews with the programme co-ordinator; and attendance records and other programme documentation.

A non-experimental case study design and mixed methods were used to evaluate a range of indicators, in accordance with the logic model, at baseline, mid-term and follow-up where possible. Data sources included:

Height/weight measurements of all children in six primary schools each year from 2016 to 2019 (collected by the community health trust as an extension to the existing National Child Measurement Programme (NCMP));

Child questionnaires (on-line, self-complete in classroom – see Additional files  1 and 2 ) with children in years two to six in the six schools: January–March each year from 2016 to 2019 (total responses = 4331);

Parent questionnaires (self-complete on paper or on-line – see Additional file  3 ): early 2016 and early 2019 with parents of children in six primary schools (total responses = 177);

Partner questionnaires (self-complete on-line – see Additional file  4 ): mid-2016 and mid-2018, with partner organisations (total responses = 37);

Semi-structured interviews with school representatives: May–June 2018 ( N  = 4);

Semi-structured interviews with key stakeholders (representing various sectors): 2017 ( N  = 8) and 2018 ( N  = 3);

Focus group discussions with purposive sample of year six children: 2018 ( N  = 21, in three focus groups);

Semi-structured interviews with parents: 2018 ( N  = 6); and focus group with mothers at local children’s centre ( N  = 5);

Other documentary information from the programme team.

All interviews were either face-to-face or via telephone. Most were audio-recorded with consent from participants; for two parent interviews, detailed notes were taken. Focus group discussions were audio-recorded, except the one with mothers at a children’s centre, for which detailed notes were taken by a scribe.

A thorough review of all existing validated questionnaires identified none that would meet our objectives and be appropriate for primary school-aged children. For example, when exploring how to capture active play, few of the existing questionnaires dealt with physical activity or exercise that might be considered ‘active play’ (e.g. Physical Activity Questionnaire for Older Children). The Day in the Life Questionnaire (DILQ) [ 26 ] asked what children did yesterday at morning break, lunchtime, and after school, but there was no attempt to measure frequency, intensity or duration. All questionnaires therefore were collaboratively designed by the evaluation and programme teams. Subject experts were consulted, and the survey structure and some specific questions were drawn from our review of existing validated questionnaires. The child questionnaire was designed to measure any significant change, over time, in the population health behaviours of children in Golborne. Questions were in a simple and suitable format (adapting those used in existing questionnaires for young children such as the DILQ), with embedded audio files and clear graphics to aid comprehension. Children in years 5 and 6 were asked 14 additional questions taken directly from the Child Nutrition Questionnaire [ 27 ] to assess attitudes towards eating fruit and vegetables. The questionnaire was pre-tested with seven children aged seven to 11 in order to explore comprehension, retrieval/recall, judgement and response. It was then piloted in a primary school with similar pupil profile ( N  = 91) and subsequently refined by the evaluation and programme teams.

The parent/carer questionnaire collected additional information on children’s behaviours, assessed parent awareness and knowledge around key themes, and assessed parents’ behaviours in relation to supporting healthy eating/activity in their children. The partner questionnaire explored the support partners received from the Go-Golborne team, the extent of partner engagement, how information was being received and used, whether capacity had been strengthened, and whether community partners were doing anything new or different to support children in making positive behaviour changes.

All data sources were analysed separately according to their methodological requirements. Survey data were analysed using statistical analysis (SPSS version 25). Outliers (which varied according to survey question and ranged from 24 to 115 participants) were removed and descriptive statistics computed. For data generated from the Child Nutrition Questionnaire, answers were provided on a five-point scale from 1 ‘strongly agree’ to 5 ‘strongly disagree’, with higher scores indicating a more negative attitude towards fruit and vegetables, and lower scores indicating a more positive attitude. Example questions include: ‘Eating vegetables makes me feel healthy’ and ‘I like the taste of most fruit’. Cronbach’s alpha for subscales on attitudes to fruit and vegetables indicated good reliability (fruit α = .81 veg, α = .94). A Linear Mixed-Effects Model (LMM) analysis was conducted to explore potential differences in mean scores. The standard level of significance ( p  < .05) was used to examine patterns in the data from 2016 to 2019.

Height and weight data for school years one to five were combined with the routine NCMP dataset to add in Reception and year six. For the extended NCMP data, the LMSgrowth tool was used to calculate BMI, BMI Standard Deviation (z-score) and BMI percentile based on sex, date of birth, date of measurement and height and weight values [ 28 ]. Weight classifications were determined using the UK90 BMI reference curves [ 29 ]. For routine NCMP the validated percentiles as provided by Public Health England were used (LMS results in the same BMI groups for these measures). For clinical BMI groups the following centiles were used as cut-offs: underweight: ≤2.3, healthy weight: 2.4 to < 90.9, overweight 90.9 and over, very overweight 97.7 and over. The analysis consisted of a series of pupil counts under different variables, e.g. by BMI classification.

Qualitative data was analysed using thematic analysis of either full audio transcripts or detailed notes, using the theory of change as an analytical framework, to which sub-themes were added inductively [ 30 ]. Two researchers independently coded a sub-set of transcripts until agreement and confidence was reached. One researcher conducted the remaining coding, bringing any arising issues to the research team for discussion and consensus. Analysis templates were populated in Microsoft Word for each data source to identify the key data organised into themes; data within each theme were synthesised into thematic statements. This enabled a close link to the data to be maintained to ensure analysis remained grounded in the data, and to ensure that a range of data sources, contributed to building explanatory models. For the overarching analysis across data sets, prominent and recurring themes from across the data were extracted, matched and cross-compared to develop an explanatory case for the propositions at the heart of the Go-Golborne programme [ 31 ]. Rival explanations were also sought and interrogated.

This section presents a summary of the main evaluation findings in relation to the elements in the RE-AIM framework.

The Go-Golborne events were attended by over 3360 local children and families, with the most popular events attracting more than 1000 participants. Given the estimate of 900 children living in the ward, and over 1700 children attending the six primary schools working with the project, this represents excellent reach into the community. Stakeholders praised the diverse range of partners that reflected the local community and offered greater relevance and reach. The involvement of all six primary schools enabled access to a large number of local children and families. Children and parents also engaged with Go-Golborne at after-school clubs and holiday activities. Parents with pre-school children had less contact with the programme content, though some recognised the logo through posters in the Children’s Centre or park events.

Qualitative data suggested that children’s knowledge about healthy foods improved over the course of the programme, and they now had an improved capability to make small changes in their dietary choices, where supported. Stakeholders had noticed positive changes in knowledge/awareness amongst children, particularly related to certain Go-Golborne campaigns.

“I think it's had a really positive impact on the community; … children are more aware of their healthy eating choices, they are aware of what they should eat and shouldn't eat”. (Statutory partner, interviewed 2017)

“My children… they love all the projects and they came home and kept talking about it and my son was like, 'oh mummy I'm not having a doughnut, because it contains so much sugar!'”. (Parent, interviewed 2017)

Key messages around physical activity do not appear to have been absorbed so readily by the children. There was a greater sense of decisions being outside of the children’s control:

“… sometimes there’s good stuff going on but then if you are busy or like I have younger brothers then you can’t always go” (Child in Focus Group Discussion, 2018).

Parents reported that Go-Golborne had raised awareness of healthy eating and activity in a fun and enjoyable way, and had provided them with greater motivation to further support healthy choices for their children. The follow-up parent questionnaires, however, did not suggest an improvement in knowledge around key health-related recommendations.

Data from partners, parents, teachers and children appeared to suggest that attitudes amongst children and parents were shifting. Quantitative data gathered via the Child Nutrition Questionnaire (CNQ) (for years 5–6, N  = 1692) identified a positive shift in attitudes (i.e. lower value scores on CNQ) towards eating fruit and vegetables across the 4 year period. The relationship between cohort and attitudes towards vegetables showed significant variance in intercepts across participants, var.( u 0 j ) = 2.65, X 2 (9) = 130.18, p  < .01. Results from the LMM suggest that attitudes in 2019 (M = 6.56, SD = 3.70) towards vegetables improved compared to at the start of Go-Golborne in 2016 (M = 15.17, SD = 3.58), F (3,778.77) = 236.14, p  < .01, (CI 95% = 4.89, 5.83).

The relationship between cohort and attitudes towards fruit also showed significant variance in intercepts across participants, var.( u 0 j ) = 3.54, X 2 (9) = 184.12, p  < .01. Results from the LMM suggest that attitudes in 2019 (M = 6.64, SD = 3.08) towards fruit improved compared to levels in 2016 (M = 17.53, SD = 3.08), F (3,721.16) = 1201.94, p  < .01, (CI 95% = 9.95, 10.76).

The child questionnaire did not collect information on attitudes towards physical activity (due to the need to keep the length manageable), but rather focused on measuring changes in behaviour. Qualitative data highlighted that children associated physical activity with having fun and socialising with friends, rather than ‘being healthy’. However, having fun and socialising was also closely linked to the use of electronic devices. Other children, who appeared to enjoy more physical activity, pointed to the barriers to taking part and the lack of opportunities, both in school and out.

Partners reported that their collaboration with Go-Golborne improved their reach into schools or community settings, increased the creativity and relevance of the messages they delivered, and linked the campaign messages to their own frameworks. They reported making many useful new contacts, and benefiting from participating in Go-Golborne events through an increased awareness of local services. Responses to the stakeholder questionnaire highlighted, for example, new collaborations between different organisations and groups. Training provided by the programme enabled local staff members to feel more confident in delivering consistent messages about health and weight when working with families. Most partners felt the programme improved their ability to support healthy lifestyles in the community, e.g. through developing new skills or knowledge around supporting children and families.

A large proportion of parents responding to the 2019 questionnaire reported making positive changes to improve their children’s diet, increase the amount of physical activity, and decrease the amount of screen time their children engaged in. For example: 49% of parents responding to the survey reported making changes to reduce sugar (with cutting down on sweets and/or sugary snacks and having smaller portions of sugary foods/drinks being the most frequently cited examples), 56% to reduce salty/fatty snacks and 60% to increase fruit and vegetable consumption; 46% of parents reported making changes to be more active in travel to/from school; and 50% of parents reported making changes to reduce screen time. Partners and teachers reported seeing some of these changes beginning to happen, although they highlighted that there was still much progress to be made, that some families needed more support than others, and that there was a need to keep the momentum going.

Schools and local community venues/services were starting to make positive changes to support healthier diets and activity. Many different examples of changes were mentioned by organisations, including swapping the snacks and drinks provided for healthier alternatives, promoting healthier vending machines, organising and promoting walks and bike rides, creating and promoting new ways of encouraging active play, and running non-screen sessions during holiday times. Children, parents and partners referred to the changes that they had seen in local shops and venues, with, for example, some noticing a shift towards healthier options being available in shops and greater visibility of fruit and vegetables at street level. Teachers also detailed the continued and additional ways in which they were making healthier choices easier in school by, for example, having easy access to drinking water, offering active after school clubs, and proving fruit/vegetable snacks to key stage two pupils. These positive changes were being noticed by parents, with the majority of those responding to the 2019 survey agreeing that their child’s school actively supports healthy eating and active movement.

In the second stakeholder questionnaire, partners described a higher uptake of local activities – both those facilitated by their own organisation and those in other settings (e.g. local leisure centres), and there were increased referrals to child healthy weight services.

Across the six behaviour change themes, there was little quantitative evidence from the surveys of positive, sustained shifts in children’s behaviours. Most behaviours fluctuated across the four cohorts. The parent questionnaires also confirmed that there was much progress to be made in improving children’s behaviours to meet recommended levels. For example, in 2019, 65% of responding parents thought their child ate fewer than the recommended 5 a day; only 16% of parents said their child took part in vigorous activity on 5 days or more; and 27% of parents reported that their youngest child engages in two or more hours of screen time on a typical school day (60% on a typical weekend day). The behaviour change data is reported in full elsewhere (in progress).

However, qualitative data suggested some positive shifts in behaviours. For example, partners reported that parents no longer brought sweet snacks or drinks to the activity sessions; and local shops and businesses reported fewer children buying sweets where partners had banned unhealthy snacks.

The data collected on children’s heights and weights indicated that the proportion of children in the ‘healthy weight’ category (according to BMI centiles) remained stable, with no statistically significant change over the four-year time period. The proportion of children in the ‘overweight’ and ‘very overweight’ categories also remained stable over time.

The Go-Golborne partnership comprised 110 organisations and businesses, including schools, nurseries, community centres, mosques, market traders and corner shops. A small core of partners (six to nine organisation representatives, including a local councillor) met as the Steering Committee eight times during the programme. A larger stakeholder group, averaging 25 attendees, met ten times during the programme. In total, over 100 stakeholder partners representing at least 62 organisations attended at least once. Organisations included those from the third sector, Council departments, health and leisure partners and others, which brought a diversity of local knowledge, contacts and expertise to the table. Partners were also engaged through training sessions, small grants delivery, use and dissemination of resources, and in the planning and delivery of events. Between six and 25 agencies were involved in each of the community events. Further details of key programme activities and their uptake are provided in Table  1 . This highlights a high level of adoption within the community by a wide range of partners who interact with children and families.

Implementation

The six themed community-wide social marketing campaigns formed the backbone of Go-Golborne’s multi-strategy approach. Around this backbone, implementation was flexible to adapt to changing circumstances and to lessons learned. This adaptability proved to be of crucial importance: first, when due to cut-backs 5 months in, programme staffing was significantly reduced (the full-time communication and engagement officer was cut to minimal communications support), and second, when in June 2017, the Golborne community was rocked by the tragic fire at the neighbouring Grenfell Tower. The event and its aftermath traumatised members of the local community, stretched local services, took a great deal of focus and attention, and damaged relationships, particularly between the community and the Council. The Go-Golborne staff were extremely sensitive to this context. Despite some inevitable implications for programme delivery, all the campaigns largely ran as anticipated. Information was disseminated via 76,000 original health promotion resources; the majority of partners found the information to be highly trustworthy, relevant and useful. The seven community events were widely supported by partners and attended by the local community. The campaigns generated positive messages to which stakeholders and community members responded well. Training was delivered to over 75 local staff/volunteers, with consistently high feedback. Many opportunities were provided for network-building and partnership development. Twenty-six partners received 52 Go-Golborne grants to deliver activities related to the campaigns, and four schools used grants for theme-based activities. Stakeholders reported that Go-Golborne was responsive to local concerns, and aligned itself with existing/similar services and programmes, reducing the potential for overlap or unnecessary additional work, and helping to ensure that involvement was a positive experience.

Maintenance

Relationships forged in the early days of the programme were actively maintained throughout. The staggered delivery of the campaigns helped to ensure that partners could be engaged in each different theme, helping to keep their interest in the programme overall. Existing infrastructures were built on for programme delivery and programme actions were integrated into the practice of partner organisations. The collaborative way in which campaign messages and resources were designed and delivered helped to ensure that they became embedded within the minds of many key change agents (such as those working with children). Partners explained that the programme resources will continue to be used and the knowledge and connections made during the programme will continue to be valuable. The emphasis on simple messages, and realistic, achievable ideas increased the likelihood that elements of the programme would be embedded into routine practice. As these partners commented:

“The culture of our organisation is starting to shift slowly towards understanding and enabling healthier choices” (Local voluntary sector partner, partner survey 2016)

“We’re going to maintain these things; we’re not going to change anything. I took all [the Go Golborne] banners, and we’ve got the Unplug and Play poster out in the playground as a constant reminder and [the programme has] left a legacy because we have all these great things in place. So like with me, I campaign for public health, for children’s health, so it will always be on the top of my agenda when it comes to outcomes for children – it will always stay, it’s fixed” (Go-Golborne Partner, interviewed 2018).

“I think it’s sustainable because it’s not too straining on the schools to keep doing it … I think that it’s a good thing to do” (Teacher, interviewed 2018) .

As shown in Table 1 , many activities, particularly around improving the food environment, prompted partners to implement changes in routine organisational practices and policies.

Go-Golborne was developed as a pilot approach to identifying and addressing barriers to a healthy lifestyle at community level, and a potentially effective way of reducing child obesity. The challenge set by the council was ambitious. It aimed, within 3 years, to engage the whole community and stakeholders within the ward and across the council, to design and deliver locally appropriate and co-developed activities to raise awareness and understanding of the issues, and encourage and support behaviour change amongst children and their families. The scale and complexity of this challenge, and the importance of context in shaping the success of the programme, was acknowledged early on by the programme and evaluation teams.

The design and conduct of the evaluation was fraught with challenges that are now comprehensively discussed in the literature [ 21 , 23 , 32 , 33 , 34 , 35 ]. In particular, these were multiple programme components, action at multiple levels, the importance of context, the flexible and evolving nature of the programme, the breadth and long-term nature of the outcomes being pursued, and the absence of appropriate control groups for comparison purposes [ 36 , 37 ]. The case study design sought to take account of these challenges by taking a theory-of-change approach with mixed methods and a strong process evaluation. It enabled an in-depth empirical investigation of the situation to understand the how and why questions within the evaluation. However, the evaluation was inherently political [ 38 ] and there were expectations to manage about what the evaluation would and wouldn’t be able to ‘prove’. The case study design enabled the integration of qualitative and quantitative data from a variety of sources to give an in-depth analysis of the situation and the context. Whilst qualitative data was inevitably from a small sample, efforts were made to reduce response bias, particularly by using purposive sampling methods and pro-active approaches (e.g. working with community groups to help engage specific participants) to ensure we incorporated perspectives of diverse audiences. The evaluation provided a detailed picture of programme operations and resulted in a rich understanding of how and why programme operations related to outcomes. However, in the measuring of behaviour-related outcomes, the team were obliged for pragmatic reasons to rely on self-reported data, which has obvious limitations in terms of recall and social desirability bias. Moreover, since there were no existing tools that suited our purpose given the need to assess change across six behaviour change themes, the evaluation used bespoke (and therefore unvalidated) questionnaires. Low sample sizes from the parent surveys limited our ability to detect small intervention impacts and generalise the findings to the whole community. Another limitation is sampling bias (participation was voluntary). Behaviour data reported by young children should be treated with particular caution. Evaluation findings should be considered, therefore, with these caveats in mind.

In Golborne, throughout the programme period, data collected via child surveys indicated that children (at a population level) did not make significant changes to their eating and physical activity behaviours. This is perhaps unsurprising given the time-frame, the scale of the programme, the complexity of the issue, and the limitations in the evaluation methodology. Similar findings, demonstrating inconsistent and limited success in changing healthy eating and physical activity-related behaviours, have been found in the evaluation of other comparable interventions [ 16 ]. As with the experience in Australia [ 16 ], aspects of the local context were important in relation to the achievement of behaviour change objectives. In particular, many factors outside of the programme’s sphere of control, such as the relative poverty of many Golborne residents and the Grenfell fire, affected both implementation and context.

Although population behaviours did not appear to change significantly, there was some evidence that a supportive environment was starting to be developed in Golborne’s homes, schools and neighbourhoods. This was created by giving community stakeholders information, skills and motivation to support children in making healthy choices. The programme sought to raise awareness and knowledge of healthy eating and physical activity through social marketing campaigns, at the same time as making micro-environmental changes through informing, engaging and supporting a range of stakeholders. The locally-designed campaigns were developed with strong community involvement and used established social structures of the community. Existing evidence suggests that such approaches are more likely to be implemented and sustained [ 39 , 40 ]. However, evaluation data suggested that the raised awareness and knowledge brought about by the campaigns and the changes made at micro-level were not sufficient to achieve a reduction in child overweight. This is consistent with other literature that highlights the importance of being realistic about the potential of such programmes to alter the outcomes of a system as complex and extensive as that driving the weight status of populations, especially within a three-year period [ 41 , 42 ].

Go-Golborne demonstrated that it is possible to bring stakeholders together to develop a shared commitment to tackling overweight, to recognise the part they can play, and to start to make changes in their services/behaviours. There are strengths in this design that relate to the principles of practice for collective impact, which has proven to be a powerful approach in tackling a wide range of issues in communities all over the world [ 43 ]. The findings demonstrate that capacity to tackle overweight within the Golborne community was strengthened in a number of ways, including knowledge, skills, resources and opportunities. This is significant as existing evidence suggests that a community-wide, capacity-building approach to reducing child obesity is flexible, cost-effective, sustainable, equitable and safe, and has the potential to influence the underlying social and economic determinants of health [ 44 ]. Go-Golborne strengthened and leveraged the interaction of human capital, organisational resources and social capital to help tackle child overweight as a collective problem. Most importantly, it did this in a way that strengthened community identity, built frameworks to facilitate sustainable change, and empowered the community through a strength-based approach and inclusive practice. In the context of the tragic fire at Grenfell Tower, a wide range of issues related to inequity and mental health came to the fore which couldn’t help but affect neighbouring Golborne. In this context, Go-Golborne not only managed to maintain its momentum throughout the period, but also demonstrated the value of its approach in terms of building trust, strengthening networks and reinforcing a community identity.

Go-Golborne aimed to take a ‘whole systems’ approach at a local level, which is consistent with a growing body of evidence and current thinking around how best to tackle obesity. A significant four-year action research project carried out during the same period as Go-Golborne resulted in a ‘whole systems approach to obesity’ guide and resources, published in July 2019 [ 12 ]. Using the guide as a framework of best practice, Go-Golborne could be considered as having done a good job of implementing a ‘whole systems approach’ to obesity, albeit at a very local (ward) level. It secured senior-level support and established the necessary governance and resource structure to implement the approach; it built a compelling narrative and a shared understanding of why obesity matters locally and how it can be addressed; it brought stakeholders together to understand the local system and agree a shared vision; it oversaw a number of collaborative and aligned actions; it maintained momentum by developing a stakeholder network; and it critically reflected on its approach and considered opportunities for strengthening the process. However, the explicit use of systems tools (like causal loop diagrams or group based modelling, for example) did not feature in attempts to map the local system. In addition, as a local community-centred project within a large borough, Go-Golborne placed more emphasis on Golborne-based actors and actions than on change within and driven by the Council. For improved impact, the Council should seek to scale up this systems approach to working across the whole borough – preferably in concert with a similar London-wide and indeed UK government-wide whole systems approach.

Go-Golborne represents an important attempt to implement an evidence-informed, community-based, WSA to childhood obesity prevention in a deprived inner-city ward, within a local government context that is experiencing some of the tightest financial restrictions in recent history [ 45 ].

The findings from the evaluation of the Go-Golborne intervention demonstrate that this kind of approach can establish firm foundations for supporting healthier diet and physical activity related behaviours amongst children, through engaging children and their families, schools, and the wider community. The intervention helped stakeholders and parents to develop a shared commitment to tackling overweight, to identify barriers to a healthy lifestyle, and to start to make changes in their services/behaviours. Key to this engagement was running a positive, fun and locally-tailored campaign with excellent reach into the community, broad adoption by partners, and flexible implementation plans that took account of the local context and adapted to changes and challenges. These foundations were deemed to be crucial for building trust (and therefore for acceptability of the intervention), and for maintaining the programme’s momentum in the longer-term. However, the findings also highlight the complexity of and time taken to significantly alter population behaviours, and consequently weight status. The campaigns and changes made at micro-level appeared to be not sufficient, in the face of counteracting forces and personal factors, to achieve significant behaviour change within 3 years. This highlights first, the need for local initiatives to be reinforced by supporting action at regional, national and global levels, and second, the need for all initiatives to be seen as part of a longer term vision for childhood obesity prevention.

Availability of data and materials

The data that support the findings of this study are available from Royal Borough of Kensington and Chelsea Council (RBKC) Public Health Team, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of RBKC.

Abbreviations

Royal Borough of Kensington and Chelsea

Body Mass Index

Whole Systems Approach

National Child Measurement Programme

The Day In the Life Questionnaire

Linear Mixed-Effects Model

Child Nutrition Questionnaire

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Acknowledgements

We are indebted to all those within the Golborne community who participated so generously in the evaluation. Also to Eva Hrobonova, Ellie Lewis, Connie Junghans and Eszter Vamos who collaborated in the design of the evaluation. Ellie Lewis and Connie Junghans provided helpful comments on an earlier draft. We would also like to thank Professor Harry Rutter who gave valuable advice and support throughout.

The programme and its evaluation was fully funded by the Royal Borough of Kensington and Chelsea Council in London, England. The funder collaborated in the design of the evaluation and approved the data collection tools. The funder also commissioned the collection of the child BMI data and analysed this data separately.

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EG led on the design of the work and on the analysis and interpretation of the data. SH led on the acquisition, analysis and interpretation of the quantitative data. TE led on the acquisition and analysis of the qualitative data. CL led on the analysis and interpretation of the children’s height and weight measurement data. RM contributed substantially to the conception and design of the work. All authors have approved the submitted version and have agreed both to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated, resolved, and the resolution documented in the literature.

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University of Kent Research Ethics Approval was granted prior to the start of the project (SRCEA 150). Head teachers were fully informed and provided written consent to the team to approach staff and parents/carers. Parents and children were fully informed and were given the opportunity to opt-out of survey completion. Children were also given the opportunity to decline to take part on the day the survey was conducted in schools. For qualitative interviews and focus groups, signed consent was obtained from both the head teacher and from parents/carers before approaching participants.

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The child BMI data was collected by the community health trust as part of the National Child Measurement Programme. The funding body (Royal Borough of Kensington and Chelsea Council) took part in the analysis of the child BMI data, and wrote the section pertaining to that data in this manuscript. They also collaborated in the design of the study. However, all other data collection, analysis and interpretation of data were performed by the research team.

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Additional file 1..

The survey distributed to children in years 2 to 4. (PDF 1269 kb)

Additional file 2.

The survey distributed to children in years 5 to 6. (PDF 1282 kb)

Additional file 3.

The survey distributed to parents/carers in 2019. (PDF 872 kb)

Additional file 4.

The survey distributed to Go-Golborne partners in 2018. (PDF 350 kb)

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Gadsby, E.W., Hotham, S., Eida, T. et al. Impact of a community-based pilot intervention to tackle childhood obesity: a ‘whole-system approach’ case study. BMC Public Health 20 , 1818 (2020). https://doi.org/10.1186/s12889-020-09694-2

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• Volume 29 , article number  35 , ( 2024 )

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• Claudio Maffeis   ORCID: orcid.org/0000-0002-3563-4404 1 ,
• Luca Busetto 2 ,
• Malgorzata Wasniewska 3 ,
• Daniele Di Pauli 4 ,
• Carla Maccora   ORCID: orcid.org/0000-0002-3384-6606 5 &
• Andrea Lenzi 6  

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ACTION Teens (NCT05013359) was conducted in 10 countries to identify perceptions, attitudes, behaviors, and barriers to effective obesity care among adolescents living with obesity (ALwO), caregivers of ALwO, and healthcare professionals (HCPs). Here, we report data from participants in Italy.

The ACTION Teens cross-sectional online survey was completed by 649 ALwO (aged 12– < 18 years), 455 caregivers, and 252 HCPs in Italy in 2021.

Most ALwO thought their weight was above normal (69%), worried about weight affecting their future health (87%), and reported making a weight-loss attempt in the past year (60%); fewer caregivers responded similarly regarding their child (46%, 72%, and 33%, respectively). In addition, 49% of caregivers believed their child would lose excess weight with age. ALwO (38%) and caregivers (30%) most often selected wanting to be more fit/in better shape as a weight-loss motivator for ALwO; HCPs most often selected improved social life/popularity (73%). ALwO (25%) and caregivers (22%) most frequently selected lack of hunger control and not liking exercise, respectively, as weight-loss barriers, while HCPs most often agreed that unhealthy eating habits were a barrier (93%). ALwO most often obtained weight-management information from family/friends (25%) and search engines (24%); caregivers most often obtained information from doctors (29%).

In Italy, the impact of obesity on ALwO was underestimated by caregivers, and ALwO and HCPs had different perceptions of key weight-loss motivators and barriers. Additionally, the internet was a key information source for ALwO, which suggests new education/communication strategies are needed.

Level of evidence

IV; Evidence obtained from multiple time series with/without intervention, e.g. case studies.

Trial Registration: ClinicalTrials.gov, NCT05013359.

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Introduction

Childhood obesity has a high prevalence in Italy (21% in boys and 14% in girls [aged 7–9 years]), as in most Southern European countries [ 1 ]. Excess adiposity in youth has several worrisome consequences, including the high persistence of obesity into adulthood (up to 80% of cases) and the association with increased morbidity and mortality in later life [ 2 ]. Youths with obesity can experience impaired health-related quality of life, discrimination, and stigma, which can lead to unhealthy eating behaviors, binge eating, and a reluctance to participate in physical activity, with the risk of worsening their obesity. Additionally, obesity-related stigma can increase vulnerability to depression, anxiety, low self-esteem, body image disturbance, and suicidal ideation [ 3 ].

As such, there is an urgent need for early diagnosis and treatment of obesity in children and adolescents, especially in light of evidence demonstrating that long-term outcomes (including cardiometabolic risk) are better for adolescents living with obesity (ALwO) when they receive early intervention [ 4 , 5 ]. However, parents and caregivers frequently underestimate the overweight status of their children [ 6 ]. This may lead to a delayed obesity diagnosis, which may in turn delay the initiation of treatment of obesity and any complications that are already present.

Healthcare professionals (HCPs) play an important role in the assessment and treatment of obesity in children/adolescents [ 7 ], therefore their involvement is crucial in obesity care. Three factors should be considered for improving HCP activity in this field: (i) their level of familiarity with the guidelines for obesity diagnosis and management; (ii) the potential barriers to effective communication with ALwO and their caregivers; (iii) the potential areas of misalignment between ALwO and their caregivers regarding obesity care and management [ 8 ].

The ACTION Teens study was conducted in 10 countries (including Italy) to assess ALwO, caregivers’, and HCPs’ perceptions, attitudes, and behaviors relating to obesity, plus barriers impeding effective obesity management for ALwO [ 8 ]. Analysis of global data from ACTION Teens confirmed: the need to provide adequate information regarding obesity to ALwO, caregivers, and HCPs; the presence of communication barriers between ALwO, caregivers, and HCPs; and areas of misalignment between ALwO and caregivers regarding obesity care and management [ 8 ]. Here, we report the results from an analysis of ACTION Teens participants in Italy and discuss barriers preventing ALwO from receiving effective obesity care in Italy.

Study design and participants

Methodology for the cross-sectional, survey-based ACTION Teens study (ClinicalTrials.gov; NCT05013359) has been reported previously [ 8 ].

Briefly, KJT Group Inc. (Rochester, NY, USA) collected survey responses from ALwO, caregivers, and HCPs in 10 countries (Australia, Colombia, Italy, Mexico, Saudi Arabia, South Korea, Spain, Taiwan, Turkey, and the United Kingdom) in 2021 [ 8 ]. Participants (plus parents/legal guardians of ALwO) gave informed consent to participate in the study, which was conducted in compliance with the Declaration of Helsinki, EphMRA Code of Conduct [ 9 ], and relevant regulations/laws governing data management.

In Italy, the Ethics Committee for Clinical Trials at Integrated University Hospital Verona (Verona, Italy) approved the study on August 9, 2021, and survey responses were collected from August 26 to December 13, 2021. Eligible ALwO lived in Italy, had a body mass index (BMI; calculated using self-reported weight, height, age, and sex) ≥ 95th percentile for their age and sex according to World Health Organization BMI charts [ 10 ], and were aged 12– < 18 years. Eligible caregivers resided with an ALwO in Italy ≥ 50% of the time, participated in their ALwO’s healthcare-related decisions, and were aged ≥ 25 years. HCPs had ≥ 2 years’ clinical practice experience, were practicing in Italy, spent most of their time (≥ 50%) in direct patient care, and typically saw/treated ≥ 10 ALwO per month. ALwO were excluded if they indicated that they were “extremely muscular” or had a major injury/illness that caused a significant weight change in the previous 6 months; caregivers were excluded if they responded similarly regarding their ALwO.

An external steering committee co-developed and approved separate surveys (with overlapping themes) for each respondent group [ 8 ].

Survey questions used single-/multiple-item selection, numeric entry fields, or Likert scales. As previously described [ 8 ], primary outcome measures included: attitudes and beliefs about obesity and its impact; weight-loss attempts, motivators, and barriers, and how successful weight loss is defined; history/frequency of weight-related conversations, who initiates weight conversations during HCP appointments, and who is responsible for initiating the conversation; interactions between HCPs and ALwO/caregivers, reasons why obesity is not discussed, and frequency of diagnosing obesity and scheduling weight-related follow-up appointments; and sources used to learn about healthy lifestyles/obesity and weight loss/management.

Recruitment and data collection

For Italy, the aim was to collect surveys from 650 ALwO, 650 caregivers, and 250 HCPs. This sample size was chosen to balance recruitment feasibility with statistical power.

Potential participants were identified from online databases/panels and invited to participate via email, where possible; additionally, some potential candidates (identified from databases) were contacted and screened via telephone, with eligible candidates invited to participate via email.

Caregivers were recruited from a general population sample, then asked to consent to their ALwO participating. After maximizing recruitment of “matched caregiver and ALwO pairs,” the sample size was increased by recruiting additional ALwO and caregivers. The general population sample was stratified to reflect local demographic targets gathered from government data (age, sex, region, education, and income).

Each invitation email included a unique link that was only accessible to the recipient (plus the recipient’s ALwO, if the recipient was a caregiver), which prevented unauthorized access to screening questions [ 8 ]. As ALwO and caregivers could access screening questions using the same link, response rates could not be determined for these groups.

To reduce bias, ALwO/caregiver invitation emails and screening questions were designed to conceal the topic of the study until eligibility had been confirmed. Eligible respondents could access the survey, which was provided in Italian. All respondents completed the survey online.

Decipher Survey Software (Forsta) was used to program surveys. Programming ensured that no data were missing (all questions were compulsory) and prevented “multiple participation” from respondents (surveys could not be completed more than once).

Statistical analysis

De-identified data from all respondents with completed surveys (i.e., the full analysis set) were analyzed by KJT Group using Excel (Microsoft 365), SPSS (IBM, version 23.0), and Stata (StataCorp LLC, version IC 14.2). Data weighting was used to limit selection bias and increase the generalizability of results; weights were applied to caregiver data to reflect representative demographic targets for Italy (i.e., age, sex, region, education, and household income). All data were summarized descriptively. For continuous variables, outliers (i.e., data points two standard deviations from the mean) were removed from analyses of relevant variables; where applicable, this reduced the sample size for relevant variables.

Participant characteristics

In Italy, 649 ALwO, 455 caregivers, and 252 HCPs were surveyed (Table  1 ). The response rate among HCPs was 41%; response rates for ALwO and caregivers could not be determined due to the recruitment methods utilized.

Although 42% of HCPs self-reported receiving advanced training in obesity/weight management after medical school, just 17% had > 1 day of advanced training with certification/evaluation. Most HCPs were aware of clinical guidelines for treating obesity in ALwO (64%), and 86% of HCPs in this subset found the guidelines somewhat/very effective.

Impact of obesity

The vast majority of HCPs agreed that obesity is a chronic disease (79%). Additionally, most respondents recognized that obesity has a strong impact on a person’s overall health and well-being and thought obesity was at least as impactful as cancer, heart disease, diabetes, and depression (Fig.  1 ).

Perceived impact of obesity on overall health and well-being. Participants rated how much of an impact they thought different conditions have on a person’s overall health and well-being (1: no impact; 2: slight impact; 3: moderate impact; 4: strong impact; 5: very strong impact) (ALwO/caregiver Q510; HCP Q305). Panel a shows the proportion of participants who indicated obesity has a strong/very strong impact. Panel b shows data comparing each participant’s response about how impactful they believe obesity is in relation to the impact of other health conditions: “Obesity is more impactful” indicates a higher response for obesity than for another health condition; “Obesity is as impactful” indicates an equal response. ALwO adolescents living with obesity, HCP healthcare professional, ADHD attention deficit hyperactivity disorder. Figure adapted from Halford et al. [ 8 ]

Some ALwO and caregivers believed that a person with excess weight would find it harder to make friends (38% and 38%, respectively), do well at school (17% and 19%), and get a job (34% and 36%), relative to a person without excess weight.

Many ALwO reported that their weight often/always makes them unhappy (43%) and their body often/always makes them feel insecure (45%), although fewer caregivers reported that their child had these negative feelings (24% and 30%, respectively).

Perceptions of weight/health

Only 46% of caregivers thought their ALwO’s weight was above normal, compared with 69% of ALwO. While 22% of ALwO felt they had fair/poor health, over half (52%) were at least somewhat worried about their weight, and the majority (87%) worried about weight affecting their future health, although the proportions of caregivers responding similarly for their ALwO were lower (3%, 34%, and 72%, respectively) (Fig.  2 ). Additionally, compared with HCPs, caregivers less frequently reported that their child had diagnosed comorbidities (78% of HCPs’ ALwO patients, on average, vs 33% of caregivers’ ALwO).

ALwO’s weight and health: perceptions and level of worry. Proportion of participants who selected each prespecified answer (ALwO Q106, Q101, Q108, and Q512; caregiver Q106, Q101, Q112, and Q515). Percentages may not sum to 100% due to rounding. ALwO adolescents living with obesity. Figure adapted from Halford et al. [ 8 ]

Weight-loss attitudes

Most HCPs (88%) agreed that 5–10% weight loss would be extremely beneficial for an ALwO’s overall health.

Few HCPs (11%) agreed that their ALwO patients are entirely responsible for weight loss. By comparison, a greater proportion of ALwO (69%) and caregivers (50%) agreed that they/their child were entirely responsible.

Many ALwO (71%) and caregivers (59%) agreed that they/their child could lose weight if they really set their mind to it. However, almost half (49%) of caregivers agreed that their ALwO will naturally “slim down” as they grow older/taller, although few HCPs (17%) agreed.

For ALwO and caregivers, successful weight loss was most frequently defined as the ALwO feeling better about themselves (37% and 35%, respectively); for HCPs it was defined as improved self-esteem (58%).

Weight-loss motivators/barriers

The most frequently reported weight-loss motivator among ALwO and caregivers was the ALwO wanting to be more fit/in better shape; by contrast, HCPs thought that the top motivators were ALwO wanting to have improved social life/popularity and confidence/self-esteem, and to look like their peers (Fig.  3 ). Overall, only 16% of ALwO indicated they had no desire to lose weight, whereas 29% of caregivers thought their child felt this way.

ALwO weight-loss motivators. Proportion of participants who selected each prespecified answer when asked why they/their child has wanted to lose weight (ALwO/caregiver Q208) or what most motivates adolescents to lose weight (HCP Q205). ALwO adolescents living with obesity, HCP healthcare professional. Figure adapted from Halford et al. [ 8 ]

The weight-loss barriers most frequently reported by ALwO were not being able to control hunger, lack of motivation, and enjoyment of unhealthy food. According to caregivers, not liking exercise, enjoying unhealthy food, and not being able to control their hunger were the most common weight-loss barriers for their ALwO (Fig.  4 ). Most HCPs agreed that unhealthy eating habits (93%), lack of exercise (90%), and a preference for unhealthy food (88%) were weight-loss barriers.

ALwO weight-loss barriers according to ALwO and caregivers ( a ) and HCPs ( b ). Proportion of participants who: selected each prespecified answer when asked what is keeping them/their child from losing weight (panel a : ALwO/caregiver Q210); and indicated they “strongly agree” or “somewhat agree” that each prespecified answer is a barrier to weight loss for their ALwO patients (panel b : HCP Q206). ALwO adolescents living with obesity, HCP healthcare professional. Figure adapted from Halford et al. [ 8 ]

Weight-loss attempts

HCPs thought only 41% of their ALwO patients had made a serious weight-loss attempt within the past year, with just 29% of these patients successful. A higher proportion of ALwO than caregivers reported a recent weight-loss attempt by the ALwO and that the ALwO was likely to attempt to lose weight within 6 months (Fig.  5 ).

ALwO weight-loss attempts. Proportion of participants who selected each prespecified answer (panel a : ALwO Q108a and caregiver Q110a; panel b : ALwO Q109 and caregiver Q111). In panel b , the “very likely” category includes the answers “very likely” and “extremely likely”, and the “not very likely” category includes the answers “not very likely” and “not likely at all.” Percentages may not sum to 100% due to rounding. ALwO adolescents living with obesity. Figure adapted from Halford et al. [ 8 ]

Weight-management methods

HCPs believed the most effective weight-management methods were becoming more physically active (86%), improving eating habits (79%), and reducing screen time (69%); these were also the methods that HCPs who discussed weight with ALwO most often recommended (58%, 57%, and 46% of HCPs, respectively).

The weight-management methods most frequently used by ALwO in the previous year were improving eating habits (37%) and being more physically active (30%); caregivers also reported these were their ALwO’s most commonly used methods (43% and 33%, respectively). Only 15% of ALwO said they had started a formal exercise program and only 13% had tried a specific diet/diet program; 6% had used over-the-counter weight-loss medication, 4% had taken prescription weight-loss medication, and 2% had tried weight-loss surgery.

Weight discussions

Although most ALwO felt they could talk honestly with their mother/father about their weight (62%), only 38% could with an HCP. Figure  6 shows barriers preventing weight discussions with HCPs.

ALwO and caregivers’ self-reported barriers to discussing weight with HCPs ( a ), HCPs’ self-reported barriers to discussing weight with ALwO ( b ), and HCPs’ perception of the barriers preventing ALwO from discussing weight with HCPs ( c ). Proportion of participants who selected each prespecified answer when asked: what prevents them from discussing their/their child’s weight with their/their child’s HCP (panel a : ALwO/caregiver Q425); why they might not discuss weight with ALwO patients (panel b : HCP Q413); and why their ALwO patients might not initiate conversations about their weight (panel c : HCP Q412). ALwO adolescents living with obesity, HCP healthcare professional. Figure adapted from Halford et al. [ 8 ]

HCPs generally reported feeling very/somewhat comfortable discussing weight with ALwO (93%). The factors that most frequently influenced whether HCPs initiate weight discussions were the patient’s mental/emotional state (62%), risk of developing new/additional obesity-related comorbidities (58%), BMI-for-age-and-sex (58%), and unhealthy lifestyle (58%).

Most ALwO (61%) and caregivers (73%) reported discussing their/their child’s weight with an HCP in the previous year; similarly, HCPs reported discussing weight with 72% of ALwO patients. Over half of ALwO (56%) and caregivers (55%) who had discussed weight with an HCP in the previous year reported that they started conversations about weight during HCP appointments, although HCPs felt they initiated discussions 55% of the time, on average. Equal proportions of ALwO thought that the responsibility for initiating weight discussions was with the HCP (44%) or themselves (44%); most HCPs (51%) thought this varied depending on the patient, although 23% felt HCPs should be responsible.

Only 36% of ALwO and 11% of caregivers reported that they/their child had received an obesity diagnosis, despite HCPs reporting they inform 86% of their ALwO patients/caregivers about the obesity diagnosis, on average.

Receptiveness to HCP interactions

Among ALwO ( n  = 543) and caregivers ( n  = 367) who reported no conversations about their/their child’s weight with HCPs in the previous year or reported that the HCP was not typically the initiator of weight conversations, most would like the HCP to initiate weight discussions during appointments (ALwO: 80%; caregivers: 86%). Similarly, among ALwO ( n  = 106) and caregivers ( n  = 88) who said the HCP usually started conversations about weight in the previous year, most liked that the HCP had raised the topic (ALwO: 80%; caregivers: 90%).

Among ALwO ( n  = 399) and caregivers ( n  = 330) who discussed the ALwO’s weight with an HCP in the previous year, most trusted the HCP’s weight-management advice (79% and 69%, respectively), agreed the HCP listened carefully when the ALwO talked about weight (78% and 67%), felt comfortable discussing weight with the HCP (72% and 67%), and agreed the HCP understood the difficulties of weight loss (74% and 61%). After their most recent weight conversations with HCPs, ALwO and caregivers had more positive than negative feelings overall, most often feeling motivated, supported, and hopeful (Fig.  7 ).

ALwO and caregivers’ feelings after their latest discussion with an HCP about weight. Proportion of participants who selected each prespecified answer (ALwO/caregiver Q410), among the subgroups of ALwO and caregivers who had discussed their/their child’s weight with an HCP in the prior year (per ALwO/caregiver Q201). The proportion of participants who selected at least one positive feeling (i.e., motivated, supported, hopeful, relieved, and/or surprised) is shown in the net positive category; the proportion of participants who selected at least one negative feeling (i.e., ashamed, confused, blamed, depressed, discouraged, and/or offended) is shown in the net negative category. ALwO adolescents living with obesity, HCP healthcare professional. Figure adapted from Halford et al. [ 8 ]

Information sources

The most important and frequently used sources of information about weight management for ALwO were family and friends (most important for 15%; used by 25%) and search engines (most important for 15%; used by 24%); caregivers’ top response was doctors (most important for 26%; used by 29%). HCPs’ most commonly used information sources were medical education programs (63%) and journal articles (58%).

This analysis of ACTION Teens Italy data provides important insights into the barriers to effective obesity care for adolescents in Italy.

Although most ALwO surveyed in Italy were aware of the negative impact of obesity on health/well-being and correctly perceived their weight was above normal, one-third of ALwO and over half of caregivers were not aware that their/their child’s weight was above normal. This is not surprising, as previous research suggests most parents of children with obesity underestimate their child’s weight status [ 6 ]. This may be due to caregivers having an inaccurate personal reference of “weight normality” for their children [ 11 , 12 ], which could lead to children acquiring the same inaccurate perception. Nevertheless, underestimation of weight status may explain why many ALwO and caregivers had not discussed the ALwO’s weight with an HCP. Additionally, caregivers’ common belief that ALwO will naturally slim down as they grow older/taller [ 13 ] may further contribute to reducing caregivers’ motivation to discuss their child’s weight with an HCP. Taken together, these findings suggest a need to provide information to caregivers about the natural course of obesity and its health implications [ 8 ].

The results of this analysis also indicate that ALwO in Italy are aware of the direct role they play in obesity management: most believed weight loss was entirely their responsibility. However, the discouraging results commonly reported following lifestyle intervention for obesity management [ 14 ] point to a need to implement techniques that engage and motivate ALwO to start and maintain a treatment program. It is therefore notable that ALwO and HCPs appeared to have differing perceptions of weight-loss motivators and barriers. For ALwO, the leading motivator was to be more fit/in better shape, whereas HCPs believed it was improving their social life. Additionally, ALwO identified their inability to control hunger as the leading barrier, but this was not among the top three barriers identified by HCPs (unhealthy eating habits, lack of exercise, and preference for unhealthy food). Of note, disrupted hunger/satiety regulation is a potent driver of body weight gain, and drugs restoring functionality of these disrupted pathways are effective in promoting weight loss [ 15 , 16 ]. Therefore, increasing the ability to control hunger is likely an important treatment target. However, ALwO and HCPs’ differing perceptions of weight-loss motivators/barriers might affect weight-management strategies and reduce the chance of success. Although HCPs believed that lifestyle changes were most effective for weight management, only one in seven ALwO had tried a specific diet/diet program or started a formal exercise program, and very few had tried weight-loss medication/surgery. These findings underscore the need for further training on obesity for HCPs (as reported in recent guidelines [ 17 ]), in order to increase awareness of the biological basis of obesity [ 17 ] and the benefits of multidisciplinary treatment approaches [ 17 , 18 ]. This is especially important given that only one-sixth of the HCPs surveyed had received > 1 day of advanced training in obesity with certification/evaluation.

Where misalignment was identified among ALwO, caregivers, and HCPs in Italy, lack of communication may have been a contributing factor, as many ALwO indicated they could not discuss their weight honestly with their mother/father and most could not do so with their HCP. Despite this, most ALwO would like HCPs to initiate weight discussions during appointments. Interestingly, HCPs indicated that the most important factor they consider when deciding whether to initiate weight discussions with ALwO/their caregivers is the adolescent’s mental/emotional state. Although HCPs’ attention to the psychological well-being of ALwO is important, it warrants further investigation; there is a need to determine the appropriate criteria for HCPs to consider when deciding when they should initiate weight discussions and inform ALwO/caregivers about the obesity diagnosis.

As expected, weight discussions with HCPs induced a mixture of positive and negative feelings in ALwO and caregivers, although many reported that they felt motivated, supported, and hopeful after discussing weight with the HCP. The first ALwO–HCP weight discussion may therefore play a crucial role in prompting ALwO to initiate and maintain a treatment program. This finding should encourage HCPs in Italy to be more actively involved in their patients’ weight management. Nevertheless, HCPs should not overlook the impact of negative feelings, as they could potentially discourage ALwO from discussing weight with HCPs in future. It is therefore crucial for HCPs to acquire the skills needed to motivate ALwO and have discussions about weight management in a caring, supportive, and non-judgmental way [ 19 ].

This analysis also provided further evidence that search engines are frequently used by ALwO to obtain health information [ 20 , 21 ]. Unfortunately, most of the information available online is not scientifically certified and can be misleading [ 21 ]. As such, scientific societies and healthcare authorities should ensure adequate information, communicated in a simple and captivating way, is available on web channels used by adolescents.

Based on our findings, we propose several strategies to overcome difficulties in obesity management in adolescence: (i) increase awareness of the biological basis of obesity among ALwO, caregivers, and HCPs, as well as the general public and the Italian government, as there is a need for obesity to be recognized as a chronic, relapsing, and progressive disease that deserves appropriate management; (ii) increase the level of training provided to HCPs on the clinical management of obesity in children and adolescents based on the latest treatment guidelines, emphasizing the need to diagnose obesity early and initiate appropriate therapy using effective evidence-based treatments; (iii) modify the commonly held but inaccurate belief that obesity treatment is completely the responsibility of the ALwO, for example, by increasing awareness among HCPs that weight conversations with ALwO and caregivers should be initiated early and sensitively.

Strengths and limitations

Strengths of this analysis include the use of data from ALwO, caregivers, and HCPs involved in obesity management/treatment to gain a multistakeholder perspective on adolescent obesity, and the stratified sampling method that was used to recruit ALwO and caregivers who were representative of their counterparts in the wider Italian population.

Limitations of the ACTION Teens study include the cross-sectional design and use of self-reported weight and height to calculate BMI [ 8 ]. Additionally, the HCP response rate may have reduced the representativeness of the HCPs surveyed in Italy, although the response rate in Italy was higher than in the ACTION Teens global analysis [ 8 ].

In conclusion, we identified several potential barriers to effective obesity care for adolescents in Italy. First, the caregivers surveyed appeared to underestimate the weight of their ALwO and assumed their ALwO would naturally slim down with age, while ALwO assumed excessive personal responsibility for weight loss. This highlights a need to provide more information about obesity and its management to ALwO and caregivers. Second, the HCPs surveyed were not aligned with ALwO regarding the top weight-loss motivators and barriers, and many ALwO experienced negative feelings after discussing weight with an HCP. This suggests a need to improve the quality of communication between ALwO and HCPs, for example, by offering advanced training on obesity management to HCPs. Third, the internet appears to be a key information source for ALwO, which underscores the need for new education/communication strategies.

What is already known on this subject?

The prevalence of obesity among children and adolescents is high in Italy; there is an urgent need for early diagnosis and treatment.

An international study conducted in 10 countries demonstrated there is misalignment among ALwO, their caregivers, and the HCPs who treat them regarding obesity care and management.

What this study adds?

This is the first comprehensive description of the perceptions, attitudes, and behaviors of ALwO, caregivers, and HCPs in Italy.

This analysis is also the first to explore how ALwO, caregivers, and HCPs in Italy communicate regarding obesity; the results suggest a need for new strategies to improve the quality of communication.

Finally, this analysis demonstrates there is a need to disseminate information about obesity to ALwO, caregivers, and HCPs in Italy; we recommend utilizing web-based communication channels for adolescents and offering additional training programs to HCPs.

Data availability

Data will be shared with bona fide researchers submitting a research proposal approved by the independent review board. Individual participant data will be shared in data sets in a de-identified and anonymized format. Data will be made available after research completion. Information about data access request proposals can be found at novonordisk-trials.com.

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Maffeis C, Olivieri F, Valerio G et al (2023) The treatment of obesity in children and adolescents: consensus position statement of the Italian society of pediatric endocrinology and diabetology, Italian Society of Pediatrics and Italian Society of Pediatric Surgery. Ital J Pediatr 49:69. https://doi.org/10.1186/s13052-023-01458-z

Ananthakumar T, Jones NR, Hinton L, Aveyard P (2020) Clinical encounters about obesity: systematic review of patients’ perspectives. Clin Obes 10:e12347. https://doi.org/10.1111/cob.12347

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Acknowledgements

We gratefully acknowledge the study participants and personnel involved. We thank Andrea Stoltz, Nick Henderson, Peg Jaynes, Rebecca Hahn, and Lynn Clement of KJT Group for data collection and analysis. Medical writing support was provided by Lauren McNally, MSci, of Apollo, OPEN Health Communications, and funded by Novo Nordisk A/G, in accordance with Good Publication Practice (GPP) guidelines ( www.ismpp.org/gpp-2022 ).

Novo Nordisk A/G funded the ACTION Teens study and the provision of medical writing assistance for this article. Novo Nordisk A/G also paid the article processing charge for this article.

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Department of Surgery, Dentistry, Gynecology and Pediatrics, Section of Pediatric Diabetes and Metabolism, University of Verona, Verona, Italy

Claudio Maffeis

Department of Medicine, University of Padova, Padova, Italy

Luca Busetto

Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy

Malgorzata Wasniewska

Rovereto, Italy

Daniele Di Pauli

Novo Nordisk, Rome, Italy

Carla Maccora

Department of Experimental Medicine, Section of Pathophysiology, Endocrinology and Food Sciences, University of Rome La Sapienza, Rome, Italy

Andrea Lenzi

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Contributions

Claudio Maffeis is a member of the ACTION Teens Steering Committee and thus contributed to the study design. All authors contributed to data interpretation, participated in drafting and revising this article, and approved the final article.

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Correspondence to Claudio Maffeis .

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Ethics approval.

ACTION Teens was conducted in compliance with the Declaration of Helsinki. In Italy, approval was granted by the Ethics Committee for Clinical Trials at Integrated University Hospital Verona (Verona, Italy) on August 9, 2021 (Protocol number: 46600).

Informed consent

Respondents (plus parents/legal guardians of ALwO) gave informed consent to participate.

Competing interests

Claudio Maffeis received consultancy fees from Novo Nordisk for his role as a member of the ACTION Teens Steering Committee during the conduct of the study; he also reports honoraria (for lectures) from Aboca, Eli Lilly, Novo Nordisk, Roche, and Sanofi, and participation in advisory boards for Abbott, Eli Lilly, Medtronic, and Sanofi outside the submitted work. Luca Busetto reports honoraria (for lectures) from PronoKal and Rhythm Pharmaceuticals, and participation in advisory boards for Bruno Farmaceutici, Eli Lilly, Novo Nordisk, and Pfizer outside the submitted work. Malgorzata Wasniewska is a consultant for Merck, Novo Nordisk, Pfizer, and Sandoz. Daniele Di Pauli and Andrea Lenzi have no relevant financial/non-financial interests to disclose. Carla Maccora is a permanent employee of Novo Nordisk.

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Maffeis, C., Busetto, L., Wasniewska, M. et al. Perceptions, attitudes, and behaviors among adolescents living with obesity, caregivers, and healthcare professionals in Italy: the ACTION Teens study. Eat Weight Disord 29 , 35 (2024). https://doi.org/10.1007/s40519-024-01663-7

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DOI : https://doi.org/10.1007/s40519-024-01663-7

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Severe obesity in childhood can halve life expectancy, global modeling study finds

by European Association for the Study of Obesity

New research being presented at the European Congress on Obesity (ECO) in Venice, Italy (12-15 May) has for the first time quantified the impact of different aspects of childhood obesity on long-term health and life expectancy.

The modeling by stradoo GmbH, a life sciences consultancy in Munich, Germany, presented by Dr. Urs Wiedemann, of stradoo, and colleagues at universities and hospitals in the UK, Netherlands, France, Sweden, Spain, U.S. and Germany, found that age of onset, severity and duration of obesity all take their toll on life expectancy .

The development of obesity at a very young age was found to have a particularly profound effect.

For example, a child living with severe obesity (BMI Z-score of 3.5) at the age of four, who doesn't subsequently lose weight, has a life expectancy of 39 years—about half of the average life expectancy.

Dr. Wiedemann says, "While it's widely accepted that childhood obesity increases the risk of cardiovascular disease and related conditions such as type 2 diabetes (T2D), and that it can reduce life expectancy, evidence on the size of the impact is patchy. A better understanding of the precise magnitude of the long-term consequences and the factors that drive them could help inform prevention policies and approaches to treatment, as well as improve health and lengthen life."

To learn more, the researchers created an early-onset obesity model that allowed them to estimate the effect of childhood obesity on cardiovascular disease and related conditions such as type 2 diabetes (TD2), as well as life expectancy.

Four key variables were included: age of obesity onset, obesity duration, irreversible risk accumulation (a measure of irreversible risks of obesity—health effects that remain even after weight loss) and severity of obesity.

Severity of obesity was based on BMI Z-scores. A widely used measure of weight in childhood and adolescence, BMI Z-scores indicate how strongly an individual's BMI deviates from the normal BMI for their age and sex, with higher values representing higher weight.

For example, a 4-year-old boy with an average height of 103 cm and a "normal" weight of about 16.5 kg will have a BMI Z-score of 0. A boy of the same age and height who weighs 19.5 kg will have a BMI Z-score of 2, which is just in the obese range, and one who weighs 22.7 kg will have a BMI Z-score of 3.5, which indicates severe obesity.

Data came from 50 existing clinical studies on obesity and obesity-related comorbidities, such as type 2 diabetes, cardiovascular events and fatty liver. The studies included more than 10 million participants from countries around the world, approximately 2.7 million of whom were aged between 2 and 29 years.

The model shows that earlier onset and more severe obesity increase the likelihood of developing related comorbidities.

For example, an individual with a BMI Z-score of 3.5 (which indicates severe obesity ) at age 4 and who doesn't go on to lose weight has a 27% likelihood of developing T2D by the age of 25 and a 45% chance of developing T2D by the age of 35.

In contrast, an individual with a BMI Z-score of 2 at age 4 will have a 6.5% chance of T2D by the age of 25 and 22% chance by the age of 35.

The early-onset obesity model also shows that a higher BMI Z-score at an early age leads to a lower life expectancy.

For example, a BMI Z-score of 2 at age 4 without subsequent weight reduction decreases average life expectancy from approx. 80 to 65 years. Life expectancy is further reduced to 50 years for a BMI Z-score of 2.5 and 39 years for a BMI Z-score of 3.5.

In contrast, a BMI Z-score of 3.5 at age 12 without subsequent weight reduction yields an average life expectancy of 42 years.

Comparisons with data from studies not included as input for the model and the opinions of leading experts confirmed the model's accuracy.

It was also possible to model the effect of weight loss on life expectancy and long-term health. For example, an individual living with severe early-onset obesity (BMI Z-score of 4 at age 4) who doesn't subsequently lose weight has a life expectancy of 37 years and a 55% risk of developing type 2 diabetes at age of 35. Weight loss that results in a BMI Z-score of 2 (just in the obese range) at age of 6, will increase the life expectancy to 64 and reduce the risk of type 2 diabetes to 29%.

The modeling also shows that earlier weight loss returns more years of life than later weight loss .

Dr. Wiedemann says, "The early-onset obesity model shows that weight reduction has a striking effect on life expectancy and comorbidity risk, especially when weight is lost early in life."

The model's limitations include not taking into account the cause of obesity, genetic risk factors, ethnic or sex differences, as well as not factoring in how different co-morbidities interact with each other.

Dr. Wiedemann concludes, "The impact of childhood obesity on life expectancy is profound. It is clear that childhood obesity should be considered a life-threatening disease. It is vital that treatment isn't put off until the development of type 2 diabetes, high blood pressure or other 'warning signs' but starts early. Early diagnosis should and can improve quality and length of life."

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Young children with persistent severe obesity could have half average life expectancy, study finds

Research finds four-year-old boy who remains severely obese into adulthood has life expectancy of 39

Children who are severely obese could have just half the average life expectancy if they don’t lose weight in adulthood, according to a study.

Research suggests that a severely obese four-year-old boy has a life expectancy of 39, half that of a boy the same age with a healthy weight in the UK.

Life expectancies give the further number of years a person can expect to live on average given the age they have attained.

The modelling, by Stradoo GmbH, a life sciences consultancy in Munich, used data from 50 existing clinical studies – with more than 10 million participants from across the world – on obesity and obesity-related diseases such as type 2 diabetes and cardiovascular issues.

The study measured severe obesity based on BMI Z-scores. These indicate how strongly an individual’s BMI deviates from the norm for their age and sex, with higher values representing higher weight.

The variables the study looked at included the age of obesity onset, duration, severity, and a measure of the irreversible risks.

For example, a four-year-old boy with an average height of 103cm and a healthy weight of about 16.5kg (2st 8lb) will have a BMI Z-score of 0.

By contrast, a boy with the same age and height who is 19.5kg would have a score of 2, while a boy at 22.7kg would be 3.5.

A child with a BMI Z-score of 2 would also see their life expectancy reduce from 80 to 65.

The research found that early onset of severe obesity in childhood increased the likelihood of developing related co-morbidities such as heart disease and type 2 diabetes.

For example, a four-year-old child with severe obesity who doesn’t lose weight had almost a third (27%) chance of developing type 2 diabetes by 25, and a 45% chance by 35.

Dr Urs Wiedemann, who presented the study, said the impact of childhood obesity on life expectancy is “profound” and it should be considered a “life-threatening disease”.

He said: “While it’s widely accepted that childhood obesity increases the risk of cardiovascular disease and related conditions such as type 2 diabetes, and that it can reduce life expectancy, evidence on the size of the impact is patchy.

“A better understanding of the precise magnitude of the long-term consequences and the factors that drive them could help inform prevention policies and approaches to treatment, as well as improve health and lengthen life.”

Wiedemann added: “It is clear that childhood obesity should be considered a life-threatening disease. It is vital that treatment isn’t put off until the development of type 2 diabetes, high blood pressure or other ‘warning signs’ but starts early.

“Early diagnosis should and can improve quality and length of life.”

A quarter of children aged 10 and 11 in England are living with obesity, and worldwide 159 million children are obese.

• Life expectancy

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Racial disparities in childhood obesity on the rise

The new study included data spanning 2011 to 2020 on nearly 1.4 million students in new york city public schools.

Among public school students in New York City, some of the greatest increases in childhood obesity in recent years were among those socioeconomic and demographic groups already bearing the greatest burden of obesity, including Black and Hispanic students and youth living in poverty. That is the conclusion of a new study published this week in the open-access journal PLOS ONE by Emily D'Agostino of Duke University, US, and colleagues.

Childhood obesity is a major public health concern associated with chronic health conditions and adverse mental health outcomes into adulthood. In the new study, researchers analyzed height, weight and socioeconomic and demographic data on 1.37 million unique students in the New York City public school system aged 5 to 15 from school years 2011-2012 through 2019-2020.

Among a study sample representative of over 600,000 youth in the school year 2019-20, 20.9% had obesity and 6.4% had severe obesity. Overall, rates of obesity and severe obesity decreased slightly between 2011-12 and 2019-20 (2.8% relative decrease in obesity and 0.2% in severe obesity, p<0.001), but increases were seen among Black, Hispanic, and foreign-born students (p<0.05). Moreover, nearly all groups experienced increases in obesity and severe obesity between 2016-17 and 2019-20. Some of the largest increases in obesity and severe obesity during these years were among those who already had higher prevalence, such as Black and Hispanic students and youth living in very-poor neighborhoods. Although White students experienced a relative increase in obesity prevalence between 2016-17 and 2019-20, the change was less than half that observed among Black students (2.3% vs. 6.5%, both p<0.01).

The authors conclude that the disparities in childhood obesity are widening, and point toward a need for greater implementation of equity-centered obesity prevention efforts.

The authors add: "Our study found that overall obesity prevalence has continued to decline among NYC public school youth. However, these findings warrant research exploring the role of the COVID-19 pandemic in childhood obesity in NYC to better evaluate and address disparities."

• Diet and Weight Loss
• Chronic Illness
• Staying Healthy
• Educational Policy
• Public Health
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• Poverty and Learning
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Story Source:

Materials provided by PLOS . Note: Content may be edited for style and length.

Journal Reference :

• Kira L. Argenio, Sophia E. Day, Emily M. D’Agostino, Cody Neshteruk, Brooke E. Wagner, Kevin J. Konty. Increasing disparities in obesity and severe obesity prevalence among public elementary and middle school students in New York City, school years 2011–12 through 2019–20 . PLOS ONE , 2024; 19 (5): e0302099 DOI: 10.1371/journal.pone.0302099

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Strange & offbeat.

Severe obesity in young children could cut life expectancy by half, researchers warn

A new study suggests being very obese as a young child could cut life expectancy by about half. Losing weight however, could add years back on.

Tuesday 14 May 2024 23:00, UK

Severely obese young children could cut their life expectancy by around half, according to a new study, but losing weight could add years back on.

Analysis led by Germany-based life sciences consultancy stradoo used data from 50 existing studies to establish the impact of childhood obesity on life expectancy and type 2 diabetes.

Researchers used a body mass index (BMI) z score, which measures how much a youngster's weight deviates from their normal range, to estimate obesity - the higher the score, the more a child weighs.

The research found children who were severely obese by age four, with a BMI z score of 3.5, had a life expectancy of 39 if they didn't lose weight.

Those with a score of 2.0 had a life expectancy of 65 without weight loss, while children with a score of 2.5 had one of 50 years.

According to the Office for National Statistics, the latest figures suggest life expectancy for men in the UK is 78.6 and 82.6 for women.

"The impact of childhood obesity on life expectancy is profound," stradoo's Dr Urs Wiedemann said, adding it should be considered a "life-threatening disease".

"It is vital that treatment isn't put off until the development of type 2 diabetes, high blood pressure or other warning signs but starts early. Early diagnosis should and can improve quality and length of life."

The team found severely obese four-year-olds were also 27% more likely to develop type 2 diabetes by the age of 25 and had a 45% chance of developing the condition by 35.

Children with BMI z scores of two at age four, however, had a 6.5% chance of developing type 2 diabetes by 25 and a 22% chance by 35.

Keep up with all the latest news from the UK and around the world by following Sky News

But weight loss can reverse the chances, with a child cutting their score from 4.0 to 2.0 gaining a life expectancy of 64, rather than 37 - while the risk of diabetes falls from 55% to 29%.

While it's "widely accepted" childhood obesity increases the risk of certain conditions and can cut life expectancy, Dr Wiedemann said evidence on the scale of the impact is "patchy".

Read more: Obesity drug 'cuts risk of heart attack regardless of weight lost' Study finds obese people more likely to take more sick days

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"A better understanding of the precise magnitude of the long-term consequences and the factors that drive them could help inform prevention policies and approaches to treatment, as well as improve health and lengthen life," he added.

The study has been presented at the European Congress on Obesity in Venice.

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StarsInsider

Childhood obesity: what are the causes and how you can fight it

Posted: December 20, 2023 | Last updated: December 20, 2023

Childhood obesity rates are rising and global figures don't make for easy reading. The World Health Organization (WHO) estimates that over 124 million children and teenagers around the world are obese, resulting in a host of health concerns for the next generation. 

Click on to learn about the causes of childhood obesity and get some tips to combat it. 

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Methodology

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Most effected

The study showed that white American and Asian-American children had significantly lower obesity rates than other groups, such as African Americans and Hispanic Americans.

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Other factors

The CDC (Centers for Disease Control and Prevention) added that use of medication and sleep patterns should be taken into account.

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Immediate risks

Childhood obesity can effect the body in many ways. The CDC warns that overweight children are more vulnerable to high blood pressure and high cholesterol, which can lead to cardiovascular disease.

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The CDC also warns that obese kids may display breathing problems like asthma or sleep apnea.

Kids can develop problems later on such as muscular discomfort as well as liver problems, gallstones, and heartburn.

The CDC also notes the psychological side. Overweight children are more vulnerable to anxiety and depression.

They are also more vulnerable to low self-esteem as well as bullying and other problems.

You may also like: Amber Tamblyn, David Cross share how couples therapy helped both on- and off-screen

Future risks

Adulthood obesity is linked to numerous serious illnesses, such as heart disease, type 2 diabetes and cancer, according to the CDC.

Sources: (WHO) (PBS)

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Study Shows Alarming Rise in Heart Failure Deaths, Especially Among Younger Adults

After decades of decline, heart failure mortality is climbing, with a dramatic rise in heart failure deaths among younger adults. 

The number of people dying from heart failure in the United States went down steadily from 1999 to 2009. However, progress made in treating heart failure began unraveling from 2009 to 2012 when heart failure-related mortality rates plateaued, according to a study led by Duke University School of Medicine.  

From 2012 onwards, heart failure mortality rates have been increasing. 

Marat Fudim, MD, an associate professor in the Duke Department of Medicine and lead author of the study published April 24 in JAMA Cardiology , points to widespread obesity and rising rates of diabetes and hypertension putting more people at risk for heart failure. Yet, the high cost of new heart medicines and difficulty accessing health care may be hindering effective heart failure treatment.  

“The gains made from 1999 to 2012 have been entirely undone by reversals from 2012 to 2021, meaning that contemporary heart failure mortality rates are higher than in 1999,” said Fudim, who treats patients with heart failure at Duke Health .

A surge in heart failure deaths in 2020 and 2021 masks a longer-term trend as “the origins of the reversals preceded the COVID-19 pandemic,” Fudim said. “Disruptions in health care caused by COVID-19 added fuel to a smoldering fire and heart failure mortality rates accelerated dramatically.”  

Researchers developed the cohort analysis from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiological Research .

The CDC data is based on information from death certificates and study authors acknowledge that relying on death records has limitations. Death certificates might not always accurately identify the cause of death, especially when symptoms of heart failure are similar to those of other conditions like COVID-19. 

Still, the government data revealed reversals in the decline of heart failure mortality as improving trends started to worsen. 

In 2012, the heart failure-related mortality rate of about 82 deaths per 100,000 people started going up, reaching 106 per 100,000 by 2021. This spike hasn’t been seen since 1999 when the heart failure-related mortality rate stood at 105 per 100,000 people. 

Reversals affected various groups differently. According to the study’s results, the greatest increases in mortality were seen in adults under age 45 (906.3%), adults aged 45-64 (384.7%), men (119%), African-Americans (166%), and rural residents (92%). Parts of the U.S. with the largest jumps in heart failure were the South (118%) and Midwest (115%).

Although heart failure is typically linked to old age and damage to the heart over time, the study suggests young adults are encountering heart failure.  

It’s a trend that Fudim and other experts in cardiovascular medicine believe could be connected to the repercussions of childhood obesity catching up to millennials and Gen Z.

Combating Heart Disease 

While there's no cure for heart failure, medications can ease common symptoms of fatigue, shortness of breath, and swelling.

To help the heart pump more efficiently, doctors may prescribe patients a combination of medicines from four main classes of drugs that include beta blockers and sodium-glucose cotransporter-2 inhibitors . However, patients may struggle to access newer therapies due to substantial co-pays or inadequate prescriptions from physicians .

For severe cases of heart failure, heart valve surgery or implantable cardioverter defibrillators might be necessary. 

Addressing the resurgence in heart failure deaths doesn’t solely depend on treatment, Fudim said.

Curbing heart failure mortality includes educating the public about heart disease prevention, diagnosing heart failure earlier, and offering remote care to the millions of rural Americans who live hours away from a hospital or heart doctor.  

“By focusing on these areas, we could enable better management to help people live longer and with a better quality of life,” Fudim said. 

Additional authors include Ahmed Sayed, MBBS; Dimitry Abramov, MD; Gregg C. Fonarow, MD; Mamas A. Mamas, MD, PhD; Ofer Kobo, MD; and Javed Butler, MD, MPH.  

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Psychosocial Factors and Obesity in Adolescence: A Case-Control Study

Elisabeth k. andrie.

1 MSc Program “Strategies of Developmental and Adolescent Health”, Second Department of Pediatrics, P. & A. Kyriakou Children’s Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece; [email protected] (A.R.); rg.oohay@sinatnegrest (T.N.S.); rg.htlaeh-htuoy@ofni (A.T.)

Marina Melissourgou

2 Department of Endocrinology & Metabolism—Diabetology Center, Korgialenio Benakio—Hellenic Red Cross General Hospital of Athens, 11526 Athens, Greece; rg.oohay@4002aniramlem

Alexandros Gryparis

3 Department of Diabetes Mellitus and Metabolism, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, 11528 Athens, Greece; [email protected]

Elpis Vlachopapadopoulou

4 Department of Endocrinology, Growth and Development, P. & A. Kyriakou Children’s Hospital, 11527 Athens, Greece; [email protected] (E.V.); moc.liamg@sokalahcimts (S.M.)

Stephanos Michalacos

Anais renouf, theodoros n. sergentanis.

5 Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, School of Medicine, 11528 Athens, Greece

Flora Bacopoulou

6 Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece; moc.liamtoh@fuopocab

Kyriaki Karavanaki

7 Diabetes and Metabolism Clinic, Second Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, P. & A. Kyriakou Children’s Hospital, 11527 Athens, Greece; rg.oohay@varakk

Maria Tsolia

8 Second Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, P. & A. Kyriakou Children’s Hospital, 1527 Athens, Greece; rg.aou.dem@ailostam

Artemis Tsitsika

Associated data.

The data presented in this study are available on request from the corresponding author.

Introduction: The continuously increasing prevalence of childhood obesity is reaching epidemic proportions. Greece is among the countries with the highest childhood obesity prevalence rates. The present study aims to identify psychosocial factors associated with excess body weight of adolescents. Methods: This case-control study was conducted in Athens, Greece, and included 414 adolescents aged 11–18 years. Anthropometric measurements were recorded, and an anonymous self-completed questionnaire captured the psychosocial background, family environment, peer relations, and school environment. Results: Of the total sample of adolescents, 54.6% had normal body weight and 45.4% were overweight or obese. A multivariate logistic regression analysis showed that the factors related to the presence of overweight/obesity were adolescents’ age (OR = 0.416, p < 0.001), area of residence, presence of anxiety (OR = 4.661, p = 0.001), presence of melancholia (OR = 2.723, p = 0.016), participation in sports (OR = 0.088, p <0.001), smoking (OR = 0.185, p = 0.005), and mother’s occupation (OR = 0.065, p < 0.001). Conclusion: Psychological problems, maternal occupation, the absence of physical activity, and poor school performance were associated with adolescent overweight/obesity. It is important that screening for the presence of psychosocial issues is included in childhood obesity policies and treatment.

1. Introduction

Childhood and adolescent obesity is considered to be a major public health problem of the 21st century that has reached epidemic proportions [ 1 ]. During the last decade, its prevalence has increased, as the number of overweight and obese children has risen dramatically from 4% in 1975 to 18% in 2016 [ 2 ]. In 2016, approximately 340 million children and adolescents aged between five and 19 years old worldwide were diagnosed with overweight or obesity [ 2 ]. Boys tend to be overweight or obese more frequently than girls; among children and adolescents aged between five and 17 years, 22.9% of boys and 21.4% of girls were overweight or obese in the countries of the Organization for Economic Cooperation and Development (OECD) [ 3 ]. Greece, Italy, and Spain are among the countries with the highest childhood obesity rates in Europe [ 4 ]. Previous research documents the prevalence of overweight and obesity in Greek children, varying between 30–40% [ 5 ]. Other studies report rates of 37% for girls and 45% for boys for overweight or obesity in Greece [ 3 ].

The etiology of obesity is multifactorial. Genetic and environmental factors include certain infections, lifestyle, and eating behaviors. [ 2 , 6 , 7 ]. Psychosocial issues may also contribute to the development of obesity. During emotional or physical stress, the hypothalamic–pituitary–adrenal (HPA) axis is activated, while dopamine may also be involved [ 8 ]. Stress is associated with a change in eating behaviors; approximately 40% of people increase their food intake in time of stress. During stress periods, highly palatable foods, which are usually rich in sugar and fat, are consumed regardless of the presence of hunger [ 9 ].

Children may develop psychological stress due to physical, emotional, or sexual abuse as well as emotional or physical negligence [ 10 ]. Besides dysfunction within the family, lack of friends, bullying, and the perception of non-integration in the neighborhood can also lead to stress, depression, and low self-esteem [ 11 ]. Bullying is a type of aggression that can take place in any human relationship. Examples of adolescents who may be targeted are those who seem to be different from their peers because of their race, clothing, or weight status, but also because of their anxiety, low self-esteem, or disabilities. Furthermore, discrepancies in regard to social level and parental income may trigger bullying among peers [ 12 ]. Adolescents who are victims of bullying are at high risk for adverse mental health outcomes, such as low self-esteem [ 13 ], depression, anxiety, and suicide [ 14 ]. Psychological trauma during childhood is one of the most significant predictors for the development of obesity [ 15 , 16 ].

Although previous research documents the fact that childhood obesity is associated with psychosocial problems [ 17 ], to our knowledge there are no published data addressing the association between psychosocial factors and overweight/obesity in Greek adolescents. The aim of the present study was to identify differences in the psychosocial background between adolescents with normal weight and adolescents with overweight/obesity, as well as associations of psychosocial issues with excess body weight, among adolescents visiting a tertiary children’s hospital, in Athens, Greece.

2. Participants and Methods

This case-control study drew data from adolescents aged 11–18 years who attended the tertiary “P. & A. Kyriakou” Children’s Hospital in Athens, Greece, in 2017 and 2018. The group of cases was recruited from the Adolescent Health Unit (A.H.U.) of the Second Department of Paediatrics of the “P. & A. Kyriakou” Children’s Hospital and consisted of overweight or obese adolescents who approached the Unit for that issue as new clients. The control group of adolescents with normal weight was recruited from outpatient services of the same hospital. They were attending for mild conditions such as mild respiratory conditions, gastrointestinal or genitourinary conditions, and various manifestations of allergy that are not related to obesity. Adolescents with severe underlying medical conditions, underweight or overweight adolescents, and those receiving chronic medication were excluded from the control group. The recruitment of normal-weight adolescents who attended the A.H.U. over the study period was avoided, as the majority of them had underlying psychological issues and chronic medical conditions that had affected their body weight.

Signed informed consent was obtained from the participating adolescents and their parents or legal guardians. The study was approved by the “P & A Kyriakou” Children’s Hospital Ethics Committee.

2.1. Data Collection Procedure

Findings from the clinical examination and anthropometric measurements of participants were recorded. Height was measured using a SECA 217 stadiometer, weight was measured with a Tanita Total Body Composition Analyzer TBF-410GS, and the body mass index (BMI) was calculated. Participants’ BMI classification was carried out in accordance with the International Obesity Task Force cut-off points for age and gender [ 18 ]. All anthropometric measurements were carried out by pediatricians.

All participants completed the Achenbach Youth Self-Report questionnaire for children and teenagers (11 to 18 years) to assess their psychological profiles. The Youth Self-Report (YSR) is an instrument measuring psychosocial wellbeing as well as adolescents’ competence and problems in social, academic, cognitive, internalizing, and externalizing behaviors [ 17 ]. It has been standardized for use in Greece [ 19 ].

Participants’ school performance was classified as follows:

• Below the base: < 10 (for middle school and high school) or <5 (for primary school).
• Below average: 10–14.5 (for middle school and high school) or 5–6 (for primary school).
• Average: 14.5–16 (for middle school and high school) or 7–8 (for primary school).
• Above average: 16–20 (for middle school and high school) or 9–10 (for primary school).

All measurements were recorded, and instruments were administered upon entry to the study by staff who had received appropriate training.

2.2. Statistical Analysis

Variables that are normally distributed are presented as mean ± SD. Categorical variables are presented as absolute and relative frequencies (%). In order to investigate whether two categorical variables were related, Pearson’s chi-square test was used. The Mann–Whitney U test was also used to compare the medians of two independent samples. To investigate possible confounding by sex, the same analysis was performed stratified by gender.

Multivariate logistic regression analysis was then performed to confirm which parameters were significantly associated with the presence of overweight or obesity. Results with a two-sided p -value < 0.05 were considered statistically significant, whereas results with a two-sided p -value between 0.05 and 0.10 were considered as suggestive. All statistical analyses were performed using IBM SPSS v.23 (IBM Corp. Released2015. IBM SPSS Statistics for Windows, Version 23.0, IBM Corp., Armonk, NY, USA) software.

Initially, 573 adolescents were recruited, but 159 were subsequently excluded from the analysis due to incomplete data.

Thus, a total of 414 adolescents with mean age (±SD) of 15.09 ± 1.81 years participated in this study. Among them, 233 (56.3%) were girls and 181 (43.7%) were boys. The mean weight (± SD) of the participants was 68.63 ± 16.57 kg, the mean height (±SD) was 1.67 ± 0.08 m, and the mean BMI (± SD) was 24.54 ± 5.56 kg/m 2 . In terms of their BMI, 54.6% had a normal BMI, 20.3% were in the overweight range, and 25.1% were in the obese range.

The demographic data of the participants, according to BMI categories, are shown in Table 1 . In the overweight–obese group, boys made up only one third of the overweight but about half of the obese ( p = 0.008). The average age (± SD) differed significantly ( p -value < 0.001) between participants with normal weight (15.8 ± 1.3) and adolescents with overweight or obesity (14.3 ± 2.0). Regarding maternal occupation, household status was reported for the majority (30.7%) of normal weight participants and “public sector employee” for the majority (28.6%) of participants with overweight or obesity ( p = 0.009). Most of the participants (96.1%) lived in the Attica Region, and only 3.9% lived in other areas of Greece; 38.9% of normal weight participants were living in the western suburbs, while 35% of the overweight/obese adolescents lived in the center of Athens ( p -value < 0.001). The vast majority of adolescents were Greek (92.8%), while 29 (7.2%) had other nationalities, mostly Albanian. Regarding parental marital status, 82.4% of the participants with normal weight had married parents, while adolescents with overweight or obesity exhibited lower rates ( p = 0.007).

Participants’ demographic data by weight status (normal weight, overweight/obese, overweight and obese separately).

* Statistical analysis was performed with the Chi-Square test.

Table 2 presents the psychosocial factors, in relation to BMI categories. Among study participants, 245 (66.6%) suffered from anxiety, which was more pronounced in the overweight/obese group ( p < 0.001). Furthermore, 118 (32.6%) of the participants had melancholic depression (with overweight/obese adolescents exhibiting higher rates, p = 0.003), and 35 (9.6%) had suicidal behaviors. Additionally, 66 (18%) reported low self-esteem, with normal weight adolescents exhibiting higher rates ( p < 0.001). Concerning bullying, 91 (25.3%) adolescents reported that they had been victims of bullying at least once in their life.

Participants’ psychosocial factors by weight status (normal weight, overweight/obese, overweight and obese separately).

The peer relations of the participants were also examined ( Table 3 ). Among study participants, 170 (45.7%) had already been in a romantic relationship and 89 (24.9%) had complete sexual activity; significantly more adolescents with normal weight than those with overweight/obesity ( p < 0.001). Additionally, 294 (77.6%) participants were participating in at least one sport activity, significantly more adolescents with normal weight (89.9%) than those with overweight/obesity (61.1%, p -value < 0.001). Concerning school performance ( Table 4 ), most adolescents (281, 99.6%) were going to school, and only one (0.4%) did not attend school. There was a statistically significant difference in school performance between normal and overweight/obese adolescents ( p < 0.001); although most of the participants were above average, more normal-weight participants had average grade (37.2%), while most participants with overweight or obesity (27.6%) were below average. Moreover, normal-weight participants reported more unjustified absences (49%) compared to adolescents with overweight or obesity (24.1%, p < 0.001).

Participants’ activities by weight status (normal weight, overweight/obese, overweight and obese separately).

Participants’ school performance by weight status (normal weight, overweight/obese, overweight and obese separately).

When stratified by sex, similar results were found between normal weight and adolescents with overweight or obesity for both girls and boys. Nevertheless, in terms of parental marital status, a statistically significant difference was observed between normal weight and boys with overweight or obesity ( p = 0.006), which was not found in girls ( p -value = 0.103). Additionally, maternal occupation differed significantly between the two BMI groups in girls ( p = 0.045), with the majority (39.0%) of normal weight participants’ mothers being housewives and the majority of overweight/obese participants’ mothers being employees in the public or private sectors (30.2%). No significant differences in maternal occupation were found in boys according to their BMI ( p = 0.187). Finally, in terms of school performance, statistically significantly more unjustified absences were reported by normal-weight girls vs. girls with overweight or obesity (42.5% vs 12.5% respectively, p = 0.002). No significant differences in unjustified absences in boys according to their BMI were observed.

A multivariate logistic regression analysis ( Table 5 ) showed that the factors statistically related to the presence of overweight/obesity were younger age (OR = 0.416, p < 0.001), area of residence, presence of anxiety (OR = 4.661, p = 0.001) or melancholic depression (OR = 2.723, p = 0.016), sport’s activities (OR = 0.088, p < 0.001), smoking (OR = 0.185, p = 0.005), and maternal occupation (OR = 0.065, p < 0.001). Other parameters that were included in the model but were not related significantly to the presence of obesity were parental occupation, ethnicity, bullying, number of siblings, and romantic or sexual relationships.

Multivariate logistic regression results.

a Reference levels; Sex: Girls; Parental marital status: Divorced/Death of a parent; Residency area: Center of Athens/North suburbs/South suburbs/East suburbs; Siblings: No; Sports: No; Smoking: No; Hobbies: No; Maternal occupation: Unemployed.

4. Discussion

The prevalence of childhood overweight and obesity is increasing rapidly worldwide and is recognized as a leading threat to public health. The present study examined the psychosocial correlates of obesity in adolescents in Greece. Statistically significant differences between overweight/obese cases and controls were observed in terms of sex, maternal employment, parental marital status, anxiety, melancholic depression, low self-esteem, romantic and sexual relationships, sports, school performance, and school absenteeism.

In the present study, maternal employment was significantly associated with adolescents’ obesity. Thus, in the normal weight group, most mothers were unemployed, while in the overweight/obese group most of them were public sector employees. On the other hand, no relation between overweight/obesity and paternal employment was observed. Our results concerning mothers’ employment status are consistent with several studies [ 20 , 21 , 22 , 23 , 24 , 25 ] that have linked maternal employment to children’s and adolescents’ obesity. In addition, Anderson et al. observed that the more hours the mothers worked, the higher the risk for the children to become overweight or obese [ 25 ]. Nevertheless, the mechanisms that mediate these associations remain largely unknown. The main channels associated with greater weight include less time allocated to housework (including meal preparation) and a reduction in maternal supervision regarding children’s food intake and physical activity [ 26 , 27 , 28 ]. The present study showed that a significantly higher percentage (28%) of overweight and obese adolescents than normal-weight participants (15.3%) had divorced parents. The GENDAI study carried out in Greece confirmed that parental marital status plays a key role in the emergence of obesity in adolescents [ 28 ]. This was confirmed not only in Greece, where traditional family status is more frequent, but also in studies from other European countries, such as Poland, the United Kingdom, Iceland, and Sweden [ 20 , 29 , 30 , 31 , 32 ], indicating that a stable family environment is important for the preservation of normal body weight [ 33 ]. Research has indicated that children of single parents are less likely to eat at the table together with the parent and are allowed to play and watch television during meals [ 34 ]. Children of single-parent households are reported to consume more total fat, saturated fat, and sweetened beverages and also watch television/video for more than two hours daily more frequently when compared to children of two-parent family households [ 35 ]. On the other hand, a similar study from Nordic countries did not confirm our results [ 31 ].

In the present study, anxiety was also linked to higher BMI in both genders. This result confirmed the findings of previous studies [ 25 , 36 , 37 ] that revealed a gender difference in the link between anxiety and the development of obesity. In particular, most of them identified a stronger link between the development of overweight and obesity due to anxiety in girls [ 25 , 36 ]. Separation anxiety was associated with increased waist circumference and BMI in boys, whereas in girls, somatic symptoms of anxiety were associated with waist circumference and higher body fat [ 25 ].

Previous research has demonstrated associations between obesity and depression in children and adolescents [ 38 ]. Nevertheless, the mental well-being and psychiatric health of children and adolescents suffering from obesity are the subject of considerable debate [ 25 , 36 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. There are two systematic reviews and a meta-analysis on this topic [ 37 , 45 , 46 ] suggesting that obese children and adolescents are more likely to suffer from depression and depressive symptoms, with females being at higher risk. Consistent with previous reports, our study indicated that melancholic depression was related to overweight/obesity in adolescents [ 25 , 40 , 41 , 47 , 48 ]. There are three possible pathways that could account for these disorders. Obesity could lead to depression through weight stigma [ 49 ], poor self-esteem [ 50 ], and/or reduced mobility and ability to engage in activities [ 51 ]. Depression could lead to obesity directly through the occurrence of depressive symptoms (e.g., increased appetite, poor sleep, lethargy resulting in decreased calorie expenditure, and/or reduced energy to obtain and cook healthy foods), antidepressant medication side effects, or attempts to self-medicate depressive feelings with unhealthy foods [ 51 , 52 , 53 ]. Further investigation of the mechanisms underlying the observed comorbidity is needed.

We found that the frequency of participation in sport activities was significantly higher in normal-weight than overweight/ obese adolescents. This is expected and has also been demonstrated in previous studies, as a lack of physical activity in adolescence has been found to lead to obesity [ 54 , 55 ]. There is a bidirectional effect between the lack of physical activity and increased BMI, as the lack of physical activity may lead to an increase in BMI, but inversely, an increased BMI may lead to reduced participation in sport activities [ 55 ]. In addition, adolescents may also be more self-conscious about their physical appearance and thus refrain from exercising in front of others [ 56 ]. In this survey, apart from assessing the frequency of physical activity among adolescents, we also found that those who were socially integrated and participated in team sports had a lower probability of being overweight because of higher self-esteem and better relationships with their peers.

In our study, both school performance and unjustified absences were associated with overweight/obesity. To our knowledge, there is no similar research identifying a link between school truancy and development of overweight/obesity. In addition, poor school performance may be related to obesity. Poor school performance is associated with negative feelings of failure and inability to succeed. These in turn are related to depressive symptoms, worrying about school results, and overeating [ 57 ].

To our knowledge, this is the first study to examine whether psychosocial factors are associated with increased prevalence of overweight and obesity among Greek adolescents. One limitation of the study is the relatively small sample, which in addition is not representative of the population of all of Greece, as it is restricted to adolescents living in the Attica Region, although this does represent 35% of the country’s population.

In conclusion, this study showed that psychological problems, such as anxiety and melancholic depression, are associated with obesity. Moreover, maternal occupation, the absence of physical activity, and poor school performance were associated with adolescent overweight/obesity. Therefore, it is of great importance that screening for the presence of psychosocial issues should be included in childhood obesity policies and proper handling of these issues should be provided. In addition, public health policies should be formulated and strengthened in the future targeting physical activity, maternal employment, and work schedules early in adolescence, with special attention to girls.

Acknowledgments

We would like to thank the adolescents and their guardians who participated in this study for their valuable contribution.

Author Contributions

Conceptualization: A.T.; methodology: A.G.; validation: T.N.S.; formal analysis: A.G.; investigation: A.R.; resources: M.M.; data curation: A.R.; writing—original draft preparation: E.K.A. and M.M.; writing—review and editing: E.K.A., E.V., S.M., F.B., and K.K.; supervision: M.T.; project administration: A.T. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by “P & A Kyriakou” Children’s Hospital Ethics Committee (11885/4-7-2019).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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