research paper on childhood obesity

Childhood obesity: A review of current and future management options

Affiliations.

• 1 Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK.
• 2 Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK.
• 3 Department of Paediatric Dietetics, Alder Hey Children's Hospital, Liverpool, UK.
• 4 Department of Paediatric Clinical Psychology, Alder Hey Children's Hospital, Liverpool, UK.
• PMID: 34750858
• DOI: 10.1111/cen.14625

Obesity is becoming increasingly prevalent in paediatric populations worldwide. In addition to increasing prevalence, the severity of obesity is also continuing to rise. Taken together, these findings demonstrate a worrying trend and highlight one of the most significant challenges to public health. Childhood obesity affects multiple organs in the body and is associated with both significant morbidity and ultimately premature mortality. The prevalence of complications associated with obesity, including dyslipidaemia, hypertension, fatty liver disease and psychosocial complications are becoming increasingly prevalent within the paediatric populations. Treatment guidelines currently focus on intervention with lifestyle and behavioural modifications, with pharmacotherapy and surgery reserved for patients who are refractory to such treatment. Research into adult obesity has established pharmacological novel therapies, which have been approved and established in clinical practice; however, the research and implementation of such therapies in paediatric populations have been lagging behind. Despite the relative lack of widespread research in comparison to the adult population, newer therapies are being trialled, which should allow a greater availability of treatment options for childhood obesity in the future. This review summarizes the current evidence for the management of obesity in terms of medical and surgical options. Both future therapeutic agents and those which cause weight loss but have an alternative indication are also included and discussed as part of the review. The review summarizes the most recent research for each intervention and demonstrates the potential efficacy and limitations of each treatment option.

Keywords: BMI; childhood obesity; lifestyle interventions; paediatrics; pharmacotherapy.

© 2021 John Wiley & Sons Ltd.

Publication types

• Medical History Taking
• Pediatric Obesity* / therapy
• Weight Loss

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Review article, childhood and adolescent obesity: a review.

• 1 Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
• 2 Division of Adolescent Medicine, Department of Pediatrics, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI, United States
• 3 Division of Adolescent Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States

Obesity is a complex condition that interweaves biological, developmental, environmental, behavioral, and genetic factors; it is a significant public health problem. The most common cause of obesity throughout childhood and adolescence is an inequity in energy balance; that is, excess caloric intake without appropriate caloric expenditure. Adiposity rebound (AR) in early childhood is a risk factor for obesity in adolescence and adulthood. The increasing prevalence of childhood and adolescent obesity is associated with a rise in comorbidities previously identified in the adult population, such as Type 2 Diabetes Mellitus, Hypertension, Non-alcoholic Fatty Liver disease (NAFLD), Obstructive Sleep Apnea (OSA), and Dyslipidemia. Due to the lack of a single treatment option to address obesity, clinicians have generally relied on counseling dietary changes and exercise. Due to psychosocial issues that may accompany adolescence regarding body habitus, this approach can have negative results. Teens can develop unhealthy eating habits that result in Bulimia Nervosa (BN), Binge- Eating Disorder (BED), or Night eating syndrome (NES). Others can develop Anorexia Nervosa (AN) as they attempt to restrict their diet and overshoot their goal of “being healthy.” To date, lifestyle interventions have shown only modest effects on weight loss. Emerging findings from basic science as well as interventional drug trials utilizing GLP-1 agonists have demonstrated success in effective weight loss in obese adults, adolescents, and pediatric patients. However, there is limited data on the efficacy and safety of other weight-loss medications in children and adolescents. Nearly 6% of adolescents in the United States are severely obese and bariatric surgery as a treatment consideration will be discussed. In summary, this paper will overview the pathophysiology, clinical, and psychological implications, and treatment options available for obese pediatric and adolescent patients.

Introduction

Obesity is a complex issue that affects children across all age groups ( 1 – 3 ). One-third of children and adolescents in the United States are classified as either overweight or obese. There is no single element causing this epidemic, but obesity is due to complex interactions between biological, developmental, behavioral, genetic, and environmental factors ( 4 ). The role of epigenetics and the gut microbiome, as well as intrauterine and intergenerational effects, have recently emerged as contributing factors to the obesity epidemic ( 5 , 6 ). Other factors including small for gestational age (SGA) status at birth, formula rather than breast feeding in infancy, and early introduction of protein in infant's dietary intake have been reportedly associated with weight gain that can persist later in life ( 6 – 8 ). The rising prevalence of childhood obesity poses a significant public health challenge by increasing the burden of chronic non-communicable diseases ( 1 , 9 ).

Obesity increases the risk of developing early puberty in children ( 10 ), menstrual irregularities in adolescent girls ( 1 , 11 ), sleep disorders such as obstructive sleep apnea (OSA) ( 1 , 12 ), cardiovascular risk factors that include Prediabetes, Type 2 Diabetes, High Cholesterol levels, Hypertension, NAFLD, and Metabolic syndrome ( 1 , 2 ). Additionally, obese children and adolescents can suffer from psychological issues such as depression, anxiety, poor self-esteem, body image and peer relationships, and eating disorders ( 13 , 14 ).

So far, interventions for overweight/obesity prevention have mainly focused on behavioral changes in an individual such as increasing daily physical exercise or improving quality of diet with restricting excess calorie intake ( 1 , 15 , 16 ). However, these efforts have had limited results. In addition to behavioral and dietary recommendations, changes in the community-based environment such as promotion of healthy food choices by taxing unhealthy foods ( 17 ), improving lunch food quality and increasing daily physical activity at school and childcare centers, are extra measures that are needed ( 16 ). These interventions may include a ban on unhealthy food advertisements aimed at children as well as access to playgrounds and green spaces where families can feel their children can safely recreate. Also, this will limit screen time for adolescents as well as younger children.

However, even with the above changes, pharmacotherapy and/or bariatric surgery will likely remain a necessary option for those youth with morbid obesity ( 1 ). This review summarizes our current understanding of the factors associated with obesity, the physiological and psychological effects of obesity on children and adolescents, and intervention strategies that may prevent future concomitant issues.

Definition of Childhood Obesity

Body mass index (BMI) is an inexpensive method to assess body fat and is derived from a formula derived from height and weight in children over 2 years of age ( 1 , 18 , 19 ). Although more sophisticated methods exist that can determine body fat directly, they are costly and not readily available. These methods include measuring skinfold thickness with a caliper, Bioelectrical impedance, Hydro densitometry, Dual-energy X-ray Absorptiometry (DEXA), and Air Displacement Plethysmography ( 2 ).

BMI provides a reasonable estimate of body fat indirectly in the healthy pediatric population and studies have shown that BMI correlates with body fat and future health risks ( 18 ). Unlike in adults, Z-scores or percentiles are used to represent BMI in children and vary with the age and sex of the child. BMI Z-score cut off points of >1.0, >2.0, and >3.0 are recommended by the World Health Organization (WHO) to define at risk of overweight, overweight and obesity, respectively ( 19 ). However, in terms of percentiles, overweight is applied when BMI is >85th percentile <95th percentile, whereas obesity is BMI > 95th percentile ( 20 – 22 ). Although BMI Z-scores can be converted to BMI percentiles, the percentiles need to be rounded and can misclassify some normal-weight children in the under or overweight category ( 19 ). Therefore, to prevent these inaccuracies and for easier understanding, it is recommended that the BMI Z-scores in children should be used in research whereas BMI percentiles are best used in the clinical settings ( 20 ).

As BMI does not directly measure body fat, it is an excellent screening method, but should not be used solely for diagnostic purposes ( 23 ). Using 85th percentile as a cut off point for healthy weight may miss an opportunity to obtain crucial information on diet, physical activity, and family history. Once this information is obtained, it may allow the provider an opportunity to offer appropriate anticipatory guidance to the families.

Pathophysiology of Obesity

The pathophysiology of obesity is complex that results from a combination of individual and societal factors. At the individual level, biological, and physiological factors in the presence of ones' own genetic risk influence eating behaviors and tendency to gain weight ( 1 ). Societal factors include influence of the family, community and socio-economic resources that further shape these behaviors ( Figure 1 ) ( 3 , 24 ).

Figure 1 . Multidimensional factors contributing to child and adolescent obesity.

Biological Factors

There is a complex architecture of neural and hormonal regulatory control, the Gut-Brain axis, which plays a significant role in hunger and satiety ( Figure 2 ). Sensory stimulation (smell, sight, and taste), gastrointestinal signals (peptides, neural signals), and circulating hormones further contribute to food intake ( 25 – 27 ).

Figure 2 . Pictorial representation of the Hunger-Satiety pathway a and the various hormones b involved in the pathway. a, Y1/Y5R and MC3/4 are second order neuro receptors which are responsible in either the hunger or satiety pathway. Neurons in the ARC include: NPY, Neuropeptide Y; AgRP, Agouti-Related Peptide; POMC, Pro-Opiomelanocortin; CART, Cocaine-and Amphetamine-regulated Transcript; α-MSH, α-Melanocyte Stimulating Hormone. b, PYY, Peptide YY; PP, Pancreatic Polypeptide; GLP-1, Glucagon-Like Peptide- I; OMX, Oxyntomodulin.

The hypothalamus is the crucial region in the brain that regulates appetite and is controlled by key hormones. Ghrelin, a hunger-stimulating (orexigenic) hormone, is mainly released from the stomach. On the other hand, leptin is primarily secreted from adipose tissue and serves as a signal for the brain regarding the body's energy stores and functions as an appetite -suppressing (anorexigenic) hormone. Several other appetite-suppressing (anorexigenic) hormones are released from the pancreas and gut in response to food intake and reach the hypothalamus through the brain-blood barrier (BBB) ( 28 – 32 ). These anorexigenic and orexigenic hormones regulate energy balance by stimulating hunger and satiety by expression of various signaling pathways in the arcuate nucleus (ARC) of the hypothalamus ( Figure 2 ) ( 28 , 33 ). Dysregulation of appetite due to blunted suppression or loss of caloric sensing signals can result in obesity and its morbidities ( 34 ).

Emotional dysfunction due to psychiatric disorders can cause stress and an abnormal sleep-wake cycles. These modifications in biological rhythms can result in increased appetite, mainly due to ghrelin, and can contribute to emotional eating ( 35 ).

Recently, the role of changes in the gut microbiome with increased weight gain through several pathways has been described in literature ( 36 , 37 ). The human gut serves as a host to trillions of microorganisms, referred to as gut microbiota. The dominant gut microbial phyla are Firmicutes, Bacteroidetes, Actinobacteria, Proteobacteria, Fusobacteria, and Verrucomicrobia, with Firmicutes and Bacteroidetes representing 90% of human gut microbiota ( 5 , 38 ). The microbes in the gut have a symbiotic relationship within their human host and provide a nutrient-rich environment. Gut microbiota can be affected by various factors that include gestational age at birth, mode of infant delivery, type of neonatal and infant feeding, introduction of solid food, feeding practices and external factors like antibiotic use ( 5 , 38 ). Also, the maturation of the bacterial phyla that occurs from birth to adulthood ( 39 ), is influenced by genetics, environment, diet, lifestyle, and gut physiology and stabilizes in adulthood ( 5 , 39 , 40 ). Gut microbiota is unique to each individual and plays a specific role in maintaining structural integrity, and the mucosal barrier of the gut, nutrient metabolism, immune response, and protection against pathogens ( 5 , 37 , 38 ). In addition, the microbiota ferments the indigestible food and synthesizes other essential micronutrients as well as short chain fatty acids (SCFAs') ( 40 , 41 ). Dysbiosis or imbalance of the gut microbiota, in particularly the role of SCFA has been linked with the patho-physiology of obesity ( 36 , 38 , 41 , 42 ). SCFAs' are produced by anaerobic fermentation of dietary fiber and indigestible starch and play a role in mammalian energy metabolism by influencing gut-brain communication axis. Emerging evidence has shown that increased ratio of Firmicutes to Bacteroidetes causes increased energy extraction of calories from diets and is evidenced by increased production of short chain fatty acids (SCFAs') ( 43 – 45 ). However, this relationship is not affirmed yet, as a negative relationship between SCFA levels and obesity has also been reported ( 46 ). Due to the conflicting data, additional randomized control trials are needed to clarify the role of SCFA's in obese and non-obese individuals.

The gut microbiota also has a bidirectional interaction with the liver, and various additional factors such as diet, genetics, and the environment play a key role in this relationship. The Gut- Liver Axis is interconnected at various levels that include the mucus barrier, epithelial barrier, and gut microbiome and are essential to maintain normal homeostasis ( 47 ). Increased intestinal mucosal permeability can disrupt the gut-liver axis, which releases various inflammatory markers, activates an innate immune response in the liver, and results in a spectrum of liver diseases that include hepatic steatosis, non-alcoholic steatohepatitis (NASH), cirrhosis, and hepatocellular carcinoma (HCC) ( 48 , 49 ).

Other medical conditions, including type 2 Diabetes Mellitus, Metabolic Syndrome, eating disorders as well as psychological conditions such as anxiety and depression are associated with the gut microbiome ( 50 – 53 ).

Genetic Factors

Genetic causes of obesity can either be monogenic or polygenic types. Monogenic obesity is rare, mainly due to mutations in genes within the leptin/melanocortin pathway in the hypothalamus that is essential for the regulation of food intake/satiety, body weight, and energy metabolism ( 54 ). Leptin regulates eating behaviors, the onset of puberty, and T-cell immunity ( 55 ). About 3% of obese children have mutations in the leptin ( LEP ) gene and the leptin receptor (LEPR) and can also present with delayed puberty and immune dysfunction ( 55 , 56 ). Obesity caused by other genetic mutations in the leptin-melanocortin pathway include proopiomelanocortin (POMC) and melanocortin receptor 4 (MC4R), brain-derived neurotrophic factor (BDNF), and the tyrosine kinase receptor B (NTRK2) genes ( 57 , 58 ). Patients with monogenic forms generally present during early childhood (by 2 years old) with severe obesity and abnormal feeding behaviors ( 59 ). Other genetic causes of severe obesity are Prader Willi Syndrome (PWS), Alström syndrome, Bardet Biedl syndrome. Patients with these syndromes present with additional characteristics, including cognitive impairment, dysmorphic features, and organ-specific developmental abnormalities ( 60 ). Individuals who present with obesity, developmental delay, dysmorphic features, and organ dysfunction should receive a genetics referral for further evaluation.

Polygenic obesity is the more common form of obesity, caused by the combined effect of multiple genetic variants. It is the result of the interplay between genetic susceptibility and the environment, also known as the Gene-Environment Interaction (GEI) ( 61 – 64 ). Genome-wide association studies (GWAS) have identified gene variants [single nucleotide polymorphism (SNPs)] for body mass index (BMI) that likely act synergistically to affect body weight ( 65 ). Studies have identified genetic variants in several genes that may contribute to excessive weight gain by increasing hunger and food intake ( 66 – 68 ). When the genotype of an individual confers risk for obesity, exposure to an obesogenic environment may promote a state of energy imbalance due to behaviors that contribute to conserving rather than expending energy ( 69 , 70 ). Research studies have shown that obese individuals have a genetic variation that can influence their actions, such as increased food intake, lack of physical activity, a decreased metabolism, as well as an increased tendency to store body fat ( 63 , 66 , 67 , 69 , 70 ).

Recently the role of epigenetic factors in the development of obesity has emerged ( 71 ). The epigenetic phenomenon may alter gene expression without changing the underlying DNA sequence. In effect, epigenetic changes may result in the addition of chemical tags known as methyl groups, to the individual's chromosomes. This alteration can result in a phenomenon where critical genes are primed to on and off regulate. Complex physiological and psychological adjustment occur during infancy and can thereafter set the stage for health vs. disease. Developmental origins of health and disease (DOHaD) shows that early life environment can impact the risk of chronic diseases later in life due to fetal programming secondary to epigenetic changes ( 72 ). Maternal nutrition during the prenatal or early postnatal period may trigger these epigenetic changes and increase the risk for chronic conditions such as obesity, metabolic and cardiovascular disease due to epigenetic modifications that may persist and cause intergenerational effect on the health children and adults ( 58 , 73 , 74 ). Similarly, adverse childhood experiences (ACE) have been linked to a broad range of negative outcomes through epigenetic mechanisms ( 75 ) and promote unhealthy eating behaviors ( 76 , 77 ). Other factors such as diet, physical activity, environmental and psychosocial stressors can cause epigenetic changes and place an individual at risk for weight gain ( 78 ).

Developmental Factors

Eating behaviors evolve over the first few years of life. Young children learn to eat through their direct experience with food and observing others eating around them ( 79 ). During infancy, feeding defines the relationship of security and trust between a child and the parent. Early childhood eating behaviors shift to more self-directed control due to rapid physical, cognitive, communicative, and social development ( 80 ). Parents or caregivers determine the type of food that is made available to the infant and young child. However, due to economic limitations and parents having decreased time to prepare nutritious meals, consumption of processed and cheaper energy-dense foods have occurred in Western countries. Additionally, feeding practices often include providing large or super-sized portions of palatable foods and encouraging children to finish the complete meal (clean their plate even if they do not choose to), as seen across many cultures ( 81 , 82 ). Also, a segment of parents are overly concerned with dietary intake and may pressurize their child to eat what they perceive as a healthy diet, which can lead to unintended consequences ( 83 ). Parents' excessive restriction of food choices may result in poor self-regulation of energy intake by their child or adolescent. This action may inadvertently promote overconsumption of highly palatable restricted foods when available to the child or adolescent outside of parental control with resultant excessive weight gain ( 84 , 85 ).

During middle childhood, children start achieving greater independence, experience broader social networks, and expand their ability to develop more control over their food choices. Changes that occur in the setting of a new environment such as daycare or school allow exposure to different food options, limited physical activity, and often increased sedentary behaviors associated with school schedules ( 24 ). As the transition to adolescence occurs, physical and psychosocial development significantly affect food choices and eating patterns ( 25 ). During the teenage years, more independence and interaction with peers can impact the selection of fast foods that are calorically dense. Moreover, during the adolescent years, more sedentary behaviors such as video and computer use can limit physical exercise. Adolescence is also a period in development with an enhanced focus on appearance, body weight, and other psychological concerns ( 86 , 87 ).

Environmental Factors

Environmental changes within the past few decades, particularly easy access to high-calorie fast foods, increased consumption of sugary beverages, and sedentary lifestyles, are linked with rising obesity ( 88 ). The easy availability of high caloric fast foods, and super-sized portions, are increasingly common choices as individuals prefer these highly palatable and often less expensive foods over fruits and vegetables ( 89 ). The quality of lunches and snacks served in schools and childcare centers has been an area of debate and concern. Children and adolescents consume one-third to one-half of meals in the above settings. Despite policies in place at schools, encouraging foods, beverages, and snacks that are deemed healthier options, the effectiveness of these policies in improving children's dietary habits or change in obesity rate has not yet been seen ( 90 ). This is likely due to the fact that such policies primarily focus on improving dietary quality but not quantity which can impact the overweight or obese youth ( 91 ). Policies to implement taxes on sugary beverages are in effect in a few states in the US ( 92 ) as sugar and sugary beverages are associated with increased weight gain ( 2 , 3 ). This has resulted in reduction in sales of sugary drinks in these states, but the sales of these types of drinks has risen in neighboring states that did not implement the tax ( 93 ). Due to advancements in technology, children are spending increased time on electronic devices, limiting exercise options. Technology advancement is also disrupting the sleep-wake cycle, causing poor sleeping habits, and altered eating patterns ( 94 ). A study published on Canadian children showed that the access to and night-time use of electronic devices causes decreased sleep duration, resulting in excess body weight, inferior diet quality, and lower physical activity levels ( 95 ).

Infant nutrition has gained significant popularity in relation to causing overweight/obesity and other diseases later in life. Breast feeding is frequently discussed as providing protection against developing overweight/obesity in children ( 8 ). Considerable heterogeneity has been observed in studies and conducting randomized clinical trials between breast feeding vs. formula feeding is not feasible ( 8 ). Children fed with a low protein formula like breast milk are shown to have normal weight gain in early childhood as compared to those that are fed formulas with a high protein load ( 96 ). A recent Canadian childbirth cohort study showed that breast feeding within first year of life was inversely associated with weight gain and increased BMI ( 97 ). The effect was stronger if the child was exclusively breast fed directly vs. expressed breast milk or addition of formula or solid food ( 97 ). Also, due to the concern of poor growth in preterm or SGA infants, additional calories are often given for nutritional support in the form of macronutrient supplements. Most of these infants demonstrate “catch up growth.” In fact, there have been reports that in some children the extra nutritional support can increase the risk for overweight/obesity later in life. The association, however, is inconsistent. Recently a systemic review done on randomized controlled trials comparing the studies done in preterm and SGA infants with feeds with and without macronutrient supplements showed that macronutrient supplements may increase weight and length in toddlers but did not show a significant increase in the BMI during childhood ( 98 ). Increased growth velocity due to early introduction of formula milk and protein in infants' diet, may influence the obesity pathways, and can impact fetal programming for metabolic disease later in life ( 99 ).

General pediatricians caring for children with overweight/obesity, generally recommend endocrine testing as parents often believe that there may be an underlying cause for this condition and urge their primary providers to check for conditions such as thyroid abnormalities. Endocrine etiologies for obesity are rarely identified and patients with underlying endocrine disorders causing excessive weight gain usually are accompanied by attenuated growth patterns, such that a patient continues to gain weight with a decline in linear height ( 100 ). Various endocrine etiologies that one could consider in a patient with excessive weight gain in the setting of slow linear growth: severe hypothyroidism, growth hormone deficiency, and Cushing's disease/syndrome ( 58 , 100 ).

Clinical-Physiology of Pediatric Obesity

It is a well-known fact that early AR(increased BMI) before the age of 5 years is a risk factor for adult obesity, obesity-related comorbidities, and metabolic syndrome ( 101 – 103 ). Typically, body mass index (BMI) declines to a minimum in children before it starts increasing again into adulthood, also known as AR. Usually, AR happens between 5 and 7 years of age, but if it occurs before the age of 5 years is considered early AR. Early AR is a marker for higher risk for obesity-related comorbidities. These obesity-related health comorbidities include cardiovascular risk factors (hypertension, dyslipidemia, prediabetes, and type 2 diabetes), hormonal issues, orthopedic problems, sleep apnea, asthma, and fatty liver disease ( Figure 3 ) ( 9 ).

Figure 3 . Obesity related co-morbidities a in children and adolescents. a, NAFLD, Non-Alcoholic Fatty Liver Disease; SCFE, Slipped Capital Femoral Epiphysis; PCOS, Polycystic Ovary Syndrome; OSA, Obstructive Sleep Apnea.

Clinical Comorbidities of Obesity in Children

Growth and puberty.

Excess weight gain in children can influence growth and pubertal development ( 10 ). Childhood obesity can cause prepubertal acceleration of linear growth velocity and advanced bone age in boys and girls ( 104 ). Hyperinsulinemia is a normal physiological state during puberty, but children with obesity can have abnormally high insulin levels ( 105 ). Leptin resistance also occurs in obese individuals who have higher leptin levels produced by their adipose tissue ( 55 , 106 ). The insulin and leptin levels can act on receptors that impact the growth plates with a resultant bone age advancement ( 55 ).

Adequate nutrition is essential for the typical timing and tempo of pubertal onset. Excessive weight gain can initiate early puberty, due to altered hormonal parameters ( 10 ). Obese children may present with premature adrenarche, thelarche, or precocious puberty (PP) ( 107 ). The association of early pubertal changes with obesity is consistent in girls, and is well-reported; however, data is sparse in boys ( 108 ). One US study conducted in racially diverse boys showed obese boys had delayed puberty, whereas overweight boys had early puberty as compared to normal-weight boys ( 109 ). Obese girls with PP have high leptin levels ( 110 , 111 ). Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) is a cross-sectional study and suggested an indirect relationship between elevated leptin levels, early puberty, and cardiometabolic and inflammatory markers in obese girls ( 112 ). Additionally, obese girls with premature adrenarche carry a higher risk for developing polycystic ovary syndrome (PCOS) in the future ( 113 , 114 ).

Sleep Disorders

Obesity is an independent risk factor for obstructive sleep apnea (OSA) in children and adolescents ( 12 , 115 ). Children with OSA have less deleterious consequences in terms of cardiovascular stress of metabolic syndrome when compared to adolescents and adults ( 116 , 117 ). In children, abnormal behaviors and neurocognitive dysfunction are the most critical and frequent end-organ morbidities associated with OSA ( 12 ). However, in adolescents, obesity and OSA can independently cause oxidative systemic stress and inflammation ( 118 , 119 ), and when this occurs concurrently, it can result in more severe metabolic dysfunction and cardiovascular outcomes later in life ( 120 ).

Other Comorbidities

Obesity is related to a clinical spectrum of liver abnormalities such as NAFLD ( 121 ); the most important cause of liver disease in children ( 122 – 124 ). NAFLD includes steatosis (increased liver fat without inflammation) and NASH (increased liver fat with inflammation and hepatic injury). While in some adults NAFLD can progress to an end-stage liver disease requiring liver transplant ( 125 , 126 ), the risk of progression during childhood is less well-defined ( 127 ). NAFLD is closely associated with metabolic syndrome including central obesity, insulin resistance, type 2 diabetes, dyslipidemia, and hypertension ( 128 ).

Obese children are also at risk for slipped capital femoral epiphysis (SCFE) ( 129 ), and sedentary lifestyle behaviors may have a negative influence on the brain structure and executive functioning, although the direction of causality is not clear ( 130 , 131 ).

Clinical Comorbidities of Obesity in Adolescents

Menstrual irregularities and pcos.

At the onset of puberty, physiologically, sex steroids can cause appropriate weight gain and body composition changes that should not affect normal menstruation ( 132 , 133 ). However, excessive weight gain in adolescent girls can result in irregular menstrual cycles and puts them at risk for PCOS due to increased androgen levels. Additionally, they can have excessive body hair (hirsutism), polycystic ovaries, and can suffer from distorted body images ( 134 , 135 ). Adolescent girls with PCOS also have an inherent risk for insulin resistance irrespective of their weight. However, weight gain further exacerbates their existing state of insulin resistance and increases the risk for obesity-related comorbidities such as metabolic syndrome, and type 2 diabetes. Although the diagnosis of PCOS can be challenging at this age due to an overlap with predictable pubertal changes, early intervention (appropriate weight loss and use of hormonal methods) can help restore menstrual cyclicity and future concerns related to childbearing ( 11 ).

Metabolic Syndrome and Sleep Disorders

Metabolic syndrome (MS) is a group of cardiovascular risk factors characterized by acanthosis nigricans, prediabetes, hypertension, dyslipidemia, and non-alcoholic steatohepatitis (NASH), that occurs from insulin resistance caused by obesity ( 136 ). Diagnosis of MS in adults requires at least three out of the five risk factors: increased central adiposity, hypertension, hyperglycemia, hypertriglyceridemia, or low HDL level. Definitions to diagnose MS are controversial in younger age groups, and many definitions have been proposed ( 136 ). This is due to the complex physiology of growth and development during puberty, which causes significant overlap between MS and features of normal growth. However, childhood obesity is associated with an inflammatory state even before puberty ( 137 ). In obese children and adolescents, hyperinsulinemia during puberty ( 138 , 139 ) and unhealthy sleep behaviors increase MS's risk and severity ( 140 ). Even though there is no consensus on diagnosis regarding MS in this age group, when dealing with obese children and adolescents, clinicians should screen them for MS risk factors and sleep behaviors and provide recommendations for weight management.

Social Psychology of Pediatric Obesity in Children and Adolescents

Obese children and adolescents may experience psychosocial sequelae, including depression, bullying, social isolation, diminished self-esteem, behavioral problems, dissatisfaction with body image, and reduced quality of life ( 13 , 141 ). Compared with normal-weight counterparts, overweight/obesity is one of the most common reasons children and adolescents are bullied at school ( 142 ). The consequence of stigma, bullying, and teasing related to childhood obesity are pervasive and can have severe implications for emotional and physical health and performance that can persist later in life ( 13 ).

In adolescents, psychological outcomes associated with obesity are multifactorial and have a bidirectional relationship ( Figure 4 ). Obese adolescents due to their physique may have a higher likelihood of psychosocial health issues, including depression, body image/dissatisfaction, lower self-esteem, peer victimization/bullying, and interpersonal relationship difficulties. They may also demonstrate reduced resilience to challenging situations compared to their non-obese/overweight counterparts ( 9 , 143 – 146 ). Body image dissatisfaction has been associated with further weight gain but can also be related to the development of a mental health disorder or an eating disorder (ED) or disorder eating habits (DEH). Mental health disorders such as depression are associated with poor eating habits, a sedentary lifestyle, and altered sleep patterns. ED or DEH that include anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED) or night eating syndrome (NES) may be related to an individual's overvaluation of their body shape and weight or can result during the treatment for obesity ( 147 – 150 ). The management of obesity can place a patient at risk of AN if there is a rigid focus on caloric intake or if a patient overcorrects and initiates obsessive self-directed dieting. Healthcare providers who primarily care for obese patients, usually give the advice to diet to lose weight and then maintain it. However, strict dieting (hypocaloric diet), which some patients may later engage in can lead to an eating disorder such as anorexia nervosa ( 151 ). This behavior leads to a poor relationship with food, and therefore, adolescents perseverate on their weight and numbers ( 152 ).

Figure 4 . Bidirectional relationship of different psychological outcomes of obesity.

Providers may not recognize DEHs when a morbidly obese patient loses the same weight as a healthy weight individual ( 149 ). It may appear as a positive result with families and others praising the individual without realizing that this youth may be engaging in destructive behaviors related to weight control. Therefore, it is essential to screen regarding the process of how weight loss was achieved ( 144 , 150 ).

Support and attention to underlying psychological concerns can positively affect treatment, overall well-being, and reduce the risk of adult obesity ( 150 ). The diagram above represents the complexity of the different psychological issues which can impact the clinical care of the obese adolescent.

Eating family meals together can improve overall dietary intake due to enhanced food choices mirrored by parents. It has also may serve as a support to individuals with DEHs if there is less attention to weight and a greater focus on appropriate, sustainable eating habits ( 148 ).

Prevention and Anticipatory Guidance

It is essential to recognize and provide preventive measures for obesity during early childhood and adolescence ( 100 , 153 , 154 ). It is well-established that early AR is a risk factor for adult obesity ( 66 – 68 ). Therefore, health care providers caring for the pediatric population need to focus on measures such as BMI but provide anticipatory guidance regarding nutritional counseling without stigmatizing or judging parents for their children's overweight/obesity ( 155 ). Although health care providers continue to pursue effective strategies to address the obesity epidemic; ironically, they frequently exhibit weight bias and stigmatizing behaviors. Research has demonstrated that the language that health care providers use when discussing a patient's body weight can reinforce stigma, reduce motivation for weight loss, and potentially cause avoidance of routine preventive care ( 155 ). In adolescents, rather than motivating positive changes, stigmatizing language regarding weight may negatively impact a teen and result in binge eating, decreased physical activity, social isolation, avoidance of health care services, and increased weight gain ( 156 , 157 ). Effective provider-patient communication using motivational interviewing techniques are useful to encourage positive behavior changes ( 155 , 158 ).

Anticipatory guidance includes educating the families on healthy eating habits and identifying unhealthy eating practices, encouraging increased activity, limiting sedentary activities such as screen time. Lifestyle behaviors in children and adolescents are influenced by many sectors of our society, including the family ( Figure 1 ) ( 3 , 24 ). Therefore, rather than treating obesity in isolation as an individual problem, it is crucial to approach this problem by focusing on the family unit. Family-based multi-component weight loss behavioral treatment is the gold standard for treating childhood obesity, and it is having been found useful in those between 2 and 6 years old ( 150 , 159 ). Additionally, empowering the parents to play an equal role in developing and implementing an intervention for weight management has shown promising results in improving the rate of obesity by decreasing screen time, promoting healthy eating, and increasing support for children's physical activity ( 160 , 161 ).

When dietary/lifestyle modifications have failed, the next option is a structured weight -management program with a multidisciplinary approach ( 15 ). The best outcomes are associated with an interdisciplinary team comprising a physician, dietician, and psychologist generally 1–2 times a week ( 15 , 162 ). However, this treatment approach is not effective in patients with severe obesity ( 122 ). Although healthier lifestyle recommendations for weight loss are the current cornerstone for obesity management, they often fail. As clinicians can attest, these behavioral and dietary changes are hard to achieve, and all too often is not effective in patients with severe obesity. Failure to maintain substantial weight loss over the long term is due to poor adherence to the prescribed lifestyle changes as well as physiological responses that resist weight loss ( 163 ). American TV hosts a reality show called “The Biggest Loser” that centers on overweight and obese contestants attempting to lose weight for a cash prize. Contestants from “The Biggest Loser” competition, had metabolic adaptation (MA) after drastic weight loss, regained more than they lost weight after 6 years due to a significant slow resting metabolic rate ( 164 ). MA is a physiological response which is a reduced basal metabolic rate seen in individuals who are losing or have lost weight. In MA, the body alters how efficient it is at turning the food eaten into energy; it is a natural defense mechanism against starvation and is a response to caloric restriction. Plasma leptin levels decrease substantially during caloric restriction, suggesting a role of this hormone in the drop of energy expenditure ( 165 ).

Pharmacological Management

The role of pharmacological therapy in the treatment of obesity in children and adolescents is limited.

Orlistat is the only FDA approved medication for weight loss in 12-18-year-olds but has unpleasant side effects ( 166 ). Another medicine, Metformin, has been used in children with signs of insulin resistance, may have some impact on weight, but is not FDA approved ( 167 ). The combination of phentermine/topiramate (Qsymia) has been FDA approved for weight loss in obese individuals 18 years and older. In studies, there has been about 9–10% weight loss over 2 years. However, caution must be taken in females as it can lead to congenital disabilities, especially with use in the first trimester of pregnancy ( 167 ).

GLP-1 agonists have demonstrated great success in effective weight loss and are approved by the FDA for adult obesity ( 168 – 170 ). A randomized control clinical trial recently published showed a significant weight loss in those using liraglutide (3.0 mg)/day plus lifestyle therapy group compared to placebo plus lifestyle therapy in children between the ages of 12–18 years ( 171 ).

Recently during the EASL conference, academic researchers and industry partners presented novel interventions targeting different gut- liver axis levels that include intestinal content, intestinal microbiome, intestinal mucosa, and peritoneal cavity ( 47 ). The focus for these therapeutic interventions within the gut-liver axis was broad and ranged anywhere from newer drugs protecting the intestinal mucus lining, restoring the intestinal barriers and improvement in the gut microbiome. One of the treatment options was Hydrogel technology which was shown to be effective toward weight loss in patients with metabolic syndrome. Hydrogel technology include fibers and high viscosity polysaccharides that absorb water in the stomach and increasing the volume, thereby improving satiety ( 47 ). Also, a clinical trial done in obese pregnant mothers using Docosahexaenoic acid (DHA) showed that the mothers' who got DHA had children with lower adiposity at 2 and 4 years of age ( 172 ). Recently the role of probiotics in combating obesity has emerged. Probiotics are shown to alter the gut microbiome that improves intestinal digestive and absorptive functions of the nutrients. Intervention including probiotics may be a possible solution to manage pediatric obesity ( 173 , 174 ). Additionally, the role of Vitamin E for treating the comorbidities of obesity such as diabetes, hyperlipidemia, NASH, and cardiovascular risk, has been recently described ( 175 , 176 ). Vitamin E is a lipid- soluble compound and contains both tocopherols and tocotrienols. Tocopherols have lipid-soluble antioxidants properties that interact with cellular lipids and protects them from oxidation damage ( 177 ). In metabolic disease, certain crucial pathways are influenced by Vitamin E and some studies have summarized the role of Vitamin E regarding the treatment of obesity, metabolic, and cardiovascular disease ( 178 ). Hence, adequate supplementation of Vitamin E as an appropriate strategy to help in the treatment of the prevention of obesity and its associated comorbidities has been suggested. Nonetheless, some clinical trials have shown contradictory results with Vitamin E supplementation ( 177 ). Although Vitamin E has been recognized as an antioxidant that protects from oxidative damage, however, a full understanding of its mechanism of action is still lacking.

Bariatric Surgery

Bariatric surgery has gained popularity since the early 2000s in the management of severe obesity. If performed earlier, there are better outcomes for reducing weight and resolving obesity-related comorbidities in adults ( 179 – 182 ). Currently, the indication for bariatric in adolescents; those who have a BMI >35 with at least one severe comorbidity (Type 2 Diabetes, severe OSA, pseudotumor cerebri or severe steatohepatitis); or BMI of 40 or more with other comorbidities (hypertension, hyperlipidemia, mild OSA, insulin resistance or glucose intolerance or impaired quality of life due to weight). Before considering bariatric surgery, these patients must have completed most of their linear growth and participated in a structured weight-loss program for 6 months ( 159 , 181 , 183 ). The American Society for Metabolic and Bariatric Surgery (AMBS) outlines the multidisciplinary approach that must be taken before a patient undergoing bariatric surgery. In addition to a qualified bariatric surgeon, the patient must have a pediatrician or provider specialized in adolescent medicine, endocrinology, gastroenterology and nutrition, registered dietician, mental health provider, and exercise specialist ( 181 ). A mental health provider is essential as those with depression due to obesity or vice versa may have persistent mental health needs even after weight loss surgery ( 184 ).

Roux-en-Y Gastric Bypass (RYGB), laparoscopic Sleeve Gastrectomy (LSG), and Gastric Banding are the options available. RYGB and LSG currently approved for children under 18 years of age ( 166 , 181 , 185 ). At present, gastric banding is not an FDA recommended procedure in the US for those under 18y/o. One study showed some improvements in BMI and severity of comorbidities but had multiple repeat surgeries and did not believe a suitable option for obese adolescents ( 186 ).

Compared to LSG, RYGB has better outcomes for excess weight loss and resolution of obesity-related comorbidities as shown in studies and clinical trials ( 183 , 184 , 187 ). Overall, LSG is a safer choice and may be advocated for more often ( 179 – 181 ). The effect on the Gut-Brain axis after Bariatric surgery is still inconclusive, especially in adolescents, as the number of procedures performed is lower than in adults. Those who underwent RYGB had increased fasting and post-prandial PYY and GLP-1, which could have contributed to the rapid weight loss ( 185 ); this effect was seen less often in patients with gastric banding ( 185 ). Another study in adult patients showed higher bile acid (BA) subtype levels and suggested a possible BA's role in the surgical weight loss response after LSG ( 188 ). Adolescents have lower surgical complication rates than their adult counterparts, hence considering bariatric surgery earlier rather than waiting until adulthood has been entertained ( 180 ). Complications after surgery include nutritional imbalance in iron, calcium, Vitamin D, and B12 and should be monitored closely ( 180 , 181 , 185 ). Although 5-year data for gastric bypass in very obese teens is promising, lifetime outcome is still unknown, and the psychosocial factors associated with adolescent adherence post-surgery are also challenging and uncertain.

Obesity in childhood and adolescence is not amenable to a single easily modified factor. Biological, cultural, and environmental factors such as readily available high-density food choices impact youth eating behaviors. Media devices and associated screen time make physical activity a less optimal choice for children and adolescents. This review serves as a reminder that the time for action is now. The need for interventions to change the obesogenic environment by instituting policies around the food industry and in the schools needs to be clarified. In clinical trials GLP-1 agonists are shown to be effective in weight loss in children but are not yet FDA approved. Discovery of therapies to modify the gut microbiota as treatment for overweigh/obesity through use of probiotics or fecal transplantation would be revolutionary. For the present, ongoing clinical research efforts in concert with pharmacotherapeutic and multidisciplinary lifestyle programs hold promise.

Author Contributions

AK, SL, and MJ contributed to the conception and design of the study. All authors contributed to the manuscript revision, read, and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: obesity, childhood, review (article), behavior, adolescent

Citation: Kansra AR, Lakkunarajah S and Jay MS (2021) Childhood and Adolescent Obesity: A Review. Front. Pediatr. 8:581461. doi: 10.3389/fped.2020.581461

Received: 08 July 2020; Accepted: 23 November 2020; Published: 12 January 2021.

Reviewed by:

Copyright © 2021 Kansra, Lakkunarajah and Jay. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Alvina R. Kansra, akansra@mcw.edu

This article is part of the Research Topic

Pediatric Obesity: From the Spectrum of Clinical-Physiology, Social-Psychology, and Translational Research

• Research article
• Open access
• Published: 06 November 2018

A qualitative insight into informal childcare and childhood obesity in children aged 0–5 years in the UK

• Eleanor Diana Lidgate 1   na1 ,
• Bai Li   ORCID: orcid.org/0000-0003-2706-9799 2   na1 &
• Antje Lindenmeyer 2  

BMC Public Health volume  18 , Article number:  1229 ( 2018 ) Cite this article

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Previous studies in various countries have found that informal childcare (provided by relatives, friends etc.) was associated with an increased risk of obesity in children aged 0–5 years. However, no qualitative research has been done to explore possible reasons for such a relationship and potential interventions to tackle it. We conducted a qualitative study with both parents and informal carers to explore their 1) experiences in receiving or giving informal childcare for British children aged 0–5 years; 2) perceived explanations of the relationship between informal childcare and childhood obesity and 3) preferred intervention ideas and delivery strategies for preventing obesity among those children under informal care.

Four in-depth focus groups with a total of 14 participants (7 parents, 7 informal caregivers) were conducted in Birmingham and Edinburgh (1 parent group and 1 informal caregiver group in each city). Data were audio recorded, transcribed verbatim and analysed using a thematic approach.

The significance of informal care to parents, carers, and society was recognised (theme one). Informal carers were identified to have practical and emotional support roles for the parents (theme two). Informal care was perceived to contribute to childhood obesity in four ways (theme three): cross-generation conflict preventing adoption of healthy practices; the trade-off for parents between receiving childcare and maintaining control; reduced energy capacity of carers; and increased snacking. Potential intervention ideas and delivery strategies (theme four) were identified. Examples of identified ideas included providing carers with up-to-date weaning advice, and suggestions of healthy snacks and ways to increase physical activity level in informal care. The suggestion of utilising existing primary care platforms (e.g. health visitor check-ups) to reach and deliver low-cost information based interventions, to all children aged 0–5 years who receive informal care, was highlighted.

Conclusions

This exploratory qualitative study provided novel insights into potential explanations for the evidenced link between informal care and childhood obesity in children aged 0–5 years, despite a small size and limited participants in each focus group. Our findings support the idea of and inform the development towards an information based and low-cost intervention delivered through existing primary care platforms.

Peer Review reports

Childhood obesity has become a global epidemic. In the UK, year on year the number of children who are either overweight or obese is increasing, and the age at which the onset of obesity occurs is reducing [ 1 ]. Approximately one in four children are overweight or obese by the age of 3 years [ 2 ]. There is an urgent need for more research and policies targeting the prevention of obesity in children aged 0–5 years [ 3 , 4 ]. The early years are an important time for the development of healthy habits. These include an active lifestyle, a low intake of unhealthy snacks and sufficient sleep time – all of which are protective factors against obesity [ 5 , 6 , 7 ], and can be influenced by carers in the early years [ 8 ]. Since the majority of young children receive some form of childcare [ 9 ], this period is a crucial target area for obesity prevention, and for the creation of healthy habits [ 10 ].

Informal care - care provided by grandparents, friends, neighbours, nannies [ 2 , 11 , 12 ] - is a popular childcare choice in the UK. By 2010, at least a quarter of British children under the age of three were in informal care, and around three-quarters of informal caregivers were grandparents [ 2 ]. There is an increasing body of evidence, including a range of study designs from a number of different countries, to suggest that children in informal childcare are more likely to be overweight or obese than their counterparts in parental care [ 2 , 11 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. A recent systematic review of the relationship between childcare settings and risk of overweight and obesity, found that before the age of 3 years, informal care was associated with significantly increased BMI or likelihood of overweight and obesity when compared to parental care [ 19 ]. However, no qualitative research has been done to explore possible reasons for, or potential interventions to tackle, such a relationship. In addition, according to published reviews of interventions aimed to prevent obesity in young children [ 3 , 20 , 21 , 22 , 23 , 24 , 25 ], there are currently no interventions specifically designed to encompass informal caregivers of children under five [ 26 ]. Previous interventions targeting the early years were often delivered to children or their parents through formal platforms such as child care centres [ 20 ]. Further investigation into the obesogenic aspects of informal care is necessary and is at the centre of informing future childhood obesity preventative measures [ 19 ]. The success of these measures relies on in-depth understanding of the needs of informal caregivers [ 8 ] and parents who use informal care.

Therefore, in order to inform future development of tailored interventions to prevent obesity in children under five in informal care, we conducted a novel qualitative study with parents and informal caregivers. The aims of this study were to explore their 1) experiences in receiving or providing informal childcare; 2) perceived reasons behind the relationship between informal childcare and childhood obesity and 3) favoured intervention ideas and delivery strategies for preventing obesity in those children.

Informal childcare givers and parents of children under five who were (or used to be) in informal care were recruited into focus groups between September 2016 and January 2017. Participants were recruited from two major cities of the UK (Birmingham and Edinburgh) to provide a range of socio-demographic perspectives.

Participant selection and recruitment

Participants were recruited using a purposive sampling method. Initial recruitment strategies included advertising via a grandparent carer charity, a childcare website and a mailing list of staff at the University. Inclusion criteria included: (a) informal carers or parents who were providing/using or had used/provided informal childcare, (b) the child was aged 0–5 years at time of care, and (c) willingness to participate in a focus group. There was no time limit on how long ago the care took place. All participants had a comprehensive information sheet emailed to them prior to attending a focus group, and had a chance to ask questions. Interested and eligible participants were contacted to arrange a convenient time and place to run the focus group. For practical reasons, participants read and signed an informed consent form at the beginning of the focus group. Each participant received a £10 voucher as a token of appreciation for taking part, and parking expenses were compensated.

Slow and difficult recruitment was anticipated, and occurred, owing to the unique characteristics of the research population (i.e. informal carers had no or minimal connections with any formal childcare organisations or settings). A number of strategies and media were applied to overcome the challenges in participant recruitment. These included: advertising via local baby and toddler groups; and putting up posters in community centres.

Data collection process

Focus groups were chosen as the data collection method as they encourage interaction between participants [ 27 ]. This interaction allows the researcher to elicit people’s understandings and views, or to explore how these are advanced in a social context [ 28 ]. Focus groups were held in locations chosen by the participants, two occurred in University meeting rooms and two in participants’ own homes. Parents and carers were invited to separate focus groups to encourage open discussions of shared experiences. A semi-structured topic guide for the focus groups was created in line with the project aim and objectives. This was piloted in a practice focus group with five participants to test and refine the design of our topic guide and questions. The main questions are summarised in Table 1 . The wording and the order of the questions were adapted flexibly at each group depending on the natural flow of the discussions and the identity of the group. A single researcher moderated both the pilot focus group and the four focus groups involved in this study. One of the focus groups was co-moderated with another researcher. Focus groups began with friendly ice-breaking questions to help all participants feel comfortable before moving on to more specific and targeted questions. Member checking occurred at the end of each group to ensure that the participants agreed with the moderators’ interpretation of the main concepts discussed. Focus groups lasted between one and 2 hours. All discussions were audio recorded with consent on a password-protected device. The moderator made field notes after each focus group, to record the key concepts that arose and participant interaction, and to aid transcript coding.

Data collection was continued until a range of responses had been collected in the different focus groups; however it was not deemed necessary to achieve data saturation as our analysis aimed to capture parents’ and carers’ experiences and understandings rather than develop theory [ 29 ].

Data analysis

Given a scarce knowledge basis on why informal care is linked to childhood obesity, an inductive thematic analysis approach was chosen to analyse the data set, as described by Braun and Clarke [ 30 ]. Focus group recordings were anonymised and transcribed verbatim. Each participant was assigned a unique ID relating to their identity and group number (for example PG1M1: Parent Group 1 Mother 1; CG1G2: Carer Group 1 Grandparent 2); this ID is reported alongside the relevant quotes in the results. To aid the generation of initial codes, the first author became familiar with the data by repeatedly reading the transcripts. Initial codes were produced systematically with the help of NVivo computer software [ 31 ]. A coding book was first developed by the first author, with guidance and contributions from the other authors, based on the richest dataset. This was expanded and refined as it was applied to the rest of the transcripts. The authors made use of visual representations, such as mind-maps and theme piles (codes on small pieces of paper which are arranged with similar codes), to develop initial higher-level themes from the descriptive codes and to begin to identify those with added significance. To increase the authenticity and credibility of the results, analyst triangulation, with three researchers from a range of backgrounds, was adopted in the final stages. This involved reviewing the finalised codebook and reaching a group consensus on the definition and content of the final themes. The analysts ensured that the dataset within each theme was connected whilst also being sufficiently different to the data within the other themes [ 32 ]. In order to minimise researcher bias, a reflexivity journal was maintained by the author to reveal their thinking process behind the development of codes and emerging patterns, and to reflect on how their opinions may impact on the analysis.

A total of 14 participants took part in four in-depth focus groups, including seven parents and seven informal care providers (Table 2 ). Two focus groups were run in Edinburgh, one group with four mothers, and the other with three informal care providers. The remaining two groups were run in Birmingham, one consisting of three mothers and the other with four informal care providers.

Four core themes emerged from the analysis: (1) the importance of informal care to families and society; (2) practical and emotional roles of informal carers; (3) potential explanations for the link between childhood obesity and informal care and (4) potential intervention opportunities and strategies. Detailed results are presented below and illustrated with quotes.

Theme 1: The importance of informal care to families and society

Both parents and carers consistently discussed how vital informal care was to both their family and to society.

All parents reported that the main reason they used informal care was to allow them to work, and that informal care had the advantage of being flexible. In most cases, informal care was unpaid. This was an important consideration for parents when deciding what type of child care to use. Formal care was generally thought to be very expensive and often parents had no choice financially but to go back to work, and relied on informal carers:

“It was sort of to help with the cost if you’ve got 2 children we didn’t put them both into nursery for 3 days a week so my mum ended up having both children when I came back to work” (PG2M1).

Informal care usually stems from an existing relationship, e.g. with a family member or friend, which means that parents know and trust the carer. All the parents noted this as another reason for choosing informal care over formal care:

“Certainly I wouldn’t be happy passing him to somebody I didn’t know and in a nursery that was one of my main concerns cos the staff turnover can be quite high” (PG1M3).

Informal care also means a lot to the carers themselves. For the nanny and the child-minder in this study, the childcare they provide is their form of employment. Whereas with grandparent carers, both parents and grandparents stated that the care arrangement was a whole family decision and that the grandparents offered to care as they wanted to help:

“I didn’t mind cos I prefer to look after her and know that she’s being looked after properly and being treated properly and happy” (CG1G1).

“Oh no I wouldn’t miss it [caring for her grandchild] for the world” (CG1G2).

In addition to being important to both the parents and the carers, one participant gave insight into how necessary informal care is to society:

“Grandparents care of children… is worth about fourteen point seven billion to the state every year because people are able to work and all that type of thing, we are a really useful resource” (CG1G3).

Theme 2: Practical and emotional roles of informal carers

All participants recognised and agreed that a large part of the informal carers’ role is to provide practical support to both the parent and the child. Carers noted that it is an ever-changing role and can be either rigid or fluid in structure, depending on the carer. Some of the key responsibilities of the carers are:

“I get the children dressed” (CG2G4).

“They’ve got gymnastics class booked so granny takes (name of daughter) to that” (PG1M1).

“No mum’s gonna go for me because ((laughs)) so my informal child carer is going to go to his 27 month check, so that’ll be quite good” (PG1M4).

Not only do carers have a role in practical support they also play a part in emotionally supporting the parents. One mother, of twin’s aged 2 and a 4 year old, used grandparent care to take her children to classes and clubs to give her a break for a couple of hours on the days she was not working. Informal care relieves pressure on parents in two ways: the first being that the parents know their children will be safe:

“They were well looked after and I didn’t have to worry” (CG1G1).

The second is to allow parents to work to relieve financial pressure:

“It’s to enable them to continue their careers when they really needed to work just to pay their mortgage” (CG2G1).

In addition parents look to their parents for advice and support with parenting as they have done it before. With increasing numbers of people living away from their families, emotional support, via the telephone, is often the only support grandparents can give if they live far away:

“With my mum even though she wasn’t there all the time she’d phone me and I was upset ‘oh is she still not sleeping just give her some baby rice’” (PG2M2).

Theme 3: Potential explanations for the link between childhood obesity and informal care

Participants were asked to comment on reasons why children in informal care might be more likely to be overweight or obese. Four potential explanations provided by participants are presented below.

Cross-generation conflict preventing adoption of healthy feeding practice in family

This was a common experience and predominant topic discussed by all mothers in one of the parent focus groups. It refers to the battle parents had between current recommendations, and the previous experience and opinions of older caregivers in the family:

“I would definitely tell my mum how I’d want them to be fed especially when they were younger only because we had different views about weaning and stuff like that” (PG2M1).

“Cos we did baby led weaning that was a bit controversial with both grandmas so particularly my mum there was a lot of ‘well shall I just give him some puree that I bought from the shop’ and (the participant replied) ‘I’d rather you didn’t’ sort of thing” (PG2M3).

As mentioned in Theme two, parents looked to their parents for advice and support, especially regarding breastfeeding and when to introduce solid foods. Unfortunately grandparents often had out-dated opinions regarding these topics (e.g. embracing bottle feeding and encouraging early weaning) as medical advice had changed over time, but they wanted to influence parent choices:

“My mum actually encouraged me to wean early which I think a lot of mums do because (name of daughter) was struggling and she wasn’t sleeping… so I did start a little bit early” (PG2M2).

In some cases the conflicting beliefs between generations in childcare practice put enormous pressure on parents to adopt undesirable feeding behaviour:

“My mum was like ‘well give him some baby rice give him some baby rice’ and I remember at 5 months I was pushed that hard that I offered him baby rice and he didn’t want it and I was like ‘see he doesn’t want it’” (PG2M1).

When parents were adopting a health guideline recommended practice, such as breastfeeding, that the grandparents did not believe in, or did not do with their children, it was hard for grandparents to provide support. This made the adoption of healthy feeding behaviours among the parents very difficult:

“No my mother-in-law was the same yeh she didn’t agree with breastfeeding at all… it was really hard cos she was the only other person I had as support apart from my husband” (PG2M2).

There was a feeling that grandparents might also take this change in practice as a personal attack:

“I think with her it’s because she bottle fed me and my sister and I think she felt it was a bit of a personal well are you saying it wasn’t good enough what I did” (PG2M3).

The constant pressure that was put on some parents by grandparents meant that they had to constantly justify their decisions why they had chosen to do something differently:

“And it’s really hard cos you don’t trust your own instincts do you… I used to have to have a book to sort of back it up… because otherwise you do feel so peer-pressured that you have to justify yourself don’t you as to why you do things” (PG2M1).

Despite all of the above, the parents reported that they had the final say as the carers respected their decisions. However, they described that this respect did not come easy and the parents had to be strong-minded and stubborn to get what they wanted. Interestingly, this respect for parents may be cultural. British grandparents were reported to respect the parent to have the final decision, whereas grandparents from other countries may not:

“Do you know what that’s quite interesting cos my mum’s not English, no my mums Dutch and they are very forthright people and she is less respectful of my opinions than my mother-in-law who is English” (PG2M3).

Although grandparents might promote bottle-feeding and early introduction of solid foods, their intention might be to be more helpful for the parents. For example bottle-feeding would allow other family members to feed the baby and to give the mother a break:

“I don’t think she (referring to her mother) does believe that bottle feeding is much better but that it is a lot easier, it means she could have helped so like especially when I used to have it really rough in the nights” (PG2M5).

Trade-off between receiving childcare support and maintaining control

As mentioned in Theme 1, an informal care arrangement usually arose from a relationship. This theme refers to the balancing act parents faced between maintaining that relationship yet also promoting healthy weight in their child. In terms of the trade off, parents received care for their children, but in exchange lost control over what the child ate as they felt unable to give healthier suggestions, as they did not want to affect their relationship with the carer. This was a common theme that arose in all parent groups but not discussed in the carer groups, suggesting that caregivers may be unaware the parents felt this way:

“Yeh rock the boat or be too critical, it’s the relationship that is there as well as the kind of helping you yeh giving you care so it would be very difficult” (PG1M4).

In some cases the parents relied on the care so much that they wanted to make it as easy as possible for the carer, so they did not feel comfortable giving suggestions regarding their feeding or activity. Parents also felt indebted to their informal carer and did not feel they could criticise what they were doing:

“You know my mum is doing me a huge favour by helping me out with this I can’t really say to her ‘come on down and I’ve got something stuck to the wall” (PG1M3, referring to an intervention suggestion given by another parent in the focus group).

Parents were also wary that suggestions might be taken as an insult and it might look like the parent did not trust the carer to feed their child. One mother also stated that she would feel more comfortable disagreeing with someone she did not know, as there was no relationship to think about:

“Yeh find that easier to say to someone I’m paying for it, but when it is a favour yeh to help you out its harder to say what you really want maybe” (PG1M1).

As one mother-in-law used to work in a nursery, she was likely to have had experiences of parents providing feeding suggestions for their children, so she was more receptive to suggestions:

“I know that she wouldn’t leave him crying because she knows that I don’t and it’s not her child and she is very good like that so maybe that does actually come from working with other people’s children and being used to that advice” (PG2M3).

Fewer opportunities for physical activity

This was a common perception across all stakeholder groups (i.e. both parents and carers). Childcare is a demanding task. Parents were younger and had more energy to keep up with children and keep them engaged in more active play. In contrast, most informal carers were grandparents who were older with a natural decline in energy levels. In addition, some grandparent carers in this study were still working; this could also lead to exhaustion:

“Certainly if grandparents as they are shortening their working day but they’re still at work to look after the kids then I think they’re probably knackered” (CG1G3).

As a result, screens, such as televisions and tablet computers, were often used as a way of entertaining or distracting children in order for the informal carer to get along with household tasks:

“I think as people get older they do get tireder and looking after kids as you get older is harder work you are more likely not to play with them you are more likely to… say ‘go and watch the tv or what about your computer or even do some drawing’ rather than playing outside” (CG1G3).

Parents recognised that their children would be more physically active if they were in formal care, and that activity levels were at their lowest in the winter months in informal care due to the weather. Equally, parents were aware that formal facilities were set up for outside play for all months of the year with toys under rain shelters and activities centred on the weather, so children were active throughout the year. In formal care:

“You wouldn’t have those hours where they would be sat down” (PG1M1).

Increased snacking

One common view among parents was that informal care, especially grandparent care, was more lenient. One grandparent gave a possible explanation for this:

“I think when it’s your grandchildren they say ‘please granny can I have it’ it’s very hard to not to be totally sort of ‘nope’” (CG2G1).

Multiple participants, including both parents and carers, were aware that grandparents treated their grandchildren with sugary foods such as sweets and chocolates:

“Well I must say I always had to prevent granddad buying packets of sweets… he would be thinking he was being kind” (CG2G2).

Theme 4: Potential intervention opportunities and strategies

Participants discussed potential strategies that would help parents gain support or understanding from grandparents/carers, and strategies that would support carers to promote healthy behaviours in the children in their care. Participants provided suggestions for implementation strategies related to the questions of ‘why’, ‘what’, ‘how’ and ‘when’ interventions should be delivered.

Why are interventions needed?

A common theme that emerged across all groups was that grandparents’ knowledge might need updating. As parenting and childcare advice change regularly, it was believed that grandparents’ knowledge was out of date owing to the fact that most of them raised their children decades ago. Specific learning needs were highlighted, including for example an update on nutritional advice (e.g. when to wean), and an understanding of the influence of time spent in front of screens. As parents and grandparents comment below:

“People will argue ‘oh well you’ve done it already because you had your own kids’ but actually society and we’ve talked about the screens and so on has changed so much” (CG1G3).

“Yeh there’s always different sort of nutritional advice changing and it’s always handy to know the up to date information” (PG1M2).

All parent groups discussed a second reason for educational intervention. Parents mentioned that when they wanted to choose a specific way for childcare/feeding, and ask grandparents to follow, it would be useful to have ‘back-up’, whether it was from professionals or in the form of a leaflet. Having this support from an outside source was repeatedly stated by parents as a positive way of decreasing the pressure from grandparents and as a gentle way of encouraging healthier habits. Parents felt that if grandparents were equipped with the knowledge then they could better support the parent in the decision they made.

“It’s almost like back up you say ‘this is the way I want you to do it, this (imitating a leaflet) is where I got the information from’ it might be quite helpful” (PG2M2).

What should be included in the intervention?

The participants also recognised that the intervention programme must be tailored to the different needs of the child at different ages and suggested that the content of the intervention should be divided into information for: 1) zero to 5 years; 2) under 1 year; and 3) over 1 year.

Information that was considered useful for all children aged 0–5 years included: recipe ideas, cookery lessons, activities to keep children entertained while carers are trying to do tasks, and signposting of events and days out in local area:

“New recipes… to help people think of different things to do for their children” (CG2G1).

“Say random days out and things to do” (PG1M1).

In terms of information for children aged one and under, participants suggested including: weaning advice, healthy snack suggestions, and a reference guide about sugar content in common drinks. It was preferred that advice at this age was mainly focussed on healthy eating and feeding:

“Healthy snacks is always a good thing, I think carers, not in my case, they’re the ones that ‘oh well give him a biscuit give him a bag of crisps’ you know cos you just run out of ideas sometimes” (PG2M2).

“And like about the drinks and stuff and… sugar in drinks” (PG2M1).

Participants suggested including the following information for children aged one and over: ways to increase activity level in informal care, and directing children away from screen time:

“Once they get to sort of from 3 to 5 I think you really need to focus on steering away from like tablets which are an easy thing to do” (PG2M1).

How can the intervention be delivered?

With regard to the question of ‘how’ interventions should be delivered, all participants welcomed the format of either workshops or leaflets for carers, containing the information listed above. However, both stakeholder groups recognised that a potential challenge with workshops is that people would not attend. It was also agreed that physical resources were better than Internet ones and that materials should be addressed to and target carers but re-phrase the word ‘informal’ as it may imply that the carers are not good enough. It was also suggested that communication should not make anyone feel targeted or criticised, and participation in any workshops should be voluntary and include the children as well:

“Even like a little leaflet book and it’s actually for carers outside parents so that you could give it to them and they could flick through it in their own time” (PG2M1).

“Make it friendly and not as if they’re being criticised” (CG2C1).

All parents shared the opinion that the information for carers is better provided from an outside source than from the parent themselves. They agreed that the education would be better coming from a healthcare professional, as grandparents would take the information more seriously, especially if their views were being challenged. Moreover, parents stated that they preferred to hear information and advice from healthcare professionals who were also parents themselves, as they understood better what the parent was going through. Parents stated that this would probably be the case with their informal carer too:

“I think it kind of would make it less awkward to approach my mother if ‘oh (name of son) got this at nursery and it’s for grandparents’” (PG1M3).

“I think if it’s somebody like a health care professional or somebody that is sort of qualified at the children’s centre I think they’re more likely to take what they say is the right thing” (PG2M1).

When and where should the intervention be delivered?

All study participants were aware that current and prospective informal carers and parents of children aged 0–5 years are very difficult to reach because they have little or no engagement with a formal site or institution. It was agreed that future interventions targeting this population should utilise existing primary care platforms to deliver an intervention with maximal reach and minimal costs. Existing and population-wide platforms include, for example, antenatal and postnatal health visitor appointments, child development check-ups or national routine vaccination appointments:

“The health visitor could say oh you know ‘who’s going to look after your child’… so that could be through a health visiting situation they could feed out you know because they would be talking to them hopefully… but you know if people are maybe thinking about going back to work just feed that into the information that’s available from a year on if you are going to have (an informal carer} these are the packs you can get” (CG2C1: Carer Group 2 Child-minder 1).

The participants also suggested using radio, newspapers and social media to distribute educational and supportive information on healthy weight promotion among children under 5 years in informal care, to reach people of all socio-economic classes.

Informal childcare is a popular choice for British parents. Despite the well-documented link between informal childcare and childhood obesity in children aged 0–5 years, no studies have explored potential explanations for this link. Moreover, no intervention programmes have been designed specifically for children outside formal care. This UK-based exploratory qualitative study explored the informal childcare arrangement from both parents and carers’ perspectives. It obtained insights into possible explanations for the relationship between informal childcare and obesity among children aged 0–5 years. Moreover, potential intervention opportunities and delivery strategies to support informal carers and parents to promote healthy weight in those children were also identified.

The importance of informal care to families and society was highlighted. We have identified that carers want to care, and they value the special bond they develop with the child in their care. This reasoning for caring was found in a previous study [ 33 ].

Informal carers were identified to provide practical, emotional and financial support for the family. Informal childcare, especially that provided by grandparents, is appreciated by parents and is an important source of financial support that permits parents to undertake paid employment [ 34 ]. In addition, grandparents may be able to spend more time with their grandchildren than the parents, enabling good social and emotional wellbeing in the grandchildren [ 26 ].

Four potential explanations for the evidenced link between childhood obesity and informal care were identified. The first relates to cross-generation conflict preventing adoption of healthy feeding practices within the family. Our findings have shown that grandparents may be influencing parents with out-dated information due to personal experience or preference, especially regarding breastfeeding and weaning. Initial breastfeeding [ 35 , 36 ] and baby-led weaning (as evidenced by case-control [ 37 ] and cohort studies [ 38 ]) have both been noted as significant protective factors against obesity in children. Formal and informal childcare is associated with a reduced likelihood of breastfeeding, when compared to parental care [ 2 ]. The influence grandparents have on breastfeeding initiation and early introduction of solid food is significant and is well documented in the literature. A recent systematic review of 13 studies from a range of low and high-income countries, found that if grandmothers had their own breastfeeding experience or were positively inclined towards it, then this would have a positive impact on the mother breastfeeding [ 39 ]. In addition, a German cohort study of 3822 mothers noted that if the maternal grandmother had a negative attitude towards breastfeeding the mother was up to 3.62 times more likely not to initiate breastfeeding [ 40 ]. Our finding that lack of emotional support from grandparents, due to differences in opinion, can have a negative impact on breastfeeding initiation and continuation is supported by the literature [ 41 , 42 ]. If friends, and family perceive that the mother should exclusively breastfeed the infant, the mother’s intention will be the same as that of the people around her [ 43 ]. Another reason for early weaning has been hypothesised. Grandparents often care for a group of children of different ages, so they may be more likely to encourage early introduction of solids to make mealtimes easier [ 14 , 16 ].

Participants described that despite instances of cross-generation conflict, grandparents respected the parents to have the final decision. However, participants reported this respect was cultural, with British grandparents being more respectful than those from other cultures. For example, in Chinese culture the infant feeding preferences of significant others in the family (especially the mother-in-law) are often followed by new mothers, even when they are different to the mother’s desires [ 44 ]. Recognising the impact of culture on parental and family decisions is of importance when designing future interventions, as Britain has a culturally diverse population.

A second potential explanation for obesity in informal care relates to the trade-off between parents receiving childcare for their children and losing control over feeding and activity choices. This trade-off has also been documented in two qualitative studies in the US. One of those reported that parents felt they had limited ability to control grandparents’ feeding practices as they relied on their care [ 45 ]. The other reported that mothers who accept support from their mothers may lose control over the food their children eat [ 46 ]. Future interventions should recognise this trade off that parents are balancing and should try to minimise the cross generation knowledge gap in childcare practice (as evidenced by this study) by providing the necessary knowledge and skills that grandparents need. This would help parents in receiving the valuable support from grandparents in terms of childcare without compromising the relationship.

Reduced energy capacity of informal carers, leading to decreased activity levels in the children, has been identified as a third perceived cause of childhood obesity. Parents consistently stated that their children were less active in informal care compared to formal care. This is a consistent finding with current British literature [ 20 ]. Interventions should incorporate a physical activity component, as physical inactivity and sedentary behaviours, including television watching, are repeatedly reported in the literature as being linked to childhood obesity [ 47 , 48 , 49 , 50 ]. Interestingly a mixed methods study, including both qualitative and cross-sectional aspects, conducted in China, offered a different explanation for decreased energy levels in informal care [ 51 ]. The study reported that due to the single-child family structure, grandparents tended to overprotect their grandchildren from household chores, therefore limiting their physical activity levels.

Increased food consumption in informal care was identified as a final perceived cause of obesity. These findings are in line with literature from Asia. A Japanese Cohort study found that compared to parental care, children who were cared for by grandparents at the age of 3 years had a higher prevalence of snacking and subsequently had a higher mean BMI over time [ 52 ]. Cross-sectional data of dietary habits and physical activity of 497 schoolchildren in China found that children who were primarily cared for by a grandparent consumed over two or more portions of unhealthy snacks per week than those children who were primarily cared for by their parents or other adults [ 51 ]. Qualitative data from the same study reported that grandparents overindulged their grandchildren and had misperceptions about what comprises a healthy diet in children.

The final theme of this study referred to potential intervention opportunities and strategies.

We identified that in order for informal carers to provide appropriate support to parents and to encourage healthy habits, their knowledge needs updating on current best practices. Grandparents have been reported to be the second most commonly cited source for information, after health visitors [ 53 ]. As the majority of informal carers are grandparents [ 2 ], this highlights the need to target up to date information and advice to this group. Participants identified that a way of achieving this could be via a brief intervention, centred on a leaflet, targeted to carers with the aim of preventing obesity in children in informal care. An intervention feasibility study that delivered an antenatal session centred on a leaflet written specifically for fathers and grandmothers about breastfeeding, found this to be acceptable, useful and enjoyable by all participants [ 54 ]. In addition, a recent English randomised control trial found a low-cost opportunistic 30-s brief intervention, delivered by primary care physicians, was acceptable to patients and an effective way to reduce weight in patients with obesity [ 55 ]. This intervention strategy could be adopted by future interventions targeting informal carers and adapted to include more topics related to healthy weight promotion in young children.

Adopting this approach would mean an existing primary care communication platform (such as a community midwife, health visitor or GP appointment) could be used, making it virtually cost neutral. Most previous interventions that aimed to prevent childhood obesity were labour intensive and required certain equipment or facilities. However, none of the recently completed large trials of childhood obesity prevention programmes in the UK showed evidence of effectiveness [ 56 , 57 ]. Involving informal carers in routine antenatal and postnatal appointments provided by the NHS may provide a window to access this hard to reach population, which would increase intervention uptake. Findings from a recent qualitative study in Canada support this idea [ 58 ]. The authors found that both physicians and parents engaged with and welcomed the idea of childhood obesity prevention interventions based within the primary care setting. However, two systematic reviews from the US that assessed paediatric primary care-based obesity interventions found that the majority of studies were based on obesity treatment, rather than focusing on obesity prevention [ 59 , 60 ]. This signifies that the evidence base regarding childhood obesity prevention in primary care is insufficient in terms of study quantity and quality, which highlights a need for a greater number of randomised control trials based in primary care that assess obesity prevention interventions.

Strengths and limitations

This is the first qualitative study specifically designed to explore potential explanations for the link between informal childcare and childhood obesity in children aged 0–5 years as evidenced by previous epidemiological studies in various countries. The study also generated rich insights into potential components and delivery strategies of future interventions. These findings could inform the development of tailored obesity prevention strategies targeted to informal caregivers and parents of children aged 0–5 years in this country. The suggestion for delivering interventions (e.g. educational information) to this difficult to reach target audience through existing points of contact with health care providers may be useful for example for, general practitioners, health visitors, and nurses who have direct and regular contacts with children under the age of five and their families. Moreover, multiple steps were taken to ensure the credibility of the results. These included involving a number of different researchers with mixed disciplinary backgrounds and experience in the data analysis process, and reporting the analysis methods and results transparently. Finally, gaining opinions from two sources, parents and carers, would allow tailored development of future interventions to both groups’ needs and wants, this may help uptake and success of the intervention in the future.

However, the results of this study should be interpreted with certain limitations. Firstly, despite numerous efforts to recruit both parents and carers into this study, only 14 participants took part in this study within our project’s limited timeframe. However, all the focus groups generated rich data and as discussed earlier, our findings are largely consistent with relevant, previously published literature. This indicates a level of validity of the study. Challenging recruitment has also provided valuable lessons for future studies whose success depend on the participation of informal carers. Effective recruitment strategies included advertising via social media, University mailing lists and word of mouth. Secondly, participants were mainly of Caucasian origin, thus potential cultural variations in the results could not be explored fully. This is significant due to the wide cultural diversity of the British population. Thirdly, all participants reported to have university or college level education so they might be more comfortable with educational interventions, compared to those with a lower level of educational achievement. Future studies should aim to include participants from more varied ethnic and socio-economic backgrounds.

Further research should explore the views of primary and community health care providers (e.g. antenatal midwives, health visitors, GPs and nurses) regarding potential opportunities and barriers for them to support or deliver an intervention programme that targets children under the age of 5 years in informal care for obesity prevention in those children.

This qualitative study, with both informal carers and parents of children aged 0–5 years, provided novel insights into the informal care arrangement. Potential explanations for the previously evidenced link between informal care and childhood obesity were identified. Conflicting opinions between older members of the family and healthcare professionals made adoption of healthy feeding practices, such as breastfeeding and baby-led weaning, difficult and almost impossible for some parents if they were not getting the support they needed. Parents reported a balancing act between receiving childcare for their children but in return losing control over the child’s feeding and activity levels, as they felt indebted to their carer. Both parents and carers identified that children in informal care have less physical activity than their peers in formal care, potentially due to advancing age of many informal carers, and eat more energy-dense snacks. Our findings highlight that education targeted towards informal carers will help them to support the parents, and also to prevent obesity in the children in their care. We propose that future childhood obesity prevention interventions aimed at this population are delivered via existing primary care platforms (such as midwife, health visitor or GP appointments) in order to provide a cost-effective approach to reach as many families as possible. Future research should explore the feasibility and acceptability of this intervention idea to healthcare professionals who have contact with children under five and their families.

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Acknowledgements

The authors gratefully acknowledge the contribution from all study participants.

University of Birmingham. The funder played no role in any part of the study.

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Eleanor Diana Lidgate and Bai Li contributed equally to this work.

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College of Medical and Dental Sciences, University of Birmingham, Birmingham, West Midlands, UK

Eleanor Diana Lidgate

Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, West Midlands, B15 2TT, UK

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BL (Principal Investigator) conceived the study idea and obtained the study funding. BL and AL (Co-Investigator) advised on the study design and implementation (data collection and analysis). EL recruited study participants and moderated all focus groups with support from BL. Data analysis was done by EL with contributions from BL and AL. EL produced the first draft of the manuscript which was critically revised by BL. All authors contributed to the revisions of the manuscript and approved the final version of the manuscript.

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Lidgate, E.D., Li, B. & Lindenmeyer, A. A qualitative insight into informal childcare and childhood obesity in children aged 0–5 years in the UK. BMC Public Health 18 , 1229 (2018). https://doi.org/10.1186/s12889-018-6131-0

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Childhood Obesity Research Demonstration (CORD) 3.0

Childhood obesity remains a pressing public health concern, affecting nearly 1 in 5 US children . In addition, some groups experience higher rates, such as children from lower-income families.

Building on previous CORD projects, CORD 3.0 research teams focus on adapting, testing, and packaging effective programs to reduce obesity among children from lower-income families. In addition, CORD 3.0 projects work towards programs that are sustainable and cost-effective in multiple settings. Research teams will translate these programs into user-friendly, packaged materials and messages for healthcare, community, or public health organizations.

CORD 3.0 has the potential to reduce childhood obesity by increasing the availability of effective family healthy weight programs for millions of children from lower-income families.

CORD 3.0 funds five recipients for 5 years (2019-2024).

• CORD 3.0 Publications

CDC launched CORD 1.0  in 2010 and funded four recipients to use a whole-community approach to address childhood obesity. Several sites saw reductions in children’s body mass index (BMI), a body measurement that can be used to screen for weight categories.

Findings from CORD 1.0 suggest that interventions that address two or more levels of influence, such as the patient, healthcare provider, family, or community, can improve childhood obesity prevention and management. In 2016, CDC launched CORD 2.0 , funding two recipients to continue to conduct research on the effectiveness of using obesity screening and behavioral counseling to combat childhood obesity. Recipients put into place and evaluated a family-centered, weight management intervention for children. Referrals to these interventions were based on electronic health records. Recipients also collaborated with state Child Health Insurance Programs and Medicaid offices to recommend sustainable and scalable program components.

An important step in translating evidence-based programs into routine practice is the creation of user-friendly intervention materials and messages. CORD 3.0 builds on prior CORD projects by increasing the availability and number of packaged, effective programs to address childhood obesity. Projects ensure that these programs can be used by healthcare, community, or public health organizations to serve families with lower incomes and that the programs are sustainable in multiple settings.

Title: A dissemination strategy to identify communities ready to implement a pediatric weight management intervention in geographically underserved areas. Authors: Golden C, Hill JL, Heelan KA, Bartee R, Abbey B, Malmakar A, Estabrooks PA. Journal: Preventing Chronic Disease Released: 2021 Link to Abstract:  https://www.cdc.gov//pcd/issues/2021/20_0248.htm

Title: Qualitative Comparative Analysis of Program and Participant Factors That Explain Success in a Micropolitan Pediatric Weight Management Intervention. Childhood Obesity. Authors: Golden CA, Heelan KA, Hill JL, Bartee RT, Abbey B, Estabrooks PA. Journal: Childhood Obesity Released: 2021 Link to Abstract: https://pubmed.ncbi.nlm.nih.gov/34780274/

Special supplement to the journal, Childhood Obesity: “Childhood Obesity Research Demonstration 3.0: Study Designs for Scaling Effective Pediatric Weight Management Interventions for High-Risk Children through Packaging and Implementation.”

Special supplement to the journal, Childhood Obesity: “ Childhood Obesity Research Demonstration 3.0: Study Designs for Scaling Effective Pediatric Weight Management Interventions for High-Risk Children through Packaging and Implementation.”

This supplement describes the study protocols and implementation and dissemination plans of five recipients of CDC’s  Childhood Obesity Research Demonstration (CORD) 3.0 Project , including their use of public health strategies to facilitate the spread and scale of family-centered, evidence-based pediatric healthy lifestyle interventions in venues engaged with low-income families.

Massachusetts General Hospital

Massachusetts General Hospital CORD 3.0 packages together two childhood obesity interventions –  Connect for Health  and the  Mass in Motion   Kids Healthy Weight Clinic – in collaboration with the American Academy of Pediatrics’ Institute for Healthy Childhood Weight. Massachusetts General Hospital works with three community-based health centers in Mississippi to ensure the packaged programs can be effective and sustainable in primary care settings where the majority of patients use Medicaid, and with substantially high prevalence of obesity.

The Miriam Hospital (Providence, Rhode Island)

The Miriam Hospital CORD 3.0 evaluates the  JOIN for ME  program in two settings: the housing authority and patient-centered medical home sites. The  JOIN for ME  program is a child weight management intervention that can be used in many community settings.  JOIN for ME  includes strong parental involvement and has found meaningful reductions in body mass index in children 6-12 years of age.

Stanford University

Stanford University CORD 3.0 uses technology, design, behavioral theory, and biomedical business innovation strategies to prepare the Stanford Pediatric Weight Control Program (SPWCP) to reach children throughout the United States. SPWCP is a family-based group program to address childhood obesity. Stanford University will evaluate the effectiveness of this program in four local organizations serving low-income families.

University of Nebraska

University of Nebraska CORD 3.0 builds on their previous work that adapted the Building Healthy Families (BHF) program to a micropolitan area of 10,000 to 50,000 residents. In the past BHF researchers saw significant decreases in child BMI. University of Nebraska CORD 3.0 will package BHF for successful adaptation to rural communities and other micropolitan areas to decrease the number of adults and children with obesity.

Washington University in St. Louis

Washington University CORD 3.0 evaluates the evidence-based Family-based Behavioral Treatment (FBT) for use in diverse primary care settings, such as in urban and rural communities, and with families with lower-incomes. FBT is a proven behavioral program that works with both children and parents. Research indicates that FBT can reduce child BMI, and the average parent loses about 20 pounds during treatment. This CORD 3.0 project tests whether FBT can be cost-effective and sustainable when used in diverse primary care settings.

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Nutritional Management in Childhood Obesity

1 Research Institute of Medical Nutrition, Kyung Hee University, Seoul, Korea

Hyunjung Lim

2 Department of Medical Nutrition, Graduate School of East-West Medical Science, Kyung Hee University, Yongin, Korea

The increasing prevalence of overweight and obese children and adolescents poses a major concern worldwide. Dietary practice in these critical periods affects physical and cognitive development and has consequences in later life. Therefore, acquiring healthy eating behaviors that will endure is important for children and adolescents. Nutrition management has been applied to numerous childhood obesity intervention studies. Diverse forms of nutrition education and counseling, key messages, a Mediterranean-style hypocaloric diet, and nutritional food selection have been implemented as dietary interventions. The modification of dietary risk in terms of nutrients, foods, dietary patterns, and dietary behaviors has been applied to changing problematic dietary factors. However, it is not easy to identify the effectiveness of nutritional management because of the complex and interacting components of any multicomponent approach to intervention in childhood obesity. In this review, we describe the modifiable dietary risk factors and nutritional components of previous nutrition intervention studies for nutritional management in childhood obesity. Furthermore, we suggest evidence-based practice in nutrition care for obese children and adolescents by considering obesity-related individual and environmental dietary risk factors.

INTRODUCTION

The childhood obesity epidemic has reached 124 million individuals, and nearly one in five children and adolescents are overweight or obese. 1 The worldwide trend in childhood obesity shows a steadily increasing body mass index (BMI) in children and adolescents across four decades. In East and South Asia, including South Korea, the BMI increase among children and adolescents has accelerated since 2000. 2 The prevalence of obesity in children and adolescents increased from 11.6% in 2008 to 17.3% in 2017. 3 Obesity in early life is of concern due to health consequences and its influence on later life. 4 Increased adiposity levels are strongly associated with developing metabolic disorders and signs of adverse cardiometabolic diseases. 5 The severity of these comorbidities typically increases with the severity of the obesity. 6

Dietary- and health-related behaviors and food preferences are established in early childhood and continue into adulthood. 7 Poor food choices and overconsumption are associated with a higher risk of developing obesity. 8 The prevalence of diet-related metabolic disorders such as obesity, glucose intolerance, elevated blood pressure, and dyslipidemia is increasing due to unbalanced food intake among adolescents. 9 Dietary factors are the most important factors associated with childhood obesity, 10 and prevalence rates of nutrition-related noncommunicable diseases such as obesity and diabetes in children and adolescents have prompted prioritizing healthy diets. 1

Dietary intervention and multisectoral approach intervention studies have reported positive changes in body composition and dietary factors for overweight and obese children and adolescents. 11 – 16 Dietary components such as energy-dense foods, sugar-sweetened beverages (SSBs) and patterns of processed food consumption are discussed among the modifiable risk factors associated with obesity in children and adolescents. 17 – 19 In the present review, we describe the dietary risk factors associated with childhood obesity and summarize the previous efforts at nutrition management in multisectoral interventions. In addition, we suggest customized nutrition care for obese children and adolescents to improve young children’s dietary factors.

DIETARY RISK FACTORS IN CHILDHOOD OBESITY

Numerous diet-related modifiable risk factors (nutrients, foods, dietary patterns, and eating behaviors) have been considered in previous clinical research studies and suggested in guidelines on childhood obesity ( Table 1 ). A higher intake of saturated fats and carbohydrates, including the overconsumption of energy-dense foods such as pizza, soda, and SSBs, has been associated with obesity in children and adolescents. 20 , 21 Dietary patterns during childhood have identified associations between diet and diseases such as diabetes, hypertension, cardiometabolic risk, and childhood obesity. 4 , 18 , 22 The Western dietary pattern, which contains high amounts of saturated fatty acids, is energy-dense, is micronutrient poor, and is limited in non-starch polysaccharides (fiber), is known to be a dietary risk factor encouraging childhood obesity. 17 , 23 Diet patterns that are rich in meat, soda, fried food, instant noodles, burgers, and pizza increased the risk of obesity by 30% compared to diet patterns rich in whole grains, legumes, potatoes, fish, mushrooms, seaweed, fruits, and vegetables. 24

Diet-related modifiable factors affecting childhood obesity

Guidelines and recommendations 17 – 19 , 23 , 24 , 26 – 34 , 36 – 40 of diet-related modifiable factors for nutritional management in childhood obesity.

Unhealthy eating habits and patterns formed during childhood have been associated with nutrition-related noncommunicable diseases such as obesity and diabetes. 25 Sedentary behavior among children and adolescents, higher intake of snacks, consumption of SSBs, fast food consumption, eating while watching television, skipping breakfast, reduced numbers of family meal times spent eating together, and lower daily intake of milk, fruits, and vegetables have all been associated with increased rates of childhood obesity, leading to adverse health and dietary outcomes. 26 , 27

Meanwhile, an adequate nutritional intake of vitamins and minerals, whole grains, milk and dairy products, fruits, and vegetables in a balanced diet has been found to not only protect growth but also manage childhood obesity. 17 , 28 – 31 In addition, it is recommended that proper dietary behaviors with family support include meals at home, eating together as a family, regular mealtimes, and portion sizes appropriate for the daily requirements of children and adolescents. 19 , 32 , 33

NUTRITION-BASED MULTIDISCIPLINARY INTERVENTION COMPONENTS AFFECTING CHILDHOOD OBESITY

Systematic reviews have suggested that multiple strategies and components and a multilevel approach that focuses on diet and health-related activities have provided the most sustainable and beneficial effects on childhood obesity intervention, rather than single-component interventions. 34 , 35 Furthermore, social support such as individualized coaching, text messaging, face-to-face communication, and Internet-based approaches with a theoretical background have been adapted to change obesity-related dietary behaviors in children and adolescents. 12 – 16 , 41 – 43 The most promising approaches for childhood obesity management are intervening with support at levels ranging from individual to community via sustainable and multisectoral strategies. 44

Let’s Move was a program of the U.S. government in collaboration with the American Academy of Pediatrics intended to provide Internet-based resources for BMI and diet and to develop activity screening in primary care, including counseling and advocacy methods for healthcare professionals. 11 Consistent with this initiative, innovative use of health information technology was implemented via individualized coaching for behavior change, 12 text messaging to provide outreach support for obesity management, 41 and study-specific website and email programs, which had achievements similar to those found with face-to-face support. 42

The B’More Healthy Communities for Kids trial was a multilevel childhood obesity prevention intervention guided by social cognitive theory, social ecology, and systems theory. According to these theories, psychosocial factors, social-environmental factors, and physical factors interact at multiple levels to shape health-related outcomes. 13 In this study, wholesalers, corner stores, take-out restaurants, recreation centers, and households worked together to improve availability, purchasing, and consumption of healthier foods and beverages (low sugar, low fat) in low-income African American zones in the city of Baltimore, MD, USA. 13

The Childhood Obesity Demonstration (CORD) project was designed to cover 4 years, including three grantees, Massachusetts (MA CORD), California (CA CORD), and Texas (TX CORD), funded by the Centers for Disease Control and Prevention. 14 This set of three unique multilevel, multi-setting demonstration projects aimed to prevent childhood obesity by supporting healthy eating and active living among 2- to 12-year-old children. The results from the MA CORD study included changes in organizational policies and environments to better support healthy living and improvements in health behaviors of children, parents, and stakeholders. 15

The identification and prevention of dietary- and lifestyle-induced health effects in children and infants (IDEFICS) study was developed by eight European countries to implement and evaluate diet- and lifestyle-related diseases and was strongly focused on childhood obesity in a large population-based cohort of 16,228 European children aged 2 to 9 years. 16 The IDEFICS intervention focused on the three main concepts of nutrition, physical activity, and stress, and it formulated six key messages. The prospective study reported that children consistently allocated to the “processed” cluster increased their BMI, waist circumference, and fat mass gain compared to children allocated to the “healthy” cluster. Being in the “processed”–“sweet” cluster combination was also linked to increased BMI, waist circumference, and fat mass gain over time compared to the “healthy” cluster. 43

RECENT DIETARY INTERVENTIONS AND OUTCOMES

We performed a systematic review of the literature for identifying the effectiveness of nutritional interventions using the electronic databases PubMed, Cochrane Library, and Web of Science, covering the past 5 years (2015 through August 2019). The following search terms were used: childhood obesity, obese children and adolescents, nutritional intervention, and dietary outcomes. Trials published in English were included in this study; the primary outcomes examined were energy, nutrient intake, fruit and vegetable consumption, and dietary behaviors.

Dietary interventions

Only articles on dietary outcomes were extracted from the databases by two researchers. Six studies 45 – 50 are summarized in Table 2 among the dietary intervention studies that were selected by titles and abstracts. Nutritional components (nutrition education, key messages, Mediterranean-style hypocaloric diet, and nutritional food selection) and outcomes (energy and nutrient intake; fruit, vegetable, and dairy product consumption; and dietary behaviors) of the dietary intervention studies are presented in Table 2 .

Changes in dietary factors and weight status of children and adolescents after participating in nutritional interventions

PA: physical activity; BMI, body mass index; CAFAP: Curtin University’s Activity, Food and Attitudes Program.

Nutrition education was delivered by health instructors at selected schools. Face-to-face training was used, with a book for guidance when necessary, for weekly nutrition sessions for the participants. Monthly lifestyle education sessions focusing on childhood obesity and its causes, cooking methods, and plans to reduce inactivity were provided to parents of the participants. 45 Curtin University’s Activity, Food and Attitudes Program (CAFAP) study focused on healthy food choices and key messages: eat more fruit; eat more vegetables; and eat less junk food. Regarding general nutritional themes, energy balance, food labeling, diet variety, fast food, lunchbox food, portion size, and recipe modification were the key topics reinforced in each session, delivered in 12 group education sessions with parents and adolescents together. Parents took part in nutritional sessions and in practical training in shopping at a supermarket and cooking classes for healthy foods such as fruits and vegetables. 46

The Intervention Grupo Navarro de Estudio de la Obe- sidad Infantil study consisted of an 8-week phase and a 2-year follow-up program. The usual care group received standard pediatric recommendations and anthropometric measurements, while the intensive care group was advised to adhere to a Mediterranean-style hypocaloric diet. Nutritional theme-based topics included controlling healthy lifestyle behavior, food preparation, portion control, eating behavior, food composition, and the importance of being physically active during leisure time. In addition, information on healthy lifestyles and how to manage obesity-related problems was provided to the caregivers by dietitians. 48

The Nereu Program (NP) was an intensive, 8-month, family-based, multicomponent behavioral intervention on healthy eating and physical activity in 6- to 12-year-old children who were overweight and obese. The NP consisted of the following four components: physical activity, family theoretical and practical training for parents, a behavioral component for both children and parents, and activities. For the usual treatment group, a 10-minute monthly family meeting based on the same NP components was provided over an 8-month period. Based on the food frequency questionnaire and main nutritional characteristics, the intervention addressed the following foods for participants and their families: all fruits, which have high levels of antioxidants, fiber, and vitamins; processed meats, which contain fatty acids; superfluous foods characterized by a high level of lipid content and/or simple sugars; and soft drinks, which have a high simple sugar content without nutrients. 49

The school-based Educació en Alimentació (the EdAl study) 50 program was designed to verify the sustainability of the benefits from a previous EdAl study by assessing the obesity-related outcomes and lifestyles of 13- to 15-year-old adolescents. The EdAl program was comprised of 12 educational intervention activities that were based on improving health-related habits such as nutritional food selection, hand washing, and avoiding sedentary behavior. 50

Energy and nutrient intake

Two studies reported higher energy, protein, and fat intake after the intervention compared to baseline. 45 , 46 Despite the lack of positive changes in macronutrient intake, lower levels of saturated fat and sugar consumption were presented in the CAFAP cohort study. In another multidisciplinary intervention study, lower energy intake and macronutrient intake were reported after the dietary intervention (at 8 weeks) in both the usual care group and the intensive care group. 47

Consumption of fruits, vegetables, and dairy products

Improvements in consumption of fruits and vegetables among the children and adolescents were reported in three of the multicomponent-approach intervention studies. 46 – 49 Smith et al. 46 stated that perceived fruit consumption and vegetable consumption of the participants were higher after the dietary intervention. Ojeda-Rodríguez et al. 47 and Serra-Paya et al. 49 presented higher levels of dairy product consumption as well as fruit and vegetable consumption after the intervention in both groups. Meanwhile, a 4-year follow-up study showed decreased consumption of dairy products, fruits, and fish among children and adolescents. 50

Unhealthy dietary behaviors

Lower consumption levels of sugar-sweetened juices and soft drinks and sweet, superfluous foods (cookies, pastries, dairy-based desserts, and French fries, which contain high levels of lipids and/or simple sugars) were shown after the dietary intervention in three of the preceding studies. 46 , 47 , 49

Body composition

Most of the studies showed decreased BMI z-scores of obese children and adolescents after 6 weeks to 6 months for each of the intervention studies. Theme-based nutritional sessions, involving portion size and food groups, 51 feelings of hunger and satisfaction, 52 nutrition counseling and phone calls, 53 nutrition education group sessions and leaflets for caregivers, 54 healthful and balanced diet with fruits and vegetables, 55 and healthy beverage intake and increased consumption of fruits, nuts, legumes, vegetables, fish, and dairy products 50 were implemented in childhood obesity intervention studies (data not shown).

EFFECTS OF INDIVIDUALIZED NUTRITIONAL MANAGEMENT ON CHILDHOOD OBESITY

There are numerous risk factors for obesity in children and adolescents, and these factors interact with a high level of complexity. The nutritional care process model (NCP) 56 ( Fig. 1 ) could be adapted well to this complex task through dietitian-delivered lifestyle interventions. 57 The Academy of Nutrition and Dietetics developed the NCP, a highly qualified systematic approach to care, by employing four interrelated steps: nutritional assessment, diagnosis, intervention, and monitoring/evaluation. There is a requirement for standardizing the NCP and increasing the quality and consistency of nutritional care by using the International Dietetics and Nutrition Terminology (IDNT). 58 , 59 Previously, we developed a study protocol 60 to manage the dietary problems of moderately to severely obese children and adolescents by adopting the NCP and IDNT. Three general domains—nutrition intake, nutrition clinical, and nutritional behavioral—were employed for nutritional diagnosis ( Table 3 ). Nutrition diagnosis is the act of identifying a disease or condition from its signs and symptoms by a dietetics profession. An identified nutritional problem is summarized into a structured sentence called a PES (Problem, Etiology, Symptom) statement. This statement is linked by the connecting terms problem/nutrition diagnosis related to etiology as evidenced by the signs and symptoms. The identified etiology, signs and symptoms point to a certain type of nutrition intervention and monitoring/evaluation that is needed. It is an important process in the implementation of a nutrition intervention and monitoring/evaluation of the NCP. A structured recommendation for nutritional management of childhood obesity was presented as a tool in another research study that helped practitioners structure their actions according to the four interrelated steps of the NCP model. This practice-based, evidence-informed approach assisted not only the dietitians but also the professionals in pediatric obesity. The NCP four-step structured framework made it possible to structure patient-centered nutritional care and management of childhood obesity. 61

Nutrition Care Process and Model. Academy of Nutrition and Dietetics. Adapted from Lacey and Pritchett. J Am Diet Assoc 2003;103:1061–72, with permission from Elsevier. 56

Adoptable nutrition diagnosis of NCP components employed while using IDNT for childhood obesity

NCP, nutritional care process model; IDNT, International Dietetics and Nutrition Terminology; DRI, dietary reference intake; FBG, fasting blood glucose; BMI, body mass index.

Dietary intervention with a multisectoral approach has had positive outcomes in modifying obesity-related dietary risk factors for obese children and adolescents. Excellent results from previous meta-analyses have reported a reduction in SSB intake and changes in body fatness, 62 reduction in high-fat food and sugary beverages, increased intake of fruits and vegetables, reduction in snacks, and maintenance of a balanced diet. 63

These positive changes were found immediately after the intervention; however, unfavorable outcomes were reported after long-term follow-up in terms of weight fluctuation, increased energy intake, macronutrient intake, and unhealthy dietary behaviors. Furthermore, it is hard to distinguish isolated impacts of nutrition care in childhood obesity because of the complex and interacting components of the multidisciplinary interventions. 64 Behavioral modification and motivational interviewing on the health and diet of children and adolescents, to improve their self-control and mindful eating for sustainable healthy weight and nutritional status, are required to provide nutritional education and management.

From this viewpoint, evidence-based practice in dietary problem solving can suggest effective methods by considering behavioral and environmental risk factors in a diet and providing tailored nutritional therapy according to the stages of change among children and adolescents. In spite of these beneficial effects, we are facing barriers to providing this intervention due to the time and cost of developing more methods for countering childhood obesity. For this reason, individual, familial, social, and political-level involvement are recommended for effective and sustainable nutritional management of childhood obesity. In addition, practical key messages for health and diet may be helpful in establishing healthful habits and lifestyles in this public health crisis.

ACKNOWLEDGMENTS

We thank Seran Choi and Nayoung Kim from Kyung Hee University for assisting with the review and identifying recent intervention studies.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

AUTHOR CONTRIBUTIONS

Study concept and design: HL; analysis and interpretation of data: JK; drafting of the manuscript: all authors; critical revision of the manuscript: all authors; administrative, technical, or material support: JK; and study supervision: HL.