Obesity Medicine 22 (2021) 100327

Contents lists available at ScienceDirect

Obesity Medicine
journal homepage: www.elsevier.com/locate/obmed

Review

A community perspective of COVID-19 and obesity in children: Causes

and consequences
Maido Tsenoli a, Jane Elizabeth Moverley Smith b, Moien AB Khan c, d, *
a
Community Healthcare NHS Foundation Trust, Birmingham, B32 2TR, UK
b
Bodreinallt Surgery, NHS Wales, Conwy, LL32 8AT, United Kingdom
c
Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, 15551, United Arab Emirates
d
Primary Care, NHS North West London, London, TW3 3EB, UK

A R T I C L E I N F O A B S T R A C T

Keywords: The pandemic of childhood obesity that has been increasing over the last decade has collided with the current
COVID-19 pandemic of COVID-19. Enforced behavioural changes have resulted in a myriad of problems for children
Childhood obesity particularly in weight management. Restricted activity is the most obvious but many other aspects of life have
Pandemic
exacerbated biological, psychosocial, and behavioral factors identified as risks for childhood obesity. Significant
Primary care
Community interventions
effort is required to turn around the prevailing tide of weight gain necessitating changes in personal and family
Biopsychosocial model behavior and diet, as well as high-level governmental and educational policy. Evidence-based, focused, long-term
interventions which are adequately funded are required. Enthusiasm and optimism for change coupled with
public engagement by utilization of new technology as well as traditional methods offers hope for change. Public
health interventions in isolation are inadequate and bolder changes to central policies and social structure are
needed for sustained change. This will allow some mitigation of the affects of COVID-19 but also reduce negative
outcomes in future comparable situations.

1. Introduction
Childhood obesity is a major and rapidly accelerating public health
challenge (Wang and Lobstein, 2006). Recent governmental strategies to
minimize the spread of COVID-19 through school closures, lockdowns,
and alterations in social interaction have complicated childhood weight
management efforts (Workman, 2020) Widespread disruption of normal
educational and social routines has affected 75% of the world’s students
(Di Pietro et al., 2020), and, as school closure is associated with weight
gain (Rundle et al., 2020), and the precipitous nature of school closures
has led to rapid increases in body mass for some children. Children with
higher body mass index (BMI) have greater risk of poor outcomes from
COVID-19 infections. This is in addition to having increased rates of
morbidity and mortality from obesity-related chronic diseases (Eriksson
et al., 2003; Zachariah et al., 2020). Other added burdens of childhood
obesity are lower educational achievement and psychological distress
(Rankin et al., 2016).
COVID-19 has put more strain and burden on the healthcare system
(Al Falasi and Ab Khan, 2020). Health inequality has been apparent for
years, but the present pandemic has highlighted its effects due to the
catastrophic outcomes of many of the affected obese victims of
COVID-19 (Martin-Howard and Kyle Farmbry, 2020). The bio­
psychosocial (BPS) model underpins the complex dynamic interactions
between the biological, psychological, and social constructs causing
obesity (Engel, 1978). In 2020, the world has witnessed perhaps a
greater exacerbation of these biopsychosocial factors than ever before.
Visualizing the effect of the pandemic from the perspective of the BPS
framework allows identification of the causes and manifestations of
weight gain in children. This approach will help identify strategies for
weight management in children during pandemic conditions from a
community perspective. We also appraise policies in th is review to
mitigate the factors leading to childhood weight gain in future
situations.

* Corresponding author. Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Tawam Hospital Campus, Al
Ain, 17666, United Arab Emirates.
E-mail address: moien.khan@uaeu.ac.ae (M.A. Khan).

https://doi.org/10.1016/j.obmed.2021.100327
Received 12 November 2020; Received in revised form 6 February 2021; Accepted 10 February 2021
Available online 15 February 2021
2451-8476/© 2021 Elsevier Ltd. All rights reserved.
M. Tsenoli et al.
2. Biologicalfactors
2.1. Obesity and immune dysregulation; added risks of COVID-19 in
obesity
The severity of many viral infections is positively correlated with
obesity, and COVID-19 is no exception. Whilst children generally have
mild symptoms from COVID-19 infections, those with obesity are at
increased risk of serious disease. Adipose tissues is an active endocrine
organ and excess causes a low grade inflammatory state (Finelli, 2020;
Steene-Johannessen et al., 2010) with increased production of multiple
proinflammatory adipokines such as leptin, TNF-α and IL-6 (Finelli,
2020). Inflammatory markers are raised and the pre-existing state of
subclinical inflammation, heightenen by daily stress, reduces immunity
to viral illnesses such as COVID-19 (Khedri et al., 2020). Children
infected with COVID-19 have an altered and overactive immune system
with an increased production of inflammatory markers such as such as
CRP, IL-6 or IL-1 (Finelli, 2020). Though children have milder symptoms
from COVID-19 infections, due to a differential expression of cell surface
enzyme angiotensin-converting enzyme 2 (ACE2) (Gabbert et al., 2010;
Luzi and Radaelli, 2020). The risk of severe disease increases and a child
with a raised BMI is more likely to be hospitalised with COVID-19 (Chao
et al., 2020; Zachariah et al., 2020). Vulnerability is further heightened
by low levels of physical activity imposed by lockdown which reduces
pro-inflammatory cytokine inhibition and macrophage activation (Luzi
and Radaelli, 2020). Obesity is more common in deprived socioeco­
nomic communities and in ethnic populations and so the observation of
higher mortality and morbidity in these groups can be explained
partially through immune dysregulation secondary to excess adipose
tissue (Iguacel et al., 2018).
Ethnic origin also has links to severe disease via Vitamin D levels.
Vitamin D deficiency has been linked to worse COVID-19 outcomes
(Grant et al., 2020). Vitamin D is postulated to have anti-inflammatory
and anti-microbial properties, decreasing the production of inflamma­
tory cytokines (Grant et al., 2020). Overweight children are therefore at
risk from adipose tissue activity, biome changes and vitamin D
deficiency.
A further immune dysfunction common to both obese children and
COVID-19 patients is an altered gut biome with changes in Firmicutes/
Bacteroidetes ratio (Indiani et al., 2018) and altered colonized Lacto­
bacillus and Bifidobacterium bacterium. An increase in opportunistic
gut pathogens and reduction in beneficial commensals is seen in
COVID-19 patients and thought to be related to disease severity (Zuo
et al., 2020).
3. Psychosocial factors and behavioural change
3.1. Family and school
COVID-19 has altered many aspects of family life that will impact on
childhood weight gain. Determinents of weight are at work from birth,
and factors such as maternal weight gain in pregnancy, parental smok­
ing, infant feeding methods and parental obesity all contribute (Griffiths
et al., 2010). COVID-19 lockdown may well have affected these
influences.
Behavioural changes steming from school closures will have weight-
related consequences. School holidays have been shown to result in
weight increases (Franckle et al., 2014) and this is more pronounced in
those of ethic backgrounds and those already overweight (Franckle
et al., 2014; Hawkins et al., 2009). Rapid childhood weight gain is
particularly significant as a predictor of adult obesity (Griffiths et al.,
2010) and that experienced during school breaks is likely to be swift.
Quick weight gain also predisposes children to obesity-related medical
conditions, such as insulin resistance, type 2 diabetes, hypertension, and
dyslipidemia in adolescence (Khan et al., 2019; Silva et al., 2020).
Reasons for this ‘holiday’ change in weight can be related to more
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Obesity Medicine 22 (2021) 100327
time spent on eating, access to food, particularly unhealthy choices is
easier, and eating larger food portions more frequently in the presence of
others is observed (Díaz-Zavala et al., 2017). At the same time, those
more deprived children experience food insecurity, having limited and
unreliable access to healthy food at home. The lack of school meals can
result in malnutrition (Van Lancker and Parolin, 2020) and obesity
(Eisenmann et al., 2011). Country of origin, racial and ethnic differences
are also implicated (Cecchini and Vuik, 2019; Inchley et al., 2016).
These observations, seen in prearranged school holidays, are likely to be
reflected in lockdown closures although, as these have been unplanned
and prolonged, the outcomes are likely to be more significant.
3.2. Screen and media time
During lockdown, children tend to spend more time online and
watching television (Nagata et al., 2020). Concerns exist regarding the
influence of repreated exposure to aggressive advertising by food man­
ufactuers on TV, the internet and through video games. The practice of
promoting unhealthy food choices directly to children has recently
intensified. (Castelló-Martínez and Tur-Viñes, 2020; Khajeheian et al.,
2018; Radesky et al., 2020). Recognition of this trend, in 2020, led the
UK government to place a ban on TV advertising before 9 p.m. of foods
high in fat, sugar, and salt.
A focused family meal time is a recognized protective factor against
obesity (Fiese et al., 2012) and this is being eroded with the observation
that half of children’s meals are consumed in front of a screen (Khan
et al., 2019; Matheson et al., 2004). Reduced recognition of the
importance of meal times is associated with being overweight.
Furthermore, dining in front of the television is associated with un­
healthy foods and snacking (Trofholz et al., 2019)
3.3. Physical inactivity
Lockdown has had substantial effects of levels of childhood physical
activity. The lockdown enacted in response to COVID-19 has altered
lifestyle patterns, possibly exacerbating weight gain (Khan and Mover­
ley Smith, 2020; Rundle et al., 2020). The forms of routine physical
exercise that are ordinarily practiced by children, such as walking to and
from school, have been lost (Margaritis et al., 2020), and the closure of
parks and other leisure facilities has made exercise difficult. Outside
activity is believed by some to increase the risk of infection; therefore,
some children have been rendered housebound. Anxiety related to
perceived risk, and low motivation are cited as reasons for reduced play
activity (Hiatt et al., 2012). All age groups have been affected, including
pre-school infants, for whom interaction with peer group friends is vital
(Loades et al., 2020).
3.4. Psychological factors
COVID-19 has had significant effects on the mental health of both
adults and children with 25% of adults and 14% of children reporting a
deterioration (Patrick et al., 2020). Parental pressures have been
intensified by the pandemic, namely employment and financial insecu­
rity, home educating and relationship strain. There have also been more
incidents of domestic abuse and family breakdowns. Stresses are trans­
mitted to children, adding to their psychological burden which naturally
has a negative impact on children’s wellbeing (Woo Baidal et al., 2020).
Reduced social interaction also causes feelings of isolation and
loneliness, which can precipitate or worsen mental health disorders
(Hiatt et al., 2012; Margaritis et al., 2020) and such psychologial diffi­
culties can lead to emotional eating in adolescents (Gouveia et al., 2019)
which in turn is associated with obesity.
3.5. Health inequalities and poverty
Health inequalities seen in vulnerable populations and ethnic groups
M. Tsenoli et al.
have been highlighted during the pandemic (Townsend et al., 2020).
Poverty, ethnicity, living conditions, density of population and under­
lying medical conditions have had both a direct and indirect impact on
both COVID-19 infections and obesity (Townsend et al., 2020).
Food insecurity, discussed earlier, can cause long-term develop­
mental, psychological, emotional, and physical distress, even when it is
of a short duration (Balanzá–Martínez et al., 2020; Branscum et al.,
2010). Vulnerable groups tend to have lower educational attainment
and limited access to technology and the internet. Van Lancker and
Parolin (2020) gave food security as an example of a many recurring
social problems that persists through generations when inequalities
relating to education and social advancement are not addressed.
4. Perspectives and solutions
The impact of lockdown conditions on weight gain in vulnerable
children needs acknowledgment and future planning is required to
minimize resultant health problems and avoid future repetions.
As the OECD reports, many countries have developed strategies to
address obesity, but often these are limited to adults. Childhood obesity
tends to be neglected, and few child-specidic policies have been imple­
mented. The high risk from severe COVID-19 infections among the obese
population must intensify public health efforts to reduce childhood
obesity. Addressing modifiable factors is of paramount importance and
one of the most compelling is that of poverty. Other socio economical
factors such as food insecurity, poor physical health and lower educa­
tional attainment, deprived communities need central policies to
improve their outcomes.
Food insecurity and malnutrition emerging from a lack of food access
during school closures requires direct governmental action. Provisions
to bridge the gap such as the “Grab-n-Go” meal scheme in South Car­
olina, in which five days’ worth of food was given to those normally
receiving free school meals, have proved popular (Dunn et al., 2020).
This offers advantages over vouchers in that a balanced diet can be
guaranteed. In the UK’s “Healthy Start” scheme successfully used tar­
geted vouchers enable low-income families with children under the age
of five to receive help with milk, fruit, and vegetable costs (McFadden
et al., 2014). Highlighting healthy food choices and advocating physical
activity via TV and multi-media interfaces is a beneficial means of
promoting healthy behaviors among teenagers which has been utilized
in the English campaign “change4life” (Fiese et al., 2012).
It is apparent from evidence regarding the influences behind weight
change during lockdown that family relationships and functioning play
a significant role (Skelton et al., 2020). Early intervention in family
nutritional education such as promoting breastfeeding, weaning
appropriately, regulating portion size for children, and encouraging
heathy food choices, enhance self-regulation, which, as we have seen, is
a key feature in maintaining a healthy weight. Improving parental skill
in managing children’s feeding is essential (Cormack et al., 2020; Ord­
way et al., 2018). Hiatt et al. (2012) have identified challenges such as
financial and time constraints as well as a failure of parental engagement
Parent-child relationship and the familial relationship to food and eating
are influential in weight gain (Savage et al., 2007) so providing educa­
tion regarding diet and the provision of healthy meals and avoiding the
unrealistic assumption that children will choose healthy options over
unhealthy ones will be rewarding (Tan and Holub, 2011). The emer­
gence of virtual parenting groups allows parents and professionals to
share child-rearing tips, including advice on healthy eating, physical
activity, and behavior management.
Psychological stress and tension, which have been exacerbated
during lockdown, can also be alleviated by the practice of mindfulness.
Achieved in a variety of ways, mindfulness can be comforting and
relaxing (Seabrook et al., 2020). Successul use of mindfulness involving
children and their parents has reduced childhood weight gain. (Jas­
treboff et al., 2018). Seabrook et al. (2020) have used virtual reality
technology effectively with positive outcomes (Seabrook et al., 2020).
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Obesity Medicine 22 (2021) 100327
Table 1
Childhood obesity prevention and management recommendations during
COVID-19 pandemic.
RECOMMENDED INTERVENTIONS REQUIRED FROM STAKEHOLDERS
Government/Regulators
Scale up childhood obesity prevention policies (Pietrobelli et al., 2020; Vidgen et al.,
2018; Wang and Lobstein, 2006).
Deliver advertising promoting healthy choices during lockdown (Radesky et al.,
2020).
Maintain services for childhood obesity prevention (Inchley et al., 2016).
Increase and support research that look at consequences of extended school closures
on obesity. (Radesky et al., 2020; Rundle et al., 2020).
Healthcare providers
Adopt service delivery that is cost-effective and COVID-19-secure by using telehealth
to deliver services (Cohen et al., 2012; DeSilva and Vaidya, 2020; Fedele et al.,
2017; Woo Baidal et al., 2020).
Support creativity in families by providing activity packs (Tan and Holub, 2011).
Consider modular teams for continuity of services (Hiatt et al., 2012).
Make mental health services available for children as well as their parents (Zhang
et al., 2020).
Provide vulnerable families with activity packs that will help decrease screen time (
Tan and Holub, 2011).
Provide virtual parenting lessons aimed at behavior change (Woo Baidal et al., 2020).
Utilize self-weighing with e-scales alongside weight management discussion. (
Johansson et al., 2020).
Offer relationship counseling to reduce family breakdown. (Woo Baidal et al., 2020).
Schools
Prioritize physical education alongside traditional subjects during lockdown (Rundle
et al., 2020).
Require daily physical activity within school hours (Rundle et al., 2020).
Integrate physical movement into routine lessons (Rundle et al., 2020).
Social media, influencers, and technology
Work with governments to enhance healthier advertising options (Khajeheian et al.,
2018).
Create age-appropriate apps that encourage physical activity (Khajeheian et al., 2018;
Partridge and Redfern, 2018; Seah and Koh, 2020).
Create video games that discourage and decrease physical inactivity (Khajeheian
et al., 2018; Woo Baidal et al., 2020).
Provide mindfulness apps and virtual reality technology (Seabrook et al., 2020).
Utilize the appeal of apps and capitalize on their use to promote behavior change (
Shomaker et al., 2019; Partridge and Redfern, 2018).
Families
Develop and encourage virtual education for parents to promote breastfeeding,
discourage early weaning, and encourage appropriate portion sizes for infants and
children and healthy food choices (Skelton et al., 2020).
Self-monitor physical activity and nutritional intakes and set goals (Griffiths et al.,
2010; Skelton et al., 2020).
Focus and increase parents’ role modeling of healthy lifestyles, physical activity, and
healthy food choices (Griffiths et al., 2010; Skelton et al., 2020).
Encourage children to join their parents when they go out for daily allowed exercise or
walks during lockdown (Skelton et al., 2020).
Such methods of delivery may be extremely valuable in times of con­
strained activity, as they can allow a sense of escape from COVID-19
restrictions. Already proven to improve sleep and reduce overeating
(Shomaker et al., 2019; de Carvalho et al., 2017), mindfulness has great
potential and should be encouraged.
Although using information technology (IT) for interventions have
often been sidelined in the past and considered inadequate, the evidence
now suggests that both preventative and management measures can be
delivered remotely and cost-effectively with high levels of engagement
and client satisfaction (Cohen et al., 2012). IT has been utilized in a
number of ways; virtual parenting groups allows parents and pro­
fessionals to share information and interventions for children with
eating disorders. Behaviour management though personalized digital
packages aimed at changing responses are being developed. Weight loss,
healthy food choices, and increased physical activity have been suc­
cessfully achieved in adolescents in the short term, with improvement in
BMI and lifestyle changes (Fedele et al., 2017). Teenagers have suc­
cessfully increased their physical activity with the aid of mobile appli­
cations (Seah and Koh, 2020) and virtual groups in New York have had
positive outcomes regarding increasing physical activity (Woo Baidal
et al., 2020). The regular monitoring of weight at home using electronic
M. Tsenoli et al.
Fig. 1. Biopsychosocial factors that influence COVID -19 pandemic related obesity in children.
scales that transfer data to mobile applications is associated with a
greater reduction in weight along with positive patient experience
(Johansson et al., 2020). The development of more culturally sensitive
and appealing presentations directed at behavioural change and health
promotion will engage our target audience and encourage perseverance.
The smart use of personalized apps can encourage behavioral change
even when children are confined to their homes.
IT or “Telehealth” can overcome many barriers associated with
limited patient resources (Davis et al., 2020; Woo Baidal et al., 2020).
Telehealth bypasses non-engagement because of travel issues or costs
and possibly reduces patient embarrassment due to lack of visual con­
tact. Furthermore, the evidence indicates that the feeling of being
judged reduces clients’ trust in their healthcare providers (Pont et al.,
2017); and virtual services may circumvent thisemotion and enhance
engagement. “Telehealth” allows sustained continued remote care
despite COVID-19 restrictions and limitations (Davis et al., 2020).
Table 1 places the complex biopsychosocial interactions that need to
be considered when managing weight gain are considered along side
necessary involvement of stakeholders to ensure a cohesive and effective
response. Due to the very nature of the BPS model, the response needs to
be multifaceted, multidisciplinary and involve a wide range of interested
parties. An accurate understanding of the biopsychosocial interactions
that contribute to weight gain and weight management, properly
applied, will support more effective management of weight gain during
and beyond the pandemic.
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Obesity Medicine 22 (2021) 100327
5. Implications for practice
The family, community, home and school environments have
changed in unimaginable ways during the COVID-19 pandemic. The
juxtaposition of another pandemic, that of childhood obesity, has
created a perfect storm, increasing the risk of developing adiposity as
well as worsening pre-existing obesity (Browne et al., 2021). Socioeco­
nomic, psychosocial, cultural, genetic, behavioral, psychological, and
environmental factors all play a part (Hiatt et al., 2012) similar to other
chronic diseases (Khan et al., 2020). COVID-19 has had a significant
impact on many of these variables (Fig. 1). emphasizes the complex
biopsychosocial interactions that need to be considered when managing
weight gain.
Although there is no quick fix that can solve all weight management
problems in children during the pandemic, interventions can still be
delivered while adhering to social distancing and lockdown rules,
especially through novel channels such as telehealth and software ap­
plications. However, technology alone is not enough. Close communi­
cation between parents, schools, and communities will allow integrated
care, even when further lockdowns or school closures cause stress for
children; this important role shows us that we must provide adequate
funding for the initiatives described above.
The COVID – 19 pandemic has amplified the need for an integrated
interdisciplinary approach to weight management. The collision of both
the obesity and the COVID-19 pandemic due to an abrupt and dynamic
M. Tsenoli et al.
change in the biopsychosocial environment has put children at an
increased risk of obesity and,therefore, at increase risk of serious COVID-
19 disease(Browne et al., 2021). To produce effective programs that will
both prevent and combat childhood obesity, governments, public health
organizations, educational establishments, primary health teams, and
local communities must be engaged. It is essential that all stakeholders
review critically the biopsychosocial needs of our children. Such an
approach will aid in significantly reducing the negative impact of
obesity and COVID-19 (Browne et al., 2021).
Patient consent for publication
Not required.
Ethics approval
Not required.
Authors contributions
MT, MABK contributed to the conceptualization and carried out the
literature review. MT, MABK and JEMS contributed to the writing of the
review and editing of all the drafts. All authors read and approved the
final version.
Funding
No funding was involved in the preparation of this review.
Declaration of competing interest
None declared.
Acknowledgment
None.
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