1. Introduction

There is a need for providing an up to date guidelines on childhood obesity and its comorbidities in high-risk minority populations based on understanding the prevalence and effectiveness of preventative lifestyle interventions. First, we highlight how inadequate obesity screening by body mass index (BMI) can be resolved by using objective adiposity fat percentage measurements alongside anthropometric and physiological components, including lean tissue and bone density. National healthcare childhood obesity prevention initiatives should embed obesity cut-off points for minority ethnicities, especially Asian and South Asian ethnicities within UK and USA populations, whose obesity-related metabolic risks are often underestimated. Secondly, lifestyle interventions are underutilised in children and adolescents with obesity and its comorbidities, especially in minority ethnicity population groups. The overwhelming evidence on lifestyle interventions involving children with obesity comorbidities from ethnic minority populations shows that personalised physical activity and nutrition interventions are successful in reversing obesity and its secondary cardiometabolic disease risks, including those related to cardiorespiratory capacity, blood pressure and glucose/insulin levels. Interventions combining cultural contextualisation and better engagement with families are the most effective in high-risk paediatric minority populations but are non-uniform amongst different minority communities. A sustained preventative health impact can be achieved through the involvement of the community, with stakeholders comprising healthcare professionals, nutritionists, exercise science specialists and policy makers. Our guidelines for obesity assessment and primary and secondary prevention of childhood obesity and associated comorbidities in minority populations are fundamental to reducing global and local health disparities and improving quality of life.

Disparity in childhood obesity: There are wide gaps in the prevalence of childhood obesity within high income countries (HICs) based on factors such as ethnicity and socioeconomic status [1-3]^[1][2][3]. Within most western HICs such as USA, UK, Australia and New Zealand, minority ethnicity populations exhibit a higher prevalence of childhood obesity than their white counterparts [1,2]^[1][2]. In the USA, for example, data from the 2011–12 National Survey of Children’s Health and the 1999–2014 National Health and Nutrition Examination Survey of 6–17-year-olds showed that about 25% of black, Hispanic and American Indian/Alaska Native were obese, compared to 12% among non-Hispanic white American children ^[4]. Similarly, in England, children from black ethnic groups have greater odds of being obese or overweight compared to white children (Odds Ratio of 1.7 and 1.4 for Black Caribbeans and Black Africans respectively) ^[5]. In England, deprivation is often a factor in explaining long term conditions such as obesity, and the prevalence of obesity among children living in the most deprived areas is more than double that of those living in the least deprived areas. Similarly socioeconomic status is another factor as children from households with a low income and low education in the USA were reported to have about four times higher odds of obesity than children from households with a higher income [1,5]^[1][5]. Therefore, in HICs, intervention for the prevention of childhood obesity should be designed to address both the risks of disparities directly as well as the socioeconomic drivers of childhood obesity.

Ethnic disparities in the prevalence of childhood obesity are evident across several HICs (Table 1). However, the prevalence among minority ethnic groups is not uniform, but Black, Asian and Hispanic ethnicities tend to show the highest prevalence of childhood obesity, and a higher risk of developing associated comorbidities especially hypertension, type-2 diabetes and fatty liver. Except for Chinese people in the UK and Non-Hispanic Asians in the USA, all minority ethnicities have a higher prevalence than their white counterparts (Table 1). In fact, Chinese ethnicities in the UK exhibit a lower burden of disease than white counterparts ^[1]. Despite ethnic minorities in western HICs being very diverse, interventions are very challenging, and one size does not fit all. Therefore, there is need for contextualised approach to the prevention of and interventions for obesity and its comorbidities within populations at higher risk from minority ethnicity groups who are disproportionately affected.

Table 31. The prevalence of childhood obesity by ethnicity in selected HICs.

Lifestyle Interventions and guidelines on childhood obesity in minority ethnicity populations: Lifestyle Interventions are effective: Lifestyle prevention of disease is well established across adult groups for a range of long-term conditions, including obesity, diabetes and cardiovascular disease [1,6,7]^[1][6][7]. We have also shown that they are effective in Children populations ^[10]. However, some HICs health authorities and funders still resist implementing lifestyle interventions in their populations due to their perceived implementation barriers and cost-effectiveness, with major negative consequences for high-risk groups, including children and minority ethnicities. For example, in the UK an NICE statement in 2011 concluded that the implementation of obesity-related lifestyle, PA and nutrition interventions in high-risk ethnic minority groups in England was not effective due to perceived cultural, religious and familial engagement barriers in high-risk ethnic minority populations [8]^[8]. Lifestyle characteristics apply to all populations that present with obesity, not only those considered minorities. Therefore, understanding why some population groups, especially those from minority ethnicities, who have a higher prevalence of obesity and its comorbidities, are hard to reach is crucial to implementing effective lifestyle interventions.

Contrary to the perception that a lack of health awareness causes minority ethnicities’ lack of engagement in lifestyle interventions, the existing evidence suggests other factors, especially the methods of engagement and cultural context. For example, a qualitive study of healthy eating and PA in children aged 8 to 13 in a multi-ethnic community, found that awareness of key dietary messages and an emphasis on dietary variety and balance were high among the entire population, but for ethnic minorities, places of worship were key focal points for social support through which they could be fully engaged [9]. Furthermore, our preliminary study in the North East of England showed that parents were fully aware of their children’s obesity and its comorbidities’ status but were less aware of the available preventative support from the National Health Service, especially lifestyle and weight management services [11]. Therefore, a dichotomy exists between health provision and end users, such as between what is offered by the health authorities and what minority ethnicities perceive as being offered. A more direct and engaging “bottom-up” approach is likely to be most effective in minority ethnicities within HICs. Our work We recommend the following as shown below (Table 2).

References:

1. Alkhatib, A.; Obita, G. Childhood Obesity and Its Comorbidities in High-Risk Minority Populations: Prevalence, Prevention and Lifestyle Intervention Guidelines. Nutrients2024, 16, 1730. https://doi.org/10.3390/nu16111730
2. Obita, ; Alkhatib, A. Disparities in the Prevalence of Childhood Obesity-Related Comorbidities: A Systematic Review. Front. Public Health 2022, 10, 923744. https://doi.org/10.3389/fpubh.2022.923744.
3. Isong, A.; Rao, S.R.; Bind, M.A.; Avendaño, M.; Kawachi, I.; Richmond, T.K. Racial and Ethnic Disparities in Early Childhood Obesity. Pediatrics 2018, 141, e20170865. https://doi.org/10.1542/peds.2017-0865.
4. Singh, K. Chapter 7—Trends and Contemporary Racial/Ethnic and Socioeconomic Disparities in US Childhood Obesity. In Global Perspectives on Childhood Obesity, 2nd ed.; Bagchi, D., Ed.; Academic Press: Cambridge, MA, USA, 2019; pp. 79–94. https://doi.org/10.1016/B978-0-12-812840-4.00007-4.
5. Zilanawala, ; Davis-Kean, P.; Nazroo, J.; Sacker, A.; Simonton, S.; Kelly, Y. Race/ethnic disparities in early childhood BMI, obesity and overweight in the United Kingdom and United States. Int. J. Obes. 2015, 39, 520–529. https://doi.org/10.1038/ijo.2014.171.
6. Alkhatib, ; Tuomilehto, J. Lifestyle Diabetes Prevention. In Encyclopedia of Endocrine Diseases, 2nd ed.; Huhtaniemi, I., Martini, L., Eds.; Academic Press: Oxford, UK, 2019; pp. 148–159. https://doi.org/10.1016/B978-0-12-801238-3.64358-1.
7. Robinson, S.M. Preventing childhood obesity: Early-life messages from epidemiology. Nutr. Bull. 2017, 42, 219–225. https://doi.org/10.1111/nbu.12277.
8. Type 2 Diabetes Prevention: Population and Community-Level Interventions: Public Health Guideline. 2011. Available online: https://www.nice.org.uk/guidance/ph35/resources/review-2-interventions-to-reduce-risk-factors-for-prediabetes-among-uk-adults-from-black-and-minority-ethnic-groups3 (accessed on 19 March 2024).
9. Rawlins, E.; Baker, G.; Maynard, M.; Harding, S. Perceptions of healthy eating and physical activity in an ethnically diverse sample of young children and their parents: The DEAL prevention of obesity study. J. Hum. Nutr. Diet. 2013, 26, 132–144. https://doi.org/10.1111/j.1365-277X.2012.01280.x.
10. Obita, ; Alkhatib, A. Effectiveness of Lifestyle Nutrition and Physical Activity Interventions for Childhood Obesity and Associated Comorbidities among Children from Minority Ethnic Groups: Systematic Review and Meta-analysis. Nutrients 2023, 15, 2524. https://doi.org/10.3390/nu15112524.
11. Obita, G.; Burns, M.; Nnyanzi, L.A.; Kuo, C.-H.; Barengo, N.C.; Alkhatib, A. Childhood Obesity and comorbidities-related perspective and experience of parents from Black and Asian Minority Ethnicities in England; a Qualitative Study". Public Health 2024. DOI: 10.3389/fpubh.2024.1399276