It should be considered that nutritional approaches targeting childhood obesity are not limited to restricted energy intake but rather, the most appropriate nutrition strategy for long-term weight reduction and the promotion of metabolic and mental health is shifting to healthy food choices [43] that include predominantly whole food plant-based sources [44,45]. This dietary pattern restricts added sugars, refined grains, sweetened beverages, fast foods, calorie-dense snacks, and high-fat processed foods and includes fruits, vegetables, nuts, and whole-grains along with well-structured meal frequencies [6,44,46]. The weight-related benefits rising from plant-based diets are attributable to a reduced caloric intake and an increase in postprandial energy expenditure by a higher thermogenic response [47,48]. Additionally, whole food plant-based diets lead to favorable changes in cardio-metabolic and digestive health, which are both associated with further weight-related advantages as well [49,50]. Increasing nutritional literacy of children and their parents (regarding agriculture, food industries, food safety, cooking, and theoretical knowledge of energy balance, nutrition, and diets) could further promote sustainable changes that contribute to healthier dietary patterns [51]. While these are general principles and recommendations, no single diet should be prescribed or recommended as the best for all children with obesity [43]. Researchers believe that the optimal macronutrient composition depends on factors such as appetite, thermogenesis, energy homeostasis, and gut microbiota [52]. Furthermore, the ideal diet for treating overweight and obesity should be safe, efficacious, nutritionally adequate, culturally acceptable, and economically affordable [43]. To date, however, the majority of nutritional strategies targeting childhood obesity are still based on a “one-size-fits-all” model, which does not take into account the inter-individual variability [53], which often results in a reduced adherence rate to dietary changes [54].

On the other side of the energy balance equation, PA has been emphasized as a critical component for healthy body weight. Promoting PA is considered an effective intervention strategy in pediatric weight management [55,56], which attributes to the concept of energy flux [19]. Energy flux represents the rate of energy expenditure and energy intake [19,57], and a higher energy flux (obtained by increased PA) results in better regulation of energy balance during weight loss [57] and/or the prevention of weight gain [58]. PA could also result in favorable improvements in mental and physiological health, and both are indirectly associated with further weight-related advantages [59]. In children and adolescents with obesity, the most common barriers to engage in regular PA programs are lack of self-discipline, lack of someone to engage in PA with, self-consciousness about appearance [60], and decreased level of motivation due to the limited motor abilities and/or being out of shape [61]. Daily physical activities of children are not limited to regular physical education classes or sport/exercise engagements. Active travel to school, unstructured active play during school recess, and activities at home or playgrounds can be additional viable PA sources [32]. Currently, however, due to the COVID-19 pandemic and social lockdowns, the movement opportunities have been significantly diminished [62], and home exercises have been highly recommended [63].

In addition to diet and PA, other lifestyle parameters (e.g., psychological behaviors, modifying sleep patterns) are considered effective interventions in weight management programs. Independently or along with educational interventions, additional lifestyle behaviors could further increase the efficiency of PA and dietary interventions [1]. A controlled experimental study showed that a two-year, multi-component obesity intervention focusing on a lifestyle educational curriculum resulted in beneficial changes in Body Mass Index (BMI) percentiles in the intervention groups [64]. There is also evidence suggesting that mindfulness interventions [65,66] and forethoughtfulness (defined as being oriented more towards the future than the present) [67] might be advantageous for improving obesity-related eating and behavioral patterns. Mindfulness, defined as the awareness that arises from purposefully paying attention in the present moment with non-judgment [68], is suggested as an effective intervention strategy targeting childhood obesity [69]. Evidence also indicates that sleep is an important modifiable risk factor for managing childhood obesity, as eating and PA behaviors can be affected by the quality and duration of sleep [70]. Modifying sleep patterns in school-age children resulted in healthy dietary patterns via decreased food consumption, in particular, thus promoting favorable weight outcomes [71].

In general, it has been well-established that multi-component interventions including PA, nutritional, lifestyle, and educational strategies have been shown to yield better outcomes than single-component strategies [1,41,72]. In a systematic review of the effectiveness of lifestyle interventions targeting children’s weight and cardio-metabolic health, beneficial outcomes were observed only following the multi-component interventions [73]. However, due to the complex interaction in these approaches, identifying the degree of effectiveness for each component remains controversial.

Parental beliefs, attitudes, behaviors, and social support are vital for a child’s health and body composition [76]. Available evidence indicates that parents are involved in about half of the interventions targeting childhood obesity, and successful improvements on children’s BMI are in 75% of studies with parental involvement [74]. Results show, from a meta-analysis of 22 randomized control trials examining home-based interventions to control childhood obesity, that parents can play a crucial role in managing children’s weight by facilitating, motivating, and coaching the healthy behaviors of their children [77]. Due to the close familiarity of parents and their child, parents may better understand and consider the lifestyle parameters contributing to the development of obesity in their child [78]. Although parent-only interventions may be more cost-effective compared to school- and community-based programs [79], evidence suggests to combine home-based programs with other settings to deliver more favorable effects on anthropometry and BMI in children [80]. The effectiveness of grandparental supervision, on the other hand, has been reported to be close to zero with no association between children’s BMI z-scores and grandparental child care (whether as the primary caregiver or co-residence) [81].

School is an important setting for improving child health behaviors, as children spend a significant part of their daily life in schools [82,83]. Moreover, the following conditions of the school environment also benefit the setting for implementing overweight/obesity-related interventions: schools offer a structured environment for applying interventions with ease; schools may provide one or two meals per day and, therefore, potentially dictate healthy food choices in their cafeteria; schools usually provide opportunities for PA and active games during recess and daytime; schools produce and expand extracurricular educational resources and wellness policies for both children and parents; schools could run an indirect competitive and encouraging atmosphere to promote children’s motivation and adherence towards interventions; schools could introduce their physical education instructors and/or athletic trainers as role-models; schools benefit from the contribution of staff and teachers to facilitate, deliver, and supervise the interventions [74,84,85]. Interestingly, successful school-based interventions are also highly effective in improving children’s anti-obesogenic behaviors at home [83]. However, because of time and budget constraints, many schools are not able to implement health and weight management programs [72].

In addition to home- and school-based strategies, the community environment and clinical settings are also common areas for managing childhood obesity and prevention [20,75]. Community interventions targeting obesity incorporate policies and strategies and aim to reduce the population risk of obesity [75]. These interventions involve but are not limited to the availability and use of health and fitness facilities, media-based activities, and health-oriented businesses by local and central administrations [1,86]. The EPODE program (Ensemble Prévenons l’Obésité Des Enfants: together, let us prevent childhood obesity) could be considered a successful example of a community-based intervention, which emphasizes a multifactorial approach targeting childhood obesity at different community levels [87]. Interventions using a community-based approach could achieve the long-term goals of reducing the prevalence of childhood obesity [88], especially for children who live in low-income societies [75]. Clinical or primary-care interventions, on the other hand, include any medical or non-medical strategies implemented by healthcare and pediatric specialists [89]. Clinical and community-level interventions can significantly improve lifestyle patterns when applied simultaneously [90]. Significant improvements in body weight have been achieved in pre-school children aged 2–5 years following multi-component clinical interventions (e.g., PA, nutrition, education) with parental involvement [91]. However, reports from different meta-analytic studies indicate poor effectiveness of primary-care programs on childhood obesity [89,92,93], which might be attributed to a dose-response relationship, where the frequency and duration of treatment contact highly affect the outcomes [1]. Additionally, the “sustainability” of intervention effects could be another limitation in clinical approaches, as the time of engagement is limited compared to other settings [94,95].

 

In general, it seems that due to the multi-factorial nature of childhood obesity, a maximally efficient strategy to manage childhood obesity requires integrating multiple settings for delivering multi-component interventions. Evidence shows that school-based interventions with family inclusion have the largest effect on weight outcomes when multi-component programs are implemented, including PA and diet [84,96]. Results from a study comparing the effectiveness of home versus school settings on nutritional habits, PA behaviors, and BMI changes showed that the home environment had a stronger association with health in general compared to the school setting [97]. It should be mentioned, however, that parental involvement in many preventive studies can be more effective in pre-school and early-school children, whereas school- and community-based intervention strategies lead to more favorable outcomes in older children and adolescents [1], particularly for those who are above twelve [98]. Nevertheless, to enhance the effectiveness of strategies, it appears important that parents permanently engage in supporting and reinforcing their children’s health behaviors [99].

Some limitations can affect the progress of weight management programs, similar to any preventative and therapeutic strategy. Time and financial resources are major limitations for the implementation of multi-component weight management strategies [100]. In addition, poor awareness and lack of self-discipline have been reported as personal barriers when adhering to a healthy lifestyle [60]. Furthermore, difficult-to-reach goals set by parents and clinicians are considered a vital but hidden limitation, as it is well-established that strict targets may often lead to failure in weight control programs in children [101]. Age also appears to be an important moderator for weight control outcomes as older children displayed larger and more beneficial effects than younger children following weight-management interventions [92,93]. Beyond these limitations, the obesity prevention strategies seem to follow a dose-effective manner, as more intensive and longer-lasting interventions are associated with better outcomes in children [93]. Further, it appears that purposeless and/or unsupervised strategies not based on the individual needs and personal characteristics of the targeted child could minimize intervention effects [54].