The prevalence of obesity has surged in the setting of the obesity epidemic. Among U.S. children and adolescents 2-19 years old, over the ten years between 2007-2008 and 2017-2018 the prevalence of obesity increased from 16.8 percent to 19.3 percent while severe obesity rose from 4.9 percent to 6.1 percent. Nationally, a greater percentage of non-Hispanic Black and Hispanic children are affected. It is particularly important to address obesity during childhood, as there are life-long health effects including increased morbidity and mortality stemming from the higher risks of developing diabetes, several autoimmune diseases, kidney disease, and mental health impacts of stigmatization. The 2023 American Academy of Pediatrics Clinical Practice Guidelines emphasize the role of social determinants of health as risk factors for increased prevalence of obesity among children and adolescents. The guidelines highlight how experiencing inequality throughout one’s life contributes to differences in disease prevalence among different racial, ethnic, and socioeconomic groups. Treatment requires addressing these inequities at different levels. Here we will focus on identifying disparities at the primary care level that can inform risk assessment and possible interventions to improve the care of children with obesity. 

Sociodemographic factors and social determinants of health

When considering population-level data, certain patient characteristics may be either risk factors for or protective factors against childhood obesity. A large cross-sectional study using the U.S. National Survey of Children’s Health data found that children of male gender or identifying as Hispanic were more likely to have obesity than their counterparts, and children of single parents had higher rates of being overweight than those growing up in dual-parent households. The prevalence of obesity and overweight also increased with worsening levels of poverty. Protective factors for healthy weight included parents with education beyond the high school level and having private insurance. It has also been shown that the cardiometabolic health of the mother at the time of her pregnancy is a predictor of childhood obesity, and maternal cardiometabolic health itself varies by education status and insurance type (public versus private).

Social determinants of health such as food insecurity, housing insecurity, access to education, community resources, and access to health care all play an important role in relation to disparities in obesity care. Living in a higher-opportunity neighborhood with regards to access to education, positive environmental factors, and on-average higher socioeconomic success may offer some protection against childhood obesity compared to living in more vulnerable neighborhoods. Children with food insecurity have a greater risk for obesity, especially within the early childhood period and if food insecurity is chronic over time. This association may be due to several factors including eating/feeding behaviors and access to grocery stores with nutritious and fresh foods. The presence of factors such as proximity to fast food and lack of access to healthier food options, crime rate, places that are safe to exercise, and environmental toxins increase risk. Furthermore, the degree of intersectionality of risk factors may compound each other. Children who present with a history of adverse childhood experiences (ACEs) also have a greater probability of developing obesity. Of note, across these social risk factors, girls seem to have increased sensitivity when compared to boys. While it is important to consider each patient as an individual, these factors can help identify children with a greater likelihood of presenting with obesity due to structural and social barriers.

Community resources availability 

Considering the importance of community factors in relation to obesity risk, leveraging community resources and opportunities for partnering with them is of utmost importance as we think about treatment plans. There are a number of resources within communities shown to affect children’s health overall such as sidewalks or walking paths, having a playground or park, a recreation center, and a library or access to a bookmobile. Specifically, access to community amenities has been shown to impact the rate of obesity. Children who live in neighborhoods with either one or zero amenities are 27 percent more likely to have obesity or overweight as compared to children who live in a community with full amenities. As primary care providers, advocating for the availability of community resources such as nutrition programs and opportunities for physical activity is important, since those patients most likely to benefit from these resources may also live in communities without them.

Communication with children and families

Good communication can shape patient care, but initiating the conversation about weight with families is difficult. The lack of understanding of the complexity of obesity may transmit internal bias about body weight that will ultimately shape how we discuss a patient’s health. Language and cultural barriers pose an additional challenge. Providers and interpreters need appropriate training in using first-person language and defining obesity as a disease. The message and translation should focus on obesity treatment rather than the need for weight loss. Appropriate training of all those involved in communication with families will ensure that the message that reaches the patient and helps shape clinicians’ views of obesity is both free of stigma and culturally appropriate. Seeking creative and efficient ways to communicate with our patients may also promote health. The Greenlight Plus Trial, a randomized controlled trial using an individualized, texting-based digital intervention to support healthy behaviors during the first two years of life, showed improved weight-for-height trajectory in a racially and ethnically diverse group of families. This trial highlights the critical importance of engaging our pediatric patients’ guardians and caretakers in their treatment plans. The impact of adults modeling healthy lifestyle practices including physical activity, diet, screen time, stress management, and sleep must be considered and actively supported.

Referral to specialized care

Many aspects of pediatric obesity are managed within primary care, however severe obesity and the presence of comorbidities warrant sub-specialty referral. As pharmacotherapy becomes more widely available for the pediatric population, it is important to understand how the use of medications—particularly GLP-1 receptor agonists—will affect this population. One modeling study was able to suggest that while the use of these medications could lead to an absolute decrease in the prevalence of childhood obesity, it has the potential to exacerbate existing racial and ethnic disparities in obesity rates. Even with equal utilization of these medications, there would still be a larger proportion of the population from racial and ethnic minorities that have obesity, putting them at risk for further obesity-related comorbidities. While pharmacotherapy has helped to change the landscape of pediatric obesity management, there is still the need to deliberately address social determinants of health—such as community resource availability—in order to equitably treat obesity.  

Looking to the future for childhood obesity treatment

The care of children with obesity in the primary care setting poses many challenges. There is a growing number of families seeking care as this epidemic affects more children at younger ages. Further, sociodemographic differences present a challenge that goes beyond the care given inside the clinic. Policy changes are necessary. However, the impact primary care can have on healthy practices cannot be underestimated. Pediatricians and family doctors play an essential role in the care of children with obesity and their families’ lives. Given the complexity of this disease, clinicians taking care of children need a support system. Partnering with community resources, understanding the pathophysiology and management options, optimizing communication, and designing a comprehensive referral system to allow for escalation of care based on severity are needed.

Additional information

The Connect for Health Program at the Mass General for Children has online resources available for families and medical professionals to support healthy lifestyles, including advice on diet, sleep, physical activity, behavioral goals, and screen time.

Connect for Health is also a pediatric weight management program that can be integrated into regular pediatric visits. For clinicians wishing to implement this model of support for children and families within their primary care practices, a free implementation guide is available.

This article was published as part of a series for Obesity for World Obesity Day, March 4, 2025. View the full Special Series for more articles and messages from the editors regarding language and content.

Special Series

About the authors

Leora Allen, MD is a pediatric endocrinology clinical and research fellow. Her primary research interests are obesity and its related complications, including Type 2 Diabetes Mellitus. She is working on the DISCOVERY Study, which is following children at risk for Type 2 Diabetes to better determine risk factors of Type 2 Diabetes and strategies to prevent its onset. She is committed to pediatric research to build the evidence base to address our greatest health challenges in children, among which are obesity and its complications.

Rachel Whooten, MD, MPH is an Assistant Professor of Pediatrics at Massachusetts General Hospital for Children in Boston, Massachusetts. She is board certified in Pediatrics, Pediatric Endocrinology, and Obesity Medicine. She has a longstanding interest in community-based strategies for healthy lifestyles, specifically relating to physical activity promotion in childcare and schools as well as clinical settings. She is currently supported by a K23 award from NIDDK addressing physical activity as a potential strategy for PCOS prevention.

Jacqueline Maya, MD is a Pediatric Endocrinologist and junior faculty Physician-Investigator at Massachusetts General Hospital (MGH) and Harvard Medical School. Clinically, she practices pediatric endocrinology at the Massachusetts General Hospital for Children at the Boston and Chelsea sites and obesity medicine at the MGH Weight Center. Her current research is supported by the American Diabetes Association and MGH Physician/Scientist Development Award. Her research focuses on risk factors that contribute to the development of childhood obesity and diabetes to work towards interventions that decrease the risk of developing diabetes and other long term cardiometabolic complications over the life course.

**Feature photo obtained with a standard license on Shutterstock. 

Interested in other articles like this? Subscribe to our newsletter.

Interested in contributing to Perspectives in Primary Care? Review our submission guidelines.