Collateral Damage from the COVID-19 Pandemic: Pediatric Obesity

As we struggle with the COVID-19 pandemic, we face a serious secondary health consequence: the increase in pediatric obesity. The Centers for Disease Control and Prevention's most recent data from 2017 to 2018 notes that 19.3% of American children (14.4 million) were considered obese. ¹ Beginning in March 2020, with at least 50.8 million public school closures across the United States, children were forced into new daily routines, making them vulnerable to conditions correlated with obesity, such as increased screen time, worse nutrition, and decreased physical activity. ² Although school closures were a critical step in containing the pandemic, COVID-19 has created or exacerbated unhealthy conditions for children that must be addressed by families, pediatricians, schools, and communities.

In a recent article in Pediatrics, Jenssen et al. analyzed 500,417 pediatric visits in the Children's Hospital of Philadelphia Care Network between January 1919 and December 2020. They saw an increase from 13.7% to 15.4% for children of ages 2 to 17 years who were categorized as obese. ³ Increased pediatric obesity and other COVID-19–associated effects were particularly associated among those children with social vulnerability and disparities in health care access. ³ Poverty is perhaps the universal thread that threatens children's ability to be healthy. Obese children are at high risk of becoming obese adults, with all the concomitant chronic health problems: diabetes, hypertension, and cardiac disease among others. ⁴ We need to make pediatric obesity a national health priority.

School closures immediately placed millions of children at risk for food insecurity, a status associated with five times higher risk for pediatric obesity than children from food-secure households. ⁵ Before the pandemic, public elementary, middle, and high schools provided food through the National School Lunch Program (NSLP) to combat food insecurity with nutritious lunches. The NSLP lunches are aligned with the Dietary Guidelines for Americans (2020–2025 edition) to ensure that students receive adequate amounts of protein, calcium, iron, vitamin A, and vitamin C. ⁶

However, when the COVID-19 pandemic caused school closures in March 2020, students had limited access to school-provided lunches. A study in Philadelphia showed that, with just 3 days of school closures, 405,000 children missed meals, with an increase in purchases of high calorie processed foods. ⁷ More specifically, during the pandemic, data suggest that children ate 18% more salty snacks, 20% more sweet snacks, and drank 18% more soft drinks. ⁸

Another way in which school closures increased the risk of childhood obesity was through the loss of structured programs that encourage physical activity. Public elementary, middle, and high schools incorporate physical activity during the school day, something that children may not have access to otherwise. ⁹ Recess is critical to children's access to the outdoors and exercise, and can also help children develop healthy routines. Similarly, physical education offers an opportunity for children to exercise in a structured environment playing games or on teams.

Both of these mainstays of school schedules help to safeguard children's health and protect against increased rates of obesity. ¹⁰ During the pandemic, however, many children's opportunities for physical activity were sharply curtailed. Urban children, especially, were profoundly affected as safe outdoor spaces were not very accessible to them, and social distance measures were enforced. ⁷ In addition, not only were many children forced to stay inside, they also spent more time in sedentary activities such as playing video games and seeing friends on screens. ¹¹

Children's use of technology these past few years has grown exponentially, as children were spending an average of 3 hours on screens per day (prepandemic), and now spend an average of 6 hours daily on screens. Often, screens offer their only human engagement with peers. ¹² Ellis et al. report that, among children, “Beyond COVID-19 stress, more time connecting to friends virtually during the pandemic was related to greater depression.” ¹³ Increased depression and obesity have emerged as critical downstream effects of the COVID-19 pandemic.

Some will argue that there are more pressing national crises than childhood obesity, but it is important to remember that childhood obesity serves as a marker for other underlying social, economic, and health issues. It is a vital sign for the health of our society and we ignore it at our peril. Addressing pediatric obesity through orchestrated efforts by families, communities, schools, and health care providers will have important effects on all health parameters.

We are in the midst of navigating the collateral damage from the COVID-19 pandemic. Although school closures were clearly necessary to prevent further spread of COVID-19, they also exacerbated existing inequities and put poorer children, if not all children, at risk for obesity. By closing the schools, we were also forced to see the disparities that many children navigate daily including poor diet, no place or space for physical activity, and an increase in screen time. Through these three key changes in children's daily habits and their negative repercussions, it is now clear that we must take action.

We are confident that families, pediatricians, schools, and communities can address childhood obesity in a variety of ways to ensure the long-term health of children in the United States. We believe that we should declare pediatric obesity a national health crisis. We need a coordinated national effort from families, schools, communities, and health care workers to develop nutrition, exercise, and education programs that reach into and are driven by our communities.

We believe an obesity czar should spearhead these efforts, similar to prior federal leadership on drug abuse and the COVID-19 pandemic. Hand in hand with locally driven community-based efforts, we believe we can make an impact. Health care providers need to discuss a child's BMI. Families need to be educated about proper nutrition. Communities need to expand sports programs and parks, making exercise easier to access and fun. We need to make pediatric obesity part of the national dialogue on health to protect our kids.

Authors' Contribution

All authors contributed to the conception, design, writing, and editing of this project.