Shifts in Child Health Behaviors and Obesity After COVID-19

As COVID-19 captured the world’s attention, a more silent epidemic grew in its wake. Pediatric obesity rates in the US rose from 19.3% in August 2019 to 22.4% in August 2020.¹ The rate of child body mass index growth (calculated as weight in kilograms divided by height in meters squared per unit of time) nearly doubled during this time, from 0.052/mo prepandemic to 0.100/mo midpandemic, despite a relative stabilization in previous years.¹ The recent rise in obesity and body mass index disproportionately affected youths with preexisting overweight, those of color, and those from low-income households, exacerbating existing health inequities. The increase in obesity reflects a deterioration of health behaviors,² fueled by pandemic disruptions (eg, physical distancing; remote school, work, and socializing) that worsened existing systemic inequities. In this article, we examine recent behavioral shifts in children’s diet, physical activity, sleep, and screen time from a health equity perspective and provide upstream interventions to support overall child health.

System-level disruptions in food economies along with rising inflation critically hindered healthy food availability, accessibility, and affordability, resulting in nearly 33.8 million people experiencing food insecurity in 2021, according to the US Department of Agriculture. Estimates were even higher among low-income, Black, and Latine households and those with children,³ many of whom experienced disrupted access to school meals with school closures. The pandemic also adversely affected eating behaviors and diet quality. Emotional overeating (a coping response to pandemic-related stress, isolation, and boredom) and snack consumption between meals increased among children during spring of 2020.⁴

School and community disruptions also reduced moderate-to-vigorous physical activity among youths by an estimated 17 min/d between 2020 and 2022.⁵ School and childcare closures meant that most children, particularly those from historically disinvested communities, lost critical access to organized activity and unstructured free play. The closure of activity spaces like community centers, gyms, and even parks and playgrounds in some localities prevented many children from engaging in physical activity outside the home. Socioeconomic disparities in physical activity and obesity risk subsequently widened,⁶ with youths residing in higher-income households and those in safer, greener neighborhoods better equipped to find alternative means for physical activity. Physical activity during confinement was especially challenging among those facing extreme weather conditions,⁷ which serve as another barrier to outdoor activity.

Youths also experienced sleep disruptions in the first year of the pandemic, due in part to heightened family stress and altered routines, which were more severe among economically insecure households.² Notably, children of color experienced the greatest decrease in sleep duration from prepandemic (July 2019 to March 2020) to postpandemic (December 2020 to August 2021) timeframes, exacerbating existing racial sleep disparities rooted in structural racism.⁸ These shifts in sleep patterns during critical developmental periods have significant implications for overall child health, impacting hormone regulation, diet, activity levels, and chronic disease risk across the life span.

With nearly all forms of education, social connection, information sharing, and entertainment pivoting to the virtual world, new screen time norms have been established. Globally, screen time use among youths increased by 52% (approximately 84 additional daily minutes), according to a systematic review of studies spanning 2020 to 2022.⁹ While online platforms offer important opportunities for connection and community building, excessive screen use is linked with heightened risk of depression, anxiety, and mood disorders as well as increased obesity, non–high-density lipoprotein cholesterol level, and diabetes risk among youths.

As we navigate the aftermath of the COVID-19 pandemic, addressing this complex interplay of new societal shifts in child health behaviors requires comprehensive, multisectorial, and upstream approaches that address the social and structural determinants of health. We offer 4 guideposts to target these concerning trends.

First, the shift from food security (access to adequate amounts of food) to nutrition security (equitable access to nutritious, affordable foods) is critical. One approach, aligning with the Society of Behavioral Medicine’s Call to Action in 2021, is to enhance access and participation in federal nutrition assistance programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP), which support healthier household-level grocery purchases and community-level food retail economies. Providing subsidies for healthy produce, ensuring consistent access to free nutritious school meals, and implementing healthy food environmental policies (eg, zoning and land use policies to increase grocery stores and farmers markets in historically disinvested areas) are additional strategies to promote healthy eating at a systems level.

Second, environmental planning, community investment, and family support are pivotal for promoting youth physical activity. Advocating for policies and initiatives to maintain safe outdoor and indoor spaces year-round, as the American Medical Society for Sports Medicine has done, with priority given to neighborhoods most in need, is necessary to bridge disparities in physical activity opportunity. Adapting zoning laws can encourage mixed-use development, reduce urban sprawl, and enhance walkability and bikeability. Allocating additional resources to schools, community-based recreation programs, and youth organizations that serve economically diverse households and subsidizing costs for low-income families can further facilitate physical activity inide and outside of school.

Third, with record-high screen time and social media use among youths, technology can play a significant role in promoting healthy behaviors. Tech companies can partner with health experts to develop high-quality, evidence-based digital health apps for children and families that offer nutrition education, meal planning support, age-appropriate exercise routines, and sleep improvement strategies. Smart devices can be used to monitor children’s sleep patterns, physical activity, diet, and screen time, which can provide valuable data for parents, caregivers, and clinicians to discuss personalized recommendations. In 2021, the American Academy of Pediatrics advocated for expanding and reimbursing pediatric care via telehealth platforms for nonurgent visits, which can increase access to health care professionals who may offer individualized guidance on eating, physical activity, screen time, and sleep.

Fourth, while commercial determinants, such as the food and beverage industry, are linked with adverse child health, they can also drive healthy behaviors depending on their products, marketing practices, and the policies that guide them. Aligning with the 2014 call from the American Society of Nutrition, food and beverage companies can reformulate products to prioritize nutritional value (eg, reduce sugar and sodium), disclose clear labeling (eg, calorie and nutrient labeling, “black box” warnings), and actively participate in and support monitoring and enforcement systems (eg, impose fines for noncompliance). Policymakers can incentivize advertising of healthy food and physical activity products, limit marketing of unhealthy products during children’s programming and in online spaces, establish recommended or mandatory limits on food additives (eg, trans–fatty acids, sugar, sodium), implement zoning restrictions on food vendors (eg, supermarkets and farmers markets vs fast food chains), and establish funding pathways for public-private research.¹⁰ Revenue generated from taxing unhealthy products, such as sugary drinks, can be invested back into communities to support child health initiatives.

Promoting healthy behaviors in the wake of COVID-19 demands comprehensive, upstream approaches that integrate nutrition security, community investment, industry engagement, and policy reform. By collaborating with diverse stakeholders across sectors and engaging with communities to identify sustainable strategies tailored to their needs, we can collectively cultivate a more resilient society where opportunities for healthy behaviors outweigh the barriers.

Corresponding Author: Monica L. Wang, ScD, MS, Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118 ([email protected]).

Published Online: March 4, 2024. doi:10.1001/jamapediatrics.2024.0027

Conflict of Interest Disclosures: None reported.