A Descriptive Study on Childhood
Obesity: Examining Research Gaps, Evaluating Interventions, and Informing
Policy for Sustainable Health
Md Rakibul Hasan1*, Samir Kumar Sarker Rony1 ,
Moryom Akter Muna2, Sajid Hassan3
1Department of Health Promotion
& Behavioral Sciences, University of Louisville, United
States of America
2Medical Officer, Department of Medicine, Mirpur General
Hospital, Dhaka, Bangladesh
3Dhaka Medical College Hospital, Bangladesh
*Corresponding
author: mdrakibul.hasan@louisville.edu
Submitted: 18.01.2025 Revised: 19.02.2025 Accepted: 22.02.2025 Published: 01.04.2025
Keywords: Childhood obesity, Dietary habits, Psychosocial impacts,
Public health interventions, Socioecological Model, Community engagement
Introduction
Childhood obesity is a significant public health
challenge defined by excessive accumulation of body fat, which poses serious
risks to physical, psychological, and social well-being. It is typically
assessed using Body Mass Index (BMI), where children with a BMI at or above the
95th percentile for their age and gender are classified as obese
Kentucky stands out as one of the states most severely
affected by childhood obesity, with 24% of adolescents aged 10–17 classified as
obese. The state also reports that 36% of children are either overweight or
obese, making it a national hotspot for this public health issue
The development of childhood obesity is influenced by a
complex interplay of genetic, behavioral, and environmental factors. Genetic
predispositions can contribute to obesity, but these are often compounded by
behavioral aspects, such as poor dietary habits and lack of physical activity
The consequences of childhood obesity extend beyond
immediate health concerns. Obese children are at a higher risk of developing
chronic diseases such as type 2 diabetes, hypertension, and cardiovascular
issues at an earlier age
Despite extensive research on childhood obesity,
significant gaps remain in addressing its complex and multifaceted nature. Most
studies focus on individual-level interventions, such as promoting physical
activity and nutritional education, but often overlook the broader systemic and
environmental factors that contribute to obesity. While programs like Marathon
Kids and school-based initiatives have been successful in urban settings, their
scalability, long-term sustainability, and effectiveness in rural communities
remain underexplored.
Current research primarily emphasizes urban populations,
where access to healthcare, structured physical activity programs, and
nutritional guidance is relatively well-developed. However, obesity rates in
rural areas continue to rise due to unique socioeconomic and environmental
barriers that receive little attention in mainstream studies. This report
highlights these disparities, particularly in Kentucky, where food deserts,
healthcare shortages, and limited recreational opportunities exacerbate the childhood
obesity crisis. By analyzing both rural and urban data, this study provides a
comparative perspective on risk factors, intervention challenges, and policy
gaps, ensuring that solutions are inclusive and adaptable across different
community settings
Rural communities face distinct challenges that
contribute to higher obesity rates compared to urban areas. Limited access to
healthcare means that children in rural areas often lack early intervention
programs, obesity screenings, and specialized dietary counseling
This study aims to examine the key determinants of
childhood obesity, considering individual behaviors, environmental influences,
and systemic factors. It seeks to assess the effectiveness of existing
interventions, identify gaps in current policies and healthcare access, and
explore socioeconomic and geographical disparities in obesity prevalence. By
providing a balanced analysis, the study aims to support evidence-based
recommendations that can guide policymakers, healthcare professionals, and
educators in developing sustainable and inclusive strategies for obesity
prevention and management.
Methods
The study combines a comprehensive review of statistical
data, targeted surveys, and an analysis of existing literature to provide a
multifaceted understanding of childhood obesity. The approach integrates both
quantitative and qualitative insights to examine the factors contributing to
this public health issue and the effectiveness of current interventions.
Primary data were obtained from the Centers for Disease Control and Prevention
(CDC) and state-level reports, particularly focusing on Kentucky, where
childhood obesity rates are among the highest in the nation. These sources
provided a detailed overview of trends over the past decade, including
socioeconomic disparities, environmental determinants, and access to
healthcare. Additional secondary data were drawn from global studies and
intervention outcomes, enabling a comparative perspective across regions and
populations.
Targeted online surveys were conducted to gather
real-world perspectives from parents, educators, healthcare providers, and
community leaders in Kentucky. These surveys examined barriers to healthy
behaviors, such as limited access to nutritious food, inadequate physical
activity spaces, and insufficient awareness of health education programs.
Participants included families of children aged 10–17 and school administrators
from high-risk areas. The editorial also synthesizes evidence from academic
literature, public health reports, and successful intervention models
worldwide, such as Finland’s “Schools on the Move”
By integrating statistical trends, stakeholder insights,
and intervention evaluations, the methodology provides a robust foundation for
identifying gaps, proposing evidence-based solutions, and offering actionable
recommendations tailored to diverse populations and settings. This approach
aims to ensure the editorial is both comprehensive and relevant to ongoing
efforts in combating childhood obesity.
Study
Design
This study employs a mixed-methods approach, integrating
both quantitative and qualitative data to assess childhood obesity prevalence,
intervention effectiveness, and policy gaps. A cross-sectional design was used,
analyzing existing statistical data from national and state-level public health
sources, including the Centers for Disease Control and Prevention (CDC) and
state health reports from Kentucky. Additionally, targeted online surveys were
conducted with key stakeholders, including parents, educators, and healthcare
providers, to explore barriers to healthy behaviors, food accessibility, and
opportunities for physical activity. The study also incorporates a comparative
review of global obesity prevention programs, such as Finland’s "Schools
on the Move" initiative and the UK's MEND program, to evaluate scalability
and sustainability of interventions.
Study
Population
The study focuses on children and adolescents aged 10–17
years, particularly in high-risk regions such as Kentucky, where childhood
obesity rates are among the highest in the United States. The study population
also includes parents, school administrators, and healthcare providers, as
their perspectives are critical in understanding the environmental and systemic
factors affecting childhood obesity. By incorporating these diverse
stakeholders, the study aims to provide a comprehensive analysis of intervention
feasibility, implementation challenges, and areas for policy improvement.
Sampling
Methods
A purposive sampling method was employed to select
relevant public health datasets, intervention studies, and survey participants.
Secondary data sources were chosen based on availability, reliability, and
relevance to childhood obesity trends, with a focus on government reports,
epidemiological studies, and peer-reviewed literature. The online surveys
targeted parents, educators, and healthcare professionals from Kentucky’s
high-risk regions, ensuring that the study captured real-world insights on obesity-related
barriers and potential solutions. This sampling approach ensures that the study
incorporates diverse perspectives while maintaining a data-driven analytical
framework.
Data
Analysis
The study applies descriptive analysis to evaluate
obesity prevalence, intervention effectiveness, and policy impacts. Statistical
data from national and state health agencies are examined to identify patterns,
trends, and disparities in obesity rates across different socioeconomic and
geographic groups. Additionally, thematic analysis was conducted on survey
responses from parents, educators, and healthcare providers, highlighting
barriers to healthy behaviors and intervention challenges. Comparative analysis
of global obesity prevention programs was also undertaken to assess best
practices, scalability, and adaptability for policy implementation in high-risk
regions like Kentucky. The findings provide evidence-based recommendations
aimed at informing targeted policy interventions, school-based programs, and
community-driven initiatives.
Evaluation
Theory
The evaluation of interventions to combat childhood
obesity is most effectively guided by a theoretical framework that recognizes
the multifactorial and interconnected nature of the issue. The Socioecological
Model (SEM) serves as the foundational theory for this editorial, offering a
comprehensive lens through which the interplay of individual, interpersonal,
organizational, community, and policy-level factors can be analyzed
Overview
of the Socioecological Model (SEM)
The Socioecological Model (SEM) provides a comprehensive
framework for understanding how various factors interact to influence health
behaviors, including childhood obesity. This model recognizes that obesity is
not solely a result of individual choices but is shaped by multiple levels of
influence, ranging from personal behaviors to broader societal structures.
Addressing childhood obesity effectively requires a multi-level approach that
integrates individual, interpersonal, organizational, community, and policy-level
interventions.
At the individual level, personal behaviors, knowledge,
and attitudes toward health play a crucial role in obesity prevention. Factors
such as dietary habits, physical activity levels, and self-monitoring directly
influence a child’s weight and overall well-being. Interventions at this level
often focus on nutrition education, behavioral change strategies, and the use
of technology-driven tools such as wearable fitness trackers and mobile
applications to promote physical activity. Encouraging children to engage in
regular exercise and healthy eating habits from an early age can significantly
reduce obesity risk and establish lifelong wellness behaviors.
The interpersonal level emphasizes the impact of social
relationships, particularly within families and peer groups. Parents and
caregivers play a pivotal role in shaping children’s dietary preferences and
activity levels. Family-based interventions, such as cooking workshops, shared
physical activities, and structured meal planning, help reinforce healthy
behaviors at home. Peer influences, including school friendships and
extracurricular engagement, can also promote an active lifestyle and discourage
sedentary behavior. Strengthening parental involvement and peer support
networks is essential for creating a positive environment that fosters
long-term healthy habits
At the organizational level, institutions such as
schools, healthcare facilities, and workplaces provide structured environments
that can either support or hinder obesity prevention efforts. Schools play a
critical role in shaping children's daily health behaviors by implementing
physical education programs, offering nutritious meals, and integrating health
education into the curriculum. Healthcare institutions also contribute by
conducting regular BMI screenings, providing dietary counseling, and facilitating
early intervention programs. Strengthening institutional policies to support
healthier food options, increased physical activity, and access to medical
guidance is essential for addressing obesity at a systemic level.
The community level encompasses the broader social and
environmental context in which children grow and develop. Access to safe
recreational spaces, affordable healthy food, and community-driven health
initiatives directly impacts obesity risk. Many underserved communities face
challenges such as food deserts, limited public parks, and inadequate
recreational facilities, making it difficult for children to maintain an active
lifestyle. Community-wide programs, such as public awareness campaigns, local farmer’s
markets, and organized physical activity initiatives, can help address these
barriers by creating environments that encourage and support healthy behaviors.
Strengthening community resources and infrastructure is crucial in reducing
disparities and promoting overall public health.
Table-1:
The Socioecological Model (SEM) addressing childhood obesity
|
Level |
Description |
|
Individual Level |
Interventions target personal
behaviors, such as promoting physical activity and healthy eating. For
example, wearable fitness trackers and gamified apps provide motivation and
self-monitoring tools for children. |
|
Interpersonal Level |
Families play a crucial role in shaping children’s
habits. Programs engaging parents, such as cooking workshops and shared
physical activities, strengthen the household’s ability to support healthful
behaviors. |
|
Organizational Level |
Schools and healthcare
institutions are pivotal in creating structured environments for healthy
lifestyles. Policies to enhance physical education, provide nutritious meals,
and conduct routine health screenings are key initiatives at this level. |
|
Community Level |
Access to resources like parks, farmer’s markets, and
safe recreational spaces directly impacts community health. Community-wide
events, such as running clubs or public awareness campaigns, further
encourage active participation. |
|
Policy Level |
Broader systemic changes, such as
implementing soda taxes or subsidizing fresh produce in underserved areas,
address macro-level barriers to healthy behaviors. |
At the policy level, government regulations and broader systemic
initiatives play a fundamental role in shaping the health environment.
Effective policies include school nutrition standards, taxation on
sugar-sweetened beverages, subsidies for fresh produce, and urban planning
measures that prioritize walkability and recreational access. Public health
policies should focus on reducing socioeconomic disparities, improving
healthcare accessibility, and ensuring that schools and communities are
equipped with the necessary resources to support obesity prevention. Strong
policy interventions create a sustainable framework for long-term behavioral
change and reduce the structural barriers that contribute to childhood obesity.
By applying the Socioecological Model, this study
underscores the necessity of a multi-level, integrated approach to childhood
obesity prevention. Each level—individual, interpersonal, organizational,
community, and policy—must work in synergy to create an environment that
supports healthier choices, reduces systemic barriers, and fosters sustainable
improvements in childhood obesity outcomes. Addressing obesity through
evidence-based, cross-sectoral collaboration ensures that interventions are
both effective and scalable, promoting long-term public health benefits. The
SEM provides an essential framework for understanding these interconnected
determinants, emphasizing that health outcomes are shaped by complex
interactions among individual, interpersonal, organizational, community, and
societal factors
Application
of SEM in Evaluation
Using the Socioecological Model (SEM) as an evaluative
framework allows for a comprehensive assessment of childhood obesity
interventions across multiple dimensions. This approach ensures that evaluation
goes beyond individual behavior changes and considers the broader
interpersonal, organizational, community, and policy-level impacts that
contribute to long-term health improvements. For instance, a program like
‘Marathon Kids’ can be evaluated at different levels to determine its overall
effectiveness. At the individual level, success can be measured by tracking
changes in participants' Body Mass Index (BMI), physical fitness levels, and
dietary habits over time. The interpersonal level focuses on the extent of
parental involvement and shifts in family health practices, such as increased
participation in physical activities and healthier meal planning at home.
Socioecological
Model (SEM) Global/Societal
Level (Health
policies & Economic Systems) E.g.,
Nutrition guidelines, food marketing policies Community
Level (Ecosystem) e.g.,
Access to parks, community gardens, reducing food deserts Organizational
level (Mesolevel) E.g.,
School nutrition programs, Healthcare screenings Interpersonal
level (Microlevel) E.g.,
Family and peer influence, Parental support programs Individual
level (Health
Belief Model (HBM) (Perceived
susceptibility, severity, benefits, barriers, cues to action,
self-efficacy)
Fig-1:
Flowchart depicting the SEM (The flowchart illustrates the hierarchical integration
of the Health Belief Model (HBM) within the broader Socioecological Model
(SEM), specifically targeting childhood obesity in Louisville, Kentucky). Beginning
at the Global/Societal level, it details how macro-level health policies
influence community environments, organizational structures, interpersonal
networks, and ultimately, individual behaviors. Each level provides distinct
contributions toward health promotion, culminating at the individual level
where the HBM's constructs directly guide personal behavior changes to address
childhood obesity effectively.
At the organizational level, the program's effectiveness
can be assessed based on its integration into school curricula, the adoption of
structured physical education initiatives, and institutional support for
student engagement in health programs. The community level examines the
availability and utilization of public recreational spaces, participation in
local health events, and overall community engagement in obesity prevention
efforts. Finally, at the policy level, evaluation includes analyzing the adoption
of supportive policies, such as increased government funding for health
programs, school nutrition reforms, and stricter regulations on unhealthy food
advertising targeted at children. By applying SEM to program evaluation, a more
holistic understanding of intervention success can be achieved, ensuring that
strategies are scalable, sustainable, and effective in addressing childhood
obesity across diverse populations.
Significance
of SEM in Childhood Obesity Interventions
By adopting the Socioecological Model (SEM), this study
emphasizes the importance of a holistic and multi-dimensional approach to
addressing childhood obesity. SEM ensures that interventions are not only
effective at the individual level but also sustainable within the broader
societal context, recognizing that obesity is influenced by a complex interplay
of personal behaviors, social relationships, institutional policies, community
environments, and systemic regulations. This model provides stakeholders, including
policymakers, healthcare professionals, educators, and community leaders, with
a structured framework to design, implement, and evaluate interventions that
target both immediate behavioral changes and long-term structural improvements.
By highlighting the interconnected pathways through which interventions shape
health outcomes, SEM reinforces the need for collaborative, multi-sectoral
strategies that integrate health promotion, policy reform, and community
engagement. Ensuring that interventions address the root causes of obesity—such
as socioeconomic disparities, limited healthcare access, and environmental
barriers—helps create more equitable and sustainable public health solutions.
This approach serves as a critical guide for developing policies and programs
that foster systemic, scalable, and enduring improvements in childhood obesity
prevention and management.
Interventions
Effectively addressing childhood obesity requires a
comprehensive, multi-level approach that targets individual, familial, school,
community, and policy factors. Sustainable interventions must go beyond
short-term behavior changes and focus on creating environments that
consistently support healthy choices. By integrating evidence-based strategies,
interventions can enhance nutritional awareness, increase physical activity,
and improve access to health-promoting resources. Drawing on successful models
from various countries, this section outlines key interventions that have
demonstrated effectiveness in reducing obesity rates and mitigating associated
health risks.
School-Based
Interventions
Schools are pivotal environments for instilling healthy
habits among children. Programs that integrate physical activity into daily
routines, such as enhanced physical education curricula and extracurricular
fitness clubs, have demonstrated significant success globally. For instance,
Finland's nationwide Schools on the Move initiative increased physical activity
by 30%, with participating schools reporting higher student engagement and
improved academic performance
Fig-2: Physical activity level among
children in United States
Family-Based
Interventions
The role of families is critical in shaping children’s
dietary and activity behaviors. Comprehensive family-based programs emphasize
parental involvement through education on meal preparation, portion control,
and active lifestyle promotion. In the UK, the MEND (Mind, Exercise,
Nutrition...Do It!) Program resulted in a 4.2% reduction in BMI among children,
highlighting the efficacy of combining physical activity with family nutrition
education.
Community
and Environmental Interventions
Community-based strategies aim to address environmental
barriers to healthy living. Investments in parks, playgrounds, and cycling
paths have shown transformative effects on activity levels. In Colombia, the
Ciclovía Program, which closes city streets to traffic on Sundays, has
encouraged widespread physical activity, engaging over 1.5 million participants
weekly. In low-income neighborhoods in the United States, the establishment of
farmer’s markets increased fresh produce consumption by 20% among children and
families. Addressing food deserts—areas with limited access to nutritious
food—is another priority. Urban gardening projects in Kenya and India have
improved fruit and vegetable availability while fostering community engagement
in health promotion.
Healthcare-Driven
Initiatives
Healthcare providers are essential in early detection
and management of childhood obesity. Routine BMI monitoring and obesity
counseling during pediatric visits have demonstrated effectiveness in countries
like Denmark, where structured healthcare interventions led to a 10% reduction
in obesity prevalence over five years
Fig-3: Bar chart showing healthcare access
(%) among obese children in USA
Technology-Based
Interventions
Technology offers innovative solutions to engage
children in health promotion. Gamified platforms like Zamzee in the U.S.
increased physical activity by 59% among participants by providing real-time
feedback and rewards for movement
Behavioral
and Cognitive Interventions
Behavioral change theories have informed interventions
aimed at modifying eating habits and encouraging physical activity.
Cognitive-behavioral therapy (CBT) has been effectively employed in Sweden,
where participants in family-based CBT programs showed sustained reductions in
obesity over three years. Goal setting, self-monitoring, and reinforcement are
integral to these strategies, which have been adapted across cultures to suit
local needs.
National
and Global Campaigns
Mass campaigns promoting awareness about childhood
obesity have been implemented successfully in several countries. The
Change4Life campaign in the UK, emphasizing healthier diets and increased
activity, reached millions of families through television, social media, and
community events. In South Korea, government-backed initiatives focusing on
traditional diets and regular exercise reduced childhood obesity rates by 3%
over a decade
Integrated
Outcomes of Multilevel Interventions
Combining these approaches yields the most significant
results. For instance, New Zealand’s Healthy Futures Initiative, which
integrates school, family, and community interventions, reported a 7% decline
in childhood obesity over four years
Results
Effective interventions targeting childhood obesity are
expected to yield multi-dimensional benefits, influencing not only individual
health outcomes but also psychosocial well-being, academic performance,
long-term behavioral patterns, and broader policy reforms. By addressing key
risk factors and implementing evidence-based strategies, interventions can
create a sustainable impact on both individuals and communities. The following
outcomes highlight the potential benefits of comprehensive childhood obesity
prevention efforts.
One of the most immediate and significant outcomes is
the enhancement of physical and nutritional health. Interventions promoting
structured physical activity, improved dietary habits, and access to nutritious
foods can significantly improve children’s overall health status. Research
suggests that children participating in structured exercise programs can
increase their daily physical activity by up to 30 minutes, which contributes
to meeting the CDC-recommended 60 minutes of moderate-to-vigorous activity per
day. Additionally, increasing access to healthy school meals, community
nutrition programs, and local food initiatives can help reduce reliance on
high-calorie, nutrient-poor diets, especially in high-risk regions such as
Kentucky, where 24% of adolescents aged 10–17 are classified as obese.
Interventions addressing food deserts and sedentary lifestyles have the
potential to reduce these numbers significantly over time
A second expected outcome is the reduction in obesity
prevalence and associated health risks. Childhood obesity is a major risk
factor for chronic conditions such as type 2 diabetes, hypertension, and
cardiovascular diseases, which are now being diagnosed at younger ages. In
addition, childhood obesity can significantly increase the risk of pediatric
sepsis and various infections due to a compromised immune system and chronic
inflammation
Beyond physical health, psychosocial and emotional
well-being are also expected to improve significantly. Obesity-related stigma
often leads to low self-esteem, social isolation, and increased risk of anxiety
and depression, particularly among children who experience bullying or
discrimination
Another critical outcome is the improvement in academic
performance and cognitive function. Research has consistently shown that
physical fitness is linked to better cognitive function, with children who
engage in regular physical activity demonstrating enhanced concentration,
memory retention, and problem-solving abilities. Schools that integrate
health-promoting interventions, such as daily exercise programs and nutrition
education, often see a 10–15% increase in academic performance. Additionally,
healthy eating habits, particularly those that emphasize balanced nutrition and
reduced sugar consumption, have been linked to better focus and sustained
energy levels throughout the school day. By creating healthier school
environments, interventions can contribute not only to better physical and
mental health but also to stronger educational outcomes that shape children’s
long-term success
A long-term expected outcome of obesity prevention
efforts is the establishment of lifelong healthy behaviors. Early exposure to
structured fitness programs, nutritional education, and health-promoting
community initiatives fosters a culture of wellness that extends into
adolescence and adulthood. Studies indicate that children who adopt healthy
habits at an early age are significantly less likely to develop obesity in
adulthood. Additionally, family and community engagement in health-related
initiatives, such as cooking workshops, family exercise programs, and public
health campaigns, reinforce positive behavior patterns. These interventions
help instill lifelong habits that prevent obesity and contribute to sustained
well-being across generations.
At a broader level, successful childhood obesity
interventions can drive systemic policy changes that create a more
health-supportive environment. As programs demonstrate their effectiveness,
they can influence policy reforms in areas such as school nutrition standards,
funding for public health initiatives, and improved access to recreational
spaces. Additionally, research-driven evidence on the impact of childhood
obesity interventions may encourage governments to introduce stricter
regulations on unhealthy food marketing to children, improve food labeling
policies, and expand taxation on sugar-sweetened beverages. Beyond individual
benefits, these policy-level changes contribute to long-term reductions in
obesity rates, easing the economic burden on healthcare systems and fostering a
healthier future for the next generation.
Discussion
Childhood obesity is a complex and multifactorial public
health challenge that requires addressing underlying socioeconomic,
environmental, and behavioral factors. The insights presented in this report
underscore the significance of implementing comprehensive, evidence-based
interventions that target these root causes. The United States mirrors this
troubling trend, with obesity rates among children aged 2–19 increasing from
16.9% in 2009-2010 to 19.7% in 2017-2020. This represents approximately 14.7 million
American children who are currently obese
Table-2:
Key Statistics on Childhood Obesity
|
Statistics |
Value |
Source |
|
Global childhood obesity prevalence (ages 5–19) |
340 million children and adolescents (2020) |
WHO |
|
Childhood obesity rate in the U.S. (ages 2–19) |
Increased from 16.9% (2009–2010) to 19.7% (2017–2020) |
CDC |
|
Number of obese children in the U.S. |
14.7 million |
CDC |
|
Adolescent obesity rate in Kentucky (ages 10–17) |
24% |
Kentucky Health News, Oct 3, 2022, |
|
Overweight/obesity prevalence among Kentucky children |
36% |
Kentucky Health News, October 3, 2022, |
|
Food deserts in Kentucky |
Limited access to affordable, nutritious food in
several areas |
|
|
Reduction in obesity rates through structured physical
activity programs |
1–3% BMI reduction in participating children |
Marathon Kids Program |
|
Impact of school meal programs on diet quality |
Improved dietary intake for 30 million children
annually |
USDA Guidelines |
Childhood obesity is highly prevalent in Jefferson
County, with many children affected due to poor dietary habits, including high
consumption of calorie-dense foods and sugary beverages. Additionally, physical
inactivity and a lack of recreational facilities further exacerbate the issue,
limiting opportunities for children to engage in regular exercise and healthy
activities
Fig-4:
Bar chart showing food deserts—geographic areas where residents have limited
access to affordable and nutritious food
Childhood obesity is notably prevalent in Jefferson
County, with recent data indicating that approximately 30% of children are
affected, a rate significantly higher than the national average of 25%.
Compared to other states, Kentucky's childhood obesity rate is among the
highest, highlighting the urgent need for targeted interventions to address
poor dietary habits, physical inactivity, and limited access to recreational
facilities
Fig-5: Pie Chart showing Obesity rate among
U.S. children and adolescents
The
Role of Socioeconomic and Environmental Factors
Socioeconomic and environmental determinants play a
critical role in shaping childhood obesity rates. Children from low-income
households are disproportionately affected, with limited access to nutritious
foods and safe spaces for physical activity being key barriers. In Kentucky,
for instance, 36% of children are classified as overweight or obese, with the
prevalence reaching 24% among adolescents aged 10–17 years, reflecting a
national trend exacerbated by economic disparities
Environmental factors, such as food deserts and
inadequate recreational infrastructure, further compound the issue. Communities
with limited access to fresh produce and reliance on high-calorie,
nutrient-poor foods report significantly higher obesity rates
The
Potential of Multilevel Interventions
Programs like Marathon Kids exemplify the transformative
potential of community-based interventions in combating childhood obesity. By
integrating physical activity and nutrition into daily routines, such
initiatives have demonstrated measurable success in improving children’s health
behaviors. For example, children participating in structured physical activity
programs have shown a 1–3% reduction in Body Mass Index (BMI) and a 15%
increase in daily physical activity levels
However, to achieve widespread impact, interventions
must adopt a multilevel approach. Schools, as key stakeholders, can incorporate
physical education reforms and healthy meal programs, while healthcare
providers can play a pivotal role in early identification and intervention
through routine BMI monitoring.
Challenges
and Barriers
Despite the potential effectiveness of childhood obesity
interventions, several structural, economic, and social challenges hinder their
successful implementation. Inconsistent funding and resource limitations,
particularly in underserved and rural areas, remain a significant barrier. Many
communities lack sustained financial support for school nutrition programs,
public health campaigns, and infrastructure improvements, making it difficult
to maintain long-term engagement. In states like Kentucky, where food
insecurity affects 18% of households, the affordability and accessibility of
healthy food options and physical activity programs are persistent concerns,
requiring multi-sectoral funding strategies to ensure equitable implementation
Community engagement and participation also pose
significant challenges, as cultural norms, socioeconomic conditions, and
logistical constraints often influence adoption and adherence to health
interventions. In many high-risk populations, lack of awareness, limited health
literacy, and competing daily priorities reduce participation in nutrition
education programs, physical activity initiatives, and preventive healthcare
services. Additionally, language barriers, distrust in public health
institutions, and limited parental involvement further restrict the
effectiveness of community-based interventions, highlighting the need for
culturally tailored outreach and education efforts.
At the policy level, systemic challenges such as weak
regulatory enforcement, industry influence, and political resistance can hinder
large-scale obesity prevention efforts. While fiscal policies like Mexico’s
soda tax have successfully reduced sugary drink consumption by 12%, similar
measures often face opposition from food and beverage industries, limited
public buy-in, and enforcement gaps
Addressing these barriers requires collaborative efforts
between governments, healthcare providers, educational institutions, community
organizations, and private sector stakeholders. Sustainable solutions must
integrate long-term policy commitments, targeted financial investments, and
culturally inclusive health promotion strategies to ensure interventions are
both scalable and adaptable to diverse populations. Strengthening
interdisciplinary partnerships, expanding public-private funding models, and leveraging
data-driven policy reforms will be essential in overcoming these challenges and
establishing effective, lasting solutions to childhood obesity.
Vision
and Call to Action
Our editorial aims to shed light on the multifaceted
nature of childhood obesity and the necessity of adopting a holistic,
multi-stakeholder approach to its prevention. By presenting evidence-based
strategies and emphasizing the interconnectedness of individual, family, and
community-level interventions, we seek to inspire actionable change. The
editorial’s discussion highlights not only the successes of existing programs
but also the gaps in implementation that must be addressed to achieve long-term
impact.
The vision extends beyond immediate health improvements,
aiming for a future where childhood obesity rates decline significantly through
sustained efforts. Targeted strategies, such as those employed in Denmark’s
healthcare system or the UK’s national campaigns, illustrate the potential of
coordinated action in achieving measurable outcomes
Ultimately, the editorial underscores the critical
importance of evidence-based, inclusive interventions that prioritize equity
and accessibility. With ongoing collaboration and commitment from all
stakeholders, the fight against childhood obesity can achieve transformative
results, paving the way for healthier generations and reducing the long-term
economic and social burdens associated with this epidemic.
Limitations
While this study provides a comprehensive analysis of
childhood obesity interventions, certain limitations must be acknowledged. The
reliance on secondary data sources, such as statistical reports and
international programs, may not fully capture local sociocultural and economic
variations, limiting the generalizability of recommendations. The
Socioecological Model (SEM), while effective in evaluating multi-level
influences, does not account for individual psychological factors, such as
intrinsic motivation and emotional eating, which are critical in obesity
prevention. Additionally, the study lacks longitudinal data, making it
difficult to assess the long-term sustainability and scalability of
interventions. The absence of qualitative insights from affected communities
further limits the understanding of behavioral and social determinants of
obesity. Lastly, policy recommendations may face feasibility challenges,
particularly in resource-constrained settings where funding, enforcement, and
political will may be barriers to implementation. Future research should
integrate primary data collection, behavioral health models, and
cost-effectiveness assessments to refine intervention strategies and ensure
their practical application across diverse populations.
Future
Directions and Recommendations
Future efforts to combat childhood obesity should
prioritize long-term, community-based research to evaluate the sustainability
and scalability of interventions across diverse populations. Longitudinal
studies are essential to assess the long-term impact of obesity prevention
programs by tracking BMI trends, dietary behaviors, and physical activity
levels over time. Additionally, intervention trials focused on school-based
programs, family-centered initiatives, and policy-driven strategies can
generate empirical evidence on the most effective approaches for reducing
childhood obesity. Expanding research to include qualitative studies will
provide deeper insights into behavioral, cultural, and socioeconomic factors
influencing intervention success, ensuring that programs are tailored to
community-specific needs rather than broad, generalized approaches.
Furthermore, integrating behavioral health models alongside the Socioecological
Model (SEM) can enhance understanding of psychological barriers, such as emotional
eating and motivation, which are critical in sustaining healthy behaviors.
At the policy level, strengthening regulations on
unhealthy food marketing, increasing subsidies for nutritious foods, and
investing in safe public spaces for physical activity should be key priorities.
Governments should conduct cost-effectiveness studies to identify the most
impactful obesity prevention strategies while ensuring sustainable funding and
enforcement mechanisms. Schools should play a central role by enhancing
structured physical education programs, integrating hands-on nutrition education,
and improving school meal quality to reinforce lifelong healthy habits from an
early age.
A multi-sectoral approach is crucial, requiring
collaboration between governments, healthcare providers, schools, community
organizations, and the private sector. Healthcare systems should integrate
routine obesity screenings, dietary counseling, and mental health support into
pediatric care, while community-led initiatives should focus on improving
access to affordable healthy foods and recreational facilities. Additionally,
digital health solutions, such as mobile apps and wearable fitness trackers, should
be further explored for their potential to engage children and families in
sustained behavior change, particularly in underserved communities.
By prioritizing evidence-based, policy-supported, and
community-driven interventions, childhood obesity prevention efforts can become
more effective, scalable, and sustainable. A coordinated and data-driven
strategy will be essential to reducing obesity prevalence, improving health
outcomes, and fostering a healthier future generation.
Ethical
Considerations
As a descriptive study relying on secondary data
sources, literature reviews, and policy analysis, no human subjects were
directly involved, eliminating the need for informed consent or ethical
approval for participant research. However, the study adheres to ethical
research principles, including proper data sourcing, transparency, and citation
integrity. All referenced studies were appropriately credited to avoid
plagiarism and ensure academic integrity. Additionally, ethical considerations
were made to present findings objectively and without bias, particularly in
discussions of health disparities and policy recommendations, ensuring that
proposed interventions promote equity and inclusivity while avoiding
stigmatization of affected populations.
Conclusion
Childhood obesity is a multifaceted public health
challenge that demands a comprehensive, evidence-based approach to understand
its root causes and implement sustainable interventions. Influenced by
socioeconomic, environmental, behavioral, and systemic factors, effective
solutions must extend beyond individual behavior change to address structural
disparities in food accessibility, physical activity opportunities, and
healthcare services. Descriptive studies play a crucial role in identifying
prevalence trends, evaluating intervention effectiveness, and informing
policy-driven strategies that promote equitable health outcomes. While programs
like ‘Marathon Kids’ demonstrate the potential of targeted school-based
interventions, achieving long-term success requires a multi-sectoral approach
that integrates policy reforms, community engagement, and interdisciplinary
collaboration. Policymakers must implement legislation to regulate unhealthy
food marketing, expand nutritional assistance programs, and invest in safe
recreational spaces to create environments that support lifelong healthy
habits. Schools should play a central role by enhancing physical education,
improving meal programs, and incorporating health literacy into curricula,
while healthcare providers must integrate routine obesity screenings, dietary
counseling, and mental health support into pediatric care. Additionally,
technology-driven solutions such as mobile health applications and wearable
fitness trackers can enhance engagement and encourage sustained behavior
change. Ongoing research is essential to refine intervention strategies, ensure
cultural adaptability, and assess long-term effectiveness. Ultimately,
addressing childhood obesity is not just about reducing BMI but about
empowering communities, fostering healthy behaviors, and shaping environments
that support child well-being through evidence-based, scalable, and sustainable
solutions.
Acknowledgement
We extend our sincere gratitude to Dr. Jovita Murillo
León, Assistant Professor, Department of Health Promotion & Behavioral
Sciences, University of Louisville, Kentucky, United States, and Dr. Saifur
Rahman, Neuroscientist and Biomedical Researcher, University of Cambridge,
England, United Kingdom.
Aniśko B, Siatkowski I and Wójcik M
(2024) Body mass composition analysis as a predictor of overweight and
obesity in children and adolescents. Frontiers in Public Health 12:
1371420.
Asakura K, Mori S, Sasaki S and
Nishiwaki Y (2021) A school-based nutrition education program involving
children and their guardians in Japan: facilitation of guardian-child
communication and reduction of nutrition knowledge disparity. Nutrition
Journal 20: 1–13.
Blom A, Tammelin
T, Laine K and Tolonen H (2018) Bright spots, physical activity investments
that work: the Finnish Schools on the Move programme.
British Journal of Sports Medicine 52(13): 820–822.
Borawski EA, Jones SD, Yoder
LD, Taylor T, Clint BA, Goodwin MA, et al. (2018) We Run This City: impact
of a community–school fitness program on obesity, health, and fitness. Preventing
Chronic Disease 15: E52.
Brewer CJ and Balen AH (2010)
Focus on obesity. Reproduction 140(3): 347–364.
Caperon L, Saville F and Ahern
S (2022) Developing a socio-ecological model for community engagement in a
health programme in an underserved urban area. PloS One 17(9): e0275092.
Chalkley AE, Routen AC, Harris
JP, Cale LA, Gorely T and Sherar LB (2018a)
Marathon kids UK: study design and protocol for a mixed methods evaluation
of a school-based running programme. BMJ Open
8(5): e022176.
Chalkley AE, Routen AC, Harris
JP, Cale LA, Gorely T and Sherar LB (2018b)
Marathon kids UK: study design and protocol for a mixed methods evaluation
of a school-based running programme. BMJ Open
8(5): e022176.
Chung ST, Krenek A and Magge SN
(2023) Childhood obesity and cardiovascular disease risk. Current
Atherosclerosis Reports 25(7): 405–415.
Colchero MA, Molina M and
Guerrero-López CM (2017) After Mexico implemented a tax, purchases of
sugar-sweetened beverages decreased and water
increased: difference by place of residence, household composition, and
income level. The Journal of Nutrition 147(8): 1552–1557.
Council on School Health,
Committee on Nutrition, Murray R, Bhatia J, Okamoto J, Allison M, et al.
(2015) Snacks, sweetened beverages, added sugars, and schools. Pediatrics
135(3): 575–583.
Crouch E, Abshire DA, Wirth MD,
Hung P and Benavidez GA (2023) Peer Reviewed: Rural–Urban Differences in
Overweight and Obesity, Physical Activity, and Food Security Among Children
and Adolescents. Preventing Chronic Disease 20.
Dhanjani S, Allen H, Varman B,
Callender C, Dave JM and Thompson D (2024) Community-Based Participatory
Obesity Prevention Interventions in Rural Communities: A Scoping Review. Nutrients 16(14): 2201.
Di Cesare
M, Sorić M, Bovet P, Miranda JJ, Bhutta Z, Stevens GA, et al. (2019) The epidemiological
burden of obesity in childhood: a worldwide epidemic requiring urgent
action. BMC Medicine 17: 1–20.
Dietz WH (1998) Health
consequences of obesity in youth: childhood predictors of adult disease. Pediatrics
101(Supplement_2): 518–525.
Dunton
G, McConnell R, Jerrett M, Wolch
J, Lam C, Gilliland F,
et al. (2012)
Organized physical activity in young school children and subsequent 4-year
change in body mass index. Archives of Pediatrics & Adolescent
Medicine 166(8): 713–718.
Gaffney H, Ttofi
MM and Farrington DP (2021) Effectiveness of school‐based programs to
reduce bullying perpetration and victimization: An updated systematic
review and meta‐analysis. Campbell Systematic Reviews 17(2): e1143.
Haapala H (2017a) No title. Finnish
Schools on the Move: Students' Physical Activity and School-Related Social
Factors.
Haapala
H (2017b) No title. Finnish
Schools on the Move: Students' Physical Activity and School-Related Social
Factors.
Hasan E, Khanam M and Shimul SN
(2020) Socio-economic inequalities in overweight and obesity among women of
reproductive age in Bangladesh: a decomposition approach. BMC Women's
Health 20: 1–11.
Hasan MR (2024) Mental Health
Challenges in Bangladesh Based on the Integrated Assessment of Illicit Drug
Use, Substance Abuse, Tobacco Consumption, and Escalating Suicidal
Tendencies: A Comprehensive Review. Bangladesh Journal of Infectious
Diseases 11(1).
Hasan MR and Rony SKS (2024)
Exploring Parental Perspectives on Factors Influencing Sugar-Sweetened
Beverage Consumption in Children Aged 8 to 14. Asian Journal of Public
Health and Nursing 1(3).
Hasan MR, Rony SKS, Baron EL
and Wana GW (2024) Exploring Which Public Health Interventions Are More
Effective to Reduce Maternal and Child Health Inequalities in South Asia: A
Systematic Literature Review. Asian Journal of Public Health and Nursing
1(3).
Hasan MR, Yusuf MA, Rogers WT, Egbury G and Muna MA (2024) Global Patterns and
Emerging Challenges of Human Monkeypox Virus: An In-Depth Narrative Review
and Analysis. Bangladesh Journal of Medical Microbiology 18(2):
120–130.
Hasan T, Ainscough TS, West J
and Fraser LK (2020) Healthcare utilisation in
overweight and obese children: a systematic review and meta-analysis. BMJ
Open 10(10): e035676.
Hills AP, Andersen LB and Byrne
NM (2011) Physical activity and obesity in children. British Journal of
Sports Medicine 45(11): 866–870.
Hu K and Staiano AE (2022)
Trends in obesity prevalence among children and adolescents aged 2 to 19
years in the US from 2011 to 2020. JAMA Pediatrics 176(10):
1037–1039.
Kabir R, Hasan MR and Arafat SY
(2023) Epidemiology of suicide and data quality in Bangladesh. In:
Anonymous Suicide in Bangladesh: Epidemiology, Risk Factors, and
Prevention. :
Springer, 1–15.
Kasher Meron M, Eizenstein S, Cukierman-Yaffe T and Oieru
D (2024) Missed diagnosis—a major barrier to
patient access to obesity healthcare in the primary care setting. International
Journal of Obesity 48(7): 1003–1010.
Keller AS, Hurt RT, Schroeder
DR, DeJesus RS, Ganesh R, Fokken SC, et al. (2024) Perceived Health
Concerns and Barriers to Care in Persons With
Overweight and Obesity: A Patient Survey. Journal of Primary Care &
Community Health 15: 21501319241303608.
Key J, Burnett D, Babu JR and
Geetha T (2023) The effects of food environment on obesity in children: A
systematic review. Children 10(1): 98.
Knopf JA, Finnie RK, Peng Y,
Hahn RA, Truman BI, Vernon-Smiley M, et al. (2016) School-based health
centers to advance health equity: A community guide systematic review. American
Journal of Preventive Medicine 51(1): 114–126.
Kopelman PG (2000) Obesity as a
medical problem. Nature 404(6778): 635–643.
Lavie CJ, Laddu D, Arena R,
Ortega FB, Alpert MA and Kushner RF (2018) Healthy weight and obesity
prevention: JACC health promotion series. Journal of the American
College of Cardiology 72(13): 1506–1531.
Lim CS, Robinson J, Hinton E,
Gordy XZ, Gamble A, Compretta C, et al. (2022)
School-based obesity prevention programs in rural communities: a scoping
review. JBI Evidence Synthesis 20(12): 2936–2985.
Lim H, Kim J, Wang Y, Min J,
Carvajal NA and Lloyd CW (2016) Child health promotion program in South
Korea in collaboration with US National Aeronautics and Space
Administration: Improvement in dietary and nutrition knowledge of young
children. Nutrition Research and Practice 10(5): 555–562.
Mazeas A, Duclos M, Pereira B and Chalabaev A (2022) Evaluating the effectiveness of
gamification on physical activity: systematic review and meta-analysis of
randomized controlled trials. Journal of Medical Internet Research
24(1): e26779.
McLean RM, Hoek JA, Buckley S,
Croxson B, Cumming J, Ehau TH, et al. (2009) " Healthy Eating-Healthy
Action": evaluating New Zealand's obesity prevention strategy. BMC
Public Health 9: 1–8.
Norman-Burgdolf
H, DeWitt E, Gillespie R, Cardarelli KM, Slone S and Gustafson A (2023a)
Impact of community-driven interventions on dietary and physical activity
outcomes among a cohort of adults in a rural Appalachian
county in Eastern Kentucky, 2019–2022. Frontiers in Public Health
11: 1142478.
Norman-Burgdolf
H, DeWitt E, Gillespie R, Cardarelli KM, Slone S and Gustafson A (2023b)
Impact of community-driven interventions on dietary and physical activity
outcomes among a cohort of adults in a rural Appalachian
county in Eastern Kentucky, 2019–2022. Frontiers in Public Health
11: 1142478.
Odoms-Young A, Brown AG,
Agurs-Collins T and Glanz K (2024) Food insecurity, neighborhood food
environment, and health disparities: state of the science, research gaps
and opportunities. The American Journal of Clinical Nutrition
119(3): 850–861.
Ogden CL, Carroll MD, Kit BK
and Flegal KM (2014) Prevalence of childhood and adult obesity in the
United States, 2011-2012. Jama 311(8): 806–814.
Omar HA and Rager K (2005)
Prevalence of obesity and lack of physical activity among Kentucky
adolescents. International Journal of Adolescent Medicine and Health
17(1): 79–82.
Ostermeier E, Tucker P, Clark
A, Seabrook JA and Gilliland J (2021) Parents’ report of Canadian
elementary school children’s physical activity and screen time during the
COVID-19 pandemic: a longitudinal study. International Journal of
Environmental Research and Public Health 18(23): 12352.
Puder JJ and Munsch S (2010)
Psychological correlates of childhood obesity. International Journal of
Obesity 34(2): S37–S43.
Pulungan AB, Puteri HA, Ratnasari AF, Hoey H, Utari A, Darendeliler
F, et al. (2024) Childhood obesity as a global problem: a cross-sectional
survey on global awareness and national program implementation. Journal
of Clinical Research in Pediatric Endocrinology 16(1): 31.
Sacher PM, Kolotourou
M, Chadwick PM, Cole TJ, Lawson MS, Lucas A, et al. (2010) Randomized
controlled trial of the MEND program: a family‐based community intervention
for childhood obesity. Obesity 18(S1): S62–S68.
Salihu HM, Wilson RE, King LM,
Marty PJ and Whiteman VE (2015) Socio-ecological model as a framework for
overcoming barriers and challenges in randomized control trials in minority
and underserved communities. International Journal of MCH and AIDS
3(1): 85.
Santos F, Sousa H, Gouveia ER,
Lopes H, Peralta M, Martins J, et al. (2023) School-based family-oriented
health interventions to promote physical activity in children and
adolescents: a systematic review. American Journal of Health Promotion
37(2): 243–262.
Sherar LB, Chalkley AE, Gorely T and Cale LA (2020) School-based running
programs. In: Anonymous The Routledge Handbook of Youth Physical
Activity. :
Routledge, 541–556.
Siegner A, Sowerwine J and Acey
C (2018) Does urban agriculture improve food security? Examining the nexus
of food access and distribution of urban produced foods in the United
States: A systematic review. Sustainability 10(9): 2988.
Smith LR, Chadwick P, Radley D,
Kolotourou M, Gammon CS, Rosborough J, et al.
(2013) Assessing the short-term outcomes of a community-based intervention
for overweight and obese children: The MEND 5-7 programme.
BMJ Open 3(5): e002607.
Smith TA, Lin B and Guthrie J
(2024) School meal nutrition standards reduce disparities across income and
race/ethnicity. American Journal of Preventive Medicine 67(2):
249–257.
Spiga F, Davies AL, Tomlinson
E, Moore TH, Dawson S, Breheny K, et al. (2024) Interventions to prevent
obesity in children aged 5 to 11 years old. Cochrane Database of
Systematic Reviews(5).
Springer AE, Deitz D, Gabriel
KP, Harris M, Trodick B, Guzman Y, et al. (2022)
Engaging young people in running clubs: Best practices from marathon kids’
volunteer coaches. Translational Journal of the American College of
Sports Medicine 7(1): e000185.
Subramaniam M, Devi F, AshaRani PV, Zhang Y, Wang P, Jeyagurunathan
A, et al. (2022) Barriers and facilitators for adopting a healthy lifestyle
in a multi-ethnic population: A qualitative study. PLoS
One 17(11): e0277106.
Teng AM, Jones AC, Mizdrak A, Signal L, Genç M and Wilson N (2019) Impact
of sugar‐sweetened beverage taxes on purchases and dietary intake:
Systematic review and meta‐analysis. Obesity Reviews 20(9):
1187–1204.
Tiwari A and Balasundaram P
(2021) Public health considerations regarding obesity.
Torres A, Sarmiento OL, Stauber
C and Zarama R (2013) The Ciclovia and Cicloruta
programs: promising interventions to promote physical activity and social
capital in Bogotá, Colombia. American Journal of Public Health
103(2): e23–e30.
Trandafir LM, Anton-Paduraru
DT, Miron I and Indrei LL (2015) Psychosocial
implications of childhood obesity. Revista
De Cercetare Si Interventie
Sociala 49: 205.
Van Dyke ME, Chen TJ, Nakayama
JY, Moore LV and Whitfield GP (2023) Changes in physical inactivity among
US adults overall and by sociodemographic characteristics, behavioral risk
factor surveillance system, 2020 versus 2018. Preventing
Chronic Disease 20: E65.
Vilar-Compte
M, Burrola-Méndez S, Lozano-Marrufo A, Ferré-Eguiluz I, Flores D,
Gaitán-Rossi P, et al. (2021)
Urban poverty and nutrition challenges associated with accessibility to a
healthy diet: a global systematic literature review. International
Journal for Equity in Health 20: 1–19.
Walfoort NL, Clark JJ, Bostock MJ and
O'Neil K (2009) ACTIVE Louisville: incorporating active living principles
into planning and design. American Journal of Preventive Medicine
37(6): S368–S376.
Wang Y and Lim H (2012a) The
global childhood obesity epidemic and the association between
socio-economic status and childhood obesity. International Review of
Psychiatry 24(3): 176–188.
Wang Y and Lim H (2012b) The
global childhood obesity epidemic and the association between
socio-economic status and childhood obesity. International Review of
Psychiatry 24(3): 176–188.
Wells JC, Marphatia
AA, Amable G, Siervo M, Friis H, Miranda JJ, et
al. (2021) The future of human malnutrition: rebalancing agency for better
nutritional health. Globalization and Health 17: 1–25.
Williams AS, Ge B, Petroski G,
Kruse RL, McElroy JA and Koopman RJ (2018) Socioeconomic status and other
factors associated with childhood obesity. The Journal of the American
Board of Family Medicine 31(4): 514–521.
Witek K, Wydra K and Filip M
(2022) A high-sugar diet consumption, metabolism and health impacts with a
focus on the development of substance use disorder: a narrative review. Nutrients
14(14): 2940.
Wolfenden L, McCrabb S, Barnes
C, O'Brien KM, Ng KW, Nathan NK, et al. (2022) Strategies for enhancing the
implementation of school‐based policies or practices targeting diet,
physical activity, obesity, tobacco or alcohol use. Cochrane Database of
Systematic Reviews(8).
Zgodic A, Eberth JM, Breneman CB,
Wende ME, Kaczynski AT, Liese AD, et al. (2021) Estimates of childhood
overweight and obesity at the region, state, and county levels: a
multilevel small-area estimation approach. American Journal of
Epidemiology 190(12): 2618–2629.