Strategies for Paediatric Overweight and Obesity: From Nutritional Education to Clinical Management.

Childhood obesity is a chronic and multifactorial condition resulting from the complex interaction among genetic and environmental factors, family dynamics, lifestyle habits, and socioeconomic determinants. Its steadily increasing prevalence from the earliest stages of life calls for prevention and intervention strategies capable of targeting both eating behaviors and the psycho-physical factors that shape growth. Over the course of this PhD thesis, three projects were developed to counteract excess weight across different developmental stages: (1) Nutripiatto, articulated in two real-life educational interventions; (2) Fair Play a Tavola; and (3) Resilient, currently underway at the Bambino Gesù Children’s Hospital, where voluntary clinical training was carried out. 1. “Nutripiatto” was developed through a collaboration between Campus Bio-Medico University of Rome, the Italian Society of Preventive and Social Pediatrics (SIPPS), and Nestlé Italia, with the aim of translating nutritional recommendations into an immediate visual language that is easily understood by children. It consists of a physical plate visually divided into sections representing the recommended proportions of the main food groups within a balanced meal, with approximately half of the plate dedicated to vegetables and the remaining portions allocated to carbohydrate-rich foods and protein sources. Alongside the physical plate, a single booklet was developed, offering age-specific recipes calibrated according to LARN 2014 requirements and aligned with Mediterranean Diet principles. Additional thematic materials were produced: Buongiorno con Nutripiatto (breakfast), the School Guide, Nutripiatto in Movimento (linking nutrition and physical activity), and a booklet of regional recipes—designed to provide practical guidance and support families and teachers in preparing balanced meals. Over time, the project evolved into a fully integrated system to assist families and educators in planning balanced daily meals. To evaluate its effectiveness in real-life conditions, two prospective observational pre–post studies were conducted using an identical methodology, without randomization or control groups, differing only in participants’ age and intervention duration. Both studies included nutrition education sessions, completion of a Food Frequency Questionnaire (FFQ), daily use of Nutripiatto, and a final reassessment using a second FFQ. The first intervention, a pilot study conducted between September 2019 and March 2020, involved 115 children aged 4–5 years and aimed to improve dietary choices and portion-size awareness. After one month of using the tool, significant improvements were observed (p < 0.05) both in terms of portion sizes and frequency of consumption. A higher percentage of children consumed appropriate portions of pasta and derivatives, alongside improved portion control for less healthy preparations such as fried potatoes and packaged chips. Improvements were also observed in servings of animal protein sources, especially fish, white meat, and eggs. Regarding vegetables, 76% of children shifted from a small portion size to a medium or a large one, indicating increased acceptance of plant-based foods, which occupy half of the plate in the Nutripiatto model. Hydration also improved: children drinking at least six glasses of water per day increased from 21% to 51%. Food frequency patterns showed overall realignment with guidelines, with a significant reduction in weekly consumption of biscuits and refined baked goods, together with decreased or discontinued intake of packaged chips and soft drinks. Concurrently, weekly intake of fish and vegetables increased, indicating a healthier shift in dietary patterns. Parental satisfaction was extremely high: 97% considered Nutripiatto effective and intuitive, identifying the visual component as a key factor in facilitating correct portioning and promoting greater autonomy in food choices. The second study, carried out between March and May 2023, involved 781 children aged 6–10 years from Lazio, Sicily and Piedmont, 525 (67%) completed the T1 after two months of using the plate. Participants were divided into two age-based portion groups: group A, 6–7 years (“small” portion) and group B, 9–10 years (“medium” portion). At T1, statistically significant improvements (p < 0.05) were mainly observed in portion awareness and food-consumption frequency, particularly among children aged 6–7 years. In Piedmont, adherence increased for recommended portions of dairy products, pasta and potatoes (baked or fried), and meat; in Sicily, improvements were observed for plant-based drinks and non-wheat cereals. No significant changes were detected in the 9–10-year group, and regional comparisons did not reveal differences in the changes reported at T1. Regarding food frequencies, in group A, both Piedmont and Sicily showed increased consumption of fruit and vegetables and reduced intake of less healthy foods. Piedmont exhibited reduced consumption of pizza, cold cuts, and red meat, while Sicily showed reductions in fried and packaged chips and cold cuts. In Lazio, intake of crackers and fish increased, while consumption of fried potatoes decreased. In group B, although portion sizes did not change, improvements were observed in food frequencies: increased fruit and vegetable consumption in Piedmont, higher intake of nuts in Lazio, and reduced packaged chips in Sicily. Water intake increased across all groups in Lazio and Sicily. Despite these positive trends, regional dietary patterns remain consistent with existing literature: higher consumption of processed foods in Lazio, greater bread and water intake in Sicily, and higher fruit and vegetable consumption in Piedmont. More than 80% of parents considered Nutripiatto useful and effective, reporting increased whole-grain consumption, more appropriate portions, better hydration, and reduced sedentary behaviours. Overall, the two studies suggest that Nutripiatto is a practical and engaging educational tool that can promote healthier eating habits during childhood. Results are encouraging, yet the short duration of interventions and caregiver-reported FFQs highlight the need for larger, controlled studies with extended follow-up. 2. “Fair Play a Tavola” is an innovative nutrition-education program for preschool children. Launched in October 2023 and completed in February 2025, the project, designed as a multicenter cross-sectional observational study, aimed to support families, educators, and caregivers in promoting healthy lifestyles from early childhood through age-appropriate playful and multisensory activities. Structured games, sensory workshops, tactile, olfactory, and visual explorations, storytelling, and role-play guided children in discovering foods, learning to recognize colours, textures, and aromas, and building a more positive and curious relationship with food. The program involved approximately 5,000 children aged 3–5 years and was structured into three phases: (1) collection of lifestyle and nutritional data through a multilingual questionnaire (available in five languages) and anthropometric screening based on WHO 2006–2007 criteria, with measurements performed by nutritionists and a paediatrician; (2) implementation of playful and sensory educational activities designed to promote engagement and active participation; (3) feedback to families through class-level reports and, when needed, individual consultations to discuss nutritional status and provide tailored recommendations. A total of 1,542 children were included (48% female; mean age 4.4 ± 0.9 years) from 57 preschools, classified into four BMI groups, labelled A to D: normal weight (A, n = 964), at risk of overweight (B, n = 267), overweight (C, n = 210), and with obesity (D, n = 101). Significant differences (p < 0.05) emerged among groups: children with higher BMI had larger waist circumference (A: 51 ± 3 cm vs D: 61.8 ± 5.8 cm) and higher birth weight (3.75 ± 1.1 kg vs 4.20 ± 1.0 kg). Parents of children with obesity also had higher BMI (mothers: 22 ± 4 vs 25 ± 4 kg/m²; fathers: 25 ± 3 vs 27 ± 4 kg/m²), while tending to underestimate their child’s weight. Lifestyle data indicated generally low physical activity (<2 days/week), slightly lower in group B than A. Group D showed the highest video game use, with a lower proportion of non-users compared with both group A and group B during school days (67% vs 79–81%) and weekends (57% vs 70–74%). Dietary habits also differed: fish consumption was lower in group C than B (69% vs 81%); plant-based drinks were rarely consumed, with a higher proportion of non-consumers in group B versus C (91% vs 82.4%); egg consumption was lower in group D than A (60% vs 74%). Additionally, 35.2% of children in group B consumed cold cuts 1–3 times per week, compared with ~30% in groups A and C, while the proportion of children who never consumed fast food was higher in group A compared with D (62% vs 49%). Overall, adherence to CREA 2018 guidelines for fruit, vegetables, cereals, and yogurt was low across all groups, highlighting the need for targeted educational interventions from early childhood. These findings provide a relevant epidemiological picture, showing that nutritional and behavioural differences associated with excess weight emerge very early in life. 3. The “Resilient” project is an ongoing randomized study conducted at the Bambino Gesù Children’s Hospital and represents the clinical component of this PhD thesis. The protocol includes an eight-week intensive intervention followed by a three-month follow-up and involves 106 children aged 6–11 years with overweight or obesity. The original design included three arms: intensive health behaviour and lifestyle treatment (IHBLT), based on personalized nutrition education and adapted physical activity; IHBLT combined with computerized cognitive training (IHBLT + CT), including COGMED, a structured and adaptive working memory training program delivered through 25-minute sessions performed three times per week; and a psychosocial arm (IHBLT + social training, ST), consisting of a peer-support program with weekly 1.5-hour meetings held at the Explora Museum in Rome. This latter arm was not implemented and was therefore excluded from the analysis. Outcomes of the two active interventions were assessed at short term (T1) and medium term (T2) on anthropometrics, body composition, adherence to the Mediterranean diet (via the KIDMED questionnaire), and appetite-regulation mechanisms evaluated through standardized test meals. Eating behaviour was assessed using a standardized breakfast designed to ensure uniform energy intake and reduce biases in subjective hunger/satiety perception, followed by an ad libitum meal three hours later. VAS scales were administered at multiple time points (before and after breakfast, immediately after the ad libitum meal, and two hours later), enabling analysis of both immediate responses to food and the ability to sustain satiety over time. Significant and clinically meaningful improvements were observed in weight status, body composition, eating behaviour, and appetite regulation, with benefits observed at the end of the eight-week intervention and consolidated at follow-up. In both groups, BMI z-score steadily decreased: in the IHBLT group from 2.17 ± 0.42 to 2.06 ± 0.48 at T1 (p < 0.0001), with further reduction at T2 (1.99 ± 0.48; p = 0.0002). In the IHBLT + CT group, BMI z-score decreased from 2.13 ± 0.34 to 2.00 ± 0.37 at T1 (p = 0.0010), stabilizing at 1.95 ± 0.42 at T2 (p = 0.0061). Waist circumference and waist-to-height ratio also decreased in both groups, indicating improved central adiposity. Body-composition indices showed similar improvements. In the IHBLT group, total body water percentage (TBW%) significantly increased during the intervention and at follow-up (48.10 ± 6.87% vs 49.56 ± 7.32%, p = 0.0309; 50.43 ± 7.40%, p = 0.0203), while fat mass percentage (FM%) decreased at T1 (39.90 ± 7.53% vs 36.82 ± 8.09%; p = 0.0047) and further at T2 (36.07 ± 8.09%; p = 0.0014). Lean mass steadily increased, accompanied by a significant rise in basal metabolic rate (p < 0.0001). The IHBLT + CT group showed a similar pattern, with increased TBW% from T0 to T2 (50.35 ± 7.98% vs 51.98 ± 6.71%; p = 0.0418), reduced FM% (37.18 ± 8.50% vs 34.26 ± 7.75%; p = 0.0129), increased free fat mass percentage (FFM%) (63.38 ± 9.05% vs 65.76 ± 7.75%; p = 0.0397), and increased basal metabolic rate between T0 and T2 (1323.67 ± 102.82 vs 1343.72 ± 96.05 kcal; p = 0.0066). Test-meal analyses confirmed a shift toward more balanced food choices. In the IHBLT group, the standardized breakfast showed a significant macronutrient rebalance between T1 and T2: carbohydrate intake decreased (76.2 ± 16.1% vs 60.7 ± 9.7%; p = 0.0029) while protein and fat intake increased (proteins 7.4 ± 4.9% vs 12.6 ± 4.1%; p = 0.0187; fats 16.3 ± 12.2% vs 26.7 ± 8.8%; p = 0.0028). Despite a slightly higher caloric intake than at T1, the meal was overall more balanced. In the ad libitum meal, total energy intake decreased, with fewer carbohydrates and proportionally more lipids than at baseline, indicating improved dietary control. The IHBLT + CT group showed a pattern similar to the control group in terms of energy intake and macronutrient distribution at breakfast, although without statistically significant variations. However, notable changes appeared in the ad libitum meal, with reduced carbohydrates (54.9 ± 9.1% vs 45.2 ± 10.1%; p = 0.0137) and increased lipids (28.8 ± 9.6% vs 34.4 ± 5.2%; p = 0.0079), with no changes in proteins, suggesting improved ability to select foods contributing to greater satiety. Mediterranean diet adherence improved in both groups, shifting from moderate to high between T0 and T1 and remaining stable at follow-up, with comparable trajectories in the cognitive-training group. Both groups showed progressive reductions in hunger, desire to eat, and desire to continue eating, accompanied by increased satiety (p < 0.05). A distinctive result emerged in the IHBLT + CT group: only in this group the VAS item assessing satiety after the ad libitum meal significantly increased and remained high over time. Children reported greater fullness both immediately after the meal and in the hours that followed, with persistent effects at follow-up. The findings revealed consistent improvements across all evaluated domains: weight, body composition, eating behaviour, and appetite regulation in both intervention groups. Differences between arms did not reach statistical significance, likely due to limited sample size and the small number of participants completing all test-meal sessions. However, the IHBLT + CT group showed promising trends, particularly regarding the stability and duration of post-prandial satiety. In conclusion, the projects developed within this doctoral program demonstrate how educational, school-based, and clinical interventions can be integrated into a coherent approach aimed at improving eating habits, body composition, and appetite regulation. Nutrition-education programs (Nutripiatto and Fair Play a Tavola) show that behavioural change can begin early, while the RESILIENT trial confirms the effectiveness of intensive IHBLT-based interventions, in line with recent paediatric guidelines (AAP 2023). Together, they outline a continuous model that supports children from primary prevention through specialized care. Future studies with larger samples and longer follow-up periods will help consolidate these findings and clarify the contribution of cognitive components. Promoting integrated interventions represents a crucial investment in fostering health and preventing complications throughout development.