Abstract
Background
General practitioners (GPs) form the gateway to healthcare in numerous European countries. Their role in addressing and managing overweight/obesity in children is crucial. In Dutch guidelines, GPs are encouraged to proactively address weight-related issues during patient consultations, regardless of the initial reason of the visit.
Objective(s)
To examine the frequency, management and follow-up of GP visits of children for overweight/obesity and the identification by GPs of these children presenting with other complaints.
Methods
A retrospective cohort study. Health records from 2012–2021 in the Rijnmond Primary Care Database (RPCD) of children aged 2–18 with overweight/obesity who visited the GP were analysed. Children were categorised into two groups: those visiting for weight-related issues (group 1) and those visiting for other complaints but identified as overweight or obese by GPs (group 2). Data on patient demographics, reasons for contact, and management strategies were extracted.
Results
From the 120,991 children, 3035 children with documented overweight or obesity were identified, 208 were excluded. The study population comprised 2827 individuals: 55% belonging to group 1, 45% to group 2. The frequency of first visits remained stable at approximately 0.5% visits per total person-years each year. Group 1 received more referrals (74%) and follow-up consultations (45.5%) than group 2 with 17% referrals and 19.7% follow-up consultations.
Conclusion
This study highlights a concerning difference in the management of the two groups. Strategies for effective management of overweight in children and the GP’s role, warrant further investigation. Especially when overweight is not the primary reason for visit.
Keywords: Childhood obesity, general practitioners, primary care, overweight, weight management
KEY MESSAGES
Children rarely visit general practitioners for weight-related issues.
GPs recognise children with overweight but document and refer them less frequently than children who visit the GP for a weight-related issue.
Addressing overweight/obesity at the point of visit is an opportunity to improve weight control in children.
Introduction
In many European countries, general practitioners (GPs) are the initial healthcare providers to address patients’ health problems, including overweight [1]. National and international guidelines on childhood obesity are available and consistent with growth monitoring, healthy weight, and overweight management [2,3]. Dutch guidelines for GPs recommend addressing overweight, regardless of the reason for the consultation. GPs should also provide advice on healthy lifestyles to reduce obesity and improve children’s health [4].
Typically, children under 18 visit a GP on average twice a year [5], and those with overweight tend to have more yearly visits than those with normal weight [6]. Only few children visit the GP for a weight related problem [7]. If a weight problem is not the main reason of consultation, discussions between child, parent and the GP on weight management may be hindered due to factors as time constraints, visual assessments to estimate the child’s weight, or discomfort discussing weight due to social stigma [8–10]
Earlier research shows that only 0.6% of children’s GP visits were weight-related [11]. However, it remains unclear how many children initially visit for this reason or have their weight noted during visits for other issues. This study will use electronic health records (EHRs) to outline how GPs register, manage, and follow up children with overweight in daily practice.
It is hypothesised that children rarely visit their GP with concerns about their weight, and GPs rarely address overweight during consultations when the child consults for reasons other than their weight.
Therefore, the objective of this study was twofold. Firstly, we aimed to gain more insight into the frequency at which GPs record children aged 2–18 years with overweight and obesity, as well as to explore the differences between children who initially visited their GP for weight-related issues and those who visited for other complaints but were identified as overweight or obese by their GP. Secondly, we aimed to provide insight into the management and follow-up strategies of GPs in consultations with children with overweight or obesity.
Methods
Study design
This retrospective cohort study used the Rijnmond Primary Care Database (RPCD), which is a derivative of the integrated Primary Care Information (IPCI) [12,13] focused on the greater Rotterdam area in the Netherlands. The RPCD includes data from approximately 120 GPs and contains pseudonymised information from the medical records of up to 500,000 primary care patients [14]. In the Netherlands, the GP is the first point of care for patients. GP files consist of medical notes, diagnostic codes, laboratory results, prescriptions, referrals and letters from secondary care, dietitians, physiotherapist and youth doctors (YD). This study was exempt from patient consent requirements due to the use of anonymised data and a waiver from the RPCD Governance Board.
Study cohort
The study population consisted of children with overweight/obesity aged between 2 and 18 who visited their GP between 2012 and 2021. Two groups were differentiated based on the reason of consultation: those who initially (i.e. mainly/primarily) visited for weight-related issues (further referred to as group 1) and those who visited for other complaints but were also identified as overweight or obese by their GP (further referred to as group 2). To identify children with overweight/obesity in the medical file records, ICPC codes T83(Overweight)/T82(Obesity) or specific keywords were searched in the free text, including ‘Obesity’, ‘Overweight’, ‘Adipose’, ‘Worrying about weight’, and ‘Too heavy’. Children were excluded if they were identified as underweight or if negations were used in combination with keywords related to overweight or obesity. All children who were exclusively identified using ICPC T82/83 were assigned to group 1, whereas all children who were exclusively identified through free text were assigned to group 2. The algorithm was tested with samples of 100 cases by researcher (HH) and GP-researcher (JvdD) for inclusion or exclusion. The positive predictive value (PPV) for the algorithm was 99% (group 1B), and the PPV for the free text group was 95% (group 2B).
ICPC codes T82/T83 combined with other ICPC codes were manually checked by HH to confirm whether the visit was an initial visit for a weight problem (group 1A i.e. a clearly stated overweight reason for the visit or a request for help from the patient) or if the weight problem was observed by the GP while another complaint was the initial reason for the visit (group 2A i.e. if weight had been measured or observed by the GP or if it was clear that the GP had raised the issue of weight). Medical records with brief or inadequate documentation were placed in the ambiguous group. Any unclear cases were again reviewed by JvdD for the final decision on inclusion or exclusion. Cases that failed to meet the inclusion criteria for either group 1 or group 2 were subsequently excluded from further analysis.
Data extraction
From the medical files of the study population, information on sex, age, and postal code were extracted. Children were categorised into those living in deprived areas or non-deprived areas. The Dutch Healthcare Authority (NZA) [15] defines these areas using a postal code list.
The frequency of first visits was determined by identifying newly registered children with overweight status in the EHR.
The initial reason for contact in group 1 was noted as either self-referral (i.e. visit on their own initiative) or a referral by a healthcare professional. For the children in group 2, based on the ICPC code linked to the contact, the reason for their visit was examined and categorised into eight groups based on the ICPC coding: Musculoskeletal, Respiratory, Digestive, Skin, Ear, Psychosocial, General, Other.
Additionally, from both groups 10% of the children were randomly extracted. For this 10%, the management options were manually reviewed (HH and JvdD). The GP’s management of overweight and any potential follow-up visits were recorded. The management options included ‘referral’ and ‘additional examination’. For all children, follow-up was defined as a second GP visit for weight problems within one year after the initial contact. Registration of BMI/weight was extracted.
Statistics
Descriptive statistics were used to describe patient characteristics and frequency of first visits of the children documented as overweight or obese in the EHR. The frequency of first visits is calculated by number of first consultations of children with overweight and obesity per year and was divided by the total number of person-years (PY). PY was defined as the cumulative years in one year time of children and adolescents aged 2–18 in RPCD. The frequency of first visits were further analysed according to age group, categorised in children (2–11 years) and adolescents (12–18 years), sex and deprived area vs. non-deprived area.
A strobe checklist was employed and is presented as an additional file (Supplementary Appendix 1).
Results
Figure 1 shows that 3,035 children in the database (n = 120,991) are overweight or obese. We excluded 208 individuals who were assigned to an ambiguous category as they could not be allocated to either group 1 or group 2. The final study population comprised 2827 children and adolescents. Of these, 1552 (55%) were children initially visiting the GP for weight-related issues (group 1), 1275 (45%) visited for other complaints but were identified as overweight or obese by their GP (group 2).
Figure 1.
Patient selection for frequency rate of overweight or obesity of ICPC-coded T82/T83 and based on keywords in the free text.
Table 1 shows an overview of the population characteristics. Of the total of 2827 children, 1225 (43%) were boys, 938 (33%) lived in deprived areas, 1619 (57%) were aged 2–11 years and 1208 (43%) were aged 12–18 years. No clear differences between group 1 and 2 were observed regarding their general characteristics.
Table 1.
Population characteristics (N = 2827).
| Total | Group 1 visit for weight problems | Group 2 GP identified overweight | |
|---|---|---|---|
| N = 2827 | n = 1552 | n = 1275 | |
| n (%) | n (%) | n (%) | |
| Age | |||
| 2–11 Years | 1619 (57%) | 944 (61%) | 675 (53%) |
| 12–18 Years | 1208 (43%) | 608 (39%) | 600 (47%) |
| Sex | |||
| Boy | 1225 (43%) | 640 (41%) | 585 (46%) |
| Girl | 1602 (57%) | 912 (59%) | 690 (54%) |
| Neighbourhood status | |||
| Deprived | 938 (33%) | 539 (35%) | 399 (31%) |
| Non deprived | 1630 (58%) | 875 (56%) | 755 (59%) |
| Unknown | 259 (9%) | 138 (9%) | 121 (9%) |
Frequency of first visits
For visit frequency, see Supplementary File 1. Supplementary File 1a presents first visits per 1,000 person-years and shows convergence between groups 1 and 2 over time, with a stable annual rate of approximately 0.5% newly registered overweight children. Supplementary File 1c shows that girls visit the GP more frequently for weight related issues and are more likely to be observed by the GP if they present with other complaints, compared to boys. Additionally, children in deprived areas visit their GP more often for weight-related issues and have higher rates of registered overweight/obesity than those in non-deprived-areas (Supplementary File 1d). In group 1, a decrease of GP visits in time for weight-related problems was seen in children aged 2–11 years (Supplementary File 1b).
Reason for visiting the GP
In group 1, 46% of the children were referred to the GP by another healthcare professional. For group 2, various reasons for the consultations were observed, with complaints of the gastrointestinal tract (20%) and musculoskeletal complaints (16%) being most frequent (Figure 2).
Figure 2.
Reasons for GP consultation in which overweight was identified and registered by GP.
Management and follow-up
Weight or BMI of the child was registered in 59% of children in group 1, while it was documented in only 28% of children in group 2. In group 1, 74% of the children were referred at first visit, compared to only 17% in group 2. Moreover, more blood tests were performed in group 1 (13%) compared to group 2 (6%) (Table 2). Most referrals were to a dietician: 58% in group 1 and 9% in group 2.
Table 2.
Management registration by the GP during first visit.
| Total n = 280* | Group 1 Visit for weight problems n = 150* |
Group 2 GP identified overweight n = 130* |
|
|---|---|---|---|
| N (%) | N (%) | N (%) | |
| Referral, total | 137 (48%) | 116 (74%) | 21 (17%) |
| Dietitian | 101 (36%) | 90 (58%) | 11 (9%) |
| Pediatrician | 15 (5%) | 12 (8%) | 3 (2%) |
| Physiotherapist | 8 (3%) | 6 (4%) | 2 (2%) |
| Psychologist | 3 (1%) | 1 (1%) | 2 (2%) |
| Multidisciplinary interventions | 4 (1%) | 3 (2%) | 1 (1%) |
| Other | 9 (3%) | 6 (4%) | 3 (2%) |
| Additional examinationa | 28 (10%) | 20 (13%) | 8 (6%) |
*Ten percent of each group was manually checked to determine if management documentation was recorded by the GP during the first consultation.
aBlood tests (TSH, glucose).
A higher percentage of children in group 1 (45.5%) received follow-up consultation with their GP compared to group 2 (19.7%). No differences in follow-up consultations were observed in age, sex, or neighbourhood.
Discussion
Main findings
The frequency of first visits for children with overweight or obesity was comparable between group 1, where the initial reason for the visit was weight-related issues, and group 2, where overweight was identified by the GP. However, in children in group 1 more referrals and follow-up consultations were registered compared to children in group 2.
Comparison with existing literature
About 0.5% new visits per total person-years were annually recorded as overweight or obese by GPs for children aged 2–18 years, meaning 5 out of every 1,000 children were registered each year. The Netherlands Institute for Health Services Research (NIVEL) reported [16], an incidence of 4.4 per 1000 PY for overweight (T83) and 8.1 per 1000 for obesity (T82) among adults and children [16]. As no separate data were presented for children it is not possible to compare our findings with these data. Moreover, our study was performed in the Rijnmond region, known to have a relatively higher obesity rate [17]. A previous Dutch study showed that only 0.6% of children consulted a GP for overweight or obesity concerns [11]. The authors suggest that this relatively low number may be attributed to the fact that children may not proactively seek advice from their general practitioner regarding obesity [7]. This aligns with our findings, which are marked by a similarly low frequency of new consultations in our study’s group 1. While group 1 has informative data, there is insufficient focus on the documentation for children in group 2. The WHO European Childhood Obesity Surveillance Initiative (COSI) reports that one in three children in the WHO European region is overweight or obese [18]. Additionally, studies have shown that overweight children tend to visit their general practitioner (GP) relatively more often than their peers without overweight [6]. However, in line with our study, research showed that GPs do not regularly record weight in their registry system during consultation [19], and reporting rates may be relatively low due to various factors such as health system disparities, diagnostic criteria, and registry systems [19,20]. Dutch obesity guidelines for GPs emphasise the crucial role of GPs in identifying overweight or obese individuals, regardless of the purpose of the visit, to initiate secondary prevention [21]. The majority of children in group 2 did not receive the ICPC classification for overweight/obesity, suggesting that although GPs recognise the issue, they do not use the ICPC classification.
Children in group 1 received a substantial higher number of referrals (74% vs. 17%) and follow-up appointments (45.5% vs. 19.7%) than whose initial visit was not weight-related. One of the reasons for this difference may relate to the severity of the overweight, that may differ between these groups. Though, as only weight data were available in 59% of the cases in group 1 and 28% of the cases in group 2, it is not possible to make definitive conclusions on this matter as we have not analysed this data due to its limitations. Secondly, since the measurement of height, weight, and BMI is not a standard practice for GPs in the Netherlands, it is plausible that they may even have overlooked overweight children due to the challenges associated with visually estimating a child’s weight (group 2) [8,9]. Thirdly, it is uncertain whether discussions about overweight actually took place in group 2. The barriers identified by literature based on qualitative studies may impede GPs from initiating discussions about overweight resulting in the low numbers of ICPC codes in group 2 [4,10,22]. GPs may face barriers related to time constraints, stigma and fear of discussing eating disorders, or even scepticism about the relevance of this topic or the utility of their role in addressing it [8–10,23,24]. Finally, the low referral and follow-up rates at consultation may be due to the common practice of providing lifestyle advice first, or the motivation level of the child or parents [25]. However, our data does not include information on these details.
It was noticeable that when GPs did refer children, they tend to refer them to a dietician, even though literature and (European) guidelines advice a multidisciplinary approach [4,26]. This preference may be due to the limited availability of easily accessible and effective multidisciplinary programmes for both children and parents in their neighbourhood. Future research should concentrate on the role of the GP, the expectations of GPs and the practicality of implementing new approaches in everyday practice.
The frequency of visits for different patient characteristics exhibit subtle variations. In the Netherlands, while there is no difference in the prevalence of obesity between boys and girls in the open population, girls are registered more often, possibly because they are more dissatisfied with their weight than boys [27,28]. Children in a deprived area have a higher frequency of visits than those in non-deprived areas, possibly due to higher overweight prevalence in these regions [29,30]. Additionally, schools in the greater Rotterdam area promote healthy lifestyles, potentially leading to increased self-initiated actions by parents and children [31,32]. In group 1, a negative trend was seen in the frequency of first visits over time in children aged 2–11 years. This may be due to the introduction of the new Youth law in the Netherlands, which authorised specialised youth doctors (YD) to directly refer children to specialists [33]. However, the referral numbers by YD are unknown. The trend may also reflect a decrease in overweight among children aged 4–11 years in the overall population between 1990 and 2021 [28].
Strengths and limitations
To the authors’ knowledge this is the first study to assess how often GPs record children aged 2–18 years with overweight and obesity and to distinguish between children who initially visited their GP for weight-related issues versus children who visited for other complaints but were identified as overweight or obese by their GP.
The most significant limitation of this study is that the primary purpose of EHR is not data collection, which means the reliability of the data relies on the GP’s use of ICPC-codes and note-taking. We attempted to identify children with overweight using keywords in free text, but it is possible that we missed some patients. Nevertheless, we believe that our cohort was as comprehensive as possible.
Another limitation was that the existing database did not contain standardised information regarding the weight of all registered children, making it impossible to distinguish between overweight and non-overweight individuals. In only 45% of the children weight, length, or BMI were recorded in the EHR. Consequently, the absence of weight and height data for all children precluded the ability to ascertain the prevalence of overweight and obesity among children.
This study was constrained by the absence of a clearly defined threshold for deprived area. Furthermore, individual socioeconomic status data were unavailable within the consultation dataset.
For management and follow-up purposes, data were randomly selected, with 10% of the children from each group being chosen for examination. This method was chosen due to the labour-intensive nature of the manual review process, which was carried out by two project members, making it impractical to review all 2827 cases. This methodology aligns with those used in previously published studies. Considering the randomness of the selection, it is improbable that the results would have been markedly different had the entire study population been reviewed.
Conclusion
This study reveals that children who visit the GP for weight-related issues receive more referrals and follow-up than those who visit for other reasons, highlighting the need to address children with overweight/obesity in general practice. Further research should clarify the role of the GP in addressing children with overweight and obesity.
Supplementary Material
Disclosure statement
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
- 1.Semlitsch T, Stigler FL, Jeitler K, et al. Management of overweight and obesity in primary care-a systematic overview of international evidence-based guidelines. Obes Rev. 2019;20(9):1218–1230. doi: 10.1111/obr.12889. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Tully L, Arthurs N, Wyse C, et al. Guidelines for treating child and adolescent obesity: a systematic review. Front Nutr. 2022;9:902865–36313105. doi: 10.3389/fnut.2022.902865. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Richardson L, Paulis WD, van Middelkoop M, et al. An overview of national clinical guidelines for the management of childhood obesity in primary care. Prev Med. 2013;57(5):448–455. doi: 10.1016/j.ypmed.2013.08.010. [DOI] [PubMed] [Google Scholar]
- 4.Van Binsbergen JJLFDAV, Glijsteen R, Cleyndert GA, et al. NHG-Standaard Obesitas: Nederlands Huisartsen Genootschap 2010 [updated 2023 September; cited 2023 Apr 26]. Available from: https://www.nhg.org/standaarden/volledig/nhg-standaard-obesitas#idp541008.
- 5.Heins M, Bes J, Weesie Y, et al. Zorg door de huisarts. Nivel Zorgregistraties Eerste Lijn: jaarcijfers 2021 en trendcijfers 2017–2021 [Internet]. Nivel. Utrecht: Nivel; 2022 Aug [cited 2022 Oct 18]. Available from: https://nivel.nl/sites/default/files/bestanden/1004273.pdf.
- 6.van Leeuwen J, van Middelkoop M, Paulis WD, et al. Overweight and obese children do not consult their general practitioner more often than normal weight children for musculoskeletal complaints during a 2-year follow-up. Arch Dis Child. 2018;103(2):149–154. doi: 10.1136/archdischild-2017-313118. [DOI] [PubMed] [Google Scholar]
- 7.Paulis WD, Palmer M, Chondros P, et al. Health profiles of overweight and obese youth attending general practice. Arch Dis Child. 2017;102(5):434–439. doi: 10.1136/archdischild-2016-311404. [DOI] [PubMed] [Google Scholar]
- 8.Yoong SL, Carey ML, Sanson-Fisher RW, et al. A cross-sectional study examining Australian general practitioners’ identification of overweight and obese patients. J Gen Intern Med. 2014;29(2):328–334. doi: 10.1007/s11606-013-2637-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Robinson E, Parretti H, Aveyard P.. Visual identification of obesity by healthcare professionals: an experimental study of trainee and qualified GPs. Br J Gen Pract. 2014;64(628):e703-8–e708. doi: 10.3399/bjgp14X682285. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Ray D, Sniehotta F, McColl E, et al. Barriers and facilitators to implementing practices for prevention of childhood obesity in primary care: a mixed methods systematic review. Obes Rev. 2022;23(4):e13417. doi: 10.1111/obr.13417. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Paulis WD, van Middelkoop M, Bueving HJ, et al. Discussing overweight in primary care. Arch Dis Child. 2015;100(9):899–900. doi: 10.1136/archdischild-2015-308747. [DOI] [PubMed] [Google Scholar]
- 12.Vlug AE, van der Lei J, Mosseveld BM, et al. Postmarketing surveillance based on electronic patient records: the IPCI project. Methods Inf Med. 1999;38(4–5):339–344. [PubMed] [Google Scholar]
- 13.van der Lei J, Duisterhout JS, Westerhof HP, et al. The introduction of computer-based patient records in The Netherlands. Ann Intern Med. 1993;119(10):1036–1041. doi: 10.7326/0003-4819-119-10-199311150-00011. [DOI] [PubMed] [Google Scholar]
- 14.RijnmondGezond - Rijnmond Gezond Database [Internet]. Rijnmond Gezond Database. Rijnmond Primary Care Database (RPCD); 2019. [cited 2023 Apr 26]. Available from: https://www.rijnmondgezond.nl/.
- 15.Prestatie- en tariefbeschikking huisartsenzorg en multidisciplinaire zorg 2023 - TB/REG-23617-03 - Nederlandse Zorgautoriteit [Internet]. Overheid.nl; 2023. [cited 2023 Jun 12]. Available from: https://puc.overheid.nl/nza/doc/PUC_711671_22/.
- 16.Vanhommerig J, Overbeek L. Nivel-cijfers Ziekten op jaarbasis in Nederland – incidentie en prevalentie.: NIVEL; 2024 [updated 2024 Jul 16; cited 2024 Aug 13]. Available from: https://www.nivel.nl/nl/zorg-en-ziekte-in-cijfers/cijfers-ziekten-op-jaarbasis.
- 17.P. Geuijen DA,M, Hiemstra R, Boekee CM, et al. Overgewicht | Regionaal | Overgewicht: RIVM [updated 2023; cited 2024 Nov 17]. Available from: https://www.vzinfo.nl/overgewicht/regionaal/overgewicht.
- 18.WHO . WHO European childhood obesity surveillance initiative (COSI); 2024. [cited 2024 Aug 13]. Available from: https://www.who.int/europe/initiatives/who-european-childhood-obesity-surveillance-initiative-(cosi).
- 19.Firman N, Robson J, Ahmed Z, et al. Completeness and representativeness of body mass index in children’s electronic general practice records: linked cross-sectional study in an ethnically-diverse urban population in the United Kingdom. Pediatr Obes. 2021;16(8):e12772. doi: 10.1111/ijpo.12772. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Griffiths LJ, Rafferty J, Fry R, et al. Children and young people’s body mass index measures derived from routine data sources: a national data linkage study in Wales. PLOS One. 2024;19(5):e0300221. doi: 10.1371/journal.pone.0300221. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.van Binsbergen JJ, Langens FNM, Dapper ALM, et al. NHG-standaard obesitas. Huisarts en Wetenschap. 2010;53(11):609–625.
- 22.Warr W, Aveyard P, Albury C, et al. A systematic review and thematic synthesis of qualitative studies exploring GPs’ and nurses’ perspectives on discussing weight with patients with overweight and obesity in primary care. Obes Rev. 2021;22(4):e13151. doi: 10.1111/obr.13151. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Amiri P, Mansouri-Tehrani MM, Khalili-Chelik A, et al. Does motivational interviewing improve the weight management process in adolescents? A systematic review and meta-analysis. Int J Behav Med. 2022;29(1):78–103. doi: 10.1007/s12529-021-09994-w. [DOI] [PubMed] [Google Scholar]
- 24.Ling J, Wen F, Robbins LB, et al. Motivational interviewing to reduce anthropometrics among children: a meta-analysis, moderation analysis and grading of recommendations assessment, development and evaluation assessment. Pediatr Obes. 2022;17(8):e12896. doi: 10.1111/ijpo.12896. [DOI] [PubMed] [Google Scholar]
- 25.Cardel MI, Szurek SM, Dillard JR, et al. Perceived barriers/facilitators to a healthy lifestyle among diverse adolescents with overweight/obesity: a qualitative study. Obes Sci Pract. 2020;6(6):638–648. doi: 10.1002/osp4.448. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Ells LJ, Rees K, Brown T, et al. Interventions for treating children and adolescents with overweight and obesity: an overview of Cochrane reviews. Int J Obes. 2018;42(11):1823–1833. doi: 10.1038/s41366-018-0230-y. [DOI] [PubMed] [Google Scholar]
- 27.Boer M. HBSC 2021. Gezondheid en welzijn van jongeren in Nederland [Internet]. Trimbos. Utrecht: Universiteit Utrecht; 2022. [cited 2022 Oct 18]. Available from: https://www.trimbos.nl/wp-content/uploads/2022/09/AF2022-HBSC-2021-Gezondheid-en-welzijn-van-jongeren-in-Nederland.pdf.
- 28.Zantinge M. Kinderen met overgewicht en obesitas naar leeftijd 2022: Rijksinstituut voor Volksgezondheid en Milieu (RIVM); 2023 [updated 2023 Mar 17; cited 2023 May 11]. Available from: https://www.vzinfo.nl/overgewicht/leeftijd-en-geslacht-jongeren#:∼:text=Tussen%201990%20en%202021%20laat,bij%20jongens%2C%20meisjes%20als%20totaal.
- 29.Roth B, Reynaud R, Nègre V, et al. Prevalence of overweight, obesity, and early adiposity rebound in nursery school children in southeastern France. Arch Pediatr. 2022;29(5):388–394. doi: 10.1016/j.arcped.2022.03.001. [DOI] [PubMed] [Google Scholar]
- 30.Ahrens W, Pigeot I, Pohlabeln H, et al. Prevalence of overweight and obesity in European children below the age of 10. Int J Obes. 2014;38(S2):S99–S107. doi: 10.1038/ijo.2014.140. [DOI] [PubMed] [Google Scholar]
- 31.Smit MS, Raat H, Mölenberg F, et al. Study protocol for the evaluation of long-term effects of the school-based obesity prevention program Lekker Fit! (‘enjoy being fit’): a retrospective, controlled design. BMJ Open. 2021;11(8):e046940. doi: 10.1136/bmjopen-2020-046940. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Jansen W, Borsboom G, Meima A, et al. Effectiveness of a primary school-based intervention to reduce overweight. Int J Pediatr Obes. 2011;6(2–2):e70-7–e77. doi: 10.3109/17477166.2011.575151. [DOI] [PubMed] [Google Scholar]
- 33.(NJi) NJ. De geschiedenis van het jeugdstelsel: Nederlands Jeugdinstituut; 2023. [cited 2023 May 11]. Available from: https://www.nji.nl/transformatie-jeugdhulp/geschiedenis-jeugdstelsel.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.