Objectives To describe child and parent weight change during the pandemic, overall and by income precarity.
Design A cross-sectional online survey was conducted.
Setting Caregivers of children 0–17 years of age living in Ontario, Canada, during the COVID-19 pandemic from May 2021 to July 2021.
Participants A convenience sample of parents (n=9099) with children (n=9667) living in Ontario were identified through crowdsourcing.
Primary outcome measure Parents recalled, for themselves and their child, whether they lost weight, gained weight or remained the same over the past year. OR and 95% CI were estimated using multinomial logistic regression for the association between income precarity variables and weight loss or gain, adjusted for age, gender and ethnicity.
Results Overall, 5.5% of children lost weight and 20.2% gained weight. Among adolescents, 11.1% lost weight and 27.1% gained weight. For parents, 17.1% reported weight loss and 57.7% reported weight gain. Parent weight change was strongly associated with child weight change. Income precarity measures, including job loss by both parents (OR=7.81, 95% CI 5.16 to 11.83) and disruption to household food supply (OR=6.05, 95% CI 4.77 to 7.68), were strongly associated with child weight loss. Similarly, job loss by both parents (OR=2.03, 95% CI 1.37 to 3.03) and disruption to household food supply (OR=2.99, 95% CI 2.52 to 3.54) were associated with child weight gain.
Conclusions Weight changes during the COVID-19 pandemic were widespread and income precarity was strongly associated with weight loss and weight gain in children and parents. Further research is needed to investigate the health outcomes related to weight change during the pandemic, especially for youth, and the impacts of income precarity.
- Community child health
- PREVENTIVE MEDICINE
- PUBLIC HEALTH
Data availability statement
The data used in the current study are available through arrangement with the author (AG) in accordance with all relevant ethics and privacy protocols.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
The strengths of our study include the large sample size, timely data collection and extensive measures of income precarity.
There were several possible limitations, including the cross-sectional design and the parent report of recalled weight for themselves and their children.
Additional limitations were lack of information on the magnitude of weight change, lack of information on eating disorders and obesity, and possible lack of generalisability.
The COVID-19 pandemic has led to many changes in the lives of children and parents. Physical distancing requirements and temporary closures of schools, childcare centres, workplaces and recreational facilities have reduced the opportunities for physical activity and substantially increased sedentary time.1–4 Dietary changes have also been reported during the pandemic, including both increased snacking and consumption of comfort foods.1 2 Food insecurity, which is often associated with material deprivation and resulting lower diet quality, has also increased during the pandemic.5 6 These changes were exacerbated by increased stress and mental health concerns among both children and parents.1 2 7 Further, routine child growth monitoring is universally recommended in primary care8 but was substantially disrupted with the shift to virtual primary care during the pandemic. All these factors may contribute to changes in weight, in either direction (gain or loss), among children and parents. A growing body of evidence suggests that weight9 10 and the prevalence of obesity10 have increased among both children and parents during the COVID-19 pandemic. Over the same time period, the prevalence of eating disorders has also increased among both children and parents.11 12
The pandemic has also increased unemployment and income loss, resulting in higher levels of financial and material insecurity, or income precarity.13 14 Unemployment and other measures of family material deprivation have been associated with decreased adherence to public health preventive measures.15 16 Lower income, poverty and other measures of material deprivation are also established risk factors for both obesity17–20 and underweight.20–22 There is some emerging evidence that job loss and lower education levels are associated with weight gain during the pandemic,23 but the overall impact of income precarity on child and parent weight change during the pandemic is unknown. The objectives of our study were to describe parent-reported recall of child and parent weight change during the COVID-19 pandemic and to describe these changes by measures of income precarity.
Study design and sampling
A cross-sectional study was conducted using data from the Ontario Parent Survey 2.24 25 Data were collected through an open online survey from 4 May 2021 to 3 July 2021. A convenience sample of caregivers of children 0–17 years of age in the province of Ontario, Canada, were recruited through online crowdsourcing. Multiple techniques were used to advertise the survey, including online advertisements and social platforms, and emails through public health units and Ontario EarlyON centres, participating school boards, and municipal, community and professional organisations across Ontario. A market research firm was hired to recruit a subset of participants (n=730) to increase the diversity and representativeness of the sample. The target population was all parents in Ontario. The survey was available in English and French. In households with multiple children, caregivers were asked to select a target child based on which child’s birthday was closest to the date when the survey was completed.
Parents provided informed consent. The Checklist for Reporting Results of Internet E-Surveys and the Strengthening the Reporting of Observational Studies in Epidemiology statement were used to guide the reporting of this study.
Measurement of variables
All data were collected from the voluntary parent-completed online survey, which was posted on a website. REDCap was used for survey administration and data capture. Caregivers could enter a draw for one of three iPads, or one of fifty $50 Amazon cards. The survey was developed with feedback from community partners and was pilot-tested. A full copy of the questionnaire is included in the online supplemental file 1. Duplicate responses and any responses from outside of the province were eliminated.
The primary outcome of interest for this study was parent-reported recall of their child’s weight change and their own weight change during the COVID-19 pandemic. To measure children’s weight change, parents were asked ‘Over the past year, has [TARGET CHILD]’s weight changed?’, with the following response options: lost more weight than expected, healthy growth or no weight change, or gained more weight than expected. Parent recall of their own weight was collected using one question that asked if they had lost weight, no change, gained weight or if they were currently pregnant over the past year. If the parent was currently pregnant, all weight data for the parent were excluded. Our outcome questions were not validated and it is known that parent report of children’s height and weight status is poor26; however, the validity of parental recall of child weight change is unknown. Among adults, the validity of recall of long-term weight changes and prospective self-report of weight change is good,27 28 but the validity of recalled short-term changes is unknown.
The primary exposure of interest was income precarity, which was measured using several variables related to household income and financial security. Household income was not directly asked on the survey, but several income and material deprivation measures were included in the survey. For this study, we included the following seven income precarity measures: ‘job loss by one caregiver’, ‘job loss by two caregivers’, ‘adult filed for unemployment’, ‘difficulty paying bills or buying necessities (eg, food)’, ‘unable to pay for rent or mortgage’, ‘unable to access necessary supplies or food’ and ‘major disruption to household food supply’. All these questions were coded as yes or no, except for job loss which had three response options (no job loss, job loss by one caregiver, job loss by two caregivers), and the time period for all questions was during the COVID-19 pandemic.
Descriptive statistics, including the frequency and proportion of respondents, were presented for the outcomes of interest overall and stratified by population characteristics, including child and parent age, child and parent gender, and parent ethnicity. The descriptive association between parent and child weight change was presented graphically and the adjusted OR and 95% CI were estimated using multinomial logistic regression with child weight change as the dependent variable comparing the odds of ‘weight gain’ and ‘weight loss’ with ‘no weight change’ as the referent group. The model was adjusted for child age, child gender, parent age, parent gender and parent ethnicity. Similarly, the association between each of the income precarity variables was evaluated in relation to parent and child weight change separately using multinomial logistic regression with ‘no weight change’ as the referent group. Each income precarity variable was evaluated separately. Child models were adjusted for child age, child gender and parent ethnicity, and parent models were adjusted for parent age, parent gender and parent ethnicity. Secondary analyses were conducted stratified by child age group and by gender. For the analysis stratified by gender, the results were only reported for males and females due to small sample sizes for all other reported gender identities (<1% of sample). The number of participants with missing data is reported in the results and complete case analysis was conducted. All statistical analyses were conducted using SAS 9.4.
Patient and public involvement
Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.
A total of 13 920 participants opened the survey and completed the informed consent to participate. Of the 13 920, there were 1192 (9%) participants who provided no responses to any questions, 950 (7%) were considered invalid and were excluded (eg, based on age or region of residence), and 11 778 (85%) parents/caregivers participated in the study. Of the 11 778 participants, there were 9667 (82%) parents who reported on their child’s weight change. Overall, parents’ recall of their children’s weight change over the past year (during the first year of the COVID-19 pandemic) indicated that 5.5% of children lost more weight than expected, 74.3% of children had no change or healthy growth, and 20.2% of children gained more weight than expected (table 1).
The prevalence of weight change was similar in boys and girls, but both weight loss and weight gain were more commonly reported in children who identified as transgender or other genders, although this subgroup was small. The frequency of both child weight loss and weight gain increased with child age, such that 11.1% of children 13–17 years of age lost more weight than expected and 27.1% gained more weight than expected. Both child weight loss and weight gain were also more common among children whose parents had lower education levels and who did not identify to be of European or North American ethnicity.
Of the 11 778 participants, there were 9099 (77%) parents who reported on their weight change. Based on parents’ recall of their own weight change, 17.1% reported weight loss, 25.2% reported no change and 57.7% reported weight gain over the past year (table 2).
Weight loss was more common among men and other gender identities, whereas women were more likely to report weight gain. Some changes in the frequency of parent weight loss and weight gain were observed by parent age, ethnicity and education, but these were less pronounced than the changes for children. Parent weight change was strongly associated with child weight change (figure 1). Parent weight gain, compared with no change, was associated with 2.46 times increased odds (95% CI 2.11 to 2.87) of child weight gain. Similarly, parent weight loss, compared with no change, was associated with 2.89 times increased odds (95% CI 2.16 to 3.85) of child weight loss.
Figure 2 presents the proportion of parents experiencing each of the income precarity variables. Table 3 presents the association between income precarity variables and child weight loss and weight gain compared with no change or healthy growth, overall and stratified by gender.
Nearly all the income precarity variables were strongly associated with both child weight loss and weight gain during the pandemic. For example, job loss by two parents was associated with over a sevenfold increase in the odds of child weight loss (OR=7.81, 95% CI 5.16 to 11.83) and a twofold increase in the odds of weight gain (OR=2.03, 95% CI 1.37 to 3.03). Difficulty paying bills or buying necessities and unable to pay rent were also strongly associated with increased odds of approximately twofold and greater of both child weight gain and weight loss. Increased odds of approximately twofold and greater were also seen for variables related to food insecurity, including the inability to access necessary supplies or food and major disruption to household food supply during the pandemic. There was no evidence of an association between filing for unemployment and child weight loss or child weight gain. The results stratified by child gender did not provide strong evidence of any overall differences in boys and girls, except that the association between disruption to household food supply and child weight loss was stronger in girls (OR=7.93, 95% CI 5.67 to 11.09) than in boys (OR=4.69, 95% CI 3.30 to 6.66). The associations stratified by child age are provided in online supplemental table 1. Younger children had an increased odds of weight gain for all income-related variables and a dose–response gradient by age was evident, but this pattern was not evident for weight loss. Additionally, younger children seemed more susceptible to weight gain and weight loss if there were major disruptions to income-related variables, such as job loss by two parents and major disruption to household food supply.
Table 4 presents the association between income precarity variables and parent weight loss and weight gain compared with no change, overall and stratified by gender.
Nearly all income-related variables were strongly associated with both parent weight loss and weight gain during the pandemic. Filing for unemployment was associated with increased odds of parent weight loss (OR=1.41, 95% CI 1.13 to 1.76) and weight gain (OR=1.46, 95% CI 1.22 to 1.74). Job loss by one parent was also associated with increased odds of parent weight loss (OR=1.28, 95% CI 1.06 to 1.56) and weight gain (OR=1.32, 95% CI 1.14 to 1.53). Difficulty paying bills or buying necessities and unable to pay rent or mortgage were strongly associated with a greater than 1.5-fold increased odds of both parent weight gain and weight loss. Similar increased odds were seen for the variables related to food insecurity.
The results of our study suggest a high proportion of children and their parents may have experienced weight changes during the COVID-19 pandemic. Based on parent recall, 5.5% of children lost more weight than expected and 20.2% of children gained more weight than expected over the first year of the pandemic. Only 74.3% of parents reported that their children had healthy growth or no weight change during this time period. These changes were more pronounced in adolescents than in young children. Among parents, the proportion of self-reported weight loss (17.1%) and weight gain (57.7%) was substantial, with only 25.2% of parents reporting no weight change during the last year. Consistent with previous literature from before the pandemic, parent weight change, whether it was gain or loss, was strongly associated with child weight change.29 Further, our study results suggest that income precarity is strongly associated with both child and parent weight gain and weight loss. These associations were statistically significant after adjusting for age, gender and ethnicity, and the magnitude of the associations was very strong, many with adjusted ORs greater than 2.0. Job loss, by one or two parents, and difficultly paying bills, rent or mortgage were associated with very strong increased odds of weight loss and weight gain among both children and parents. Variables related to food insecurity, including difficulty accessing necessary supplies or food and disruption to household food supply, were also associated with very strong odds of both weight loss and weight gain in children and parents. Although the proportion of participants who experienced weight loss was smaller than those who experienced weight gain, many of the variables we evaluated had much stronger ORs for weight loss than for weight gain. It is possible that weight loss may be more susceptible to income precarity than weight gain if income precarity leads to less food access or if increased stress results in eating less. Reverse causality is also a possibility and weight loss may lead to income precarity, for example with the diagnosis of a major illness. Future studies are needed to evaluate these possible hypotheses in more detail. Overall, the results of our study are consistent with systematic reviews that found that both children and adults experienced weight gain and increased risk of obesity during the COVID-19 pandemic.9 10 23 Similar to our current study, it is a limitation that many of the previous studies have been cross-sectional, based on recall and did not consider weight change before the pandemic. This is particularly important in studies of children where growth is expected with age and parent-reported weight change does not account for expected changes in growth by age and sex. A few longitudinal studies with repeated measures of weight or growth in children from before and during the pandemic have also reported increased body weight or obesity after adjusting for usual growth in the prepandemic period.30 31 Systematic reviews also provide evidence that weight loss and eating disorders have increased in both children and adults during the pandemic.23 32 Further, there is evidence that among people with obesity or eating disorders symptoms worsened during the pandemic and a high proportion of people also experienced anxiety or depression.33 While none of the previous reviews have focused specifically on weight change in parents, there is evidence that parents experienced a greater burden of weight-related pandemic risk factors than other adults, possibly due to the added stress of school and childcare closures and additional caregiving responsibilities.34
Our findings describing child and parent weight change during the pandemic by income precarity are novel. Evidence consistently suggests the indirect consequences of the pandemic have disproportionately affected lower income families.35 36 Our study results show the profound impact that variables related to higher marginalisation, lower income, job loss and food security may have on parents’ and children’s weight change during the pandemic. Variables related to food insecurity were associated with both weight loss and weight gain, which is consistent with previous literature on children and adults.20 37 38 Our observed associations of increased risk of weight change among families with income precarity may be explained directly by poverty or material deprivation, such that families may have been unable to access the necessary resources to maintain health behaviours, or it may be indirectly through stress or mental health impacts.39 40 Future research will need to investigate the potential mechanisms. In Canada, there were programmes in place that may have mitigated the impact of the pandemic on income precarity for families, including emergency response benefits that provide financial support to eligible Canadians, but we were not able to evaluate the impact that these programmes may have had on our study findings.
The strengths of our study include the large sample size, timely data collection and extensive measures of income precarity. There are, however, also several potential limitations, primarily the cross-sectional design, with parent report of recalled weight change likely having high risk of measurement error. It is known that parents often do not accurately recall their child’s current weight,26 and the validity of parent-reported weight change during a pandemic is unknown. Parents may have incorrectly classified their child’s weight status, and it is unknown if this misclassification may have differed by income precarity; thus, the direction of bias is unknown. Similarly, the validity of self-reported parent recall of weight change during the pandemic is unknown, although adults have been shown to report their own early life weight with high accuracy.27 Further, it is a limitation of our study that the magnitude of the weight change for both parents and children was unknown and we were unable to determine if the weight change would be considered a healthy change. We hypothesise based on the increase in risk factors and other literature that a substantial proportion of the weight change, both gain and loss, may reflect adverse health as a result of increased stress, poor mental health and sedentary behaviour changes experienced by families during the pandemic.2 Further, the change in prevalence of eating disorders and obesity was not measured in this study, and to the best of our knowledge no comparable data on parent-reported change in child weight are available from before the COVID-19 pandemic. Our study measured several variables related to income precarity but did not specifically collect data on self-reported family income. Participants were recruited through multiple methods, and despite the diverse population and relatively large sample size the study population may not be generalisable to all parents and children in Ontario. Future studies with a prospective design, including prepandemic control data, and standardised measures of both parent and child weight change and income precarity would be valuable. Further, qualitative or mixed methods studies exploring the reasons for the observed weight changes may also provide important insight.
While there are recognised limitations to this study, the overall findings suggest that a high proportion of both children and parents experienced weight loss or weight gain during the pandemic in Ontario. Variables related to family deprivation, including job loss and difficulties paying for housing and food, were very strongly associated with the odds of both weight gain and weight loss. This suggests a possible widening of pre-existing health inequalities. Given the rapid increase in inflation, substantial increase in the cost of food over recent years and the affordable housing crisis in Canada, this is a very concerning trend.41 Population health interventions aimed at pandemic recovery are urgently needed to address these health inequalities.
Data availability statement
The data used in the current study are available through arrangement with the author (AG) in accordance with all relevant ethics and privacy protocols.
Patient consent for publication
The study involves human participants and was approved by the Hamilton Integrated Research Ethics Board (HiREB; #10583).
Contributors LNA conceptualised and designed the study, contributed to the analysis and interpretation of data, drafted the initial manuscript, and reviewed and revised the manuscript. YY-M conceptualised and designed the study, contributed to the analysis and interpretation of data, and reviewed the manuscript for important intellectual content. MJ and AG conceptualised and designed the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content. BS and SC conceptualised and designed the study and critically reviewed the manuscript for important intellectual content. LNA is the guarantor and accepts full responsibility for the work, had access to the data, and controlled the decision to publish.
Funding This study was funded by a grant from the Public Health Agency of Canada (#1819-HQ-000068).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.