The scale of the problem is staggering. According to the Global Burden of Disease Study, the prevalence of overweight among children and adolescents doubled between 1990 and 2021, while obesity prevalence tripled over the same period. Forecasts indicate that global obesity prevalence in young people will continue rising through 2025 across all world regions. In Germany, national surveillance data show that overweight and obesity prevalence has remained relatively stable in recent decades, but the COVID-19 pandemic triggered a marked increase in severe obesity, particularly among older children and adolescents. This is alarming because pediatric obesity carries elevated risks for type 2 diabetes, hypertension, asthma, joint pain, impaired mobility, low self-esteem, depressive symptoms, and reduced quality of life. Given that childhood obesity frequently persists into adulthood, early intervention is essential.

Existing treatments have shown only modest success. Multicomponent family-focused interventions combining nutritional guidance, physical activity promotion, and behavioral strategies remain the best-established approach, but systematic reviews demonstrate only short-term improvements in body mass index (BMI) z-scores, with limited long-term evidence. Evidence suggests that high-intensity treatments requiring at least 26 contact hours are most effective, yet such intensity is rarely feasible in routine care. Meanwhile, newer pharmacological options such as glucagon-like peptide-1 analogs liraglutide and semaglutide have shown promise in children and adolescents, but evidence from adults indicates that stopping these medications often leads to rapid weight regain. This underscores the need for sustainable lifestyle-based strategies embedded in everyday life. Pediatric practices are the professional environment parents most prefer for guidance on their child’s weight, and e-health tools such as mobile applications and web-based platforms may further facilitate the transfer of clinical advice into daily routines.

STARKIDS was designed as a step-wise, tailored, e-health supported multicomponent family-focused intervention program, the first of its kind to be implemented in pediatric primary care in Germany and evaluated against optimized treatment-as-usual in a cluster-randomized trial. The researchers enrolled children and adolescents aged 3 to 17 years with overweight (BMI above the 90th percentile) or obesity (BMI above the 97th percentile) from pediatric and family practices across the state of Baden-Wuerttemberg. A cluster randomization was chosen to prevent contamination of interventions between practices. Of 89 randomized practices, 71 enrolled families in the study. Between April 2022 and July 2023, 611 families were enrolled, 559 underwent baseline assessments and started the intervention or control condition, and 421 and 422 families were assessed for primary endpoints after 12 and 18 months respectively. Overall dropout was 25 percent, a relatively low attrition rate that compares favorably with rates reported elsewhere in family-based pediatric obesity interventions, which have reached up to 83 percent.

The intervention itself was a carefully structured hybrid program. Families in the STARKIDS group attended individual 90-minute face-to-face sessions every three months over one year, each conducted by pre-trained medical assistants who were part of the families’ usual care teams. The sessions followed the principles of motivational interviewing, a person-centered counseling style designed to reduce ambivalence and strengthen intrinsic motivation for change. Each session covered one of five core modules in sequence: STARKIDS Start, Eating and Drinking, Activity and Media, Family Life, and STARKIDS Keep on, with an optional STARKIDS Joker module addressing barriers and motivational difficulties. Content was individually tailored based on pre-session assessments and family-specific needs, addressing dietary energy density, physical activity enjoyment, media consumption, sleep habits, stress, weight stigmatization, and self-worth. Between sessions, families had continuous access to an accompanying e-health online platform offering educative texts, short films, serious games, reflection tools, and printable tip sheets aligned with the goals agreed upon in each session. Families who consented also received biweekly text message reminders to monitor their individually selected goals and the child’s weight. In the control group, families received a single 30-minute structured counseling session covering the same core topics but limited to guideline-based recommendations without behavioral tools or follow-up.

The primary outcome was the proportion of children achieving a reduction of at least 0.2 BMI z-score, a threshold considered to represent a clinically meaningful difference. After 12 months, 33 percent of participants in the intervention group achieved this criterion compared with 22 percent in the control group, a statistically significant difference with a risk difference of 0.11 (95 percent CI 0.03 to 0.20, p = 0.0256). The analysis of BMI z-score development over time as a continuous outcome showed a greater decrease in the intervention group between baseline and 12 months, with mean BMI z-scores falling from 2.41 to 2.24 in the STARKIDS group versus 2.37 to 2.32 in the control group. However, after 18 months, the advantage disappeared: 30 percent of the intervention group and 28 percent of the control group achieved the criterion, with no statistically significant difference between groups. The researchers attribute this to the fact that the period between 12 and 18 months functioned as a follow-up phase during which the STARKIDS group had access only to the online platform, suggesting that the e-health component alone may not be sufficient to maintain achieved weight reductions without continued personal interaction with the practice team.

For the second primary outcome, health-related quality of life measured with the KINDL questionnaire, no significant differences between groups were detected in either parental reports or adolescent self-reports. Quality of life scores in both groups were lower than in a German reference population, possibly reflecting lingering pandemic effects and the known burden of pediatric obesity on psychological well-being. The parent-reported within-group change in the intervention group corresponded to only 0.14 standard deviations of the baseline score, well below the 0.5 standard deviation threshold for clinical relevance. The researchers note that how the intervention could better address quality of life warrants further investigation.

The baseline characteristics of participants revealed the substantial burden these children already carried. Mean BMI percentile at baseline was 98.5, with 36 percent of participants in the severe obesity range, 47 percent in the obesity range, and only 17 percent in the overweight range. About one third of the sample reported snoring, concentration problems, headaches, knock-knees, or foot deformities. Notably, 17 percent of those who underwent sonographic examination showed indications of metabolic dysfunction-associated steatotic liver disease. The accompanying legal guardians were predominantly mothers with elevated mean BMI falling in the overweight range, consistent with the well-established role of parental overweight as a risk factor for childhood obesity.

Feasibility and satisfaction data were encouraging. Attendance rates at face-to-face sessions ranged from 69 to 92 percent, and engagement with educative texts, tip sheets, and videos on the online platform was good, although mindfulness audios were the least used resource. Overall satisfaction with the program was high among both parents and adolescents, and pediatricians and medical assistants reported high motivation and enjoyment conducting the program with moderate to high feasibility. However, uptake of step 2 of the program, which involved additional targeted counseling sessions delivered by public health services for families whose children had not achieved sufficient BMI z-score reduction, was poor, with only 15 percent of eligible families participating. A qualitative process evaluation suggested that families did not want to burden public health services already strained by the pandemic, did not perceive them as the right setting for further counseling, and saw no additional value in further sessions.

Based on these findings, the researchers propose a revised three-step model: the one-time structured counseling session becomes the new step 1 provided for all eligible patients, only families with insufficient progress after this counseling receive the STARKIDS face-to-face sessions and online platform as an intensification, and the original step 2 is adapted to take place within the pediatric practice with gradually fading contact hours rather than at local health departments. The study’s strengths include its step-by-step approach with prolonged intervention for non-responders, suitability for routine primary care across diverse urban and rural practices, and alignment with current German guideline recommendations. A separately reported health economic evaluation demonstrated cost-effectiveness for the subgroup with obesity, and the German Federal Joint Committee has officially recommended transfer of the counseling step into routine care for this subgroup, supporting the program’s potential for nationwide scaling. The researchers conclude that digitally enhanced and tailored treatment programs for childhood overweight and obesity can be successfully implemented in pediatric primary care settings, achieving moderate and meaningful effects with a low-threshold intervention in routine outpatient care. Future research should address the maintenance of treatment success through gradually reducing contact times instead of abruptly ending interventions, and potentially extend the approach through artificial intelligence systems allowing for further individualization.

Subject of Research: Pediatric obesity

Article Title: Effects of an e-health enhanced multicomponent outpatient intervention for children and adolescents with overweight or obesity in routine primary care (STARKIDS): a cluster-randomized controlled trial

Article References: Effects of an e-health enhanced multicomponent outpatient intervention for children and adolescents with overweight or obesity in routine primary care (STARKIDS): a cluster-randomized controlled trial. (n.d.). https://doi.org/10.1016/j.lanepe.2026.101897

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101897

Keywords: childhood obesity, e-health, primary care, cluster-randomized trial, STARKIDS, BMI z-score, family intervention, motivational interviewing, pediatric practice, digital health, Effects, enhanced