Overweight and obesity represent a significant global public health challenge, especially among children.1–3Worldwide, childhood obesity has risen sharply over the past decades, with prevalence quadrupling among children and adolescents aged 5-19 years.4

Data from the WHO European Childhood Obesity Surveillance Initiative (COSI) show that in several Member States (MS), almost 40% of boys aged 7–9 years were living with overweight and almost 20% with obesity in 2015–2017.5 The burden of disease is also higher among children from low-income families. Furthermore, the prevalence of overweight and obesity and/or mean body mass index has increased in children and adolescents during the COVID-19 pandemic.6–9Overweight and obesity are risk factors for noncommunicable diseases (NCD) in the World Health Organization (WHO) European Region.6

Childhood obesity has well-documented long-term consequences, since children with obesity are very likely to become adults with obesity and to develop obesity-related NCD. It also contributes to an earlier onset of several chronic diseases. Moreover, childhood and adolescent obesity can entail significant psychosocial consequences for children's quality of life and academic performance, as these individuals are at increased risk of experiencing discrimination, bullying, and weight-related stigma from their peers.10

Addressing this global health challenge requires a multidimensional approach that spans individual lifestyle choices, family support systems, institutional policies, and broader environmental influences, and should be grounded in a clear conceptual framework. The WHO Commission on Ending Childhood Obesity (ECHO) conceptual framework provides a comprehensive structure, viewing childhood obesity as the result of interacting biological, behavioral, environmental, and societal drivers across six interconnected action areas. This framework helps organize the multiple determinants involved and underscores the need for coordinated, multisectoral strategies.11 Social and health inequalities play a significant role in obesity prevalence, with disadvantaged populations experiencing higher risks due to limited access to nutritious foods, safe physical environments, and healthcare resources.12,13

Given the substantial health, social, and economic consequences of childhood obesity, it has become a strategic priority for international and European institutions.14–16Recent European initiatives, such as the European Union (EU) NCD Initiative and Europe's Beating Cancer Plan, highlight the need for integrated health promotion, disease prevention, and policy interventions to tackle obesity effectively. These efforts emphasize not only personal behavioural change, such as diet and physical activity, but also structural modifications in food systems, urban planning, education, and social equity to create healthier environments.14,15,17,18 Particular attention must be given to childhood obesity prevention, which requires multisectoral interventions in various settings (schools, families, healthcare facilities, and communities) and must engage a broad spectrum of stakeholders, including policymakers, educators, healthcare professionals, third sector, non-governmental organizations, and industry partners.16,19,20 Early-life interventions, with a Nurturing Care approach, combined with long-term policy changes, are crucial to addressing the root causes of obesity and its life-course implications.19–22 Indeed, childhood obesity prevention efforts need to start early, from pregnancy to childhood, and be tightly integrated with other measures to control all significant NCD risk factors.16

Halt the rise in diabetes and obesity between 2010 and 2025 is a target in the WHO Global Action Plan for the Prevention and Control of NCD 2013–2020,23 then extended by 2030.24 Furthermore, overweight, obesity, and malnutrition in all their forms are part of the Sustainable Development Goals to ensure health and well-being for all.25

In this context, the Health4EUKids Joint Action (Health4EUKids JA) was established to support childhood obesity prevention and health promotion across European MS. The Health4EUKids JA is a three-year European initiative launched in February 2023 within the EU4Health Programme 2021–2027, focusing on promoting health and preventing NCD, particularly childhood obesity. Coordinated by Greece and involving multiple European countries, it supports childhood obesity prevention by implementing, transferring and scaling up evidence-based best practices. A key component of Health4EUKids is the adaptation and dissemination of two pretested best practices: Grünau Moves (owned by Germany, coordinated by Spain as Work Package 5 Leader),26 and Smart Family (owned by Finland, coordinated by Finland as Work Package 6 Leader).27 The project also prioritizes policy development to encourage public health investments in disease prevention and management.28

Effective childhood obesity policies and programs (P/P) require clear formulation, adequate resources, multisectoral coordination, structured implementation plans, and robust monitoring and evaluation mechanisms. Mapping these elements across EU countries is essential to identify strengths, gaps, and opportunities for improvement, providing evidence to guide future policy action.29

This study aims to outline the current state of P/P related to children's obesity prevention, health promotion and responsive parenthood for children aged 0-12 years across the participating EU MS. It examines their role as enablers of best practices and identifies existing gaps in the effective implementation of health promotion and childhood obesity prevention actions.

This cross-sectional study, conducted across 12 EU MS as part of the Health4EUKids JA, provided an in-depth overview of the diversity and complexity of P/P dedicated to childhood obesity prevention, health promotion, and responsive parenthood. Based on the analysis of 79 P/P, primarily developed at the national or federal level, the findings highlighted a significant uptake of multisectoral approaches involving the health, education, and social sectors. These efforts reflect both the strengths and the ongoing challenges of current initiatives and are aligned with global and European policy priorities promoting integrated public health responses to NCD. A key strength emerging from the analysis was the widespread adoption of multisectoral approaches, present in 92% of the P/P. The high level of cross-sector collaboration, particularly among the health, education, and social sectors, including the third sector, community associations and non-governmental organizations, facilitated the implementation of evidence-based actions. It also aligns closely with international frameworks, including the EU NCD Initiative and Europe's Beating Cancer Plan, which advocate for integrated, whole-of-society, life-course strategies to prevent NCD, especially among vulnerable populations.18 Data from the previous CHRODIS-PLUS Joint Action highlights the complexity of achieving genuine cross-sectoral participation in policy-making and programme planning; however, this challenge now appears to be a well-established aspect of the health promotion policies analysed.32

Most P/P prioritized primary school-aged children and family-focused interventions, with schools, communities, and health services emerging as the dominant and interrelated settings. This pattern corresponds with literature indicating that multifaceted, community- and school-based interventions are more effective than single-setting approaches. Schools, communities, and health services are widely recognized as key leverage points for public health intervention, with evidence from the STOP project and WHO reviews showing that school-based programs targeting physical activity, healthy eating, and behavioural change can contribute meaningfully to weight status improvements in children.17,33–36 Viewed in light of the WHO Commission on ECHO framework, which identifies six interconnected action areas —e.g. healthy food environments, physical activity environments, early-life nutrition, health services and clinical management, governance and leadership, and monitoring and surveillance—, these patterns suggest that actions related to healthy diets and physical activity are more easily integrated within established institutional settings, whereas early-life and family-oriented components, which require stronger system capacity and coordinated pathways, tend to be implemented less consistently across countries.11

Although equity was explicitly addressed in nearly half of the P/P analysed, this proportion highlights the need for further commitment. Children from low-income families and marginalised communities are particularly vulnerable to obesogenic environments and often face structural barriers to access health-promoting resources and services.5 Evidence shows that (individually-based) interventions are less effective in disadvantaged settings unless they are socially and culturally adapted.35,37 Mainstreaming health equity in childhood obesity prevention, through targeted outreach and adapted interventions, remains a critical step to ensure that actions do not widen existing gaps. Evidence from WHO ECHO reviews indicates that early-life and family-based components, which are crucial for reducing inequities, are also among the least implemented and most resource-dependent, contributing to persistent gaps in vulnerable populations.11 Facing the challenges of social and commercial determinants of health in children and caregivers requires adopting a model of proportionate universalism, that is, universal policies and actions that are implemented with a scale and intensity proportionate to the level of disadvantage.38 This approach ensures that interventions do not merely benefit those already better off, but instead actively work to flatten the social gradient in health and prevent the Matthew Effect, namely the tendency for public health interventions to disproportionately benefit more advantaged groups, thereby unintentionally widening existing health inequalities.39

Another promising result was the reported high degree of innovation and consensus, this latter indicating that most P/P were seen as widely accepted rather than divisive, while structural or systemic impact remained uneven. Only a minority of P/P were perceived as having high public visibility, indicating a possible gap in public engagement and communication. This observation aligns with previous calls for stronger advocacy and media strategies to shift public norms and increase awareness of children's right to healthy lifestyles.15 The implementation of interventions was highly variable. Some policies were fully implemented, while others remained partial or theoretical. Barriers included insufficient human and financial resources, cultural mismatches with target populations, and gaps in data infrastructure. Although evaluation frameworks were often defined, consistent and structured monitoring practices are also lacking. The lack of systematic monitoring hampers the ability to assess real-time effectiveness and make timely policy adjustments. The development of more robust, standardized monitoring systems is essential to regularly measure relevant indicators and intervention impact.

Regarding evidence-based actions, some were more frequently integrated into P/P, while others were only marginally addressed, e.g. measures aimed at counteracting the marketing strategies of breastmilk substitutes and baby food were included in only 17% of cases.40 As part of the Health4EUKids JA, this study provided an opportunity to review the P/P within which the best practices Grünau Moves and Smart Family are implemented for childhood obesity prevention. The multi-stakeholder, multisectoral, multisetting, co-creation approach underpinning the P/P analysed appeared promising for the successful transferability of these best practices, aiming to provide replicable models for sustainable, context-sensitive interventions across MS. These findings align with the implementation challenges and contextual specificities explored in the CHRODIS-PLUS Joint Action. Barnfield et al. examined the transferability of good practices in health promotion across EU MS, highlighting the critical role of local context, stakeholder involvement, and a structured implementation framework in adapting effective practices to new environments.41

A final reflection concerns the nature of health promotion interventions, which are inherently long-term processes grounded in the enhancement and empowerment of individuals and communities.42 The analysed P/P incorporated several WHO Best Buys defined as evidence-based and highly cost-effective interventions for the prevention and control of noncommunicable diseases, targeting major risk factors such as unhealthy diet, physical inactivity, tobacco and alcohol use.17 Indeed, both the Grünau Moves and Smart Family best practices encompass such interventions. Health promotion is a slow and sustained process, which differs significantly from the more recent Quick Buys approach, which refers to a subset of cost-effective interventions capable of demonstrating measurable population-level health impacts within a short timeframe (≤5 years), often aligned with political and electoral cycles.43 The latter, by its very nature focused on achieving rapid, measurable, and cost-effective outcomes, may be less suited to fostering meaningful empowerment among families and communities, and is therefore more appropriate for regulatory, fiscal or single-sector interventions, while long-term, multisectoral health promotion strategies remain essential for sustainable behavioural change.45 This study has some limitations. The P/P analysed might not be exhaustive of those existing in each country and, in some cases, reflect the selection made by respondents. Moreover, the responsibility for completing the survey was delegated to the JA partners, leading to variability in the involvement of stakeholders and policy makers across countries. Furthermore, as P/P were also collected from federal or decentralized countries, the number of P/P reported varied substantially across MS: some countries reported only one P/P, whereas others (e.g. Spain) reported a much higher number, a pattern partly influenced by countries with multi-level governance systems, where both national and regional P/P may be developed. This heterogeneity in national contributions may have influenced the comparability of the findings and introduced a potential sample bias.

Although not without areas for improvement, the analysed P/P provide a solid foundation for the successful and sustainable transfer of best practices, ensuring that implementation efforts are context-sensitive, equity-oriented, and capable of generating lasting impact across MS. Framing our findings within the WHO ECHO framework also helps identify areas where future policies could be strengthened, especially those requiring more sustained and coordinated system capacity.11

The Health4EUKids JA provides valuable insights into the current landscape of childhood obesity prevention P/P across EU MS. This study highlights both promising practices and persistent challenges. While many policies demonstrate a strong commitment to multisectoral collaboration and evidence-based interventions, gaps remain in implementation, monitoring, and resource allocation. Addressing these issues requires a sustained investment in integrated, equity-oriented, and context-sensitive approaches, capable of empowering children, families, and communities. Strengthening these foundations is key to advancing public health goals and securing healthier futures for the next generation.

Data made available to those who request it.

Jorge Marcos.

The corresponding author, on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

A. Giusti and C.C. conceptualized the study. A. Giusti and V. Di Stefano wrote the main manuscript text. A. Giusti, V. Di Stefano, P. Scardetta and F. Zambri collected and analyzed the data. V. Palermo, A. Di Nolfi, F. Splendore, A. Vantarakis, G. Karydas, P. Csizmadia, M. García-Sierra, P. Mäki and C. Cattaneo contributed to manuscript revision. All authors reviewed and approved the manuscript.

None.

This work was supported by the Health4EUKids Joint Action, co-funded by the European Union and the Health and Digital Executive Agency (HaDEA) as part of the EU4Health program (Project ID n.101082462).