Development of a National System for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence

Professor Evangelia Charmandari

Professor of Pediatrics – Pediatric and Adolescent Endocrinology
National and Kapodistrian University of Athens Medical School
First Department of Pediatrics, ‘Aghia Sophia’ Children’s Hospital

Obesity in childhood and adolescence represents a major health problem of our century and the term ‘epidemic’ is commonly used to describe the increasing prevalence of obesity worldwide in the last three decades. Overweight and obesity in childhood and adolescence lead to obesity in adulthood and are associated with significant morbidity and mortality. Forecasts suggest that the ‘obesity epidemic’ may reverse the current trend of the declining rate of death from cardiovascular causes, leading to a shorter lifespan for today’s children. Complications of obesity include hypertension, dyslipidemia, hyperinsulinism, glucose intolerance, diabetes type 2, atherosclerotic cardiovascular disease, hypogonadism, orthopedic problems, fatty liver disease, cholecystitis, social stigmatization, as well as an increased incidence of malignancies. In addition to the increased morbidity and mortality, overweight and obesity account for a significant increase in public health costs. In the United States, the estimated medical expenditures attributed to overweight and obesity were 149.4 billion USD per year in 2014. The direct health care costs attributable to obesity and overweight are expected to more than double every decade, and by 2030, costs could range from 860.7 to 956.9 billion USD, accounting for 1 in every 6 dollars spent on health care. In the UK, by 2030 this condition is predicted to cost approximately £2 billion GBP per year. Therefore, it is absolutely crucial to take all necessary measures not only to treat but mostly to prevent overweight and obesity in childhood, so that we can ensure improved health in adulthood, and reduced medical costs owing to complications of overweight and obesity.

In Greece more than 30-35% of children and adolescents are overweight or obese. Given that in our country we have approximately 100,000 live births per year, in 18 years (from birth to adulthood) we will have 1,800,000 children and adolescents. Therefore, more than > 630.000 children and adolescents are currently overweight or obese.

In our prospective studies, we investigated the prenatal, perinatal, life-style and socio-economic factors associated with overweight and obesity, as well as the effect of honey on the metabolic profile of obese children and adolescents.

The progressively increasing prevalence of overweight and obesity in our country, despite the efforts of the scientific community and all health-related services to address its epidemic proportions, indicate that the current system and management plan of this condition are not effective. Some explanations for the difficulty in adequately addressing this issue include the following:

1) Not adequate documentation of the BMI in children and adolescents when seen by General Practitioners or General Pediatricians on account of acute or chronic medical problems. Amidst their busy clinical practice, physicians often concentrate on the management of the acute or chronic medical problems of their patients, and may not document their weight and height at each patient’s visit. On other occasions, they may obtain these measurements but may not calculate the child’s BMI and may not plot it on the appropriate BMI growth chart. By not doing so, they are not able to recognize overweight or obesity and, therefore, they fail to manage these patients properly.

2) General Practitioners and General Pediatricians have not received clear guidance and/or instructions about the management of overweight or obese children. Although they all understand the magnitude of the medical problem and the importance of addressing it adequately, they often do not have a step-by-step approach about dealing with overweight and obese children and their families.

3) Not adequate coordination of all health-related organizations that are involved with the management of overweight and obesity in childhood and adolescence, and

4) Not adequate education and sufficient information to parents, guardians, teachers and the public in general about obesity, its complications and management.

These problems were addressed by the Program entitled ‘Development of a National System for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence’, which was funded by the European Union and Greek funds and was completed in 2015 (MIS 370545). Professor Evangelia Charmandari was the coordinator and scientific supervisor of this project.

The aim of this project was to develop a comprehensive and personalized plan of action with respect to prevention and treatment of overweight and obesity in childhood and adolescence after taking into consideration the current infrastructure of both national and private health care services in our country.

There are three main pillars in this project: The first pillar is an Electronic Database System (EDS), which is applied regionally and nationally with the view to accomplishing two main goals: firstly, the electronic documentation of all children and adolescents regardless of BMI from birth to the age of 18 years, and secondly the guidance of General Practitioners and General Pediatricians regarding the management of children and adolescents according to their BMI. The second pillar involves actions that aim to inform and educate the General Practitioners and General Pediatricians about the correct use of the EDS. Finally, the third pillar aims to assess the effectiveness of the proposed interventions.

The introduction and implementation of this electronic database system is unique and innovative, given that to the best of our knowledge it has not been used before in any other country. It represents the core of our project and differentiates it from all other projects aiming to address the obesity ‘epidemic’.

Using information and communication technologies, we developed a web application, the “National Registry for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence”, for the online registration of all children and adolescents nationwide, as well as for the guidance and training of Pediatricians and General Practitioners (GPs) as to how to manage an overweight or obese child and adolescent. This project represents part of the overall Hellenic and European policy to develop and use reliable Patient Registries, and supports interoperability with other national infrastructures (i.e. e-Prescription) and multi-layered security spanning preventive, detective and administrative controls.

More specifically, we developed an Electronic Medical Records File (EMRF) for the electronic documentation of the history and clinical examination findings of children and adolescents, as well as Therapeutic Algorithm Files (TAF), which provide specific and detailed information on the management of overweight and obesity. There are many TAFs implemented into the Electronic Database System (EDS) to allow for the EDS to choose the most appropriate one for each patient’s case. We ensured safe access and data encryption, as well as assistance for all enquiries. The Patient Summary Dataset includes personal and demographic data (such as Social Security Number, name, surname, birth date and demographic data), medical history (perinatal history, present and past medical history, nutrition, level of physical activity and exercise, allergies, immunizations, hospitalizations, surgeries, gynaecological history and medical treatments), family history, clinical examination findings (including the anthropometric parameters and arterial blood pressure) and patient consent18.

The Hellenic National Registry for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence is the first web-based e-Health professional application in Greece. It was launched in September 2015 and is accessible by the following URL: An important distinction of the project was the BRONZE Award in the category “e-Health / H1.1 Digital Applications for Integrated Patient care’’, which was awarded by the Healthcare Business Awards in 2016.

The effectiveness of the interventions that are proposed through this web application was evaluated by our Out-patient Clinic for the Prevention and Management of Overweight and Obesity, Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, “Aghia Sophia” Children’s Hospital, Athens, Greece. At present, more than 3,000 children and adolescents are followed up on a regular basis. We demonstrated that using these interventions we were able to decrease the prevalence of obesity by 30% and of overweight by 35% within one year.

In addition to the above, the Out-patient Clinic for the Prevention and Management of Overweight and Obesity offers significant teaching and research opportunities.


17. Tragomalou A, Moschonis G, Kassari P, Papageorgiou I, Genitsaridi SM, Karampatsou S, Manios Y, Charmandari E. A National e-Health Program for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence in GreeceNutrients. 2020; 12(9): 2858.

16. Genitsaridi SM, Giannios C, Karampatsou S, Papageorgiou I, Papadopoulos G, Farakla I, Koui E, Georgiou A, Romas S, Terzioglou E, Papathanasiou C, Kassari P, Manios Y, Charmandari E. A Comprehensive Multidisciplinary Management Plan Is Effective in Reducing the Prevalence of Overweight and Obesity in Childhood and AdolescenceHormone Research Paediatrics 2020; 93(2):94-107.

15. Tragomalou A, Moschonis G, Manios Y, Kassari P, Ioakimidis I, Diou C, Stefanopoulos L, Lekka E, Maglaveras N, Delopoulos A, Charmandari ENovel e-Health Applications for the Management of Cardiometabolic Risk Factors in Children and Adolescents in GreeceNutrients. 2020;12(5):1380.

14. Gray LJ, Brady EM, Albaina O, Edwardson CL, Harrington D, Khunti K, Miksza J, Raposo JF, Smith E, Vazeou A, Vergara I, Weihrauch-Blüher S, Davies MJ; PRE-STARt Collaborative (Charmandari E). Evaluation and refinement of the PRESTARt tool for identifying 12-14 year olds at high lifetime risk of developing type 2 diabetes compared to a clinicians assessment of risk: a cross-sectional studyBMC Endocrine Disorders 2019; 19(1): 79.

13. Moschonis G, Michalopoulou M, Tsoutsoulopoulou K, Vlachopapadopoulou E, Michalacos S, Charmandari E, Chrousos GP, Manios Y. Assessment of the Effectiveness of a Computerised Decision-Support Tool for Health Professionals for the Prevention and Treatment of Childhood Obesity. Results from a Randomised Controlled TrialNutrients. 2019; 11(3). pii: E706.

12. Farakla I, Koui E, Arditi J, Papageorgiou I, Bartzeliotou A, Papadopoulos GE, Mantzou A, Papathanasiou C, Dracopoulou M, Papastamataki M, Moutsatsou P, Papassotiriou I, Chrousos GP, Charmandari E. Effect of honey on glucose and insulin concentrations in obese girls. European Journal of Clinical Investigation 2019; 49(2): e13042.

11. Katsarou MS, Karathanasopoulou A, Andrianopoulou A, Desiniotis V, Tzinis E, Dimitrakis E, Lagiou M, Charmandari E, Aschner M, Tsatsakis AM, Chrousos GP, Drakoulis N. Beta 1, Beta 2 and Beta 3 Adrenergic Receptor Gene Polymorphisms in a Southeastern European Population. Frontiers Genetics 2018; 9: 560.

10. Emmanouil CC, Pervanidou P, Charmandari E, Darviri C, Chrousos GP. The effectiveness of a health promotion and stress-management intervention program in a sample of obese children and adolescentsHormones (Athens). 2018; 17(3): 405-413.

9. Kassari P, Papaioannou P, Billiris A, Karanikas H, Eleftheriou S, Thireos E, Manios Y, Chrousos GP, Charmandari E. Electronic registry for the management of childhood obesity in GreeceEuropean Journal of Clinical Investigation 2018; 48(3). doi: 10.1111/eci.12887.

8. Stavrou S, Nicolaides NC, Critselis E, Darviri C, Charmandari E, Chrousos GP. Paediatric stress: from neuroendocrinology to contemporary disordersEuropean Journal of Clinical Investigation 2017; 47(3): 262-269.

7. Stavrou S, Nicolaides NC, Papageorgiou I, Papadopoulou P, Terzioglou E, Chrousos GP, Darviri C, Charmandari E. The effectiveness of a stress-management intervention program in the management of overweight and obesity in childhood and adolescenceJournal of Molecular Biochemistry 2016; 5(2): 63-70.

6. Moschonis G, Kalliora AC, Costarelli V, Papandreou C, Koutoukidis D, Lionis C, Chrousos GP, Manios Y; Healthy Growth Study Group (Charmandari E). Identification of lifestyle patterns associated with obesity and fat mass in children: the Healthy Growth StudyPublic Health Nutrition 2014; 17(3): 614-24.

5. Manios Y, Moschonis G, Papandreou C, Siatitsa PE, Iatridi V, Lidoriki I, Lionis C, Chrousos GP; Healthy Growth Study group (Charmandari E). Female sex, small size at birth and low family income increase the likelihood of insulin resistance in late childhood: the Healthy Growth StudyPediatric Diabetes. 2014; 15(1): 41-50.

4. Manios Y, Birbilis M, Moschonis G, Birbilis G, Mougios V, Lionis C, Chrousos GP; “Healthy Growth Study” group (Charmandari E). Childhood Obesity Risk Evaluation based on perinatal factors and family sociodemographic characteristics: CORE index. European Journal of Pediatrics 2013; 172(4): 551-5.

3. Birbilis M, Moschonis G, Mougios V, Manios Y; Healthy Growth Study’ group (Charmandari E). Obesity in adolescence is associated with perinatal risk factors, parental BMI and sociodemographic characteristicsEuropean Journal of Clinical Nutrition 2013; 67(1): 115-21.

2. Moschonis G, Chrousos GP, Lionis C, Mougios V, Manios Y; Healthy Growth Study group (Charmandari E). Association of total body and visceral fat mass with iron deficiency in preadolescents: the Healthy Growth Study. British Journal of Nutrition 2012; 108(4): 710-9.3.

1. Galata Z, Moschonis G, Makridakis M, Dimitraki P, Nicolaides N, Manios Y, Bartzeliotou A, Chrousos GP, Charmandari E. Plasma proteomic analysis in overweight and obese childrenEuropean Journal of Clinical Investigation 2011; 41(12): 1275-83.