During the COVID-19 pandemic, there has been a simultaneous presence of childhood overweight and obesity as well as malnutrition, with the pandemic response measures exacerbating this challenge (1, 2). According to the World Health Organization, nearly 39 million children were overweight in 2020, and there were almost 340 million overweight or obese children aged 5 to 18 years (3). Additionally, over 149 million children under the age of five experienced stunted growth, and in 2021, the global population affected by hunger reached 828 million (4). The school-age period is a nutritionally sensitive period for growth, and inadequate or excessive nutrient intake can impact children’s cognitive and physical development, as well as their long-term health in adulthood (5, 6). Good nutrition is beneficial for well-being throughout the entire lifespan (1, 7, 8).

The outbreak of the COVID-19 pandemic has brought challenges to the stability of the family environment and the emotions of family members. According to reports, during the outbreak in China, about 25 million rural migrant workers were unemployed or waiting to return to work, and nearly one-fourth of the urban employed population was economically affected (9, 10). Financial difficulties caused by the pandemic have forced many families to make cheaper and unhealthy food choices when purchasing food. Poverty and low-income families may not be able to access sufficient nutrition and food (11, 12). The “lockdown” or “semi-lockdown” situation has caused instability in the family environment, increased parental stress, increased family conflicts, and impaired family functioning, severely affecting the children’s food environment and promoting the selection and purchase of unhealthy foods (13, 14).

The daily calorie intake of children at home accounts for about 65%–72% of their total intake, making the family food environment crucial for their dietary intake and nutritional development (15, 16). In Chinese society, there is a strong culture of parental authority, with parents having high control over their children’s diet and limited autonomy for the children (17). Throughout childhood, parents make choices about purchasing and providing food, establish rules regarding meal times, meal frequency, and structure (18, 19). The family’s food consumption determines the types and frequency of food children are exposed to, and the availability and accessibility of healthy food can promote children’s intake of nutritious food (12). If the family provides a variety of fruits, vegetables, and healthy proteins, children have more opportunities to consume a range of nutrients (20, 21).

The nutrition of children is not only related to the family’s dietary consumption, but also to the family’s environmental atmosphere. In Chinese family culture, great importance is placed on family meals, where family members come together to share food, engage in emotional communication, and pass on healthy knowledge to children. This determines that the family environment in Chinese families plays an important role in children’s diet (22–24). A positive dining atmosphere can stimulate children’s appetite, reduce anxiety or resistance towards food, encourage children to taste a variety of foods, balance their nutritional intake, and promote their healthy growth (25, 26).

The theory of the family’s healthy ecosystem suggests that the family is a complex system composed of multiple interactive relationships and roles, with parents being considered as core members who guide and educate children (24, 27–29). Negative emotions of parents can affect children’s nutritional status. If parents display anxious and worried emotions, children will perceive these emotions and experience unease and stress, leading to a decrease in appetite or aversion to food, or using overeating as a way to cope with stress or anxiety (26, 30, 31).

The family is considered the most fundamental and important unit. The COVID-19 pandemic has had a wide-ranging impact on family members’ eating behaviors, childhood overweight and obesity, and intra-family relationships. These aspects have become hot topics in research, but there are still many unknown areas that require further investigation regarding changes in household food consumption as a unit, changes in the Chinese family environment, and the impact of these changes on children’s nutritional status. This study investigated the nutritional status of children after 6 and 18 months of continuous COVID-19 pandemic through a longitudinal study, enriching the understanding of the epidemiological trends of childhood overweight/obesity and malnutrition during the pandemic. Previous research has primarily focused on household dietary consumption during routine periods, but this study examined families as units to complement the understanding of changes in household dietary consumption during the COVID-19 pandemic. In China, family culture emphasizes family cohesion and close relationships, thus this study utilized the Chinese Family Assessment Instrument to assess family atmosphere and explore the relationship between family environment and child nutrition. By analyzing the association between household dietary consumption, family environment, parental anxiety, and child nutrition during the COVID-19 pandemic, this study filled gaps in relevant knowledge and can contribute to the development of effective, family-based interventions during significant public health events.

The aim of this study was to investigate the nutritional status of children in China during the COVID-19 pandemic and its association with family dietary consumption, family environment, and parental anxiety. The findings revealed that increased consumption of unhealthy food by families, chaotic or dysfunctional family environments, and heightened parental psychological stress were risk factors for childhood overweight and obesity. Furthermore, reduced consumption of staple foods by families was identified as a risk factor for childhood malnutrition.

Research has found that during the initial outbreak of the COVID-19 pandemic, the rates of childhood overweight, malnutrition, parental anxiety, and levels of family environmental disruption were higher compared to the period when the pandemic was prevalent. The drastic changes in the environment during the early stages of the COVID-19 outbreak disrupted many systems that children and parents rely on for health, livelihood, education, diet, and exercise (43, 44). The pandemic had an extremely disruptive effect on the family environment, known as the “hammer effect” (45). As the pandemic continued, on one hand, people gradually restored their daily routines, reducing the impact on children’s diet and exercise. On the other hand, families exhibited a certain level of resilience in the face of traumatic stress, which alleviated the psychological distress experienced by family members (46–48). Both family functioning and parental anxiety levels showed signs of recovery.

During the COVID-19 pandemic, reducing staple food consumption in households is a risk factor for child undernutrition. Staple foods are the main source of energy intake. A cohort study has shown that government lockdown measures significantly altered food intake (49). In 2020, the global prevalence of food insufficiency was 8.4%, with 418 million people in Asia unable to access adequate food (4, 50). Due to the severe economic recession caused by the pandemic, food access is jeopardized, and there is a positive correlation between food shortages and malnutrition (51).

Increasing consumption of take-out meals, sugary beverages, and desserts in households is a risk factor for child overweight and obesity. Take-out meals tend to be more energy-dense and have poorer nutrition, often containing high amounts of unhealthy ingredients such as fat, salt, and sugar, which are associated with weight gain and various negative health outcomes (52, 53). Compared to solid foods, sugary beverages provide less satiety and are easier to consume in excess, leading to energy accumulation. On the other hand, sugary beverages have a pleasant taste that can stimulate children’s appetite, leading to increased energy intake (10, 54, 55).

Our research found that family dysfunction and parental anxiety are risk factors for childhood obesity. Epidemiological studies have shown that family functioning plays a significant role in children’s diet and weight status (25). A chaotic family environment exacerbates negative parenting behaviors, leading to children’s preference for high-sugar, high-fat foods (14, 56). Anxious parents may use controlling or restrictive feeding practices, resulting in disrupted eating patterns and emotional eating in children, or they may be more inclined to use food as a means to soothe their children, thereby providing them with more convenient and unhealthy food options (57–59). Previous studies have indicated that there is a bidirectional relationship between family functioning and parental anxiety (60–62). Although this research provides evidence for the relationship between family functioning and nutrition, and parental anxiety and nutrition, the complex mechanisms underlying the interactions between parental anxiety, family functioning, and child nutrition have not been fully elucidated. The extent to which parental anxiety and family functioning jointly contribute to these effects, as well as whether there are mediating or moderating factors between them, requires further research.

Firstly, gaining a better understanding of the nutritional status of children during the ongoing COVID-19 pandemic has highlighted the changes in childhood obesity and malnutrition. This prompts us to not only focus on the issue of childhood obesity during major public health events but also pay attention to the problem of childhood malnutrition. This is important for informing the development of public health policies, which may involve food safety regulations, dietary education, social support systems, and other aspects, in order to protect the nutritional health of children.

This study provides limited evidence on the relationship between changes in household dietary consumption, family environment, parental anxiety, and child nutrition. The study suggests that dietary rules and food accessibility within the family, as well as parental emotions and parenting behaviors, can influence children’s dietary choices and quality. By further applying the theory of the family health ecosystem to research on family nutrition, the study enriches the theoretical understanding in this field. Additionally, it provides a theoretical basis for further analyzing and addressing child nutrition issues. However, it is important to note that the evidence is still limited, and further research is needed to validate and gain a deeper understanding of these relationships. Lastly, exploring the importance of the social environment in child nutrition has significant implications for policymakers and the design of intervention measures.

Research promotes the development of intervention measures, and family diet can influence children’s eating habits and intake. Family-based dietary interventions may be effective, as families can increase the consumption of healthy foods and reduce the consumption of obesity-promoting foods such as sugary beverages. At the same time, parents can improve their children’s nutritional status by establishing a supportive family environment, improving their own mental well-being, and maintaining family stability. These factors are crucial for promoting healthy eating and overall growth in children.

Research promotes family nutrition education, and the influence of family factors on child nutrition is undoubtedly important. The family is a microcosm of society, and China has its unique cultural background. For example, parents express love through food, and grandparents tend to overfeed children. When intervening in child nutrition, cultural differences should be taken into account (63). Chinese culture emphasizes parental authority and focuses on collectivism (64). In the context of Chinese social culture, it may be very effective to establish children’s healthy behaviors through role modeling and providing healthy diets. In Chinese families, the choice of what to eat is rarely an individual decision. It reminds promoters of healthy eating that nutrition education may be more effective if designed for the entire family rather than just individuals.

The research findings can provide recommendations for governments and relevant organizations to take measures to mitigate the negative impact of the COVID-19 pandemic on children’s nutrition status. This may include providing economic assistance, improving the food supply chain, promoting healthy eating campaigns, and implementing other measures to ensure children have access to adequate nutrition during the pandemic.

In this study, a large sample of children and adolescents was used, focusing not only on overweight and obesity, but also on malnutrition. The study focused on the impact of “family-based” eating behaviors on children and adolescents, which was conducted 2 years into the COVID-19 pandemic, helping to complement the impact of families on the nutritional status of children and adolescents in the ongoing pandemic.

However, there are some limitations to the research. Firstly, the study sample was limited to the Sichuan province, which may reduce the generalizability of the findings. Future research could consider recruiting participants from other regions in China to have a more comprehensive understanding of the nutritional status and weight-related behaviors of Chinese children. Secondly, due to the restrictions of the COVID-19 pandemic, the height and weight of children were reported by parents rather than measured by professionals, which may affect the accuracy of the measurements. Future research could consider using professional measurements of height and weight to improve the accuracy of the data. Thirdly, the survey on household food consumption was relatively simple and may not cover the comprehensive aspects of dietary consumption. Future research could design more detailed and scientific questionnaires to have a more comprehensive understanding of household dietary consumption patterns and changes in the consumption of food types. Lastly, there may be other confounding factors that could influence the associations found in the study. Future research could consider other confounding factors such as genetics, seasonality, weather, physical conditions, and lifestyle factors to enhance the reliability of the research findings.

In summary, the material environment of the family, the emotions of family members, and children’s perceptions of the family environment can all influence children’s eating behaviors and nutritional intake. Research findings indicate that the prevalence of malnutrition and obesity among children may be more severe during the COVID-19 pandemic. As the duration of the pandemic progresses, the rate of malnutrition in children decreases significantly, while the rate of obesity slightly decreases and the rate of overweight slightly increases. Therefore, the issue of childhood overweight and obesity should not be overlooked. The COVID-19 pandemic has also led to changes in family food consumption, family functioning, and parental emotions. Reduced consumption of staple foods by families is a risk factor for child under-nutrition, while increased consumption of take-out food and sugary beverages is a risk factor for child overweight and obesity. Family dysfunction and parental anxiety are also risk factors for childhood obesity. Family food consumption, family environment, and parental emotions are all factors that influence children’s nutrition. This study provides additional insights into the changing trends of childhood overweight, malnutrition, and other related issues during the ongoing COVID-19 pandemic. It also provides a theoretical basis for family-based intervention measures.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Medical Ethics Committee of Sichuan University ethics number: K2020025. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.

LZ: funding acquisition. LP and RH: methodology. LZ and LJ: project administration and resources. LP: software and writing—original draft. RH, YF, WS, LZ, and LJ: supervision. LP, RH, YF, and WS: writing—review and editing. All authors contributed to the article and approved the submitted version.

This work was supported by National Natural Science Foundation of China, Approval No.: 82273748.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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