European Journal of Cardiovascular Medicine

Adolescent overweight and obesity have emerged as one of the most significant public health challenges of the twenty-first century, affecting both developed and developing nations. Traditionally, malnutrition in low- and middle-income countries was predominantly characterized by undernutrition; however, rapid urbanization, economic development, dietary transitions, and increasingly sedentary lifestyles have resulted in a dual burden of malnutrition, where overweight and obesity coexist with undernutrition [1]. The World Health Organization (WHO) defines overweight and obesity as abnormal or excessive fat accumulation that presents a risk to health. Among children and adolescents aged 5–19 years, overweight is defined as a body mass index (BMI)-for-age greater than one standard deviation above the WHO Growth Reference median, whereas obesity is defined as BMI-for-age greater than two standard deviations above the reference median [2]. Globally, the prevalence of overweight and obesity among children and adolescents has increased dramatically over the past three decades, making adolescent obesity a major contributor to the growing burden of non-communicable diseases (NCDs) [1]. According to recent WHO estimates, more than 390 million children and adolescents aged 5–19 years were overweight in 2022, including over 160 million living with obesity, reflecting a nearly fourfold increase since 1990 [1].

Adolescence represents a critical period of physical growth, hormonal maturation, and behavioral development during which lifestyle habits are established and often persist into adulthood. Excessive weight gain during this stage is associated with numerous adverse health consequences, including insulin resistance, type 2 diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome, non-alcoholic fatty liver disease, obstructive sleep apnea, orthopedic disorders, and early cardiovascular morbidity [3,4]. Beyond physical complications, obesity exerts profound psychological and social effects. Overweight adolescents frequently experience poor self-esteem, body image dissatisfaction, anxiety, depression, social isolation, and bullying, all of which negatively affect academic performance and overall quality of life [5]. Furthermore, obesity during adolescence significantly increases the likelihood of obesity in adulthood, thereby predisposing individuals to chronic diseases and premature mortality [6].

The etiology of adolescent overweight and obesity is multifactorial, resulting from a complex interaction between genetic susceptibility, environmental influences, dietary behaviors, physical inactivity, socioeconomic status, and psychosocial determinants [7]. Contemporary lifestyles characterized by increased consumption of calorie-dense processed foods, sugar-sweetened beverages, excessive screen time, inadequate physical activity, irregular sleep patterns, and reduced outdoor recreation have substantially contributed to the rising prevalence of obesity among young people [1,7]. Family history, parental obesity, educational status of parents, household income, urban residence, and cultural perceptions regarding body weight further influence obesity risk [8]. The obesogenic environment created by easy access to unhealthy foods and limited opportunities for physical activity has become a major driver of this epidemic worldwide [1].

India is currently experiencing a rapid nutritional transition, with increasing rates of overweight and obesity observed among children and adolescents alongside persistent undernutrition. Economic growth, urbanization, technological advancement, changing dietary preferences, and declining physical activity have collectively altered the nutritional profile of Indian adolescents [9]. National surveys have demonstrated considerable regional variations in obesity prevalence, with higher rates generally reported in urban populations, although rural areas are increasingly affected due to changing lifestyles [10]. This epidemiological transition poses a serious challenge to the healthcare system because obesity-related disorders are appearing at progressively younger ages, increasing the long-term burden of non-communicable diseases and healthcare expenditure [9].

Within India, states such as Himachal Pradesh have undergone substantial socioeconomic development during recent decades, accompanied by lifestyle modifications that may predispose adolescents to excessive weight gain. Improved purchasing power, changing food consumption patterns, increased dependence on processed and fast foods, reduced physical activity, and expanding digital engagement have collectively contributed to an obesogenic environment. Nevertheless, the epidemiology of adolescent overweight and exogenous obesity in Himalayan regions remains relatively underexplored compared with metropolitan areas. Regional variations in geography, dietary customs, physical activity patterns, climate, educational practices, and healthcare accessibility may influence obesity prevalence differently from other parts of the country, underscoring the need for locally generated evidence.

Hospital-based studies conducted in tertiary care settings provide valuable opportunities to estimate the prevalence of overweight and exogenous obesity while simultaneously identifying associated demographic, behavioral, socioeconomic, and clinical determinants. Such information is essential for designing targeted preventive strategies, school-based health promotion programs, nutritional counseling services, and early intervention initiatives. Identification of modifiable risk factors enables healthcare professionals, policymakers, educators, and parents to formulate evidence-based approaches aimed at preventing obesity and its associated complications before adulthood.

Considering the increasing burden of adolescent obesity and the limited data available from Himachal Pradesh, the present study titled "Prevalence and Determinants of Overweight and Exogenous Obesity Among Adolescents Attending a Tertiary Care Hospital in Himachal Pradesh" seeks to determine the magnitude of overweight and exogenous obesity among adolescents attending a tertiary healthcare institution and to identify the demographic, behavioral, socioeconomic, and lifestyle factors associated with these conditions. The findings of this study are expected to contribute valuable regional evidence for strengthening adolescent health programs and developing context-specific preventive interventions to address the growing epidemic of obesity in Himachal Pradesh and similar settings.

Study design and setting

A hospital-based cross-sectional observational study was conducted in the Department of Pediatrics, Shri Lal Bahadur Shastri Government Medical College and Hospital (SLBSGMCH), Nerchowk, Mandi, Himachal Pradesh, India. The study was carried out over a period of one year, from June 2024 to June 2025, and included adolescents attending both the outpatient department (OPD) and inpatient department (IPD).

Study population

The study population comprised adolescents aged 10–18 years presenting to the Department of Pediatrics during the study period. Consecutive eligible participants fulfilling the predefined inclusion criteria were enrolled after obtaining written informed consent from parents or legal guardians and assent from adolescents, wherever applicable.

Eligibility criteria

Inclusion criteria

Adolescents aged between 10 and 18 years attending the pediatric outpatient or inpatient services of SLBSGMCH, Nerchowk, whose parents or legal guardians provided written informed consent, were eligible for inclusion.

Exclusion criteria

Participants were excluded if they had obesity secondary to identifiable pathological causes or conditions likely to interfere with anthropometric assessment. These included children with global developmental delay, chronic systemic illnesses, endocrine disorders such as hypothyroidism or Cushing syndrome, inherited metabolic disorders, nephrotic syndrome, syndromic obesity, prolonged corticosteroid therapy (>4 weeks), or treatment with medications known to influence body weight (including antipsychotics, antidepressants, antiepileptic drugs, and mood stabilizers). Adolescents whose parents declined consent were also excluded.

Sample size

A total of 400 adolescents fulfilling the eligibility criteria were enrolled during the study period using consecutive sampling.

Study variables

The primary outcome variable was the prevalence of overweight and exogenous obesity.

Independent variables included:

• Age
• Sex
• Family history of obesity
• Parental educational status
• Parental occupation
• Socioeconomic status
• Type of family
• Breastfeeding history
• Dietary practices
• Physical activity
• Screen time
• Sleep duration
• Meal frequency
• Consumption of fruits and vegetables
• Breakfast habits
• Junk food intake
• Consumption of sugar-sweetened beverages
• Sweet consumption
• Snack consumption
• Late-night snacking habits

These variables were selected based on previously reported determinants of adolescent obesity and the study objectives.

Data collection

Data were collected using a structured, predesigned interviewer-administered questionnaire in the local vernacular language. The questionnaire included information regarding demographic characteristics, parental education and occupation, family history of obesity, breastfeeding practices, dietary habits, physical activity, screen exposure, and lifestyle-related behaviours.

Socioeconomic status was assessed using the Modified Kuppuswamy Socioeconomic Scale.

Information regarding physical activity included participation in sports and recreational activities. Sedentary behaviour was assessed through the average duration of television viewing and mobile phone or video game usage. Dietary assessment included the frequency of breakfast consumption, fruit and vegetable intake, junk food consumption, sugar-sweetened beverages, sweets, snacks, meal frequency, and late-night eating habits.

Anthropometric measurements

Anthropometric measurements were obtained using standardized procedures by trained investigators.

Weight measurement

Body weight was measured using a calibrated electronic weighing scale (Safal Enterprises) with participants wearing light clothing and no footwear. The weighing scale was calibrated regularly, maintained at zero before each measurement, and readings were recorded to the nearest 0.1 kg. Participants were instructed to stand upright in the centre of the weighing platform with body weight equally distributed over both feet.

Height measurement

Standing height was measured using a wall-mounted stadiometer (Indo Surgicals Pvt. Ltd.) with participants barefoot and standing erect in the Frankfurt horizontal plane. The heels, buttocks, scapulae, and occiput were positioned against the vertical surface of the stadiometer. Height was recorded to the nearest 0.1 cm.

Body mass index

Body mass index (BMI) was calculated using the standard formula:

BMI = Weight (kg) / Height (m²)

BMI-for-age percentiles were determined using the Centers for Disease Control and Prevention (CDC) 2000 age- and sex-specific BMI growth charts.

Participants were classified as:

• Underweight: <5th percentile
• Normal weight: 5th to <85th percentile
• Overweight: ≥85th to <95th percentile
• Obesity: ≥95th percentile

Only adolescents classified as overweight or obese according to CDC criteria were considered positive outcomes for the study objectives.

Outcome definition

Exogenous obesity was defined as obesity occurring in the absence of identifiable endocrine, genetic, metabolic, or syndromic causes and classified using CDC BMI-for-age percentiles after exclusion of secondary causes through clinical evaluation.

Ethical considerations

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Approval was obtained from the Institutional Ethics Committee of Shri Lal Bahadur Shastri Government Medical College and Hospital before initiation of the study. Written informed consent was obtained from parents or legal guardians, and assent was obtained from adolescents whenever appropriate. Confidentiality and anonymity of participant information were maintained throughout the study.

Statistical analysis

Data were entered into Microsoft Excel and analysed using IBM SPSS Statistics (Version 26.0 or later).

Continuous variables were expressed as mean ± standard deviation (SD) or median (interquartile range) depending on data distribution. Categorical variables were presented as frequencies and percentages.

The prevalence of overweight and obesity was calculated with 95% confidence intervals (CI).

Associations between categorical variables and overweight/obesity were evaluated using the Chi-square test or Fisher's exact test where appropriate. Continuous variables were compared using the independent-samples t test or Mann–Whitney U test according to normality.

Variables with a p-value <0.20 on univariate analysis were entered into a multivariable binary logistic regression model to identify independent determinants of overweight and obesity. Adjusted odds ratios (AORs) with 95% confidence intervals were reported. Multicollinearity was assessed using variance inflation factors, and model fitness was evaluated using the Hosmer–Lemeshow goodness-of-fit test.

A two-tailed p-value <0.05 was considered statistically significant.

A total of 400 adolescents aged 10–18 years were enrolled in the study. The mean age of the participants was 13.6 ± 2.1 years, with females constituting 50.8% (n=203) and males 49.2% (n=197). Most participants (50.3%) belonged to the 12–16-year age group.

According to the CDC BMI-for-age percentile classification, 291 (72.8%) adolescents had normal BMI, 55 (13.8%) were overweight, 42 (10.5%) were obese, and 12 (3.0%) were underweight. Thus, the combined prevalence of overweight and obesity was 24.3%.

Table 1. Baseline demographic characteristics of study participants (N = 400)

Table 1 presents the baseline demographic characteristics of the study participants. Among the 400 adolescents included in the study, the largest proportion (50.3%) belonged to the 12–16 years age group, followed by those aged less than 12 years (34.8%) and above 16 years (15.0%). The study population comprised 203 females (50.8%) and 197 males (49.3%), indicating a nearly equal sex distribution. Based on the CDC BMI-for-age percentile classification, 72.8% of participants had normal body weight, whereas 13.8% were overweight and 10.5% were obese. Underweight was observed in only 3.0% of the participants, resulting in an overall combined prevalence of overweight and obesity of 24.3%.

Table 2. Family, parental and socioeconomic characteristics of the study participants (N = 400)

Table 2 summarizes the family characteristics, parental educational status, breastfeeding history, and socioeconomic profile of the study population. A family history of obesity was reported in 16.8% of fathers, 13.3% of mothers, and 12.8% of siblings. Most fathers had completed either high school (33.0%) or intermediate/diploma education (30.5%), while the majority of mothers had attained high school education (32.8%), followed by intermediate/diploma qualifications (25.0%). Nuclear families constituted 51.8% of the study population, whereas 48.3% belonged to joint families. Breastfeeding during infancy was reported in 78.3% of adolescents. According to the Modified Kuppuswamy socioeconomic classification, the largest proportion of participants belonged to the upper-lower socioeconomic class (39.3%), followed by the lower-middle (23.5%) and lower socioeconomic classes (21.3%).

Table 3. Lifestyle and dietary characteristics of the study participants (N = 400)

Table 3 presents the lifestyle and dietary characteristics of the adolescents. Most participants (67.3%) reported sleeping for at least eight hours daily, while three-fourths (75.0%) consumed three meals per day. Regular breakfast consumption was reported by 81.3% of participants, whereas only 37.8% reported regular fruit intake. Nearly half of the adolescents (48.8%) consumed junk food one to two times per week, while 21.0% consumed junk food more than four times weekly. Approximately one-fourth (24.5%) consumed sweetened or aerated beverages more than three times per week. Frequent consumption of sweets and snacks (>3 times/week) was reported by 28.0% and 31.8% of participants, respectively. Late-night snacking was relatively uncommon and was reported by only 9.5% of adolescents.

Table 4. Factors associated with overweight and obesity (Univariate analysis)

Table 4 presents the results of the univariate analysis examining factors associated with overweight and obesity among adolescents. Family history of obesity in fathers, mothers, and siblings demonstrated statistically significant associations with overweight and obesity. Lifestyle-related variables including frequent junk food consumption, higher intake of sweetened beverages, prolonged screen time, and physical inactivity were also significantly associated with increased odds of overweight and obesity. Adolescents belonging to nuclear families showed significantly higher odds of overweight and obesity compared with those from joint families.

Table 5. Multivariable logistic regression analysis showing independent determinants of overweight and obesity

Table 5 presents the independent determinants of overweight and obesity identified through multivariable logistic regression analysis after adjusting for potential confounding variables. Maternal obesity emerged as the strongest independent predictor of adolescent overweight and obesity (AOR = 2.49; 95% CI: 1.28–4.83; p = 0.007), followed by frequent junk food consumption (AOR = 2.56; 95% CI: 1.47–4.44; p = 0.001). Paternal obesity, physical inactivity, prolonged screen time, and frequent consumption of sweetened beverages also remained statistically significant independent predictors of overweight and obesity in the adjusted model.

Table 6. Summary of prevalence of overweight and obesity

Table 6 summarizes the BMI distribution of the study participants according to the CDC BMI-for-age percentile classification. The majority of adolescents (72.8%) had normal body weight, while 13.8% were classified as overweight and 10.5% as obese. Underweight was observed in 3.0% of participants. Overall, the combined prevalence of overweight and obesity among adolescents attending the tertiary care hospital was 24.3%.

Figure 1 illustrates the distribution of adolescents according to body mass index (BMI) categories based on the CDC 2000 BMI-for-age growth charts. The majority of participants (72.8%; n = 291) had normal BMI, indicating that most adolescents were within the healthy weight range. Overweight was observed in 13.8% (n = 55) of participants, while 10.5% (n = 42) were classified as obese. Underweight accounted for only 3.0% (n = 12) of the study population. Overall, the combined prevalence of overweight and obesity was 24.3% (n = 97), demonstrating that nearly one in four adolescents attending the tertiary care hospital had excess body weight. This finding highlights the substantial burden of overweight and obesity among adolescents in the study population.

Figure 2 illustrates the distribution of family history of obesity and socioeconomic status among the study participants. A positive family history of obesity was reported in 16.8% (n = 67) of fathers, 13.3% (n = 53) of mothers, and 12.8% (n = 51) of siblings, while the majority of adolescents had no family history of obesity in first-degree relatives. Regarding socioeconomic status, the largest proportion of participants belonged to the upper-lower socioeconomic class (39.3%; n = 157), followed by the lower-middle class (23.5%; n = 94) and the lower class (21.3%; n = 85). Only 13.5% (n = 54) of participants were from the upper-middle class, whereas 2.5% (n = 10) belonged to the upper socioeconomic class according to the Modified Kuppuswamy classification. These findings indicate that most adolescents included in the study were from lower socioeconomic strata, with a relatively small proportion reporting a positive family history of obesity.

Figure 3 illustrates the distribution of lifestyle and dietary characteristics among the study participants. Most adolescents (67.3%; n = 269) reported sleeping for at least eight hours per day, while 32.8% (n = 131) slept for less than eight hours. The majority (75.0%; n = 300) consumed three meals daily, whereas 22.3% (n = 89) reported consuming four meals per day. Regular breakfast consumption was observed in 81.3% (n = 325) of participants; however, only 37.8% (n = 151) reported regular fruit consumption. Nearly half of the adolescents (48.8%; n = 195) consumed junk food one to two times per week, while 21.0% (n = 84) consumed junk food more than four times weekly. Frequent consumption (≥3 times/week) of sweetened or aerated beverages, sweets, and snacks was reported by 24.5% (n = 98), 28.0% (n = 112), and 31.8% (n = 127) of participants, respectively. Late-night snacking was reported by only 9.5% (n = 38) of adolescents, whereas 90.5% (n = 362) denied this habit. Overall, the figure demonstrates that although several healthy lifestyle practices, such as adequate sleep and regular breakfast consumption, were common, a considerable proportion of adolescents also reported unhealthy dietary behaviors, including frequent junk food intake and consumption of sugar-sweetened beverages and snacks.

The present hospital-based cross-sectional study evaluated the prevalence of overweight and exogenous obesity among 400 adolescents aged 10–18 years attending a tertiary care hospital in Himachal Pradesh. The combined prevalence of overweight and obesity was 24.3%, comprising 13.8% overweight and 10.5% obesity, while 72.8% of adolescents had normal body weight and only 3.0% were underweight. These findings indicate that nearly one in four adolescents attending the tertiary care centre had excess body weight, reflecting the increasing burden of adolescent obesity in this region.

The prevalence observed in the present study is comparable with several recent Indian studies. Sinha et al. reported a combined prevalence of 24.3% among adolescents in urban Bihar, comprising 18.5% overweight and 5.85% obesity, highlighting the growing influence of unhealthy dietary practices and sedentary lifestyles on adolescent obesity [11]. Similarly, Kaushal et al. documented an overall prevalence of 23.2% among school-going adolescents in Rajasthan, suggesting that overweight and obesity have become increasingly common across northern India [12]. These similarities indicate that the epidemiological transition toward overnutrition is extending beyond metropolitan regions and is increasingly evident in Himalayan states such as Himachal Pradesh.

Lower prevalence estimates have been reported by Prasad et al., who observed overweight and obesity in 9.7% and 4.3% of adolescents, respectively, in Puducherry [13]. Likewise, Bhattad et al. reported overweight in 9.8% and obesity in 5.0% among adolescents in Maharashtra [14]. The higher prevalence observed in the present study may reflect differences in study setting, dietary habits, socioeconomic conditions, and the increasing adoption of sedentary lifestyles, including prolonged screen time and greater availability of energy-dense processed foods.

The study population consisted predominantly of adolescents aged 12–16 years, with an almost equal distribution of males and females. This age group represents a period of rapid pubertal development, increased independence in food choices, and behavioural changes that may predispose individuals to excessive weight gain. The low prevalence of underweight (3.0%) compared with overweight and obesity further illustrates the ongoing nutritional transition occurring in India, where overnutrition is becoming increasingly prevalent alongside persistent undernutrition.

Overall, the findings of the present study are consistent with previous Indian literature and demonstrate that adolescent overweight and obesity are emerging as important public health concerns in Himachal Pradesh. The observed prevalence warrants implementation of school- and family-based interventions aimed at promoting healthy dietary practices, regular physical activity, and early screening for obesity among adolescents [15].

The present study demonstrated that both familial and lifestyle-related factors were significantly associated with overweight and obesity among adolescents. Maternal obesity, paternal obesity, frequent junk food consumption, physical inactivity, prolonged screen time, and regular intake of sugar-sweetened beverages remained independent predictors in multivariable logistic regression. These findings suggest that adolescent obesity is influenced by a combination of genetic susceptibility and modifiable environmental factors.

Patil et al. reported that overweight children were substantially more likely to have overweight parents, emphasizing the contribution of shared family behaviours and genetic predisposition to obesity development [16]. Similar findings were observed in the present study, where parental obesity remained an independent determinant after adjustment for potential confounders. Family-centred interventions may therefore be more effective than strategies targeting adolescents alone.

Lifestyle factors also played a significant role in the present study. Jain et al. reported significant associations between obesity and unhealthy dietary habits, prolonged television viewing, and frequent junk food consumption among urban adolescents [17]. Likewise, Choudhary et al. demonstrated that physical inactivity and frequent fast-food consumption significantly increased the likelihood of overweight and obesity among school-going adolescents [18]. These findings reinforce the importance of maintaining energy balance through healthy eating and regular physical activity during adolescence.

Although most participants in the present study belonged to the upper-lower socioeconomic class, unhealthy dietary behaviours were common across the study population. Dasappa et al. similarly observed that reduced participation in sports and parental lifestyle practices were important determinants of childhood obesity regardless of socioeconomic background [19]. This suggests that obesity prevention programmes should target behavioural risk factors across all socioeconomic groups rather than focusing exclusively on affluent populations.

The findings of the present study are also consistent with current recommendations from the World Health Organization, which advocate comprehensive interventions involving healthy school environments, improved dietary practices, increased physical activity, and reduced sedentary behaviour to prevent childhood obesity [20,21]. Collectively, these findings emphasize that effective prevention of adolescent obesity requires coordinated efforts involving healthcare professionals, schools, families, and policymakers to promote healthy lifestyles from early childhood.

The present hospital-based cross-sectional study demonstrated that the combined prevalence of overweight and exogenous obesity among adolescents aged 10–18 years attending a tertiary care hospital in Himachal Pradesh was 24.3%, indicating that nearly one in four adolescents was affected by excess body weight. This finding highlights the growing burden of adolescent overweight and obesity in the region and reflects the ongoing nutritional and lifestyle transition occurring in India.

The study identified several significant determinants of overweight and obesity, including parental obesity, frequent consumption of junk food and sugar-sweetened beverages, prolonged screen time, and physical inactivity. These findings emphasize that adolescent obesity is a multifactorial condition influenced by both hereditary and modifiable lifestyle factors. The independent association of parental obesity further underscores the importance of the family environment in shaping dietary behaviours and physical activity patterns among adolescents.

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