Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Pediatrics

Family stress and child BMIz during the COVID-19 pandemic: exploring the mediating effects of cortisol

International Journal of Obesity volume 49, pages 1616–1622 (2025)Cite this article

Subjects

Abstract

Background

Previous research has suggested that children who are exposed to chronic stress are at greater risk for childhood obesity, however little research has examined the mechanism of this association. This study aimed to investigate the association between family and household stress during the COVID-19 pandemic and children’s BMIz, and whether children’s hair cortisol concentration (HCC) mediates this association.

Methods

This study used baseline data from 228 children 2–6 years from the Family Stress Study, a prospective cohort study of families with children 2–6 years. Parents responded to an online survey which assessed family and household stressors including family functioning, home chaos, financial insecurity, food insecurity, parental depression, parenting stress, stressful life events, and COVID-19 stressors. A total family chronic stress index score was calculated from parents’ responses on these measures. Hair samples were collected from children to assess their HCC. The Hayes PROCESS mediation macro was used to assess the total, direct, and indirect effect of the family chronic stress index on child BMIz, adjusting for household income and child ethnicity/race.

Results

We found that the family chronic stress index was associated with higher child BMIz (b = 0.815, 95% CI = 0.181–1.449), but this association was not mediated by children’s HCC (b = 0.004, CI = −0.042–0.076).

Conclusions

Future research should continue to investigate hair cortisol as a measure of chronic stress among children younger than 6 years and explore other mechanisms of how chronic stress is associated with children’s weight outcomes, such as through parenting practices that influence children’s eating behaviour or physical activity, or children’s weight-related behaviours.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to the full article PDF.

USD 39.95

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Simple mediation model of the association between family chronic stress and child BMIz via child HCC.

Similar content being viewed by others

Data availability

The data that support the findings of this study are available from the corresponding author, SD, upon reasonable request.

Code availability

The code that support the findings of this study are available from the corresponding author, SD, upon reasonable request.

References

  1. Gundersen C, Mahatmya D, Garasky S, Lohman B. Linking psychosocial stressors and childhood obesity. Obes Rev. 2011;12:e54–63.

    Article  CAS  PubMed  Google Scholar 

  2. Pervanidou P, Chrousos GP. Stress and pediatric obesity: neurobiology and behavior. Fam Relat. 2016;65:85–93.

    Article  Google Scholar 

  3. Lynch T, Azuero A, Lochman JE, Park N-J, Turner-Henson A, Rice M. The influence of psychological stress, depressive symptoms, and cortisol on body mass and central adiposity in 10- to-12-year-old children. J Pediatr Nurs. 2019;44:42–9.

    Article  PubMed  Google Scholar 

  4. Kappes C, Stein R, Körner A, Merkenschlager A, Kiess W. Stress, stress reduction and obesity in childhood and adolescence. Horm Res Paediatr. 2023;96:88–96.

    Article  CAS  PubMed  Google Scholar 

  5. Suglia SF, Duarte CS, Chambers EC, Boynton-Jarrett R. Cumulative social risk and obesity in early childhood. Pediatrics. 2012;129:e1173–e9.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Halliday JA, Palma CL, Mellor D, Green J, Renzaho AMN. The relationship between family functioning and child and adolescent overweight and obesity: a systematic review. Int J Obes. 2014;38:480–93.

    Article  CAS  Google Scholar 

  7. East P, Delker E, Blanco E, Burrows R, Lozoff B, Gahagan S. Home and family environment related to development of obesity: a 21-year longitudinal study. Child Obes. 2019;15:156–66.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Shorer M, Leibovich L. Young children’s emotional stress reactions during the COVID-19 outbreak and their associations with parental emotion regulation and parental playfulness. Early Child Dev Care. 2022;192:861–71.

    Article  Google Scholar 

  9. Schmidt SJ, Barblan LP, Lory I, Landolt MA. Age-related effects of the COVID-19 pandemic on mental health of children and adolescents. Eur J Psychotraumatol. 2021;12:1901407.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Adams EL, Smith D, Caccavale LJ, Bean MK. Parents are stressed! Patterns of parent stress across COVID-19. Front Psychiatry. 2021;12:626456.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Foley S, Badinlou F, Brocki KC, Frick MA, Ronchi L, Hughes C. Family function and child adjustment difficulties in the COVID-19 pandemic: an international study. Int J Environ Res Public Health. 2021;18:11136.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Feinberg ME, Mogle J, Lee JK, Tornello SL, Hostetler ML, Cifelli JA, et al. Impact of the COVID-19 pandemic on parent, child, and family functioning. Fam Process. 2022;61:361–74.

    Article  PubMed  Google Scholar 

  13. Han J-A, Chung Y-E, Chung I-H, Hong Y-H, Chung S. Impact of the COVID-19 pandemic on seasonal variations in childhood and adolescent growth: experience of pediatric endocrine clinics. Children. 2021;8:404.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Androutsos O, Perperidi M, Georgiou C, Chouliaras G. Lifestyle changes and determinants of children’s and adolescents’ body weight increase during the first COVID-19 lockdown in Greece: the COV-EAT study. Nutrients. 2021;13:930.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Vogel M, Geserick M, Gausche R, Beger C, Poulain T, Meigen C, et al. Age- and weight group-specific weight gain patterns in children and adolescents during the 15 years before and during the COVID-19 pandemic. Int J Obes. 2022;46:144–52.

    Article  CAS  Google Scholar 

  16. Kiecolt-Glaser JK, Habash DL, Fagundes CP, Andridge R, Peng J, Malarkey WB, et al. Daily stressors, past depression, and metabolic responses to high-fat meals: a novel path to obesity. Biol Psychiatry. 2015;77:653–60.

    Article  CAS  PubMed  Google Scholar 

  17. Björntorp P. Do stress reactions cause abdominal obesity and comorbidities?. Obes Rev. 2001;2:73–86.

    Article  PubMed  Google Scholar 

  18. Incollingo Rodriguez AC, Epel ES, White ML, Standen EC, Seckl JR, Tomiyama AJ. Hypothalamic-pituitary-adrenal axis dysregulation and cortisol activity in obesity: a systematic review. Psychoneuroendocrinology. 2015;62:301–18.

    Article  CAS  PubMed  Google Scholar 

  19. Moss RH, Conner M, O’Connor DB. Exploring the effects of daily hassles and uplifts on eating behaviour in young adults: the role of daily cortisol levels. Psychoneuroendocrinology. 2021;129:105231.

    Article  CAS  PubMed  Google Scholar 

  20. O’Connor DB, Thayer JF, Vedhara K. Stress and health: a review of psychobiological processes. Annu Rev Psychol. 2021;72:663–88.

    Article  PubMed  Google Scholar 

  21. Miller AL, Clifford C, Sturza J, Rosenblum K, Vazquez DM, Kaciroti N, et al. Blunted cortisol response to stress is associated with higher body mass index in low-income preschool-aged children. Psychoneuroendocrinology. 2013;38:2611–7.

    Article  CAS  PubMed  Google Scholar 

  22. Kiess W, Meidert A, Dressendörfer RA, Schriever K, Kessler U, Köunig A, et al. Salivary cortisol levels throughout childhood and adolescence: relation with age, pubertal stage, and weight. Pediatr Res. 1995;37:502–6.

    Article  CAS  PubMed  Google Scholar 

  23. Miller AL, Kaciroti N, Sturza J, Retzloff L, Rosenblum K, Vazquez DM, et al. Associations between stress biology indicators and overweight across toddlerhood. Psychoneuroendocrinology. 2017;79:98–106.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Mendoza MM, Dmitrieva J, Perreira KM, Hurwich-Reiss E, Watamura SE. The effects of economic and sociocultural stressors on the well-being of children of Latino immigrants living in poverty. Cult Divers Ethn Minor Psychol. 2017;23:15–26.

    Article  Google Scholar 

  25. Chu L, Shen K, Liu P, Ye K, Wang Y, Li C, et al. Increased cortisol and cortisone levels in overweight children. Med Sci Monit Basic Res. 2017;23:25–30.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Kunin-Batson AS, Crain AL, Gunnar MR, Kelly AS, Kharbanda EO, Haapala J, et al. Household income, cortisol, and obesity during early childhood: a prospective longitudinal study. J Pediatr. 2023;252:76–82.

    Article  CAS  PubMed  Google Scholar 

  27. Ling J, Kao TSA, Robbins LB. Body mass index, waist circumference and body fat are positively correlated with hair cortisol in children: a systematic review and meta-analysis. Obes Rev. 2020;21:e13050–n/a.

    Article  PubMed  Google Scholar 

  28. Ma L, Liu X, Yan N, Gan Y, Wu Y, Li Y, et al. Associations between different cortisol measures and adiposity in children: a systematic review and meta-analysis. Front Nutr. 2022;9:879256.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Spiga F, Walker JJ, Terry JR, Lightman SL. HPA axis-rhythms. Compr Physiol. 2014;4:1273–98.

    Article  PubMed  Google Scholar 

  30. Hellhammer J, Fries E, Schweisthal OW, Schlotz W, Stone AA, Hagemann D. Several daily measurements are necessary to reliably assess the cortisol rise after awakening: state- and trait components. Psychoneuroendocrinology. 2007;32:80–6.

    Article  CAS  PubMed  Google Scholar 

  31. Gibson EL, Checkley S, Papadopoulos A, Poon L, Daley S, Wardle J. Increased salivary cortisol reliably induced by a protein-rich midday meal. Psychosom Med. 1999;61:214–24.

    Article  CAS  PubMed  Google Scholar 

  32. Michels N, Sioen I, De Vriendt T, Huybrechts I, Vanaelst B, De Henauw S. Children’s morning and evening salivary cortisol: pattern, instruction compliance and sampling confounders. Horm Res Paediatr. 2012;77:27–35.

    Article  CAS  PubMed  Google Scholar 

  33. Russell E, Koren G, Rieder M, Van Uum S. Hair cortisol as a biological marker of chronic stress: current status, future directions and unanswered questions. Psychoneuroendocrinology. 2012;37:589–601.

    Article  CAS  PubMed  Google Scholar 

  34. Stalder T, Kirschbaum C. Analysis of cortisol in hair—state of the art and future directions. Brain Behav Immun. 2012;26:1019–29.

    Article  CAS  PubMed  Google Scholar 

  35. Miller AL, Gearhardt AN, Retzloff L, Sturza J, Kaciroti N, Lumeng JC. Early childhood stress and child age predict longitudinal increases in obesogenic eating among low-income children. Acad Pediatr. 2018;18:685–91.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Oh DL, Jerman P, Silvério Marques S, Koita K, Purewal Boparai SK, Burke Harris N, et al. Systematic review of pediatric health outcomes associated with childhood adversity. BMC Pediatr. 2018;18:83.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Huybrechts I, Beirlaen C, De Vriendt T, Slimani N, Pisa PT, Schouppe E, et al. Validity of instruction leaflets for parents to measure their child’s weight and height at home: results obtained from a randomised controlled trial. BMJ Open. 2014;4:e003768.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Huybrechts I, Himes JH, Ottevaere C, De Vriendt T, De Keyzer W, Cox B, et al. Validity of parent-reported weight and height of preschool children measured at home or estimated without home measurement: a validation study. BMC Pediatr. 2011;11:63.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Tenenbaum A, Shefer-Averbuch N, Lazar L, Yakobovitch-Gavan M, Phillip M, Oron T. Growth assessment of children during the COVID-19 pandemic—can we rely on parental measurements?. Acta Paediatr. 2021;110:3040–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Myatt M, Guevarra E. zscorer: Child Anthropometry z-Score Calculator. 2019. https://cran.r-project.org/web/packages/zscorer/index.html.

  41. World Health Organization. Child growth standards. https://www.who.int/tools/child-growth-standards.

  42. Sauve B, Koren G, Walsh G, Tokmakejian S, Van Uum SHM. Measurement of cortisol in human hair as a biomarker of systemic exposure. Clin Investig Med. 2007;30:E183–91.

    Article  CAS  Google Scholar 

  43. Hayashi S, Miyamoto I, Takeda K. Measurement of human hair growth by optical microscopy and image analysis. Br J Dermatol. 1991;125:123–9.

    Article  CAS  PubMed  Google Scholar 

  44. Kirschbaum C, Tietze A, Skoluda N, Dettenborn L. Hair as a retrospective calendar of cortisol production—increased cortisol incorporation into hair in the third trimester of pregnancy. Psychoneuroendocrinology. 2009;34:32–7.

    Article  CAS  PubMed  Google Scholar 

  45. Hayes AF. Partial, conditional, and moderated moderated mediation: quantification, inference, and interpretation. Commun Monogr. 2018;85:4–40.

    Article  Google Scholar 

  46. Moreno-Black G, Stockard J. Two worlds of obesity: ethnic differences in child overweight/obesity prevalence and trajectories. J Racial Ethn Health Disparities. 2016;3:331–9.

    Article  PubMed  Google Scholar 

  47. Isong IA, Richmond T, Avendaño M, Kawachi I. Racial/ethnic disparities: a longitudinal study of growth trajectories among US kindergarten children. J Racial Ethn Health Disparities. 2018;5:875–84.

    Article  PubMed  Google Scholar 

  48. Statistics Canada. Income statistics by economic family type and income source. 2024. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1110019101.

  49. Tate EB, Wood W, Liao Y, Dunton GF. Do stressed mothers have heavier children? A meta-analysis on the relationship between maternal stress and child body mass index. Obes Rev. 2015;16:351–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Vanaelst B, Michels N, Clays E, Herrmann D, Huybrechts I, Sioen I, et al. The association between childhood stress and body composition, and the role of stress-related lifestyle factors—cross-sectional findings from the baseline ChiBS survey. Int J Behav Med. 2014;21:292–301.

    Article  PubMed  Google Scholar 

  51. Lumeng JC, Miller A, Peterson KE, Kaciroti N, Sturza J, Rosenblum K, et al. Diurnal cortisol pattern, eating behaviors and overweight in low-income preschool-aged children. Appetite. 2014;73:65–72.

    Article  PubMed  Google Scholar 

  52. Christaki EV, Pervanidou P, Papassotiriou I, Bastaki D, Valavani E, Mantzou A, et al. Stress, inflammation and metabolic biomarkers are associated with body composition measures in lean, overweight, and obese children and adolescents. Children. 2022;9:291.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Christaki EV, Pervanidou P, Papassotiriou I, Mantzou A, Giannakakis G, Boschiero D, et al. Circulating FGF21 vs. stress markers in girls during childhood and adolescence, and in their caregivers: intriguing inter-relations between overweight/obesity, emotions, behavior, and the cared-caregiver relationship. Children. 2022;9:821.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Bryson HE, Mensah F, Goldfeld S, Price AMH. Using hair cortisol to examine the role of stress in children’s health inequalities at 3 years. Acad Pediatr. 2020;20:193–202.

    Article  PubMed  Google Scholar 

  55. Schloß S, Ruhl I, Müller V, Becker K, Skoluda N, Nater UM, et al. Low hair cortisol concentration and emerging attention-deficit/hyperactivity symptoms in preschool age. Dev Psychobiol. 2018;60:722–9.

    Article  PubMed  Google Scholar 

  56. Slopen N, Roberts AL, LeWinn KZ, Bush NR, Rovnaghi CR, Tylavsky F, et al. Maternal experiences of trauma and hair cortisol in early childhood in a prospective cohort. Psychoneuroendocrinology. 2018;98:168–76.

    Article  CAS  PubMed  Google Scholar 

  57. Larsen SC, Fahrenkrug J, Olsen NJ, Heitmann BL. Association between hair cortisol concentration and adiposity measures among children and parents from the “Healthy Start” study. PLoS ONE. 2016;11:e0163639.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Rovnaghi CR, Kala AF, Allen SL, Anand KJS. Interpretation of cortisol concentrations and reference intervals from the CALIPER database. Clin Chem. 2014;60:418–9.

    Article  CAS  PubMed  Google Scholar 

  59. Binz TM, Rietschel L, Streit F, Hofmann M, Gehrke J, Herdener M, et al. Endogenous cortisol in keratinized matrices: systematic determination of baseline cortisol levels in hair and the influence of sex, age and hair color. Forensic Sci Int. 2018;284:33–8.

    Article  CAS  PubMed  Google Scholar 

  60. Jansen E, Thapaliya G, Aghababian A, Sadler J, Smith K, Carnell S. Parental stress, food parenting practices and child snack intake during the COVID-19 pandemic. Appetite. 2021;161:105119.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  61. Walton K, Simpson JR, Darlington G, Haines J. Parenting stress: a cross-sectional analysis of associations with childhood obesity, physical activity, and TV viewing. BMC Pediatr. 2014;14:244.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Parks EP, Kumanyika S, Moore RH, Stettler N, Wrotniak BH, Kazak A. Influence of stress in parents on child obesity and related behaviors. Pediatrics. 2012;130:e1096–104.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Webb HJ, Zimmer-Gembeck MJ, Scuffham PA, Scott R, Barber B. Family stress predicts poorer dietary quality in children: examining the role of the parent–child relationship. Infant Child Dev. 2018;27.

  64. Sadeh A, Raviv A, Gruber R. Sleep patterns and sleep disruptions in school-age children. Dev Psychol. 2000;36:291–301.

    Article  CAS  PubMed  Google Scholar 

  65. Coto J, Garcia A, Hart KC, Graziano PA. Associations between disruptive behavior problems, parenting factors, and sleep problems among young children. J Dev Behav Pediatr. 2018;39:610–20.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Michels N, Sioen I, Boone L, Clays E, Vanaelst B, Huybrechts I, et al. Cross-lagged associations between children’s stress and adiposity: the Children’s Body Composition and Stress study. Psychosom Med. 2015;77:50–8.

    Article  PubMed  Google Scholar 

  67. Vismara L, Rollè L, Agostini F, Sechi C, Fenaroli V, Molgora S, et al. Perinatal parenting stress, anxiety, and depression outcomes in first-time mothers and fathers: a 3- to 6-months postpartum follow-up study. Front Psychol. 2016;7:938.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Widarsson M, Engström G, Rosenblad A, Kerstis B, Edlund B, Lundberg P. Parental stress in early parenthood among mothers and fathers in Sweden. Scand J Caring Sci. 2013;27:839–47.

    Article  PubMed  Google Scholar 

  69. Skreden M, Skari H, Malt UF, Pripp AH, BjÖRk MD, Faugli A, et al. Parenting stress and emotional wellbeing in mothers and fathers of preschool children. Scand J Public Health. 2012;40:596–604.

    Article  PubMed  Google Scholar 

  70. Vanderwall C, Randall Clark R, Eickhoff J, Carrel AL. BMI is a poor predictor of adiposity in young overweight and obese children. BMC Pediatr. 2017;17:135.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The authors would like to acknowledge and thank the families participating in the Family Stress Study. The Family Stress Study is supported by the Canadian Institutes of Health Research (419814) and the McMaster University COVID-19 Research Fund. The funding partners played no role in study design, methods, participant recruitment, data collection, analysis, or preparation of this paper.

Author information

Author notes

  1. These authors contributed equally: Katherine M. Morrison, Jess Haines.

Authors and Affiliations

  1. Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON, Canada

    Sabrina Douglas, Andrea C. Buchholz, Shannon M. Pare & Jess Haines

  2. Department of Human Health and Nutrition Sciences, University of Guelph, Guelph, ON, Canada

    Amar Laila, Alison M. Duncan, David W. L. Ma & Lori Ann Vallis

  3. Stockholm Resilience Center, Stockholm University, Stockholm, Sweden

    Amar Laila

  4. Department of Psychology, The University of Western Ontario, London, ON, Canada

    Paul F. Tremblay

  5. Department of Health Behaviour and Health Equity, School of Public Health, University of Michigan, Ann Arbor, MI, USA

    Alison L. Miller

  6. Centre for Metabolism, Obesity & Diabetes Research, Department of Pediatrics, McMaster University, Hamilton, ON, Canada

    Elizabeth Gunn & Katherine M. Morrison

Authors
  1. Sabrina Douglas
    View author publications

    Search author on:PubMed Google Scholar

  2. Amar Laila
    View author publications

    Search author on:PubMed Google Scholar

  3. Paul F. Tremblay
    View author publications

    Search author on:PubMed Google Scholar

  4. Andrea C. Buchholz
    View author publications

    Search author on:PubMed Google Scholar

  5. Alison L. Miller
    View author publications

    Search author on:PubMed Google Scholar

  6. Shannon M. Pare
    View author publications

    Search author on:PubMed Google Scholar

  7. Elizabeth Gunn
    View author publications

    Search author on:PubMed Google Scholar

  8. Alison M. Duncan
    View author publications

    Search author on:PubMed Google Scholar

  9. David W. L. Ma
    View author publications

    Search author on:PubMed Google Scholar

  10. Lori Ann Vallis
    View author publications

    Search author on:PubMed Google Scholar

  11. Katherine M. Morrison
    View author publications

    Search author on:PubMed Google Scholar

  12. Jess Haines
    View author publications

    Search author on:PubMed Google Scholar

Contributions

Conceptualization—JH, KM; methodology—AL, PT, AM, KM, JH; formal analysis—AL, PT; writing, original draft preparation—SD, JH; writing, review and editing—SD, AL, PT, AB, AM, SP, EG, AD, DM, LV, KM, JH; supervision—JH, KM. All authors have read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to Sabrina Douglas.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

41366_2025_1802_MOESM1_ESM.docx

Total, direct, and indirect effects of the family chronic stress index (including responses from two parents) on child BMIz

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Douglas, S., Laila, A., Tremblay, P.F. et al. Family stress and child BMIz during the COVID-19 pandemic: exploring the mediating effects of cortisol. Int J Obes 49, 1616–1622 (2025). https://doi.org/10.1038/s41366-025-01802-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Version of record:

  • Issue date:

  • DOI: https://doi.org/10.1038/s41366-025-01802-9

Search

Advanced search

Quick links