Mediterranean diet, eating behaviours, and nutritional intervention in childhood obesity: what works, where, and for whom–a narrative review

Childhood obesity is a leading public health challenge with rising global prevalence and significant impacts on cardiometabolic health extending into adulthood. Lifestyle intervention, with nutrition as its central component, is the main point of paediatric obesity management, yet the evidence base remains fragmented across regions, instruments, and clinical models. This narrative review synthesises European evidence on Mediterranean diet (MD) adherence assessment, multidisciplinary intervention outcomes, and global comparative patterns in paediatric obesity management. Among dietary patterns, the Mediterranean diet (MD) remains the most evidence-supported framework for cardiometabolic prevention in children and adolescents. KIDMED, a 16-item validated instrument, has been adapted for multiple European paediatric populations and consistently identifies low legume, whole grain, and extra-virgin olive oil intake as the principal adherence gaps associated with a higher body mass index (BMI) Z-score, as well as a higher age- and sex-specific BMI percentile. The Children’s Eating Behaviour Questionnaire (CEBQ) provides a complementary behavioural marker with food-approach subscales positively associated with BMI Z-score and food-avoidance subscales inversely associated, a pattern replicated across European, Latin American, and Middle Eastern cohorts. Structured multidisciplinary interventions consistently produce modest reductions in BMI Z-score, typically between 0.10 and 0.25 units over 3 to 12 months. The strongest predictors of response are younger age, lower baseline obesity severity, breakfast adherence, and the absence of obese parents. Low KIDMED score additionally functions as a screening signal for paediatric Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD). Continental comparisons suggest that dietary-quality predictors of paediatric obesity are broadly consistent across regions. However, the feasibility of Mediterranean-style approaches varies substantially with local food availability, culinary traditions and economic access, so cross-cultural application of KIDMED-based screening requires careful local adaptation. The review concludes that routine integration of KIDMED and CEBQ within structured multidisciplinary pathways represents an evidence-informed, implementation-ready step for pediatric obesity care, particularly in under-studied Central and Eastern Europe.