Obesity in childhood and adolescence represents a major health problem in our century. In Greece, more than 30%-35% of children and adolescents are either overweight or obese. Using information and communication technologies, we developed a "National Registry for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence" for guidance and training of Pediatricians and General Practitioners. The application supports interoperability with other national infrastructures and multi-layered security spanning preventive, detective and administrative controls. The Patient Summary Dataset includes information on medical history, family history, medications, immunizations, clinical examination and laboratory findings and appointment booking service. AUTHORS: Penio Kassari, Panagiotis Papaioannou, Antonis Billiris, Haralampos Karanikas, Stergiani Eleftheriou, Eleftherios Thireos, Yannis Manios, George P Chrousos, Evangelia Charmandari

1. O R I G I N A L A R T I C L E
Electronic registry for the management of childhood obesity in
Greece
Penio Kassari1
| Panagiotis Papaioannou2
| Antonis Billiris3
| Haralampos Karanikas4
|
Stergiani Eleftheriou3
| Eleftherios Thireos4
| Yannis Manios5
| George P. Chrousos1
|
Evangelia Charmandari1,6
1
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
2
Department of Informatics, University of Piraeus, Piraeus, Greece
3
Datamed Systems Integration and Consulting Services, Athens, Greece
4
Athens Medical Society, Athens, Greece
5
Department of Nutrition-Dietetics, School of Health Science and Education, Harokopio University of Athens, Athens, Greece
6
Division of Endocrinology and Metabolism, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of
the Academy of Athens, Athens, Greece
Correspondence
Penio Kassari, Industrial/Organizational
Psychologist, Healthcare Professional,
National and Kapodistrian University of
Athens Medical School, Division of
Endocrinology, Metabolism and Diabetes,
First Department of Pediatrics, “Aghia
Sophia” Children’s Hospital, Thivon and
Levadias, Athens, Greece.
Εmail: peniokassari@gmail.com
Funding information
This work was the main pillar of the
Program entitled “Development of a
National System for the Prevention and
Management of Overweight and Obesity
in Childhood and Adolescence in Greece”,
with the promotional phrase “Lose Weight
- Gain Life” (MIS 370545), which was
sponsored by the National Strategic
Reference Framework (NSRF) 2007-2013,
under the Operational Program “Human
Resources Development” (EP.AN.A.D)
2007-2013 and co-funded by the European
Social Fund (ESF) and National Funding.
Scientific Supervisor: Dr. Evangelia
Charmandari, Professor of Pediatrics-
Pediatric and Adolescent Endocrinology.
Abstract
Background: Obesity in childhood and adolescence represents a major health
problem in our century. In Greece, more than 30%-35% of children and adoles-
cents are either overweight or obese.
Materials and methods: Using information and communication technologies, we
developed a “National Registry for the Prevention and Management of Over-
weight and Obesity in Childhood and Adolescence” for guidance and training of
Pediatricians and General Practitioners. The application supports interoperability
with other national infrastructures and multi-layered security spanning preventive,
detective and administrative controls. The Patient Summary Dataset includes
information on medical history, family history, medications, immunizations, clini-
cal examination and laboratory findings and appointment booking service.
Results: The application was launched in September 2015 and is accessible by:
http://app.childhood-obesity.gr/. Based on the data that the doctor registers, the
system calculates a personalized therapeutic algorithm that provides information
on diet, physical exercise and sleep, as well as guidance on laboratory investiga-
tions and referral to specialized centres. A pilot study performed in 1270 children
and adolescents indicated that using this system resulted in a reduction in obesity
rates by 30% and overweight rates by 35% within 1 year.
Conclusions: This National e-Health System appears to be effective in the mana-
gement of overweight and obesity in childhood and adolescence.
K E Y W O R D S
algorithms, childhood obesity, e-health, obesity treatment, overweight, registries
Received: 24 August 2017
| Accepted: 8 January 2018
DOI: 10.1111/eci.12887
Eur J Clin Invest. 2018;48:e12887.
https://doi.org/10.1111/eci.12887
wileyonlinelibrary.com/journal/eci © 2018 Stichting European Society for
Clinical Investigation Journal Foundation
| 1 of 9

2. 1 | INTRODUCTION
Obesity in childhood and adolescence represents a major
health problem of our century. In the United States (US),
the prevalence of a body mass index (BMI; the weight in
kilograms divided by the square of the height in meters)
above the 95th percentile among children aged 6-11 years
increased from 4.2% in 1963-1965 to 15.3% in 1999-2002,
and might have plateaued during the first decade of the
21st century.1
In the United Kingdom (UK), 30% of adults
have obesity, while 30% of children aged 2-15 years have
overweight or obesity.2
The prevalence of obesity is pro-
jected to reach 75% by 2030 in the US population3
and
50% by 2050 in the UK population.2
In Greece, more than
30%-35% of children and adolescents have increased BMI.4
Given that in our country there are approximately 100 000
live births per year, there are currently 1 800 000 children
and adolescents (from birth to 18 years), and 540 000-
630 000 (30%-35% of 1 800 000) of those have increased
BMI. The incidence of childhood overweight and obesity
is similarly high in other European and non European
countries.2
Overweight and obesity in childhood and adoles-
cence lead to obesity in adulthood and are associated
with significant morbidity and mortality.5–10
It is likely
that the “obesity epidemic” may reverse the current
trend of the declining rate of mortality from cardiovas-
cular causes, leading to a shorter lifespan for today’s
children.
Furthermore, overweight and obesity account for a sig-
nificant increase in public health costs. The financial impli-
cations of treating obesity itself are extensive, even without
incorporating the huge costs of treating its comorbidities
and addressing its socioeconomic impact. In the US, the
estimated medical expenditures attributed to overweight
and obesity were 149.4 billion in 2014 US dollars per
year.11
A recent study in the US demonstrated that the
direct health care costs attributable to obesity and over-
weight will more than double every decade. By 2030, costs
could range from 860.7 to 956.9 billion US dollars,
accounting for 1 in every 6 dollars spent on health care. In
the UK, by 2030 this condition is predicted to cost approx-
imately £2 billion GBP per year.2
Therefore, it is imperative that we 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, as well as reduced medical costs
owing to complications of obesity.
The progressively increasing prevalence of overweight
and obesity in Greece, and possibly other countries, indi-
cate that our current health policies are not effective. Some
explanations include:
1. Inadequate documentation of the BMI when children
and adolescents are seen by Pediatricians or General
Practitioners (GPs) on account of acute or chronic medi-
cal problems.
2. Pediatricians and GPs are not given clear guidance and
instructions about the management of overweight and
obesity in childhood and adolescence.
3. In many countries, GPs conduct annual Preventive Child
Health Examinations (PCHEs) and play an important
role in preventing, identifying and managing overweight
in children. At the five-year PCHE, almost one-third of
children with increased BMI were assessed to be nor-
mal-weight by GPs.12
Additionally, few providers feel
competent in the use of behaviour-modification strate-
gies and the time available may not suffice to identify
the targets and strategies for behavioural change.13
4. Inadequate coordination of all health-related organiza-
tions involved in the management of overweight and
obesity in childhood and adolescence; and
5. Inadequate education and/or information of parents, guar-
dians, teachers and the public in general about obesity, its
complications, as well as its prevention and management.
Our aim was to develop a comprehensive and persona-
lized plan of action for the prevention and management of
overweight and obesity in childhood and adolescence in
Greece.
2 | MATERIALS AND METHODS
Using information and communication technologies
(ICT),14–16
we developed a web application, the National
Registry for the Prevention and Management of Over-
weight and Obesity in Childhood and Adolescence, which
supports interoperability with other national infrastructures
(ie ePrescription) and multi-layered security spanning pre-
ventive, detective and administrative controls. This includes
transparent data encryption, data redaction, data masking,
privileged user controls, privilege usage analysis, condi-
tional auditing and real application security. The Installa-
tion and Hosting of the Central Database have been offered
by the Athens Medical Society, and the development was
implemented by Datamed SA—a systems integration and
consulting services company.17
The project is part of the overall Greek and European
policy to develop and use reliable Patient Registries, and as
such was designed to meet all the latest European direc-
tives and regulations. In addition, it complies with all the
latest institutional developments in Greece, which are
related to the creation of National Primary Healthcare Net-
work and development of clinical governance applications.
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| KASSARI ET AL.

3. More specifically, we developed an Electronic Medical
Records File (EMRF) for the electronic documentation of
the history and clinical examination findings, 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 provide each Pediatrician and GP with a personal ID
code. We have ensured safe access and data encryption, as
well as assistance for all enquiries. We have also obtained
approval by the local Ethics Committee and by the Hel-
lenic Data Protection Authority (HDPA) for accessing and
processing personal data. It is important to note that what
distinguishes this project from a simple registry is its
dynamic design, resulting from integrated treatment proto-
cols and algorithms, which provides clinical guidelines and
management guidance for the prevention and treatment of
overweight and obesity in childhood and adolescence.
The Patient Summary Dataset includes:
• Personal and Demographic Data: personal data, such as
Social Security Number, name, surname, father’s and
mother’s names, birth date, etc., and demographic data,
such as gender, nationality and region of residence.
• Medical History: perinatal history (pregnancy, delivery
and neonatal period), present and past medical history,
nutrition, level of physical activity and exercise, aller-
gies, immunizations, hospitalizations, surgeries, gynaeco-
logical history and medical treatments.
• Family History: height, weight and BMI of the parents,
as well as any family history of disease.
• Clinical Examination: complete clinical examination,
including the anthropometry parameters (weight, height,
body mass index, waist/hip ratio) and arterial blood
pressure.
• Patient Consent: in compliance with the respective laws
and directives, the application has provisioned a process
to enable the patient to give consent to the doctor to
access his/her personal medical file.
The application core functions are the following:
• Patient File: the patients are managed in accordance with
international standards (ICD-10). There is also provision
for free text entry.
• History: any information registered is kept in the data-
base and displayed in an appropriate manner so as to be
available to the physician when needed.
• Diagnosis: based on the international standard classifica-
tion diagnosis ICD-10.
• Allergies: notification of registered allergies with appro-
priate signs.
• Visits: management of the complete history of visits and
treatment guidelines issued by the doctor.
• Immunizations: full history of previous immunizations
and reminders about future immunizations.
• Medical Report: management of medical reports.
• Laboratory Investigations: ability for documentation of
laboratory investigations.
• Reminders: reminders are forwarded to the physician or
patient via email (if given email).
• Printouts: possibility to printout every screen, such as
medical reports, nutrition guidelines, questionnaires and
recommendations to parents.
3 | RESULTS
The National Registry for the Prevention and Management
of Overweight and Obesity in Childhood and Adolescence
was launched in September 2015 and is accessible by:
http://app.childhood-obesity.gr/. Figure 1, shows the home
page, main menu, health data menu, therapeutic interven-
tions and national immunization program.
Upon entering the EMRF, each doctor has the opportu-
nity to create a new EMRF for new patients to be recorded
and is able to view only the EMRFs of the patients under
his/her care. In the EMRF, the physician records informa-
tion on the current history, the past medical history, the
family history, all anthropometry parameters (weight,
height, BMI, waist-to-hip ratio) and the findings of clinical
examination. Additional information on diet and exercise is
also included in the EMRF. The EDS then automatically
calculates the BMI from the data on height and weight and
informs the physician whether the patient has normal or
increased BMI. In addition, the corresponding growth chart
for BMI appears on the computer screen. Subsequently, the
EDS selects the most appropriate TAF, which provides a
comprehensive and personalized multidisciplinary manage-
ment plan for the prevention and/or management of over-
weight and obesity for the patient. The TAF indicates what
the initial advice to the patient and his/her family should
be; when the physician should reassess the patient; how he/
she will manage the patient if he/she responds to the thera-
peutic interventions and how if he/she does not respond to
the therapeutic interventions despite compliance with those;
when he/she will request laboratory investigations and
which ones; when he/she will refer the patient to a Pedia-
tric Dietician or Psychologist; and when he/she will refer
the patient to a Pediatric Endocrinologist and a specialist
centre with expertise in the management of overweight and
obesity.17
All the above ensure a unified approach throughout the
country with respect to the management of overweight and
obesity in childhood and adolescence and provide very
KASSARI ET AL. | 3 of 9

4. FIGURE 1 The National Registry for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence, which is
accessible by the URL: http://app.childhood-obesity.gr/. (A) Home page; (B) Main menu; (C) Health data menu; (D) Therapeutic intervention; (E)
National Immunisation Program. (A) Home page. It shows the home page of the application (http://app.childhood-obesity.gr/), where the doctors
can register and sign in. There is also a provision to contact the administration in case they have forgotten their password. (B) Main menu. Top-left:
The main menu in tabs in 1 line. Top-Right: The name of the doctor appears at the first line, beneath there is a tab in case he/she wants to change
the password code and the log-off tab. At the line, the name of the last patient is displayed. Centre: From right to left at the first line, the first tab
enters to the patients’ files already registered, the second to the visits and the third to the appointments. At the second line, the doctor presses the
first tab when he/she wants to record a new patient, the second to read or create a reminder and the last tab is for the administrator of the system.
Down: The visit status is displayed (eg in progress), as well as the name of the patient. (C) Health data menu. Left to right: The first column
includes in different fields; patient’s personal and demographic data, reference cause, allergies, laboratory investigations and examination,
psychological history, growth, health behavioural customs, perinatal history, hospital admissions, surgeries, fractures, diseases, drugs, weight
history, gynaecological history and clinical examination. The second column includes on top the list of the current visits, following by the list of
the appointments, the reminders, printouts and lastly a tab where the doctor can upload files or pictures. (D) Therapeutic intervention. The EDS
automatically calculates the BMI from the data on height and weight entered by the physician, and informs the physician whether the patient has
normal BMI or is overweight or obese. In addition, the corresponding growth chart for BMI appears on the computer screen to enable the physician
to share this information with the parents/guardians, if necessary. Based on the data that the doctor is registering, the system calculates a
personalized therapeutic algorithm that provides information on diet, physical exercise and sleep, as well as guidance on laboratory investigations
and referral to specialized centres. (E) National Immunization Program. The system fully supports the Immunization program of a child
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| KASSARI ET AL.

5. specific and detailed guidance about the management of
this problem to all Pediatricians and GPs in district areas
with limited access to specialized Pediatric Endocrinology
Clinics.
The evaluation of the effectiveness of the interventions
that are proposed through this web application was
performed through our Out-patient Clinic for the Preven-
tion and Management of Overweight and Obesity at the
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.
FIGURE 1 Continued
KASSARI ET AL. | 5 of 9

6. FIGURE 1 Continued
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| KASSARI ET AL.

7. One thousand two hundred and seventy (n = 1270)
children and adolescents (mean age SD: 10.06
3.29 years; 573 males, 697 females; 608 prepubertal, 508
pubertal) were studied prospectively for 1 year. All sub-
jects were consecutive attendees at the “Out-patient Clinic
for the Prevention and Management of Overweight and
Obesity in Childhood and Adolescence,” “Aghia Sophia”
Children’s Hospital, Athens, Greece, which was developed
as part of the program entitled “Development of a National
System for the Prevention and Management of Overweight
and Obesity in Childhood and Adolescence in Greece”
with the view to evaluate the proposed interventions.
According to their BMI, subjects were classified as obese,
overweight or of normal BMI using the International Obe-
sity Task Force (IOTF) cut-off points. All subjects were
clinically well, with no evidence of an endocrine or any
other disorder, and did not receive any medication. The
study was approved by the Committee on the Ethics
Human Research of “Aghia Sophia” Children’s Hospital.
Written informed consent was obtained in all cases by a
parent, and assent was given by children older than
7 years.
All participants were admitted to the Endocrine Unit
early in the morning on the day of the study, and a detailed
medical history and clinical examination, including pubertal
assessment and standard anthropometric measurements
(weight, height, waist circumference, hip circumference),
were obtained by a single trained observer. At initial
assessment, all subjects were evaluated by a Pediatric
Dietician with respect to their daily nutritional habits, as
well as by a professional Gymnacist/Personal Trainer with
respect to their activities and hobbies throughout the week,
including the type, frequency, duration and intensity of
each activity. They also received detailed personalized
advice on diet and exercise. Psychological and psychiatric
assessment and management was offered when required.
Endocrinological and biochemical investigations were per-
formed at the beginning and at the end of the study. Obese
subjects were followed up at least every month, overweight
subjects every 2 months and normal-BMI subjects every
3 months.
At initial evaluation, 60.2% of subjects were obese,
28.4% overweight and 11.4% of normal BMI. A signifi-
cantly higher number of boys were obese compared with
girls (68.5% vs 53.3%, P .001), while a higher number
of girls were overweight compared with boys (30.7% vs
25.6%, P .001). The onset of weight gain had been
observed beyond the age of 5 years and was progressive
throughout childhood and adolescence. Following 1 year of
the multi-disciplinary management interventions, the preva-
lence of obesity and overweight was decreased by 30% and
35%, respectively, normal BMI increased by 8%, and the
cardiometabolic risk indices improved substantially. These
results indicate that our personalized multi-disciplinary
management plan is effective at reducing the prevalence of
obesity in childhood and adolescence for at least 1 year.18
4 | DISCUSSION
Obesity should be perceived as a chronic disease.19,20
Vari-
ous scientific and health organizations have advocated the
use of new technologies20,21
to address the obesity epi-
demic. Few published studies have investigated the effect
of the use of e-health applications22
to weight loss inter-
ventions and evaluated their effectiveness for more than a
year.
Among those are the Child Health and Obesity Informat-
ics System (CHOIS), a HIPAA (Health Insurance Portability
and Accountability Act) FERPA (Family Educational
Rights and Privacy Act) compliant secure system, which
integrates large databases in a high-performance grid com-
puting environment. This is a web application that provides
web-based forms for data entry (such as demographics,
height and weight for BMI computation, as well as genomic
information), which enables school nurses to enter data on
school children, identify those at-risk for obesity and enrol
them in prevention and intervention programs.23
The Resource Information Program for Parents on Life-
style and Education (RIPPLE) represents an e-health
screening, brief intervention and referral to treatment
(SBIRT) system for parents to help prevent childhood obe-
sity in primary health care. It was viewed by the partici-
pants as practical, well-designed and innovative;
nonetheless, they recommended improvements to certain
features, such as weight-related terms, because they per-
ceived it may evoke adverse responses from some par-
ents.24
The MINSTOP (Mobile-based Intervention Intended to
Stop Obesity in Preschoolers) is a web- and mobile phone-
based intervention designed to help parents promote
healthy eating and physical activity in children. Its effec-
tiveness is still to be reported.25
The HopSCOTCH (Shared-Care Obesity Trial in Chil-
dren) included the development of a web-based shared-care
software with the following goals: (i) allow the obesity spe-
cialists and GPs to collaborate and communicate closely
for the best care of their patients, (ii) provide a structured
yet efficient approach to weight management care, (iii) pro-
vide a mechanism to allow both GPs and specialists to
record and track patient progress simultaneously, and (iv)
integrate this with the GP’s existing desktop software. The
project exceeded software cost and experienced problems
with installation, error messages and download delays. It
was difficult to implement and it underperformed in the
real-world settings.26
KASSARI ET AL. | 7 of 9

8. Finally, the Child-Teen Obesity Treatment Service Plat-
form included: (i) two patient/parent mobile applications,
(ii) one web-monitoring service for medical staff, (iii) one
mobile application for food-craving endurance, and (iv)
one mobile application for medical examinations. The inte-
gration was successfully completed to the hospital where
the pilot program took place. Its effectiveness will be veri-
fied in the future when other organizations will be involved
as well.27
In the present study, we developed a National e-Health
System for the prevention and management of overweight
and obesity, which registers all children and adolescents
in the country. To the best of our knowledge, the Hel-
lenic National Registry for the Prevention and Manage-
ment of Overweight and Obesity in Childhood and
Adolescence is unique and innovative, given that it is the
first web-based e-health professional application world-
wide that offers through predefined therapeutic algorithms
a designed comprehensive personalized multi-disciplinary
intervention program. Furthermore, it can be translated
into various languages and can be used in different coun-
tries by making the necessary adjustments on the pro-
posed interventions and by taking into consideration
cultural and societal differences.28
Moreover, it can be
used as a registry for immunizations, as it fully supports
the immunization program of a child. It can also be
expanded to include programs for the prevention and
management of obesity in adulthood or other chronic dis-
eases. It is important to note that the long-term effective-
ness of this e-health system for the prevention of
childhood obesity requires the support of public health
authorities, long-term funding by national authorities and
the commitment of Pediatricians and GPs to enter all chil-
dren and adolescents into the system.21,29
ACKNOWLEDGEMENTS
We are most grateful to the Athens Medical Society, which
supports the hosting of the Database on a nonprofit basis.
We are also grateful to the children and adolescences and
their families for participating in our studies, as well as all
the staff of the Out-Patient Clinic for the Prevention and
Management of Overweight and Obesity.
DISCLOSURE
The authors declared no conflict of interest.
AUTHOR CONTRIBUTIONS
Penio Kassari and Evangelia Charmandari undertook the
literature search and wrote the paper. Antonis Billiris, Har-
alampos Karanikas and Stergiani Eleftheriou participated in
the preparation of the figures and contributed to the litera-
ture search. Panagiotis Papaioannou, Yannis Manios, Eleft-
herios Thireos and George P. Chrousos reviewed the paper
critically and offered their comments. All the authors have
read and approved the final version of the manuscript.
ORCID
Penio Kassari http://orcid.org/0000-0003-2464-1825
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How to cite this article: Kassari P, Papaioannou P,
Billiris A, et al. Electronic registry for the
management of childhood obesity in Greece. Eur J
Clin Invest. 2018;48:e12887. https://doi.org/10.1111/
eci.12887
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