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- Clustering of Multiple Energy Balance-Related Behaviors in School Children and its Association with Overweight and Obesity-WHO European Childhood Obesity Surveillance Initiative (COSI 2015⁻2017)Publication . Bel-Serrat, Silvia; Ojeda-Rodríguez, Ana; Heinen, Mirjam; Buoncristiano, Marta; Abdrakhmanova, Shynar; Duleva, Vesselka; Sant’Angelo, Victoria; Fijałkowska, Anna; Hejgaard, Tatjana; Huidumac, Constanta; Hyska, Jolanda; Kujundzic, Enisa; Milanović, Sanja; Ovezmyradova, Guljemal; Pérez-Farinós, Napoleón; Petrauskiene, Ausra; Rito, Ana; Shengelia, Lela; Braunerová, Radka; Rutter, Harry; Murrin, Celine; Kelleher, Cecily; Breda, JoãoIt is unclear how dietary, physical activity and sedentary behaviors co-occur in school-aged children. We investigated the clustering of energy balance-related behaviors and whether the identified clusters were associated with weight status. Participants were 6- to 9-year-old children (n = 63,215, 49.9% girls) from 19 countries participating in the fourth round (2015/2017) of the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative. Energy balance-related behaviors were parentally reported. Weight and height were objectively measured. We performed cluster analysis separately per group of countries (North Europe, East Europe, South Europe/Mediterranean countries and West-Central Asia). Seven clusters were identified in each group. Healthier clusters were common across groups. The pattern of distribution of healthy and unhealthy behaviors within each cluster was group specific. Associations between the clustering of energy balance-related behaviors and weight status varied per group. In South Europe/Mediterranean countries and East Europe, all or most of the cluster solutions were associated with higher risk of overweight/obesity when compared with the cluster 'Physically active and healthy diet'. Few or no associations were observed in North Europe and West-Central Asia, respectively. These findings support the hypothesis that unfavorable weight status is associated with a particular combination of energy balance-related behavior patterns, but only in some groups of countries.
- Prevalence of Severe Obesity among Primary School Children in 21 European CountriesPublication . Spinelli, Angela; Buoncristiano, Marta; Kovacs, Viktoria Anna; Yngve, Agneta; Spiroski, Igor; Obreja, Galina; Starc, Gregor; Pérez, Napoleón; Rito, Ana Isabel; Kunešová, Marie; Sant'Angelo, Victoria Farrugia; Meisfjord, Jørgen; Bergh, Ingunn Holden; Kelleher, Cecily; Yardim, Nazan; Pudule, Iveta; Petrauskiene, Ausra; Duleva, Vesselka; Sjöberg, Agneta; Gualtieri, Andrea; Hassapidou, Maria; Hyska, Jolanda; Burazeri, Genc; Petrescu, Constanta Huidumac; Heinen, Mirjam; Takacs, Hajnalka; Zamrazilová, Hana; Bosi, Tulay Bagci; Sacchini, Elena; Pagkalos, Ioannis; Cucu, Alexandra; Nardone, Paola; Gately, Paul; Williams, Julianne; Breda, JoãoThe World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) was established more than 10 years ago to estimate prevalence and monitor changes in overweight and obesity in children aged 6-9 years. Since then, there have been five rounds of data collection in more than 40 countries involving more than half a million children. To date, no comparative studies with data on severe childhood obesity from European countries have been published.
- A Snapshot of European Children’s Eating Habits: Results from the Fourth Round of the WHO European Childhood Obesity Surveillance Initiative (COSI)Publication . Williams, Julianne; Buoncristiano, Marta; Nardone, Paola; Rito, Ana Isabel; Spinelli, Angela; Hejgaard, Tatjana; Kierkegaard, Lene; Nurk, Eha; Kunešová, Marie; Musić Milanović, Sanja; García-Solano, Marta; Gutiérrez-González, Enrique; Brinduse, Lacramioara Aurelia; Cucu, Alexandra; Fijałkowska, Anna; Farrugia Sant’Angelo, Victoria; Abdrakhmanova, Shynar; Pudule, Iveta; Duleva, Vesselka; Yardim, Nazan; Gualtieri, Andrea; Heinen, Mirjam; Bel-Serrat, Silvia; Usupova, Zhamyla; Peterkova, Valentina; Shengelia, Lela; Hyska, Jolanda; Tanrygulyyeva, Maya; Petrauskiene, Ausra; Rakhmatullaeva, Sanavbar; Kujundzic, Enisa; Ostojic, Sergej M.; Weghuber, Daniel; Melkumova, Marina; Spiroski, Igor; Starc, Gregor; Rutter, Harry; Rathmes, Giulia; Bunge, Anne Charlotte; Rakovac, Ivo; Boymatova, Khadichamo; Weber, Martin; Breda, JoãoConsuming a healthy diet in childhood helps to protect against malnutrition and noncommunicable diseases (NCDs). This cross-sectional study described the diets of 132,489 children aged six to nine years from 23 countries participating in round four (2015-2017) of the WHO European Childhood Obesity Surveillance Initiative (COSI). Children's parents or caregivers were asked to complete a questionnaire that contained indicators of energy-balance-related behaviors (including diet). For each country, we calculated the percentage of children who consumed breakfast, fruit, vegetables, sweet snacks or soft drinks "every day", "most days (four to six days per week)", "some days (one to three days per week)", or "never or less than once a week". We reported these results stratified by country, sex, and region. On a daily basis, most children (78.5%) consumed breakfast, fewer than half (42.5%) consumed fruit, fewer than a quarter (22.6%) consumed fresh vegetables, and around one in ten consumed sweet snacks or soft drinks (10.3% and 9.4%, respectively); however, there were large between-country differences. This paper highlights an urgent need to create healthier food and drink environments, reinforce health systems to promote healthy diets, and continue to support child nutrition and obesity surveillance.
- Socioeconomic differences in food habits among 6- to 9-year-old children from 23 countries-WHO European Childhood Obesity Surveillance Initiative (COSI 2015/2017)Publication . Fismen, Anne‐Siri; Buoncristiano, Marta; Williams, Julianne; Helleve, Arnfinn; Abdrakhmanova, Shynar; Bakacs, Márta; Bergh, Ingunn Holden; Boymatova, Khadichamo; Duleva, Vesselka; Fijałkowska, Anna; García‐Solano, Marta; Gualtieri, Andrea; Gutiérrez‐González, Enrique; Hejgaard, Tatjana; Huidumac‐Petrescu, Constanta; Hyska, Jolanda; Kelleher, Cecily C.; Kierkegaard, Lene; Kujundžić, Enisa; Kunešová, Marie; Milanović, Sanja Musić; Nardone, Paola; Nurk, Eha; Ostojic, Sergej M.; Ozcebe, Lütfiye Hilal; Peterkova, Valentina; Petrauskiene, Ausra; Pudule, Iveta; Rakhmatulleoeva, Sanavbar; Rakovac, Ivo; Rito, Ana Isabel; Rutter, Harry; Sacchini, Elena; Stojisavljević, Dragana; Farrugia Sant'Angelo, Victoria; Shengelia, Lela; Spinelli, Angela; Spiroski, Igor; Tanrygulyyeva, Maya; Usupova, Zhamilya; Weghuber, Daniel; Breda, JoãoBackground: Socioeconomic differences in children's food habits are a key public health concern. In order to inform policy makers, cross-country surveillance studies of dietary patterns across socioeconomic groups are required. The purpose of this study was to examine associations between socioeconomic status (SES) and children's food habits. Methods: The study was based on nationally representative data from children aged 6-9 years (n = 129,164) in 23 countries in the World Health Organization (WHO) European Region. Multivariate multilevel analyses were used to explore associations between children's food habits (consumption of fruit, vegetables, and sugar-containing soft drinks) and parental education, perceived family wealth and parental employment status. Results: Overall, the present study suggests that unhealthy food habits are associated with lower SES, particularly as assessed by parental education and family perceived wealth, but not parental employment status. We found cross-national and regional variation in associations between SES and food habits and differences in the extent to which the respective indicators of SES were related to children's diet. Conclusion: Socioeconomic differences in children's food habits exist in the majority of European and Asian countries examined in this study. The results are of relevance when addressing strategies, policy actions, and interventions targeting social inequalities in children's diets.
- Socioeconomic disparities in physical activity, sedentary behavior and sleep patterns among 6- to 9-year-old children from 24 countries in the WHO European regionPublication . Musić Milanović, Sanja; Buoncristiano, Marta; Križan, Helena; Rathmes, Giulia; Williams, Julianne; Hyska, Jolanda; Duleva, Vesselka; Zamrazilová, Hana; Hejgaard, Tatjana; Jørgensen, Maja Bæksgaard; Salanave, Benoît; Shengelia, Lela; Kelleher, Cecily C.; Spinelli, Angela; Nardone, Paola; Abdrakhmanova, Shynar; Usupova, Zhamilya; Pudule, Iveta; Petrauskiene, Ausra; Farrugia Sant'Angelo, Victoria; Kujundžić, Enisa; Fijałkowska, Anna; Rito, Ana Isabel; Cucu, Alexandra; Brinduse, Lacramioara Aurelia; Peterkova, Valentina; Gualtieri, Andrea; García‐Solano, Marta; Gutiérrez‐González, Enrique; Boymatova, Khadichamo; Yardim, Mahmut S.; Tanrygulyyeva, Maya; Melkumova, Marina; Weghuber, Daniel; Nurk, Eha; Mäki, Päivi; Bergh, Ingunn Holden; Ostojic, Sergej M.; Russell Jonsson, Kenisha; Spiroski, Igor; Rutter, Harry; Ahrens, Wolfgang; Rakovac, Ivo; Whiting, Stephen; Breda, JoãoPhysical activity, sedentary behavior, and sleep are important predictors of children's health. This paper aimed to investigate socioeconomic disparities in physical activity, sedentary behavior, and sleep across the WHO European region. This cross-sectional study used data on 124,700 children aged 6 to 9 years from 24 countries participating in the WHO European Childhood Obesity Surveillance Initiative between 2015 and 2017. Socioeconomic status (SES) was measured through parental education, parental employment status, and family perceived wealth. Overall, results showed different patterns in socioeconomic disparities in children's movement behaviors across countries. In general, high SES children were more likely to use motorized transportation. Low SES children were less likely to participate in sports clubs and more likely to have more than 2 h/day of screen time. Children with low parental education had a 2.24 [95% CI 1.94-2.58] times higher risk of practising sports for less than 2 h/week. In the pooled analysis, SES was not significantly related to active play. The relationship between SES and sleep varied by the SES indicator used. Importantly, results showed that low SES is not always associated with a higher prevalence of "less healthy" behaviors. There is a great diversity in SES patterns across countries which supports the need for country-specific, targeted public health interventions.
- Socioeconomic inequalities in overweight and obesity among 6‐ to 9‐year‐old children in 24 countries from the World Health Organization European regionPublication . Buoncristiano, Marta; Williams, Julianne; Simmonds, Philippa; Nurk, Eha; Ahrens, Wolfgang; Nardone, Paola; Rito, Ana Isabel; Rutter, Harry; Bergh, Ingunn Holden; Starc, Gregor; Jonsson, Kenisha Russell; Spinelli, Angela; Vandevijvere, Stefanie; Mäki, Päivi; Milanović, Sanja Musić; Salanave, Benoît; Yardim, Mahmut S.; Hejgaard, Tatjana; Fijałkowska, Anna; Abdrakhmanova, Shynar; Abdurrahmonova, Zulfiya; Duleva, Vesselka; Farrugia Sant'Angelo, Victoria; García‐Solano, Marta; Gualtieri, Andrea; Gutiérrez‐González, Enrique; Huidumac‐Petrescu, Constanta; Hyska, Jolanda; Kelleher, Cecily C.; Kujundžić, Enisa; Peterkova, Valentina; Petrauskiene, Ausra; Pudule, Iveta; Sacchini, Elena; Shengelia, Lela; Tanrygulyyeva, Maya; Taxová Braunerová, Radka; Usupova, Zhamilya; Maruszczak, Katharina; Ostojic, Sergej M.; Spiroski, Igor; Stojisavljević, Dragana; Wickramasinghe, Kremlin; Breda, JoãoChildhood overweight and obesity have significant short- and long-term negative impacts on children's health and well-being. These challenges are unequally distributed according to socioeconomic status (SES); however, previous studies have often lacked standardized and objectively measured data across national contexts to assess these differences. This study provides a cross-sectional picture of the association between SES and childhood overweight and obesity, based on data from 123,487 children aged 6–9 years in 24 countries in the World Health Organization (WHO) European region. Overall, associations were found between overweight/obesity and the three SES indicators used (parental education, parental employment status, and family-perceived wealth). Our results showed an inverse relationship between the prevalence of childhood overweight/obesity and parental education in high-income countries, whereas the opposite relationship was observed in most of the middle-income countries. The same applied to family-perceived wealth, although parental employment status appeared to be less associated with overweight and obesity or not associated at all. This paper highlights the need for close attention to context when designing interventions, as the association between SES and childhood overweight and obesity varies by country economic development. Population-based interventions have an important role to play, but policies that target specific SES groups are also needed to address inequalities.
- Urban and rural differences in frequency of fruit, vegetable, and soft drink consumption among 6–9‐year‐old children from 19 countries from the WHO European regionPublication . Heinen, Mirjam M.; Bel‐Serrat, Silvia; Kelleher, Cecily C.; Buoncristiano, Marta; Spinelli, Angela; Nardone, Paola; Milanović, Sanja Musić; Rito, Ana Isabel; Bosi, A. Tülay Bağci; Gutiérrrez‐González, Enrique; Pudule, Iveta; Abdrakhmanova, Shynar; Abdurrahmonova, Zulfiya; Brinduse, Lacramioara Aurelia; Cucu, Alexandra; Duleva, Vesselka; Fijałkowska, Anna; Gualtieri, Andrea; Hejgaard, Tatjana; Hyska, Jolanda; Kujundžić, Enisa; Petrauskiene, Ausra; Sacchini, Elena; Shengelia, Lela; Tanrygulyyeva, Maya; Usupova, Zhamilya; Bergh, Ingunn Holden; Weghuber, Daniel; Taxová Braunerová, Radka; Kunešová, Marie; Sant'Angelo, Victoria Farrugia; Nurk, Eha; Ostojic, Sergej M.; Spiroski, Igor; Tichá, Ľubica; Rutter, Harry; Williams, Julianne; Boymatova, Khadichamo; Rakovac, Ivo; Weber, Martin W.; Breda, JoãoIn order to address the paucity of evidence on the association between childhood eating habits and urbanization, this cross-sectional study describes urban–rural differences in frequency of fruit, vegetable, and soft drink consumption in 123,100 children aged 6–9 years from 19 countries participating in the fourth round (2015-2017) of the WHO European Childhood Obesity Surveillance Initiative (COSI). Children's parents/caregivers completed food-frequency questionnaires. A multivariate multilevel logistic regression analysis was performed and revealed wide variability among countries and within macroregions for all indicators. The percentage of children attending rural schools ranged from 3% in Turkey to 70% in Turkmenistan. The prevalence of less healthy eating habits was high, with between 30–80% and 30–90% children not eating fruit or vegetables daily, respectively, and up to 45% consuming soft drinks on >3 days a week. For less than one third of the countries, children attending rural schools had higher odds (OR-range: 1.1–2.1) for not eating fruit or vegetables daily or consuming soft drinks >3 days a week compared to children attending urban schools. For the remainder of the countries no significant associations were observed. Both population-based interventions and policy strategies are necessary to improve access to healthy foods and increase healthy eating behaviors among children.
- WHO European Childhood Obesity Surveillance Initiative: associations between sleep duration, screen time and food consumption frequenciesPublication . Börnhorst, Claudia; Wijnhoven, Trudy M.A.; Kunešová, Marie; Yngve, Agneta; Rito, Ana I.; Lissner, Lauren; Duleva, Vesselka; Petrauskiene, Ausra; Breda, JoãoBACKGROUND: Both sleep duration and screen time have been suggested to affect children's diet, although in different directions and presumably through different pathways. The present cross-sectional study aimed to simultaneously investigate the associations between sleep duration, screen time and food consumption frequencies in children. METHODS: The analysis was based on 10 453 children aged 6-9 years from five European countries that participated in the World Health Organization European Childhood Obesity Surveillance Initiative. Logistic multilevel models were used to assess associations of parent-reported screen time as well as sleep duration (exposure variables) with consumption frequencies of 16 food items (outcome variables). All models were adjusted for age, sex, outdoor play time, maximum educational level of parents and sleep duration or screen time, depending on the exposure under investigation. RESULTS: One additional hour of screen time was associated with increased consumption frequencies of 'soft drinks containing sugar' (1.28 [1.19;1.39]; odds ratio and 99% confidence interval), 'diet/light soft drinks' (1.21 [1.14;1.29]), 'flavoured milk' (1.18 [1.08;1.28]), 'candy bars or chocolate' (1.31 [1.22;1.40]), 'biscuits, cakes, doughnuts or pies' (1.22 [1.14;1.30]), 'potato chips (crisps), corn chips, popcorn or peanuts' (1.32 [1.20;1.45]), 'pizza, French fries (chips), hamburgers'(1.30 [1.18;1.43]) and with a reduced consumption frequency of 'vegetables (excluding potatoes)' (0.89 [0.83;0.95]) and 'fresh fruits' (0.91 [0.86;0.97]). Conversely, one additional hour of sleep duration was found to be associated with increased consumption frequencies of 'fresh fruits' (1.11 [1.04;1.18]) and 'vegetables (excluding potatoes)' (1.14 [1.07;1.23]). CONCLUSION: The results suggest a potential relation between high screen time exposure and increased consumption frequencies of foods high in fat, free sugar or salt whereas long sleep duration may favourably be related to children's food choices. Both screen time and sleep duration are modifiable behaviours that may be tackled in childhood obesity prevention efforts.
- WHO European Childhood Obesity Surveillance Initiative: health-risk behaviours on nutrition and physical activity in 6-9-year-old schoolchildrenPublication . Wijnhoven, Trudy M.A.; van Raaij, Joop M.A.; Yngve, Agneta; Sjöberg, Agneta; Kunešová, Marie; Duleva, Vesselka; Petrauskiene, Ausra; Rito, Ana I.; Breda, JoãoObjective: To assess to what extent eight behavioural health risks related to breakfast and food consumption and five behavioural health risks related to physical activity, screen time and sleep duration are present among schoolchildren, and to examine whether health-risk behaviours are associated with obesity. Design: Cross-sectional design as part of the WHO European Childhood Obesity Surveillance Initiative (school year 2007/2008). Children’s behavioural data were reported by their parents and children’s weight and height measured by trained fieldworkers. Descriptive statistics and logistic regression analyses were performed. Setting: Primary schools in Bulgaria, Lithuania, Portugal and Sweden; paediatric clinics in the Czech Republic. Subjects: Nationally representative samples of 6–9-year-olds (n 15 643). Results: All thirteen risk behaviours differed statistically significantly across countries. Highest prevalence estimates of risk behaviours were observed in Bulgaria and lowest in Sweden. Not having breakfast daily and spending screen time ≥2 h/d were clearly positively associated with obesity. The same was true for eating ‘foods like pizza, French fries, hamburgers, sausages or meat pies’ >3 d/week and playing outside <1 h/d. Surprisingly, other individual unhealthy eating or less favourable physical activity behaviours showed either no or significant negative associations with obesity. A combination of multiple less favourable physical activity behaviours showed positive associations with obesity, whereas multiple unhealthy eating behaviours combined did not lead to higher odds of obesity. Conclusions: Despite a categorization based on international health recommendations, individual associations of the thirteen health-risk behaviours with obesity were not consistent, whereas presence of multiple physical activity-related risk behaviours was clearly associated with higher odds of obesity.
- WHO European Childhood Obesity Surveillance Initiative: Impact of Type of Clothing Worn during Anthropometric Measurements and Timing of the Survey on Weight and Body Mass Index Outcome Measures in 6–9-Year-Old ChildrenPublication . Wijnhoven, Trudy M.A.; van Raaij, Joop M.A.; Spinelli, Angela; Yngve, Agneta; Lissner, Lauren; Spiroski, Igor; Farrugia Sant'Angelo, Victoria; Pérez-Farinós, Napoleón; Martos, Éva; Heinen, Mirjam; Kunešová, Marie; Rito, Ana I.; Hovengen, Ragnhild; Starc, Gregor; Duleva, Vesselka; Pudule, Iveta; Petrauskiene, Ausra; Braeckevelt, Lien; Hassapidou, Maria; Breda, João; van 't Veer, PieterBackground. The World Health Organization European Childhood Obesity Surveillance Initiative (COSI) conducted examinations in 6–9-year-old children from 16 countries in the first two rounds of data collection. Allowing participating countries to adhere to their local legal requirements or adapt to other circumstances required developing a flexible protocol for anthropometric procedures. Objectives. (1) Review intercountry variation in types of clothing worn by children during weight and height measurements, clothes weight adjustments applied, timing of the survey, and duration of data collection; (2) assess the impact of the observed variation in these practices on the children’s weight or body mass index (BMI) outcome measures. Results. The relative difference between countries’ unadjusted and clothes-adjusted prevalence estimates for overweight was 0.3–11.5%; this figure was 1.4–33.3% for BMI-for-age Z-score values. Monthly fluctuations in mean BMI-for-age Z-score values did not show a systematic seasonal effect. The majority of the monthly BMI-for-age Z-score values did not differ statistically within a country; only 1–3 monthly values were statistically different within some countries. Conclusions. The findings of the present study suggest that the built-in flexibility in the COSI protocol concerning the data collection practices addressed in the paper can be kept and thus do not necessitate a revision of the COSI protocol.