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- Adolescents' capacity to take action on obesity: A concurrent controlled before‐and‐after study of the European CO‐CREATE projectPublication . Herstad, Sondre Haugsbø; Grewal, Navnit Kaur; Banik, Anna; Klepp, Knut‐Inge; Knai, Cecile; Luszczynska, Aleksandra; Mendes, Sofia; Rito, Ana; Rutter, Harry; Lien, NannaThis study evaluated the effect on reported readiness for action and attitudes toward obesity prevention among older adolescents (mean age 17) who took part in a youth-led participatory action research European initiative (CO-CREATE Youth Alliances)compared with a comparison group that acted as controls. This was a concurrent before-and-after controlled study across five countries and took place between September 2019 and October 2020. Adolescents (n=159) recruited from schools and youth organizations came together with researchers and formed 15 Youth Alliances. An online questionnaire measuring their readiness for action and attitudes toward obesity prevention was administered. Alliance members (n=62) who filled in the questionnaire at both baseline and postinitiative, and adolescents from the comparison group (n=132) who completed the questionnaire twice were included in the main analysis. Two-level linear mixed models controlling for country-related variance were fitted. Alliance members scored significantly higher than the comparison group on two factors in each of the readiness for action, responsibility, and drivers of behavior concepts. The findings suggest that involving youth in co-creating policies to prevent obesity may increase adolescents' readiness for action and promote a shift in adolescents' conceptualization of obesity from an individual perspective to a societal responsibility and drivers of behavior.
- 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.
- Co‐creating obesity prevention policies with youth: Policy ideas generated through the CO‐CREATE projectPublication . Conway‐Moore, Kaitlin; Knai, Cécile; Finegood, Diane; Johnston, Lee; Brinsden, Hannah; Aguiar, Anaely; Kopainsky, Birgit; Önal, Furkan; Helleve, Arnfinn; Klepp, Knut‐Inge; Lien, Nanna; Luszczynska, Aleksandra; Rito, Ana Isabel; Rønnestad, Alfred Mestad; Ulstein, Madeleine; Blanchard, Laurence; Savona, Natalie; Rutter, HarryDespite growing recognition of the importance of applying a systems lens to action on obesity, there has only been limited analysis of the extent to which this lens has actually been applied. The CO-CREATE project used a youth-led participatory action research approach to generate policy ideas towards the reduction of adolescent overweight and obesity across Europe. In order to assess the extent to which these youth-generated policy ideas take a systems approach, we analyzed them using the Intervention Level Framework (ILF). The ILF ascribes actions to one of five system levels, from Structural Elements, the least engaged with system change, up to Paradigm, which is the system's deepest held beliefs and thus the most difficult level at which to intervene. Of the 106 policy ideas generated by young people during the CO-CREATE project, 91 (86%) were categorized at the level of Structural Elements. This emphasis on operational rather than systems level responses echoes findings from a previous study on obesity strategies. Analyzing the distribution of systems level responses using the ILF has the potential to support more effective action on obesity by allowing identification of opportunities to strengthen systems level responses overall.
- Encouraging greater empowerment for adolescents in consent procedures in social science research and policy projectsPublication . Samdal, Oddrun; Budin‐Ljøsne, Isabelle; Haug, Ellen; Helland, Trond; Kjostarova‐Unkovska, Lina; Bouillon, Claire; Bröer, Christian; Corell, Maria; Cosma, Alina; Currie, Dorothy; Eriksson, Charli; Felder‐Puig, Rosemarie; Gaspar, Tania; Hagquist, Curt; Harbron, Janetta; Jåstad, Atle; Kelly, Colette; Knai, Cecile; Kleszczewska, Dorota; Kysnes, Bjarte Birkeland; Lien, Nanna; Luszczynska, Aleksandra; Moerman, Gerben; Moreno‐Maldonado, Concepcion; NicGabhainn, Saoirse; Pudule, Iveta; Rakic, Jelena Gudelj; Rito, Ana; Rønnestad, Alfred Mestad; Ulstein, Madeleine; Rutter, Harry; Klepp, Knut‐IngeThe United Nations Convention on the Rights of the Child emphasizes the importance of allowing children and adolescents to influence decisions that are important to them following their age and maturity. This paper explores the principles, practices, and implications around using parental versus child/adolescent consent when participating in social science research and policy development. Experiences from two studies are presented: The Confronting Obesity: Co-creating policy with youth (CO-CREATE) and the Health Behaviour in School-aged Children (HBSC) study, a World Health Organization (WHO) Collaborative Cross-National study. Although parental consent may be an important gatekeeper for protecting children and adolescents from potentially harmful research participation, it may also be considered an obstacle to the empowerment of children and adolescents in case they want to share their views and experiences directly. This paper argues that evaluation of possible harm should be left to ethics committees and that, if no harm related to the research participation processes is identified and the project has a clear perspective on collaborating with the target group, adolescents from the age of 12 years should be granted the legal capacity to give consent to participate in the research project. Collaboration with adolescents in the development of the research project is encouraged.
- Ethical considerations in engaging young people in European obesity prevention research: The CO‐CREATE experiencePublication . Budin‐Ljøsne, Isabelle; Ayuandini, Sherria; Baillergeau, Evelyne; Bröer, Christian; Helleve, Arnfinn; Klepp, Knut‐Inge; Kysnes, Bjarte; Lien, Nanna; Luszczynska, Aleksandra; Nesrallah, Samantha; Rito, Ana; Rutter, Harry; Samdal, Oddrun; Savona, Natalie; Veltkamp, GerliekeEngaging youth in obesity prevention research and policy action is essential to develop strategies that are relevant and sensitive to their needs. Research with young people requires critical reflection to safeguard their rights, dignity, and wellbeing. The CO-CREATE project used various methods to engage approximately 300 European youth aged 15–19 years in the development of policies to prevent adolescent obesity. This paper discusses ethical considerations made in the project pertaining to the youth's voluntary participation, their protection from obesity stigma, respect for their time, data privacy and confidentiality, power balance, and equality of opportunity to participate in the research. We describe measures implemented to prevent or limit the emergence of ethical challenges in our interaction with youth and discuss their relevance based on our experience with implementation. While some challenges seemingly were prevented, others arose related to the youth's voluntary participation, time burdens on them, and the sustainability of participation under the Covid-19 pandemic. Concrete and ongoing ethical guidance may be useful in projects aiming to interact and build collaborative relationships with youth for long periods of time.
- Identifying the views of adolescents in five European countries on the drivers of obesity using group model buildingPublication . Savona, Natalie; Macauley, Talia; Aguiar, Anaely; Banik, Anna; Boberska, Monika; Brock, Jessica; Brown, Andrew; Hayward, Joshua; Holbæk, Helene; Rito, Ana Isabel; Mendes, Sofia; Vaaheim, Fredrik; van Houten, Marloes; Veltkamp, Gerlieke; Allender, Steven; Rutter, Harry; Knai, CecileBackground: To make effective progress towards a global reduction in obesity prevalence, there needs to be a focus on broader structural factors, beyond individual-level drivers of diet and physical activity. This article describes the use of a systems framework to develop obesity prevention policies with adolescents. The aim of this research was to use the group model building (GMB) method to identify young people's perceptions of the drivers of adolescent obesity in five European countries, as part of the EU-funded Co-Create project. Methods: We used GMB with four groups of 16-18-year-olds in schools in each of the five European countries (The Netherlands, Norway, Poland, Portugal and the UK) to create causal loop diagrams (CLDs) representing their perceptions of the drivers of adolescent obesity. The maps were then merged into one, using a new protocol. Results: Two hundred and fifty-seven participants, aged 16-18 years, engaged in 20 separate system mapping groups, each of which generated 1 CLD. The findings were largely congruent between the countries. Three feedback loops in the merged diagram particularly stand out: commercial drivers of unhealthy diets; mental health and unhealthy diets; social media use, body image and motivation to exercise. Conclusions: GMB provides a novel way of eliciting from young people the system-based drivers of obesity that are relevant to them. Mental health issues, social media use and commercial practices were considered by the young people to be key drivers of adolescent obesity, subjects that have thus far had little or no coverage in research and policy.
- Methodology and implementation of the WHO European Childhood Obesity Surveillance Initiative (COSI)Publication . Breda, João; McColl, Karen; Buoncristiano, Marta; Williams, Julianne; Abdrakhmanova, Shynar; Abdurrahmonova, Zulfiya; Ahrens, Wolfgang; Akhmedova, Dilorom; Bakacs, Márta; Boer, Jolanda M.A.; Boymatova, Khadichamo; Brinduse, Lacramioara Aurelia; Cucu, Alexandra; Duleva, Vesselka; Endevelt, Ronit; Sant'Angelo, Victoria Farrugia; Fijałkowska, Anna; Hadžiomeragić, Aida Filipović; García‐Solano, Marta; Grøholt, Else Karin; Gualtieri, Andrea; Hassapidou, Maria; Hejgaard, Tatjana; Hyska, Jolanda; Kelleher, Cecily C.; Kujundžić, Enisa; Mäki, Päivi; Markidou Ioannidou, Eliza; Melkumova, Marina; Moyersoen, Isabelle; Milanović, Sanja Musić; Nurk, Eha; Ostojic, Sergej M.; Peterkova, Valentina; Petrauskienė, Aušra; Pudule, Iveta; Rito, Ana Isabel; Russell Jonsson, Kenisha; Rutter, Harry; Salanave, Benoît; Seyidov, Nabil; Shengelia, Lela; Silitrari, Natalia; Spinelli, Angela; Spiroski, Igor; Starc, Gregor; Stojisavljević, Dragana; Tanrygulyyeva, Maya; Tichá, Ľubica; Usupova, Zhamilya; Weghuber, Daniel; Yardim, Nazan; Zamrazilová, Hana; Zbanatskyi, Vladyslav; Branca, Francesco; Weber, Martin; Rakovac, IvoEstablishment of the WHO European Childhood Obesity Surveillance Initiative (COSI)has resulted in a surveillance system which provides regular, reliable, timely, andaccurate data on children's weight status—through standardized measurement ofbodyweight and height—in the WHO European Region. Additional data on dietaryintake, physical activity, sedentary behavior, family background, and schoolenvironments are collected in several countries. In total, 45 countries in the EuropeanRegion have participated in COSI. The first five data collection rounds, between 2007and 2021, yielded measured anthropometric data on over 1.3 million children. In COSI,data are collected according to a common protocol, using standardized instrumentsand procedures. The systematic collection and analysis of these data enables inter-country comparisons and reveals differences in the prevalence of childhood thinness,overweight, normal weight, and obesity between and within populations. Furthermore,it facilitates investigation of the relationship between overweight, obesity, and poten-tial risk or protective factors and improves the understanding of the development ofoverweight and obesity in European primary-school children in order to supportappropriate and effective policy responses.
- Parental Perceptions of Children’s Weight Status in 22 Countries: The WHO European Childhood Obesity Surveillance Initiative: COSI 2015/2017Publication . Ramos Salas, Ximena; Buoncristiano, Marta; Williams, Julianne; Kebbe, Maryam; Spinelli, Angela; Nardone, Paola; Rito, Ana; Duleva, Vesselka; Musić Milanović, Sanja; Kunesova, Marie; Braunerová, Radka Taxová; Hejgaard, Tatjana; Rasmussen, Mette; Shengelia, Lela; Abdrakhmanova, Shynar; Abildina, Akbota; Usuopva, Zhamyila; Hyska, Jolanda; Burazeri, Genc; Petrauskiene, Aušra; Pudule, Iveta; Sant’Angelo, Victoria Farrugia; Kujundzic, Enisa; Fijałkowska, Anna; Cucu, Alexandra; Brinduse, Lacramioara Aurelia; Peterkova, Valentina; Bogova, Elena; Gualtieri, Andrea; Solano, Marta García; Gutiérrez-González, Enrique; Rakhmatullaeva, Sanavbar; Tanrygulyyeva, Maya; Yardim, Nazan; Weghuber, Daniel; Mäki, Päivi; Russell Jonsson, Kenisha; Starc, Gregor; Juliusson, Petur Benedikt; Heinen, Mirjam M.; Kelleher, Cecily; Ostojic, Sergej; Popovic, Stevo; Kovacs, Viktoria Anna; Akhmedova, Dilorom; Farpour-Lambert, Nathalie J.; Rutter, Harry; Li, Bai; Boymatova, Khadichamo; Rakovac, Ivo; Wickramasinghe, Kremlin; Breda, JoãoIntroduction: Parents can act as important agents of change and support for healthy childhood growth and development. Studies have found that parents may not be able to accurately perceive their child’s weight status. The purpose of this study was to measure parental perceptions of their child’s weight status and to identify predictors of potential parental misperceptions. Methods: We used data from the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative and 22 countries. Parents were asked to identify their perceptions of their children’s weight status as “underweight,” “normal weight,” “a little overweight,” or “extremely overweight.” We categorized children’s (6–9 years; n = 124,296) body mass index (BMI) as BMI-for-age Z-scores based on the 2007 WHO-recommended growth references. For each country included in the analysis and pooled estimates (country level), we calculated the distribution of children according to the WHO weight status classification, distribution by parental perception of child’s weight status, percentages of accurate, overestimating, or underestimating perceptions, misclassification levels, and predictors of parental misperceptions using a multilevel logistic regression analysis that included only children with overweight (including obesity). Statistical analyses were performed using Stata version 15 1. Results: Overall, 64.1% of parents categorized their child’s weight status accurately relative to the WHO growth charts. However, parents were more likely to underestimate their child’s weight if the child had overweight (82.3%) or obesity (93.8%). Parents were more likely to underestimate their child’s weight if the child was male (adjusted OR [adjOR]: 1.41; 95% confidence intervals [CI]: 1.28–1.55); the parent had a lower educational level (adjOR: 1.41; 95% CI: 1.26–1.57); the father was asked rather than the mother (adjOR: 1.14; 95% CI: 0.98–1.33); and the family lived in a rural area (adjOR: 1.10; 95% CI: 0.99–1.24). Overall, parents’ BMI was not strongly associated with the underestimation of children’s weight status, but there was a stronger association in some countries. Discussion/Conclusion: Our study supplements the current literature on factors that influence parental perceptions of their child’s weight status. Public health interventions aimed at promoting healthy childhood growth and development should consider parents’ knowledge and perceptions, as well as the sociocultural contexts in which children and families live.
- Physical Activity, Screen Time, and Sleep Duration of Children Aged 6-9 Years in 25 Countries: An Analysis within the WHO European Childhood Obesity Surveillance Initiative (COSI) 2015–2017Publication . Whiting, Stephen; Buoncristiano, Marta; Gelius, Peter; Abu-Omar, Karim; Pattison, Mary; Hyska, Jolanda; Duleva, Vesselka; Musić Milanović, Sanja; Zamrazilová, Hana; Hejgaard, Tatjana; Rasmussen, Mette; Nurk, Eha; Shengelia, Lela; Kelleher, Cecily C.; Heinen, Mirjam M.; Spinelli, Angela; Nardone, Paola; Abildina, Akbota; Abdrakhmanova, Shynar; Aitmurzaeva, Gulmira; Usuopva, Zhamyila; Pudule, Iveta; Petrauskiene, Aušra; Sant’Angelo, Victoria Farrugia; Kujundzic, Enisa; Popovic, Stevo; Fismen, Anne-Siri; Bergh, Ingunn Holden; Fijalkowska, Anna; Rito, Ana Isabel; Cucu, Alexandra; Brinduse, Lacramioara Aurelia; Peterkova, Valentina; Gualtieri, Andrea; García-Solano, Marta; Gutiérrez-González, Enrique; Abdurrahmonova, Zulfinissio; Boymatova, Khadichamo; Yardim, Nazan; Tanrygulyyeva, Maya; Weghuber, Daniel; Schindler, Karin; Stojisavljević, Dragana; Filipović Hadžiomeragić, Aida; Markidou Ionnaidu, Eliza; Ahrens, Wolfgang; Hassapidou, Maria; Kovacs, Viktoria Anna; Ostojic, Sergej M.; Ticha, Lubica; Starc, Gregor; Russell Jonsson, Kenisha; Spiroski, Igor; Rutter, Harry; Mendes, Romeu; Williams, Julianne; Rakovac, Ivo; Breda, JoãoBackground: Children are becoming less physically active as opportunities for safe active play, recreational activities, and active transport decrease. At the same time, sedentary screen-based activities both during school and leisure time are increasing. Objectives: This study aimed to evaluate physical activity (PA), screen time, and sleep duration of girls and boys aged 6-9 years in Europe using data from the WHO European Childhood Obesity Surveillance Initiative (COSI). Method: The fourth COSI data collection round was conducted in 2015-2017, using a standardized protocol that included a family form completed by parents with specific questions about their children's PA, screen time, and sleep duration. Results: Nationally representative data from 25 countries was included and information on the PA behaviour, screen time, and sleep duration of 150,651 children was analysed. Pooled analysis showed that: 79.4% were actively playing for >1 h each day, 53.9% were not members of a sport or dancing club, 50.0% walked or cycled to school each day, 60.2% engaged in screen time for <2 h/day, and 84.9% slept for 9-11 h/night. Country-specific analyses of these behaviours showed pronounced differences, with national prevalences in the range of 61.7-98.3% actively playing for >1 h/day, 8.2-85.6% were not members of a sport or dancing club, 17.7-94.0% walked or cycled to school each day, 32.3-80.0% engaged in screen time for <2 h/day, and 50.0-95.8% slept for 9-11 h/night. Conclusions: The prevalence of engagement in PA and the achievement of healthy screen time and sleep duration are heterogenous across the region. Policymakers and other stakeholders, including school administrators and parents, should increase opportunities for young people to participate in daily PA as well as explore solutions to address excessive screen time and short sleep duration to improve the overall physical and mental health and well-being of children.
- Prevalence of overweight and obesity among Portuguese children (6-8 years old) using three definition criteria: COSI PORTUGAL, 2008Publication . Rito, Ana; Wijnhoven, Trudy M.A.; Rutter, Harry; Carvalho, Maria Ana; Paixão, Eleonora; Ramos, Carlos; Cláudio, Débora; Espanca, Rosa; Sancho, Teresa; Cerqueira, Zélia; Carvalho, Rita; Faria, Carmo; Feliciano, Elsa; Breda, JoãoIntroduction: Previous studies places Portugal among the five countries with the highest prevalence of childhood obesity in Europe. This paper describes the prevalence of thinness, overweight and obesity in Portuguese children of 6-8 years of age, based on the first data collection from COSI Portugal, which took place during the 2007/2008 school year. Methods: Semi-longitudinal design with repeated cross-sectional national representative samples. Specific prevalence of overweight (including obesity) and obesity was determined using three different diagnostic criteria. Across the seven geographic regions 3765 children were enrolled from 181 schools with 50.3% of boys. Results: Using the IOTF reference the prevalences of thinness, overweight and obesity were 4.8%, 28.1%, and 8.9% respectively; using the CDC reference they were 2.1%, 32.2%, and 14.6%; and according to the WHO reference they were 1.0%, 37.9%, and 15.3%. Univariate analysis showed a higher risk of obesity in older children, in boys and in the Azores region. The islands of Madeira and the Azores were the regions with the highest prevalence of overweight at 39.4% and 46.6% respectively, and Algarve was the one with the lowest (21.4%). Conclusion:. These findings demonstrate the need for urgent action in Portugal, and provide policy makers with comprehensive and detailed information to assist with this.