Report on the fifth round of data collection, 2018–2020: WHO European Childhood Obesity Surveillance Initiative (COSI)

WHO European Childhood Obesity Surveillance Initiative (COSI) Report on the fifth round of data collection, 2018–2020

WHO European Childhood Obesity Surveillance Initiative (COSI) Report on the fifth round of data collection, 2018–2020 Abstract The WHO Regional Office for Europe established the WHO European Childhood Obesity Surveillance Initiative (COSI) in 2007 in response to the need for standardized surveillance data on the prevalence of overweight and obesity among school-aged children. The availability of such information is essential to develop effective policies and strategies to tackle childhood obesity in the WHO European Region. Since its first round of data collection, which involved 13 countries, COSI has grown dramatically and 45 countries participated in the fifth round, which took place between 2018 and 2020. Of these, 33 countries collected data in the fifth round and, in total, almost 411 000 children aged 6–9 years were measured. In addition, data were collected on school environments and – for countries that used the voluntary family questionnaire – on some dietary habits, physical activity and other health-related behaviours. The systematic collection and analyses of these data allow intercountry comparisons and a better understanding of the progression of childhood overweight and obesity in Europe. Together, they clearly show that childhood obesity remains a major public health problem in the WHO European Region. Keywords EUROPE CHILDREN OBESITY OVERWEIGHT PUBLIC HEALTH SURVEILLANCE NUTRITION WHO/EURO:2022-6594-46360-67071 © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). 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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. This publication contains the report of the fifth round of data collection of the WHO European Childhood Obesity Surveillance Initiative (COSI) and does not necessarily represent the decisions or policies of WHO. Contents Acknowledgements iv Abbreviations x Executive summary xi Introduction 1 1. Overweight and obesity 4 1.1 Overweight 5 1.2 Obesity 8 2. Eating habits 13 2.1 Breakfast consumption 13 2.2 Consumption of fresh fruit and vegetables 15 2.3 Soft drinks consumption 20 3. Physical activity and screen time 24 3.1 Travel to and from school 24 3.2 Time spent practising sports/dancing 27 3.3 Time spent playing actively/vigorously 29 3.4 Time spent watching television or using electronic devices (screen time) 32 Conclusion 35 References  36 Annex 1. Methodology 38 Annex 2. Supplementary data tables 47 iii Acknowledgements This report was made possible through the support and commitment of the Principal Investigators of the WHO European Childhood Obesity Surveillance Initiative (COSI) and their colleagues. Special thanks are also due to the data collectors, school officials, parents/caregivers and children who participated in the survey. The WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office) also wishes to thank the Member States of the WHO European Region for their support, leadership and commitment to this initiative. Overall technical oversight of the initiative was provided by Kremlin Wickramasinghe, Ivo Rakovac and João Breda (WHO Regional Office for Europe, Denmark). The main authors of this report are Marta Buoncristiano and Karen McColl (WHO Regional Office for Europe, Denmark). The NCD Office acknowledges the contribution of the COSI Principal Investigators, who shared data, extensive knowledge, text and comments on the report. All of the Principal Investigators are also coauthors of this document. The NCD Office also sincerely thanks Harry Rutter (University of Bath, United Kingdom) and Wolfgang Ahrens (Leibniz Institute for Prevention Research and Epidemiology, Bremen, Germany; WHO Collaborating Centre for Obesity Prevention, Nutrition and Physical Activity) for overall advice on the design of COSI and its protocol; and Gerben Rienk (Trial Data Solutions, the Netherlands) for data management. Contributors Principal Investigators and collaborators of COSI Collecting data, country-level management, contributing comments to the report, and reviewing the final draft. Albania Jolanda Hyska, Arjan Bregu, Genc Burazeri, Institute of Public Health Armenia Marina Melkumova, Yeva Movsesyan, Arabkir Medical Centre – Institute of Child and Adolescent Health Nune Pashayan, Ministry of Health Austria Daniel Weghuber, Department of Pediatrics, Paracelsus Medical University Karin Schindler, Medical University of Vienna Belgium Laurence Doughan, Federal Public Service of Public Health, Food Security Chain and Environment Machtel Wauters, Flemish Agency for Care and Health iv Bulgaria Vesselka Duleva, Ekaterina Chikova-Iscener, National Center of Public Health and Analyses Croatia Sanja Musić Milanović, University of Zagreb; Croatian Institute of Public Health Helena Krizan, Dora Bukal, Sanja Meštrić, Maja Lang Morović, Croatian Institute of Public Health Cyprus Eliza Markidou Ioannidou, Ministry of Health Czechia Marie Kunešová, Radka Taxová Braunerová, Hana Zamrazilová, Tereza Metelcová, Institute of Endocrinology Bohuslav Procházka, Paediatric Clinic Kutná Hora Denmark Tatjana Hejgaard, Danish Health Authority Lene Kierkegaard, National Institute of Public Health Estonia Eha Nurk, Merike Liivak, Natalja Gluškova, National Institute for Health Development Finland Päivi Mäki, Esko Levälahti, Tiina Laatikainen, Finnish Institute for Health and Welfare France Benoît Salanave, Santé publique France Georgia Lela Shengelia, Lela Sturua, Natia Kakutia, National Center for Disease Control and Public Health of Georgia Germany – City of Bremen Stefan Rach, Ramona Siebels, Claudia Brünings-Kuppe, Leibniz Institute for Prevention Research and Epidemiology – BIPS Wolfgang Ahrens, Leibniz Institute for Prevention Research and Epidemiology – BIPS; University of Bremen Greece Maria Hassapidou, Ioannis Pagkalos, Anna Kokkinopoulou, Department of Nutritional Sciences and Dietetics, International Hellenic University Hungary Viktória Anna Kovács, Marta Bakacs, Edit Feigl, Andrea Horvath, Kitti Susovits, Andrea Zentai, Nikolett Szilfai, Zsuzsa Sepler, National Institute of Pharmacy and Nutrition v Ireland Cecily Kelleher, Lachlan Mitchell, Silvia Bel Serrat, Mirjam Heinen, John Mehegan, Celine Murrin, National Nutrition Surveillance Centre at University College Dublin Israel Ronit Endevelt, Moran Blychfeld Magnazi, Naomi Fliss Isakov, University of Haifa, Ministry of Health Italy Angela Spinelli, Paola Nardone, Michele Antonio Salvatore, National Centre for Disease Prevention and Health Promotion, Italian National Institute of Health [Istituto Superiore di Sanità] (WHO Collaborating Centre on Childhood Obesity) Daniela Galeone, General Directorate of Prevention, Ministry of Health Kazakhstan Shynar Abdrakhmanova, Zhanar Kalmakova, Tatyana Slazhnyova, Assel Adayeva, National Center of Public Health of the Ministry of Health of the Republic of Kazakhstan Kyrgyzstan Zhamyila Usupova, Gulmira Aitmurzaeva, Republican Center for Health Promotion and Mass Communication, Ministry of Health of the Kyrgyz Republic Latvia Iveta Pudule, Biruta Velika, Centre for Disease and Prevention Control Lithuania Ausra Petrauskiene, Justina Vaitkeviciute, Monika Grincaite, Health Research Institute (WHO Collaborating Centre for the Prevention and Control Noncommunicable Diseases), Faculty of Public Health, Lithuanian University of Health Sciences Malta Victoria Farrugia Sant’Angelo, Lorraine Tabone, Primary Health Care Montenegro Enisa Kujundzic, Institute of Public Health of Montenegro Boban Mugosa, Faculty of Medicine, University of Montenegro Netherlands Jolanda Boer, National Institute for Public Health and the Environment (RIVM) Meriam Bouwmeester, Netherlands Centre for Youth Healthcare (NCJ) Paula van Dommelen, Netherlands Organisation for Applied Scientific Research (TNO) The data have been made available by the NCJ and the youth healthcare (JGZ) organizations. vi North Macedonia Igor Spiroski, Institute of Public Health, Faculty of Medicine, Ss. Cyril and Methodius University Norway Anna Biehl, Jørgen Meisfjord, Ragnhild Hovengen, Norwegian Institute of Public Health Poland Anna Fijalkowska, Hanna Nalecz, Anna Dzielska, Institute of Mother and Child Portugal Ana Rito, WHO Collaborating Centre for Nutrition and Childhood Obesity, National Institute of Health Dr Ricardo Jorge Sofia Mendes, Centre for Studies and Research in Social Dynamics and Health (CEIDSS) Maria João Gregório, Directorate General of Health Republic of Moldova Natalia Silitrari, Ion Salaru, National Agency for Public Health Galina Obreja, University of Medicine and Pharmacy Nicolae Testemiteanu Romania Constanta Huidumac-Petrescu, National Institute of Public Health Alexandra Cucu, Lacramioara Brinduse, University of Medicine and Pharmacy Carol Davila Bucharest, National Institute of Public Health Russian Federation – Moscow Valentina Peterkova, Elena Bogova, Institute of Pediatric Endocrinology, National Medical Research Centre for Endocrinology of the Ministry of Health of the Russian Federation Russian Federation – Yekaterinburg Olga Petrovna Kovtun, Elena Anufrieva, Federal State Budget Educational Institution of Higher Education “Ural State Medical University” of the Ministry of Health of the Russian Federation San Marino Andrea Gualtieri, Elena Sacchini, Health Authority Serbia Sergej Ostojic, Visnja Djordjic, Faculty of Sport and Physical Education, University of Novi Sad Slovakia Ľubica Tichá, Pediatric Department, Medical Faculty of Comenius University, National Institute of Children’s Diseases Daniela Kallayová, Department of Public Health, Screening and Prevention, Ministry of Health vii Slovenia Gregor Starc, Faculty of Sport, University of Ljubljana Spain Marta García-Solano, Enrique Gutiérrez-González, Maria Ángeles Dal-Re Saavedra, Spanish Agency for Food Safety and Nutrition – Ministry of Consumer Affairs Sweden Kenisha Russell Jonsson, Anna Jansson, Public Health Agency of Sweden Tajikistan Zulfiya Abdurrahmonova, Republican Centre for Nutrition, Ministry of Health and Social Protection of Population Khadichamo Boymatova, WHO Country Office in Tajikistan Türkiye Nazan Yardim, Public Health General Directorate, Ministry of Health of Türkiye Hilal Ozcebe, Tulay Bagci Bosi, Mahmut S. Yardim, Hacettepe University, Medical Faculty, Public Health Department Turkmenistan Maya Tanrygulyyeva, Scientific Research Institute of Maternal and Child Health Specific technical contributions by colleagues from the WHO Regional Office for Europe NCD Office Mirjam Heinen: technical support and reviewing the report Jelena Jakovljevic: training, support with round 4 data collection Stephen Whiting: technical support of COSI round 5 data collection Julianne Williams: technical support of COSI round 5 data collection, contributed to drafting and reviewing the report viii Data collection in participating countries was carried out with financial support from the following institutions and organizations: Albania: Joint Programme on Children, Food Security and Nutrition “Reducing Malnutrition in Children”, funded by the Millennium Development Goals Achievement Fund, and the Institute of Public Health; Armenia: World Food Programme Country Office, Arabkir Medical Centre – Institute of Child and Adolescent Health; Austria: Federal Ministry of Social Affairs, Health, Care and Consumer Protection, Republic of Austria; Belgium: Flemish Agency for Care and Health; Bulgaria: Ministry of Health, National Center of Public Health and Analyses; Croatia: Ministry of Health and Croatian Institute of Public Health; Cyprus: Ministry of Health Cyprus (Dietetic Department); Czechia: grants AZV MZČR 17-31670 A and MZČR–RVO EÚ 00023761; Denmark: Danish Ministry of Health; Estonia: Ministry of Social Affairs, Ministry of Education and Research (IUT 42-2) and National Institute for Health Development; Finland: Finnish Institute for Health and Welfare; France: Santé publique France, French Public Health Agency; Georgia: National Center for Disease Control and Public Health of Georgia; Germany: partially funded by the Senator for Science, Health, and Consumer Protection of the Free Hanseatic City of Bremen and implemented by the Leibniz Institute for Prevention Research and Epidemiology – BIPS; Greece:  International Hellenic University; Hungary: Ministry of Human Capacities; Ireland: Health Service Executive; Israel: Ministry of Health; Italy: Italian National Institute of Health; Kazakhstan: Ministry of Health of the Republic of Kazakhstan and United Nations Children’s Fund (UNICEF) Kazakhstan; Latvia: Ministry of Health, Centre for Disease Prevention and Control; Lithuania: Science Foundation of Lithuanian University of Health Sciences and Lithuanian Science Council; Malta: Ministry of Health; Montenegro: Institute of Public Health of Montenegro; Netherlands: Ministry of Health, Welfare and Sport; North Macedonia: COSI in North Macedonia is funded by the Government of North Macedonia Ministry of Health, through National Annual Program of Public Health and implemented by the Institute of Public Health and Centers of Public Health in the country; Norway: Ministry of Health and Care Services and Norwegian Institute of Public Health; Poland: National Health Programme, Ministry of Health; Portugal: Ministry of Health Institutions, the National Institute of Health, Directorate General of Health, Regional Health Directorates, and the kind technical support of the Centre for Studies and Research in Social Dynamics and Health (CEIDSS); Republic of Moldova: National Agency for Public Health; Romania: Ministry of Health, National Institute of Public Health; San Marino: Health Ministry, Educational Ministry, Social Security Institute and Health Authority; Slovakia: Ministry of Health and National institute of Children diseases and Office of Public Health of the Slovak Republic; Slovenia: Ministry of Education, Science and Sport of the Republic of Slovenia within the SLOfit surveillance system; Spain: Spanish Agency for Food Safety and Nutrition (AESAN); Servicio Canario de la Salud del Gobierno de Canarias; Instituto Murciano de Investigación Biosanitaria Virgen de la Arrixaca; Departamento de Salud del Gobierno Vasco; Servicio Andaluz de Salud; Consejería de Sanidad del Gobierno de Cantabria; Consejería de Salud del Gobierno de La Rioja; Sweden: Public Health Agency of Sweden; Tajikistan: Ministry of Health and Social Protection of Population; Türkiye: Türkiye Ministry of Health and World Bank; Turkmenistan: Ministry of Health and medical industry of Turkmenistan. ix Abbreviations Country code Country name ALB Albania ARM Armenia AUT Austria BEL Belgium BUL Bulgaria CRO Croatia CYP Cyprus CZH Czechia DEN Denmark EST Estonia FIN Finland FRA France GEO Georgia GER-BR Germany – City of Bremen GRE Greece HUN Hungary IRE Ireland ISR Israel ITA Italy KAZ Kazakhstan KGZ Kyrgyzstan LTU Lithuania Country code Country name LVA Latvia MAT Malta MDA Republic of Moldova MKD North Macedonia MNE Montenegro NET Netherlands NOR Norway POL Poland POR Portugal ROM Romania RUS-MS Russian Federation – Moscow RUS-YK Russian Federation – Yekaterinburg SMR San Marino SPA Spain SRB Serbia SVK Slovakia SVN Slovenia SWE Sweden TJK Tajikistan TKM Turkmenistan TUR Türkiye BMI body mass index CI confidence interval COSI Childhood Obesity Surveillance Initiative IOTF International Obesity Task Force NA not available NCD noncommunicable disease PSU primary sampling unit SDG Sustainable Development Goal SSU secondary sampling unit SU sampling unit Country codes of Member States of the WHO European Region for countries included in the report x Executive summary Overweight and obesity among children remain one of the major public health challenges facing the WHO European Region. As well as affecting a child’s immediate physical and mental health, educational attainment and quality of life, unhealthy bodyweight in early life can increase the risk of obesity and noncommunicable diseases (NCDs) later in life. Tackling obesity – including childhood obesity – is vital for achievement of the Sustainable Development Goals and for implementation of the WHO European Programme of Work 2020–2025 – “United Action for Better Health”. In order to generate reliable and valid country-level data on the prevalence of overweight and obesity among primary school-aged children, the WHO European Childhood Obesity Surveillance Initiative (COSI) was established in 2007. The initiative allows systematic collection of data on the measured weight status of children aged 7–9 years and on dietary intake, physical activity, sedentary behaviour, family background and school environment. COSI has expanded from 13 countries in 2007 to 45 countries by 2020, and the first five rounds of data collection combined have yielded measured anthropometric data on a total of over 1.3 million children. This report presents the main results of the fifth round of COSI, which took place between 2018 and 2020 and for which 33 countries collected data. In total, almost 411 000 children aged 6–9 years were measured. In addition, data were collected on school environments and – for countries that used the voluntary family questionnaire – on some dietary habits, physical activity and other health-related behaviours. For the first time, overall estimates for prevalence of overweight and obesity, in which both genders are combined, have been included. Overall, 29% of children aged 7–9 years in the countries collecting data for COSI round 5 were found to be living with overweight (including obesity – according to WHO definitions). Prevalence was higher among boys (31%) than girls (28%). Overall prevalence of obesity among 7–9-year-old children was 12% and more common in boys (14%) than girls (10%). There continued to be large differences between countries in this round of data collection, with country-specific prevalence of overweight among 7–9-year-old children ranging from 6% in Tajikistan to 43% in Cyprus. Prevalence of obesity among children ranged from 1% in Tajikistan to 19% in Cyprus. When the latest available data for all countries were considered (including data from previous rounds of COSI for countries that did not participate in round 5), the highest prevalence of both overweight and obesity for both genders was observed in Cyprus, Greece and Italy; the lowest prevalence in Tajikistan, Kyrgyzstan and Turkmenistan. Of 42 countries (including two study locations in the Russian Federation), there were only six where the proportion of children aged 7–9 years affected by overweight or obesity was less than one in five. Compared with data from the fourth round of COSI data collection, the only statistically significant differences in prevalence of overweight were a decrease among boys and girls in Malta, a decrease among boys in San Marino and a decrease among girls in Italy. For prevalence of obesity, the only statistically significant changes since the last round of data collection were an increase in prevalence among boys in Georgia, a decrease among girls in Malta and among boys in San Marino, and an increase among both boys and girls in Sweden. xi As with previous COSI data, gender differences in both overweight and obesity continued to be observed in the overall COSI sample and in many countries, with prevalence generally slightly higher among boys. In the 16 countries where data were collected for more than one age group, there was a tendency for the prevalence of overweight to increase with age among boys and girls and the prevalence of obesity to increase with age for boys. Level of parental education (“parent”, in this context, includes the following: (step) mothers, (step) fathers and/or their partners) is one of the variables used by COSI to assess family socioeconomic status. A low level of parental education was associated with higher prevalence of childhood overweight and obesity in most study locations with available data, although a reverse or no relationship was reported in five countries for overweight and in four countries for obesity. These results are broadly in line with previous COSI findings which observed an inverse relationship between the prevalence of childhood overweight/ obesity and parental education in high-income countries and an opposite relationship in middle-income countries. Unhealthy diets are a key driver of overweight, obesity and diet-related NCDs and, globally, are estimated to be responsible for 11 million deaths every year. Given the importance of diet and physical activity as determinants of overweight and obesity, COSI collects data on the frequency of consumption of breakfast, fresh fruit and vegetables – all considered to be important elements of a healthy diet – as well as frequency of soft drinks consumption. Overall, in the 29 study locations that collected data, three quarters (75%) of 6–9-year-olds ate breakfast every day and only 3% never did so. Although only a small proportion of children never ate breakfast, the results suggest that more than one in five children did not always eat or drink anything before going to school. Levels of daily breakfast consumption ranged from 94% in Portugal and Denmark to only 44% in Armenia and 49% in Greece. In most countries, the levels of boys and girls consuming breakfast every day were similar. Children whose parents had a higher level of education were generally more likely to eat breakfast on a daily basis than children of parents with a medium or low level of education. Overall, less than half (43%) of 6–9-year-olds consumed fresh fruit daily in the 27 study locations collecting data. Fruit was consumed less than once a week or not at all by 7% of 6–9-year-olds in these countries. The proportion of children consuming fruit daily was highest in Portugal (63%), Ireland (61%) and Denmark (60%), and lowest in Georgia (23%) and Latvia (27%). Overall, only a third (34%) of children aged 6–9 years ate vegetables daily in the 27 study locations collecting data. More than one in 10 children (11%) aged 6–9 years in these countries never ate vegetables or did so less than once a week. The percentage of children eating vegetables every day varied widely between countries, ranging from 57% in Portugal and Denmark – the only countries where more than half the children ate vegetables every day – to only 13% in Georgia and Spain. In most countries, daily consumption of fresh fruit was slightly more common among girls, while consumption of vegetables was similar in both genders. Eating fruit and vegetables on a daily basis tended to be more common in children of parents with a high level of education than in children of parents with a low level of education. xii Overall, almost a quarter (22%) of 6–9-year-olds consumed soft drinks on more than three days a week in the 28 study locations that collected data. Almost half (49%) never consumed soft drinks or did so less than once a week. The percentage of children consuming soft drinks frequently (more than three days a week) ranged from less than 2% in Greece to 41% in Czechia. In most countries, frequent consumption of soft drinks was similar in boys and girls, or slightly higher in boys; and in all countries, frequent consumption of soft drinks was more common in children of parents with a low level of education than in children of parents with a high level of education. Physical activity has many health benefits and, as a key determinant of energy expenditure, is important for maintaining a healthy weight. Children have become less active as environments and opportunities for safe active play, recreation and transport have decreased. For COSI round 5, key findings are presented for data on travel to and from school and on time spent practising sports/dancing, playing actively/ vigorously, and watching television and using electronic devices. Overall, in the 28 study locations that collected data, only 41% of 6–9-year-old children travelled to and from school actively (on foot, by bicycle, skating or by non-motorized scooter), while 50% travelled by motorized vehicle (car, school bus or public transport). The percentage of children actively travelling to school ranged from 6% in San Marino to 98% in Tajikistan. In line with previous COSI data, children were most likely to actively travel to school in central Asian countries and the Russian Federation (as well as in Germany – City of Bremen). In most countries with data, the percentage actively travelling to school was similar in boys and girls, or slightly higher in boys. In the majority of study locations (21), children of parents with a low level of education were more likely to walk, ride or skate to school than those whose parents had a high level of education. Overall, in the 27 study locations that collected data, more than half (53%) of 6–9-year-old children spent at least two hours a week doing sports or dancing. Four in 10 children (40%) did not spend any time doing sports or dancing. The percentage of children doing sports or dancing for at least two hours a week ranged from 27% in Kazakhstan to 86% in San Marino, which was followed by Ireland (80%) and Greece (77%). In most countries, the percentage of boys practising sports/dancing for at least two hours a week was higher than that of girls, and in all countries the children of parents with a high level of education were more likely to spend at least two hours a week doing sports or dancing than those whose parents had a low level of education. Overall, in the 27 study locations that collected data, a large majority (87%) of 6–9-year-olds spent at least one hour a day on average in active or vigorous play. The figure was slightly lower on weekdays (86%) and markedly higher at weekends (96%). In most countries, the percentage of children spending at least one hour daily in active or vigorous play was very similar in boys and girls, while the relationship between active play and parental education was mixed. The amount of time that children spend watching television or using electronic devices (screen time) increases sedentary behaviour, which has been correlated with a higher energy intake. Overall, in the 27 study locations that collected data, 43% of children aged 6–9 years spent at least two hours a day on average watching television or using electronic devices. At weekends, more than three quarters (76%) xiii of children had two hours or more screen time. In all cases, with the exception of Austria and Russian Federation (Moscow), boys were more likely than girls to have at least two hours a day of screen time. In most study locations, children of parents with a low level of education were more likely to watch television or use electronic devices for at least two hours than children of parents with a high level of education. These reliable and valid data from the fifth round of COSI, encompassing over 400  000 children aged 6–9 years across 33 countries, highlight that childhood overweight and obesity remain a major public health challenge for the countries of the WHO European Region. There continues to be a wide variation between countries in the prevalence of overweight and obesity and of behaviours related to diet and physical activity, and socioeconomic differences persist, pointing to the ongoing need for bold policy action across the European Region. A comprehensive multisectoral approach is needed – one that targets unhealthy environments and their determinants, while strengthening health systems to prevent and manage obesity and overweight more effectively. In this way, countries will be able to halt or reverse the increase in childhood overweight and obesity, thus protecting the future health and well- being of European populations. xiv Introduction Overweight and obesity among children remain one of the major public health challenges facing the WHO European Region. Overweight and obesity increase the risk of noncommunicable diseases (NCDs), such as cardiovascular disease, cancer and diabetes, and are estimated to be responsible for more than 1.2 million deaths across the WHO European Region every year; they are also the leading behavioural factor contributing to disability (1). In addition, excess bodyweight is associated with an increased risk of severe outcomes of COVID-19 (1,2), and the high prevalence of obesity in Europe has exacerbated the impact of the COVID-19 pandemic in the Region. Tackling obesity is vital if we are to achieve the Sustainable Development Goals (SDGs), especially SDG  3 on ensuring healthy lives and promoting well-being, and a commitment to mobilize society for the fight against obesity is included in the WHO European Programme of Work 2020–2025 – “United Action for Better Health” (3). Prevalence of overweight and obesity has increased consistently – across the Region almost 60% of adults are now affected – and no Member State is on track to reach the agreed target of halting the rise in obesity by 2025. Overweight and obesity in children are of particular concern because unhealthy bodyweight in early life not only affects a child’s immediate physical and mental health, educational attainment and quality of life but may also increase the risk of obesity and NCDs later in life (4). Children of all ages are affected, with 8% of children under 5 years of age and one in four children aged 10–19 years living with overweight and obesity in the European Region. In order to generate reliable and valid country-level data on the prevalence of overweight and obesity among primary school-aged children, the WHO Childhood Obesity Surveillance Initiative (COSI) was established in 2007. The initiative established a common protocol which allows systematic collection of data on children’s weight status, by routine and standardized measurement of bodyweight and height of children aged 7–9 years. Additional data on dietary intake, physical activity, sedentary behaviour, family background and school environments are also collected in many countries. COSI is now the largest childhood obesity surveillance initiative in the world, with participation increasing from 13 countries in 2007 to 45 countries in 2020 (Table 1). In total, the first five rounds of data collection have yielded measured anthropometric data on over 1.3 million children (5). Obesity is a complex, multifactorial disease which develops across the life course through the impact of maternal nutrition, unhealthy diet and physical inactivity. Comprehensive, multisectoral policy action is needed to target unhealthy (obesogenic) environments and commercial determinants of poor diet. In order to develop appropriate policy responses, countries need regular and high-quality data on the prevalence of overweight and obesity. Since publication of the first results, COSI data have helped to inform and drive policy action on nutrition and physical activity in the WHO European Region (6,7). In the fourth round of COSI data collection, conducted between 2015 and 2017, overall prevalence of overweight (including obesity) was 29% in boys and 27% in girls in the 36 countries collecting data; at the same time, 12% of boys and 9% of girls were living with obesity (8). Collection of COSI data between 2007 and 2017 allowed trends in the prevalence of overweight and obesity to be examined in 11 European countries (9). In general, the prevalence decreased in countries with high prevalence (Greece, Italy, Portugal, Spain) and in Slovenia, and remained stable or slightly increased in northern and eastern European countries included in the analysis. COSI data have also indicated worryingly high rates of severe obesity among primary schoolchildren in some countries of the Region (10). 1Report on the fifth round of data collection, 2018–2020 Table 1. Expansion of COSI, rounds 1–5, 2007–2020 a Round 1 (2007–2008) Round 2 (2008–2010) Round 3 (2012–2013) Round 4 (2015–2017) Round 5 (2018–2020) 1. Belgium 1. Belgium 1. Belgium 1. Albania 1. Albania 2. Bulgaria 2. Bulgaria 2. Bulgaria 2. Belgium 2. Austria 3. Cyprus 3. Cyprus 3. Cyprus 3. Bulgaria 3. Belgium 4. Czechia 4. Czechia 4. Czechia 4. Cyprus 4. Bulgaria 5. Ireland 5. Ireland 5. Greece 5. Czechia 5. Croatia 6. Italy 6. Italy 6. Hungary 6. Greece 6. Cyprus 7. Latvia 7. Latvia 7. Ireland 7. Hungary 7. Czechia 8. Lithuania 8. Lithuania 8. Italy 8. Ireland 8. Denmark 9. Malta 9. Malta 9. Latvia 9. Italy 9. Estonia 10. Norway 10. Norway 10. Lithuania 10. Latvia 10. Finland 11. Portugal 11. Portugal 11. Malta 11. Lithuania 11. France 12. Slovenia 12. Slovenia 12. North Macedonia 12. Malta 12. Georgia 13. Sweden 13. Sweden 13. Norway 13. North Macedonia 13. Greece 14. Greece 14. Portugal 14. Norway 14. Hungary 15. Hungary 15. Slovenia 15. Portugal 15. Ireland 16. North Macedonia 16. Spain 16. Republic of Moldova b 16. Italy 17. Spain 17. Sweden 17. Romania 17. Kazakhstan 18. Albania 18. San Marino 18. Kyrgyzstan 19. Republic of Moldova 19. Slovenia 19. Latvia 20. Romania 20. Spain 20. Lithuania 21. San Marino 21. Sweden 21. Malta 22. Türkiye 22. Türkiye 22. Montenegro 23. Austria 23. Netherlands 24. Croatia 24. North Macedonia 25. Denmark 25. Norway d 26. Estonia 26. Poland 27. Finland 27. Portugal 28. France 28. Republic of Moldova 29. Georgia 29. Romania 30. Kazakhstan 30. Russian Federation c 31. Kyrgyzstan 31. San Marino 32. Montenegro 32. Serbia 33. Poland 33. Slovakia 34. Russian Federation c 34. Slovenia 35. Serbia 35. Spain 36. Slovakia 36. Sweden 37. Tajikistan 37. Tajikistan 38. Turkmenistan 38. Türkiye 39. Netherlands b 39. Turkmenistan e 40. Armenia 41. Azerbaijan e 42. Bosnia and Herzegovina e 43. Germany f 44. Israel 45. Uzbekistan e a Countries written in red participated in COSI for the first time; only countries written in bold collected data in the relevant COSI round. b Data collected in the Netherlands and the Republic of Moldova were not included in the round 4 report, as they were not available at the time of writing and hence were not included in the calculation of the overall prevalences given in that report. However, national prevalences for the Netherlands and the Republic of Moldova (round 4) are included in Fig. 1 of the current report. c Data were collected only in Moscow (rounds 4 and 5) and Yekaterinburg (round 5). d Data collected in Norway are not included in the current report as they were not available at the time of writing. e Data collection, processing and/or analysis did not take place as a result of disruption caused by the COVID-19 pandemic. f Data were collected only in the City of Bremen. 2 WHO European Childhood Obesity Surveillance Initiative (COSI) This report presents the main results of the fifth round of COSI data collection, conducted between 2018 and 2020; it includes data on prevalence of overweight and obesity, eating habits, physical activity and screen time. Data were collected in 33 countries,1 and almost 411  000 children aged 6–9 years were measured. Thirty participating countries also collected data on school environments, while 28 used the COSI family questionnaire to collect data relating to nutrition and physical activity behaviours. This report focuses on data on prevalence of overweight and obesity, eating habits, physical activity and screen time, and how these vary by country, age, gender and level of parental education.2 A summary, including the main characteristics of the study and sample in each country, is provided in Annex 1. A more detailed description of the methodology has been published elsewhere (5). 1 In most cases, data were collected on nationally representative samples. However, in Germany data collection took place only in the City of Bremen, and in the Russian Federation only in Moscow and Yekaterinburg. It should also be noted that data collection was disrupted by the COVID-19 pandemic and could not take place in several countries. Data collected in Norway are not included in the report because they were not available at the time of writing. 2 Throughout the current report, the terms “parent” and “parental” includes the following: (step) mothers, (step) fathers and/or their partners. 3Report on the fifth round of data collection, 2018–2020 Fig.  1 shows the latest available COSI data on overweight and obesity from all countries; data from previous rounds are included for those countries that did not participate in round 5.3 The prevalence of both overweight and obesity for both genders was highest in Cyprus, Greece and Italy; it was lowest in Tajikistan, Kyrgyzstan and Turkmenistan (round 4 data for the latter two). Of 42 countries (43 study locations), there were only six where the proportion of children aged 7–9 years affected by overweight or obesity was less than one in five. 3 The classification of children’s weight status used in COSI is based on WHO definitions as provided in the 2007 WHO recommended growth reference for school-aged children and adolescents. More details are provided in Annex 1. Unless otherwise indicated, in this report overweight includes obesity. 1. Overweight and obesity a Data from the latest available COSI round were used for each country: round 3 (R3) (2012–2013); round 4 (R4) (2015–2017); or round 5 (R5) (2018–2020). Data relate to: (i) 7-year-olds in Armenia, Belgium (Flanders only), Bulgaria, Czechia, Denmark, Estonia, Finland, Germany (Bremen only), Georgia, Greece, Hungary, Ireland, Israel, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Malta, Montenegro, North Macedonia, Portugal, Republic of Moldova, Romania, Russian Federation (Moscow and Yekaterinburg), Serbia, Slovakia, Slovenia, Spain, Tajikistan, Türkiye and Turkmenistan; (ii) 8-year-olds in Albania, Austria, Croatia, France, Italy, Norway, Poland, San Marino and Sweden; and (iii) 9-year-olds in Cyprus and Netherlands. Fig. 1.A Prevalence of overweight (including obesity – WHO definitions) in boys and girls aged 7–9 years, according to latest available COSI round (%) a CY P- R5 GR E- R5 IT A- R5 SP A- R5 CR O- R5 PO L- R5 SM R- R5 SR B- R5 M AT -R 5 M N E- R5 BU L- R5 M KD -R 5 SW E- R5 GE O- R5 AR M -R 5 HU N -R 5 PO R- R5 FI N -R 5 SV K- R5 GE R- BR -R 5 TU R- R4 ES T- R5 RO M -R 5 AU T- R5 SV N -R 5 LV A- R5 RU S- YK -R 5 FR A- R4 LT U- R5 N ET -R 4 N OR -R 4 RU S- M S- R5 IR E- R5 KA Z- R5 AL B- R4 BE L- R3 CZ H- R5 IS R- R5 M DA -R 4 DE N -R 5 TK M -R 4 KG Z- R4 TJ K- R5 50 40 30 20 10 0 % Boys Girls Fig. 1.B Prevalence of obesity (WHO definitions) in boys and girls aged 7–9 years, according to latest available COSI round (%) a Boys Girls CY P- R5 GR E- R5 IT A- R5 SP A- R5 CR O- R5 PO L- R5 SM R- R5 SR B- R5 M AT -R 5 M N E- R5 BU L- R5 M KD -R 5 SW E- R5 GE O- R5 AR M -R 5 HU N -R 5 PO R- R5 FI N -R 5 SV K- R5 GE R- BR -R 5 TU R- R4 ES T- R5 RO M -R 5 AU T- R5 SV N -R 5 LV A- R5 RU S- YK -R 5 FR A- R4 LT U- R5 N ET -R 4 N OR -R 4 RU S- M S- R5 IR E- R5 KA Z- R5 AL B- R4 BE L- R3 CZ H- R5 IS R- R5 M DA -R 4 DE N -R 5 TK M -R 4 KG Z- R4 TJ K- R5 50 40 30 20 10 0 % 4 WHO European Childhood Obesity Surveillance Initiative (COSI) 1.1 Overweight Overall, in the 33 countries of the WHO European Region that collected data in the fifth round of COSI,4 29% of children aged 7–9 years were living with overweight (including obesity) according to WHO definitions (Fig. 2; Table A2.1). Prevalence among boys in this age group was 31%, while among girls it was 28% (Fig. 3; Table A2.2). As International Obesity Task Force (IOTF) cutoff points are widely used in the WHO European Region, prevalence was also calculated using these cutoffs and is presented in Annex 2. 4 In total, there were 34 study locations, including two in the Russian Federation (Moscow and Yekaterinburg). Fig. 2. Prevalence of overweight (including obesity – WHO definitions) in children aged 7–9 years (%) a a Data relate to: (i)  7-year-olds in Armenia, Bulgaria, Czechia, Denmark, Estonia, Finland, Germany (Bremen), Georgia, Greece, Hungary, Ireland, Israel, Kazakhstan, Latvia, Lithuania, Malta, Montenegro, North Macedonia, Portugal, Romania, Russian Federation (Moscow and Yekaterinburg), Serbia, Slovakia, Slovenia, Spain and Tajikistan; (ii) 8-year-olds in Austria, Croatia, Italy, Poland, San Marino and Sweden; and (iii) 9-year-olds in Cyprus. Fig. 3. Prevalence of overweight (including obesity – WHO definitions) in boys and girls aged 7–9 years (%) and difference between genders (percentage points) a a Differences between genders, measured in percentage points, were calculated by subtracting estimates for girls from estimates for boys. Data relate to: (i) 7-year-olds in Armenia, Bulgaria, Czechia, Denmark, Estonia, Finland, Germany (Bremen only), Georgia, Greece, Hungary, Ireland, Israel, Kazakhstan, Latvia, Lithuania, Malta, Montenegro, North Macedonia, Portugal, Romania, Russian Federation (Moscow and Yekaterinburg), Serbia, Slovakia, Slovenia, Spain and Tajikistan; (ii) 8-year-olds in Austria, Croatia, Italy, Poland, San Marino and Sweden; and (iii) 9-year-olds in Cyprus. CY P GR E SP A IT A CR O SM R M AT PO L M KD SR B SW E M N E PO R BU L HU N FI N GE O AR M SV K RO M ES T GE R- BR AU T LT U SV N IR E LV A RU S- M S RU S- YK CZ H KA Z IS R DE N TJ K CO SI 50 40 30 20 10 0 % Boys Girls CY P +9 SR B +8 PO L +7 KA Z +7 SM R +6 M N E +6 GE O +6 IT A +5 AR M + 5 GE R- BR + 5 GR E +4 CR O +4 M AT + 4 RU S- YK + 4 BU L +3 LV A +3 SV K +2 ES T +2 CZ H +2 TJ K +2 M KD + 1 SW E +1 FI N + 1 AU T +1 SV N + 1 RU S- M S +1 IS R +1 HU N + 0 RO M + 0 LT U +0 IR E +0 SP A -1 DE N -1 PO R -3 CO SI + 3 50 40 30 20 10 0 % 5Report on the fifth round of data collection, 2018–2020 There continue to be large differences between countries, with country-specific prevalence of overweight among children aged 7–9 years ranging from 6% in Tajikistan to 43% in Cyprus. Among boys, prevalence ranged from 7% to 48%; in girls, from 5% to 40%. Highest prevalence of overweight among children (both genders combined) was observed in Cyprus, Greece, Spain and Italy. Prevalence was lowest in Tajikistan (which was notably lower than all others), Denmark, Israel and Kazakhstan. These results appear in line with the north– south gradient previously reported (8) and with analysis of data from the previous round of data collection which found that, on average, children of northern Europe were the tallest, those of Southern Europe had the highest weight and the children living in Central Asia had the lowest weight and were the shortest (11). Previous reports have pointed to a decreasing trend in overweight prevalence in Greece, Italy, Portugal, Spain and Slovenia (8,9). Comparison of round 5 prevalence data with data from the fourth round of COSI data collection, which took place between 2015 and 2017, found that there were no statistically significant increases in prevalence of overweight, although some countries reported slightly higher figures (Fig. 4). Fig. 4. Prevalence of overweight (including obesity – WHO definitions) in boys and girls aged 7–9 years, COSI round 4 (2015–2017) and round 5 (2018–2020) (%) a a Variations between rounds, measured in percentage points, were calculated by subtracting round 4 estimates from round 5 estimates. Data relate to: (i) 7-year-olds in Armenia, Bulgaria, Czechia, Denmark, Estonia, Finland, Germany (Bremen only), Georgia, Greece, Hungary, Ireland, Israel, Kazakhstan, Latvia, Lithuania, Malta, Montenegro, North Macedonia, Portugal, Romania, Russian Federation (Moscow and Yekaterinburg), Serbia, Slovakia, Slovenia, Spain and Tajikistan; (ii) 8-year-olds in Austria, Croatia, Italy, Poland, San Marino and Sweden; and (iii) 9-year-olds in Cyprus. Countries written in bold: statistically significant difference between round 4 and round 5; error bars represent 95% confidence intervals (CI). CY P +4 .9 GE O +4 .9 PO L +4 .2 SW E +4 .2 SR B +2 .7 GR E +1 .9 BU L +1 .8 HU N + 1. 7 SV N + 1. 0 DE N + 0. 8 PO R +0 .6 FI N + 0. 3 LV A +0 .2 CR O -0 .3 M KD -0 .4 CZ H -0 .5 IT A -0 .6 ES T -1 .5 SV K -1 .8 M AT -2 .1 TJ K -2 .7 RU S- M S -3 .1 SM R -3 .3 IR E -3 .3 M N E -3 .5 SP A -3 .8 LT U -3 .9 RO M -4 .3 AU T -4 .8 50 40 30 20 10 0 % Round 4 Round 5Boys CR O +4 .7 IR E +4 .6 GE O +3 .2 AU T +2 .8 SV K +2 .6 GR E +2 .6 LT U +2 .4 SW E +2 .3 HU N + 2. 1 M KD + 1. 9 LV A +1 .9 ES T +1 .7 FI N + 1. 4 CZ H +0 .5 RO M + 0. 3 BU L +0 .3 TJ K +0 .3 RU S- M S +0 .1 PO R +0 .1 PO L -0 .2 M N E -0 .7 SV N -0 .8 DE N -1 .0 SP A -1 .1 SR B -1 .4 SM R -1 .8 IT A -2 .2 M AT -3 .5 CY P -4 .1 50 40 30 20 10 0 % Round 4 Round 5Girls 6 WHO European Childhood Obesity Surveillance Initiative (COSI) There was a statistically significant decrease in prevalence of overweight among boys and girls in Malta, among boys in San Marino, and among girls in Italy, although several locations reported slightly lower figures: Montenegro and Spain for both boys and girls; Austria, Estonia, Ireland, Lithuania, Romania, Russia (Moscow), Slovakia and Tajikistan for boys; Cyprus, Denmark, Italy, Malta, San Marino and Serbia for girls. Previously, most countries have found higher prevalence of overweight in boys than girls (8). Gender differences continued to be observed in the overall COSI sample and in many countries, with prevalence generally slightly higher among boys (Fig. 3). In several countries – Austria, Denmark, Finland, Hungary, Ireland, Israel, Lithuania, North Macedonia, Romania, Russia (Moscow), Slovenia, Spain and Sweden – there was little difference in prevalence between genders. In the 16 countries where data were collected for two or more age groups (6-,7-,8- and 9-year-olds), there was a tendency for the prevalence of overweight (including obesity) to increase with age in both boys and girls (Fig. 5; Table A2.1). Fig. 5. Prevalence of overweight (including obesity – WHO definitions) in boys and girls in countries collecting data for two or more age groups (%) CR O CZ H ES T FI N GR E IS R IT A KA Z LV A PO R RO M SP A SR B SV K SV N SW E 50 40 30 20 10 0 % 9-year-olds8-year-olds7-year-olds6-year-oldsBoys CR O CZ H ES T FI N GR E IS R IT A KA Z LV A PO R RO M SP A SR B SV K SV N SW E 50 40 30 20 10 0 % 9-year-olds8-year-olds7-year-olds6-year-oldsGirls 7Report on the fifth round of data collection, 2018–2020 Level of parental education is one of the variables used by COSI to assess family socioeconomic status. The prevalence of overweight was higher among children whose parents had a low level of education relative to children with high parental education in 23 of the 28 study locations reporting data on parental education status (Fig. 6; Table A2.4). The largest difference in prevalence between low and high level of parental education was 18 percentage points, reported in Germany (Bremen), while the smallest was 2 percentage points (in North Macedonia and Romania). Among these study locations, only in 13 a gradual inverse association was observed. A reverse or no relationship was reported in some countries, including Armenia, Georgia, Kazakhstan, Montenegro, and Serbia. 1.2 Obesity Overall, prevalence of obesity among children aged 7–9 years in the 33 participating countries of the WHO European Region was 12% (Fig. 7; Table A2.1). Prevalence among boys in this age group was 14%, compared to 10% among girls (Fig. 8; Table A2.3). As IOTF cutoff points are widely used in the WHO European Region, prevalence was also calculated using these cutoffs and is presented in Annex 2. Country-specific prevalence of obesity among children ranged from 1% in Tajikistan to 19% in Cyprus. Among boys, prevalence ranged from 2% to 24%, and among girls from 1% to 15%. Prevalence among children (both genders combined) was highest in Cyprus, Italy, Greece and Spain, and lowest in Tajikistan, Denmark, Kazakhstan and Israel. Fig.  6. Prevalence of overweight (including obesity – WHO definitions) in children aged 7–9 years, by level of parental education (low, medium or high) (%) a a Variations, measured in percentage points, were calculated as the difference between the estimate for children with low parental education and the estimate for children with high parental education. All children aged 7–9 years for whom data about parental education and nutritional status were available were included. GE R- BR + 18 AU T +1 6 IR E +1 4 ES T +1 3 SP A +1 3 CZ H +1 2 LT U +1 2 M AT + 12 CR O +1 1 IT A +1 1 PO R +1 1 HU N + 9 RU S- M S +9 RU S- YK + 7 PO L +6 DE N + 4 SM R +4 BU L +3 GR E +3 LV A +3 TJ K +3 M KD + 2 RO M + 2 SR B +0 M N E -3 KA Z- 5 AR M -7 GE O -8 50 40 30 20 10 0 % MediumLow High 8 WHO European Childhood Obesity Surveillance Initiative (COSI) Fig. 7. Prevalence of obesity (WHO definitions) in children aged 7–9 years (%) a a Data relate to: (i)  7-year-olds in Armenia, Bulgaria, Czechia, Denmark, Estonia, Finland, Germany (Bremen), Georgia, Greece, Hungary, Ireland, Israel, Kazakhstan, Latvia, Lithuania, Malta, Montenegro, North Macedonia, Portugal, Romania, Russian Federation (Moscow and Yekaterinburg), Serbia, Slovakia, Slovenia, Spain and Tajikistan; (ii) 8-year-olds in Austria, Croatia, Italy, Poland, San Marino and Sweden; and (iii) 9-year-olds in Cyprus. Fig.  8. Prevalence of obesity (WHO definitions) in boys and girls aged 7–9 years (%) and difference between genders (percentage points) a a Differences between genders, measured in percentage points, were calculated by subtracting estimates for girls from estimates for boys. Data relate to: (i) 7-year-olds in Armenia, Bulgaria, Czechia, Denmark, Estonia, Finland, Germany (Bremen), Georgia, Greece, Hungary, Ireland, Israel, Kazakhstan, Latvia, Lithuania, Malta, Montenegro, North Macedonia, Portugal, Romania, Russian Federation (Moscow and Yekaterinburg), Serbia, Slovakia, Slovenia, Spain and Tajikistan; (ii) 8-year-olds in Austria, Croatia, Italy, Poland, San Marino and Sweden; and (iii) 9-year-olds in Cyprus. CY P IT A GR E SP A M KD M AT CR O HU N BU L PO L M N E AR M PO R SR B SW E RO M GE O FI N SM R SV K GE R- BR ES T LT U AU T SV N LV A CZ H RU S- YK RU S- M S IR E IS R KA Z DE N TJ K CO SI 50 40 30 20 10 0 % CY P +9 PO L +9 GR E +8 IT A +7 CR O +6 M AT + 6 M N E +6 SR B +6 M KD + 5 AR M + 5 GE O +5 RU S- YK + 5 SP A +4 RO M + 4 SW E +4 SM R +4 GE R- BR + 4 AU T +4 BU L +3 HU N + 3 CZ H +3 RU S- M S +3 FI N + 2 ES T +2 LV A +2 SV N + 2 IR E +2 IS R +2 KA Z +2 DE N + 2 PO R +1 SV K +1 TJ K +1 LT U +0 CO SI + 4 50 40 30 20 10 0 % Boys Girls 9Report on the fifth round of data collection, 2018–2020 Decreases in the prevalence of obesity between the first round of COSI (2007–2008) and the fourth round (2015–2017) were observed in Italy, Slovenia, Portugal, Greece and Spain for both boys and girls, and in Ireland, Norway and Bulgaria for girls only (8). Comparison of round 5 obesity prevalence with data from the previous round (2015–2017) found that the only statistically significant changes were an increase in prevalence among boys in Georgia and a decrease among boys in San Marino and girls in Malta (Fig. 9). An increase among boys and girls was observed in Sweden. Prevalence of obesity was higher in boys than girls in all countries except Lithuania, Portugal, Slovakia and Tajikistan, where levels were the same or similar in both genders (Fig. 8). Fig. 9. Prevalence of obesity (WHO definitions) in boys and girls aged 7–9 years, COSI round 4 (2015–2017) and round 5 (2018–2020) (%) a a Variations between rounds, measured in percentage points, were calculated by subtracting round 4 estimates from round 5 estimates. Data relate to: (i) 7-year-olds in Bulgaria, Czechia, Denmark, Estonia, Finland, Georgia, Greece, Hungary, Ireland, Latvia, Lithuania, Malta, Montenegro, North Macedonia, Portugal, Romania, Russian Federation (Moscow), Serbia, Slovakia, Slovenia, Spain and Tajikistan; (ii) 8-year-olds in Austria, Croatia, Italy, Poland, San Marino and Sweden; and (iii) 9-year-olds in Cyprus. Countries written in bold: statistically significant difference between round 4 and round 5; error bars represent 95% CI. SW E +3 .7 GE O +3 .6 PO L +3 .3 CY P +2 .6 DE N + 1. 7 CR O +1 .5 LV A +1 .0 PO R +0 .9 FI N + 0. 9 HU N + 0. 9 GR E +0 .7 M KD + 0. 6 SR B 0. 0 ES T 0. 0 TJ K 0. 0 SV N -0 .2 RU S- M S -0 .3 M AT -0 .5 IT A -0 .5 CZ H -0 .5 BU L -0 .5 IR E -0 .8 SP A -0 .9 SV K -1 .0 AU T -1 .1 RO M -1 .4 LT U -2 .9 M N E -3 .4 SM R -6 .2 50 40 30 20 10 0 % Round 4 Round 5Boys SW E +2 .9 GE O +2 .0 M N E +1 .7 CR O +1 .5 PO R +1 .4 IR E +1 .4 LT U +1 .3 LV A +1 .3 HU N + 1. 1 ES T +1 .1 CZ H +1 .1 FI N + 1. 0 AU T +0 .9 RO M + 0. 8 BU L +0 .6 RU S- M S +0 .5 SM R +0 .2 TJ K -0 .1 SV K -0 .2 IT A -0 .2 DE N -0 .3 M KD -0 .4 SR B -0 .4 SV N -0 .6 GR E -1 .0 PO L -1 .1 SP A -2 .6 M AT -2 .7 CY P -4 .0 50 40 30 20 10 0 % Round 4 Round 5Girls 10 WHO European Childhood Obesity Surveillance Initiative (COSI) In the 16 countries that collected data for more than one age group, prevalence of obesity tended to increase with age among boys (except in Italy and Portugal), but there was no clear pattern for how prevalence changed with age for girls (Fig. 10; Table A2.1). In most of the study locations, the prevalence of obesity was higher among children whose parents had a low level of education relative to children with high parental education, with differences varying from 11 percentages points, reported in Germany (Bremen) and Spain, to 1 percentage point in Montenegro (Fig. 11; Table A2.4). A gradient emerged in 18 study locations where the obesity prevalence decreased with increasing parental education level. A reverse or no relationship was reported in Armenia, Georgia, Kazakhstan and Tajikistan. These results – and those for overweight (Fig. 6) – appear broadly in line with the findings of the previous analysis of COSI data that observed an inverse relationship between the prevalence of childhood overweight/obesity and parental education in high-income countries and an opposite relationship in middle-income countries (12). Fig. 10. Prevalence of obesity (WHO definitions) in boys and girls in countries collecting data for two or more age groups (%) CR O CZ H ES T FI N GR E IS R IT A KA Z LV A PO R RO M SP A SR B SV K SV N SW E 50 40 30 20 10 0 % 9-year-olds8-year-olds7-year-olds6-year-oldsBoys CR O CZ H ES T FI N GR E IS R IT A KA Z LV A PO R RO M SP A SR B SV K SV N SW E 50 40 30 20 10 0 % 9-year-olds8-year-olds7-year-olds6-year-oldsGirls 11Report on the fifth round of data collection, 2018–2020 a Variations, measured in percentage points, were calculated as the difference between the estimate for children with low parental education and the estimate for children with high parental education. All children aged 7–9 years for whom data about parental education and nutritional status were available were included. Fig. 11. Prevalence of obesity (WHO definitions) in children aged 7–9 years, by level of parental education (low, medium or high) (%) a GE R- BR + 11 SP A +1 1 AU T +1 0 CR O +9 GR E +9 IT A +9 CZ H +8 ES T +8 M AT + 8 PO L +8 PO R +8 RU S- M S +8 HU N + 7 LT U +7 SM R +7 BU L +5 IR E +5 RO M + 4 RU S- YK + 4 SR B +4 DE N + 3 LV A +3 M KD + 3 M N E +1 TJ K +0 KA Z -2 GE O -3 AR M -4 50 40 30 20 10 0 % MediumLow High 12 WHO European Childhood Obesity Surveillance Initiative (COSI) 2. Eating habits Unhealthy diets are one of the key drivers of overweight, obesity and diet-related NCDs and, globally, are estimated to be responsible for 8 million deaths every year (13). Given the importance of diet and physical activity as determinants of overweight and obesity, COSI collects data on a relatively small set of eating- related behaviours of children through an additional family questionnaire, which is optional for countries and is completed by parents or caregivers. COSI data have previously found that, overall, less healthy food habits are associated with lower socioeconomic status as assessed by parental education (14). This report focuses on the frequency of consumption of breakfast, fresh fruit and vegetables – all considered to be important elements of a healthy diet – as well as frequency of soft drinks consumption. Data were available on breakfast consumption in 29 study locations, on soft drinks in 28 locations, and on fresh fruit and vegetables in 27 locations. 2.1 Breakfast consumption There is some evidence that skipping breakfast is associated with increased body mass index (BMI) and overweight (15,16,17). Given the importance of regular consumption of breakfast as part of healthy eating, data were collected on the frequency of having breakfast, which are presented, by country, for the healthy habit (daily consumption) versus the less healthy habit (never consumed); and on the level of daily consumption, first by gender and then by parental education level. 2.1.1 Frequency of breakfast consumption Overall, in the 29 study locations that collected data, three quarters (75%) of 6–9-year-olds ate breakfast every day, while only 3% never did so (Fig. 12; Table A2.7). Although only a small proportion of children never ate breakfast (that is, did not consume more than just a drink such as milk or juice), the results suggest that more than one in five children did not always eat or drink anything before going to school. Levels of daily breakfast consumption ranged from 94% in Portugal and Denmark to only 44% in Armenia and 49% in Greece. The proportion of children never eating breakfast was fairly similar across most countries, but was as high as 11% in Armenia, 9% in Greece and Slovakia, and 8% in Malta, Romania and the Russian Federation (Yekaterinburg). 2.1.2 Daily breakfast consumption according to gender In most countries, the levels of daily breakfast consumption were similar in boys and girls, or just slightly lower in girls (Fig. 13; Table A2.8). The greatest differences were observed in Austria (9 percentage points), Russian Federation (Yekaterinburg) (7 percentage points) and Italy (5 percentage points). 13Report on the fifth round of data collection, 2018–2020 Fig. 12. Frequency of breakfast consumption (daily versus never consumed) among 6–9-year-olds (%) Fig.  13. Daily consumption of breakfast among boys and girls aged 6–9 years (%) and difference between genders (percentage points) a a Variations, measured in percentage points, were calculated as the difference between the estimate for boys and the estimate for girls. PO R DE N IR E M N E SR B PO L SM R GE R- BR TJ K ES T RU S- M S M KD BU L KA Z LV A CZ H IT A HU N SP A CR O RU S- YK LT U SV K AU T RO M GE O M AT GR E AR M CO SI 100 80 60 40 20 0 % Daily Never AU T +9 RU S- YK + 7 IT A +5 ES T +4 SP A +4 SV K +4 GR E +3 DE N + 2 LV A +2 M AT + 2 RO M + 2 CZ H +1 GE O +1 GE R- BR + 1 HU N + 1 IR E +1 LT U +1 PO R +1 RU S- M S +1 SR B +1 CR O +0 M KD + 0 M N E +0 PO L +0 KA Z -1 AR M -2 BU L -2 SM R -2 TJ K -2 100 80 60 40 20 0 % Boys Girls 14 WHO European Childhood Obesity Surveillance Initiative (COSI) 2.1.3 Daily breakfast consumption according to parental education Children whose parents had a higher level of education were generally more likely to eat breakfast on a daily basis than children of parents with a medium or low level of education (Fig. 14; Table A2.8). The greatest differences were observed in Lithuania (25 percentage points between low and high levels of parental education), Czechia (20 percentage points), and Austria and San Marino (both 19 percentage points). The gradient was less marked or did not emerge in Denmark, Greece, Kazakhstan, Montenegro, Portugal, Serbia and Tajikistan. 2.2 Consumption of fresh fruit and vegetables Fruit and vegetables are rich sources of essential nutrients and are important components of a healthy diet. Insufficient fruit and vegetable consumption can contribute to energy imbalance and difficulty maintaining a healthy body weight, while promoting fruit and vegetable consumption has been highlighted as important for obesity prevention (4,18). WHO recommends consumption of at least five portions of fruit and vegetables per day for the prevention of NCDs and to help ensure adequate intake of dietary fibre (19). National surveys in most countries indicate that the level of fruit and vegetable consumption in the WHO European Region is still poor (20), and all international Fig. 14. Daily consumption of breakfast among 6–9-year-olds, by level of parental education (low, medium or high) (%) a a Variations, measured in percentage points, were calculated as the difference between the estimate for children with low parental education and the estimate for children with high parental education. LT U -2 5 CZ H -2 0 SM R -1 9 AU T -1 9 RU S- M S -1 8 GE R- BR -1 7 IT A -1 7 SP A -1 7 M AT -1 7 ES T -1 6 LV A -1 5 HU N -1 5 CR O -1 4 RO M -1 4 GE O -1 4 RU S- YK -1 3 AR M -1 1 M KD -1 0 IR E -9 BU L -9 PO L -6 GR E -5 PO R -4 M N E -3 SR B -3 DE N -2 KA Z -2 TJ K -1 100 80 60 40 20 0 % MediumLow High 15Report on the fifth round of data collection, 2018–2020 and national authorities advise plentiful consumption of fruit and vegetables as part of healthy diets. In the last round of COSI data collection (2015–2017), the percentage of children who did not eat fresh fruit or vegetables daily varied widely, ranging from 19% to 82% for fruit and from 26% to 91% for vegetables; and it was higher among children whose parents had a lower level of education (14). For COSI round  5, data were collected separately on frequency of fresh fruit consumption and of vegetable consumption. In both cases, country-specific analyses are presented for the healthy habit (daily consumption) versus the less healthy habit (never or less than once a week). For daily consumption, data are presented by gender and parental education. 2.2.1 Frequency of fresh fruit consumption Overall, less than half (43%) of children aged 6–9 years consumed fresh fruit daily in the 27 study locations that collected data (Fig. 15; Table A2.9). Fruit was never consumed, or consumed less than once a week, by 7% of 6–9-year-old children in these countries. The proportion of children consuming fruit daily was highest in Portugal (63%), Ireland (61%) and Denmark (60%), and lowest in Georgia (23%) and Latvia (27%). The highest levels of children never consuming fresh fruit, or doing so less than once a week, were seen in Malta, Tajikistan and Georgia (14%, 12% and 10%, respectively). Fig. 15. Frequency of fresh fruit consumption (daily versus never or less than once a week) among 6–9-year-olds (%) PO R IR E DE N GE R- BR RU S- M S CZ H SM R M N E RU S- YK AU T IT A M AT TJ K RO M M KD SV K SR B PO L ES T BU L KA Z SP A GR E LT U CR O LV A GE O CO SI 100 80 60 40 20 0 % Daily Never or less than once a week 16 WHO European Childhood Obesity Surveillance Initiative (COSI) 2.2.2 Daily fresh fruit consumption according to gender In most countries, daily fresh fruit consumption was slightly more common among girls than boys, with the greatest difference observed in Greece (9 percentage points), followed by Denmark and Montenegro (both 6 percentage points) (Fig.  16; Table A2.10). In a few countries, however, the reverse was true, with daily consumption higher in boys than girls – notably, in the Russian Federation (Yekaterinburg) (4 percentage points). In five countries, the same or similar values were observed for boys and girls. 2.2.3 Daily fresh fruit consumption according to parental education As with daily breakfast consumption, eating fresh fruit every day appeared to be associated with level of parental education (Fig. 17; Table A2.10). In all countries except Romania, daily consumption of fresh fruit was higher in children of parents with a high level of parental education than in children whose parents had a low level of educational attainment. The greatest differences were observed in Spain (26 percentage points between high and low levels of parental education) and the lowest in North Macedonia (2 percentage points). In 18 countries a gradient was observed where daily fresh fruit consumption gradually increased with increasing levels of parental education. Fig.  16. Daily consumption of fresh fruit among boys and girls aged 6–9 years (%) and difference between genders (percentage points) a a Variations, measured in percentage points, were calculated as the difference between the estimate for boys and the estimate for girls. RU S- YK + 4 M KD + 2 PO R +2 TJ K +2 SM R +0 SP A +0 CZ H -1 ES T -1 IT A -1 CR O -2 GE O -2 GE R- BR -2 IR E -2 KA Z -2 BU L -3 LT U -3 SR B -3 LV A -4 M AT -4 RU S- M S -4 SV K -4 AU T -5 PO L -5 RO M -5 DE N -6 M N E -6 GR E -9 100 80 60 40 20 0 % Boys Girls 17Report on the fifth round of data collection, 2018–2020 2.2.4 Frequency of vegetable consumption Overall, only a third (34%) of children aged 6–9 years ate vegetables daily in the 27 study locations that collected data (Fig. 18; Table A2.11). More than one in 10 children in these countries (11%) never ate vegetables or did so less than once a week. The percentage of children eating vegetables every day varied widely between countries, ranging from 57% in Portugal and Denmark – the only countries where more than half the children ate vegetables every day – to only 13% of children in Georgia and Spain. Malta had by far the highest proportion of children who ate vegetables less than once a week or not at all (32%), followed by Georgia (17%), Greece (16%), Italy (14%), Tajikistan and Kazakhstan (both 13%), and Spain (11%). In most other countries, the percentage of children never eating vegetables, or doing so less than once a week, was below 10%. 2.2.5 Daily vegetable consumption according to gender In most countries, daily vegetable consumption was similar in boys and girls (Fig. 19; Table A2.12). The only appreciable differences were observed in Ireland (where the percentage of girls was 6 percentage points higher than that of boys), Bulgaria (5 percentage points), and Germany (Bremen), Lithuania and North Macedonia (4 percentage points each). Fig. 17. Daily consumption of fresh fruit among 6–9-year-olds, by level of parental education (low, medium or high) (%) a a Variations, measured in percentage points, were calculated as the difference between the estimate for children with low parental education and the estimate for children with high parental education. SP A -2 6 SM R -2 3 PO R -2 2 AU T -2 0 GE R- BR -1 7 CZ H -1 7 IT A -1 7 BU L -1 7 IR E -1 6 M AT -1 4 GR E -1 4 RU S- M S -1 3 SR B -1 3 ES T -1 3 RU S- YK -1 1 KA Z -1 1 LT U -1 1 M N E -1 0 CR O -9 PO L -7 TJ K -6 GE O -6 LV A -5 DE N -3 M KD -2 RO M + 0 100 80 60 40 20 0 % MediumLow High 18 WHO European Childhood Obesity Surveillance Initiative (COSI) Fig. 18. Frequency of vegetable consumption (daily versus never or less than once a week) among 6–9-year-olds (%) Fig.  19. Daily consumption of vegetables among boys and girls aged 6–9 years (%) and difference between genders (percentage points) a a Variations, measured in percentage points, were calculated as the difference between the estimate for boys and the estimate for girls. DE N PO R IR E SM R TJ K GE R- BR RU S- M S RO M SR B CZ H M KD BU L KA Z IT A AU T LT U PO L SV K M N E RU S- YK LV A CR O ES T GR E M AT GE O SP A CO SI 100 80 60 40 20 0 % Daily Never or less than once a week ES T +2 AU T +1 RU S- YK + 1 CR O +1 GR E +1 RU S- M S +0 DE N -1 SM R -1 SR B -1 RO M -1 CZ H -1 SP A -1 PO R -2 TJ K -2 KA Z -2 IT A -2 SV K -2 PO L -2 M N E -2 M AT -2 GE O -2 LV A -3 GE R- BR -4 M KD -4 LT U -4 BU L -5 IR E -6 100 80 60 40 20 0 % Boys Girls 19Report on the fifth round of data collection, 2018–2020 2.2.6 Daily vegetable consumption according to parental education Children of parents with a high level of education more commonly ate vegetables daily than children of parents with low educational attainment in all countries except Georgia (where there was no difference) (Fig. 20; Table A2.12). The largest differences were seen in San Marino (difference of 23 percentage points between high and low parental education), Germany (Bremen) and the lowest in Kazakhstan (only 1 percentage point). A gradient was observed in 18 study locations where the frequency of daily consumption of vegetables gradually increased with increasing levels of parental education. 2.3 Soft drinks consumption Across the WHO European Region, children’s sugar intake is too high, with children commonly consuming more than 10% of their daily calories from added sugars (21), and soft drinks are a major contributor. High intake of sugar-sweetened drinks is associated with a greater risk of weight gain and obesity (22,23) and has a detrimental impact on dental health (24). The last round of COSI data collection (2015–2017) found that the percentage of children consuming sugar-containing soft drinks on more than three days a week ranged from 1% to 45%, and in most countries was higher among children whose parents had a low level of education (14). Fig. 20. Daily consumption of vegetables among 6–9-year-olds, by level of parental education (low, medium or high) (%) a a Variations, measured in percentage points, were calculated as the difference between the estimate for children with low parental education and the estimate for children with high parental education. SM R -2 3 PO R -2 1 GE R- BR -2 1 IT A -1 9 DE N -1 8 IR E -1 8 CZ H -1 8 M AT -1 8 BU L -1 7 PO L -1 6 AU T -1 5 LT U -1 2 CR O -1 0 RU S- M S -9 SP A -9 TJ K -8 SR B -7 GR E -7 ES T -7 M KD -6 M N E -6 RO M -4 LV A -4 RU S- YK -2 KA Z -1 GE O +0 100 80 60 40 20 0 % MediumLow High 20 WHO European Childhood Obesity Surveillance Initiative (COSI) For COSI round 5, data collected on frequency of soft drinks consumption are used to present analyses, by country, for frequency of consumption (more than three  days a week versus never or less than once a week) and for frequent consumption (more than three days a week) by gender and by parental education level. 2.3.1 Frequency of soft drinks consumption Overall, almost a quarter (22%) of children aged 6–9 years consumed soft drinks on more than three days a week in the 28 study locations that collected data (Fig. 21; Table A2.13). Almost half (49%) never consumed soft drinks or did so less than once a week. The percentage of children consuming soft drinks on more than three days a week ranged from less than 2% in Greece to 41% in Czechia. Other countries where more than a third of children reported a similarly high level of soft drinks consumption were North Macedonia (39%), Croatia (38%) and Slovakia (36%). The percentage of children who never consumed soft drinks, or did so less than once a week, ranged from 26% in Czechia to 86% in Greece. Fig. 21. Frequency of soft drinks consumption (more than three days a week versus never or less than once a week) among 6–9-year-olds (%) CZ H M KD CR O SV K KA Z PO L TJ K GE O SR B M N E AR M BU L RU S- M S RU S- YK M AT RO M LV A IT A PO R GE R- BR AU T DE N IR E LT U SM R SP A ES T GR E CO SI 100 80 60 40 20 0 % Never or less than once a week>3 days/week 21Report on the fifth round of data collection, 2018–2020 2.3.2 Frequent consumption of soft drinks according to gender In most countries, frequent consumption of soft drinks (more than three days a week) was similar in boys and girls, or slightly higher in boys (Fig. 22; Table A2.14). The biggest differences were seen in Bulgaria (where 22% of boys consumed soft drinks on more than three days a week, as opposed to 16% of girls), Croatia (41% versus 35%), Georgia (30% versus 26%) and Montenegro (28% versus 24%). 2.3.3 Frequent consumption of soft drinks according to parental education As with consumption of breakfast, fruit and vegetables, there appears to be an association between frequent consumption of soft drinks (more than three days a week) and level of parental education (Fig. 23; Table A2.14). In all countries, frequent consumption of soft drinks was more common in children of parents with a low level of educational attainment than in children of parents with a high level of education. The greatest differences were observed in Croatia (27 percentage points between high and low parental education) and the lowest in Denmark (3 percentage points). Data shows an inverse association between frequent consumption of soft drinks and parental education in 23 study locations. 22 WHO European Childhood Obesity Surveillance Initiative (COSI) Fig. 22. Frequent consumption of soft drinks (more than three days a week) among boys and girls aged 6–9 years (%) and difference between genders (percentage points) a a Variations, measured in percentage points, were calculated as the difference between the estimate for boys and the estimate for girls. Fig. 23. Frequent consumption of soft drinks (more than three days a week) among 6–9-year-olds, by level of parental education (low, medium or high) (%) a a Variations, measured in percentage points, were calculated as the difference between the estimate for children with low parental education and the estimate for children with high parental education. CR O +2 7 BU L +2 3 RO M + 20 CZ H +1 6 PO L +1 5 M N E +1 5 M AT + 15 SR B +1 4 RU S- YK + 13 GE R- BR + 12 PO R +1 0 LV A +1 0 LT U +1 0 M KD + 9 KA Z +9 IT A +9 SM R +8 GE O +8 AU T +7 SP A +6 RU S- M S +6 IR E +6 AR M + 6 ES T +5 GR E +4 DE N + 3 TJ K -4 100 80 60 40 20 0 % MediumLow High CR O +6 BU L +6 GE O +4 M N E +4 M KD + 3 TJ K +3 RO M + 3 PO R +3 IT A +3 GE R- BR + 3 SR B +2 LT U +2 SM R +2 ES T +2 AR M + 1 RU S- M S +1 RU S- YK + 1 M AT + 1 LV A +1 SP A +1 CZ H +0 SV K +0 KA Z +0 AU T +0 DE N + 0 IR E +0 GR E -2 PO L -2 100 80 60 40 20 0 % Boys Girls 23Report on the fifth round of data collection, 2018–2020 3. Physical activity and screen time Physical activity is a foundation of health throughout life, with multiple health benefits for physical and mental health; also, as a key determinant of energy expenditure, it is important for maintaining a healthy weight (25). Physical inactivity contributes to development of NCDs, is responsible for 6% of deaths globally (26), and is among the leading risk factors for death and disability in the WHO European Region (27). In addition, in adults infected with COVID-19, it is associated with a higher risk of severe outcomes (28). Establishing healthy physical activity patterns in childhood helps shape habits throughout adolescence and into adulthood. Physical activity levels remain low in the WHO European Region, with 30% of adults insufficiently active in 2016 and only 25% of 15-year-old boys and 15% of 15-year-old girls achieving the recommended levels of physical activity in 2014 (29). The physical environment – including workplaces, transport systems, neighbourhoods, houses and sports grounds – provide opportunities for participation in physical activity, while schools are a key setting for encouraging physical activity. Opportunities for safe active play, recreation and transport are important. In the fifth round of COSI, data on travel to school were collected in 28 study locations; data on time spent practising sports/dancing or actively playing and on time spent watching television or using electronic devices in 27 locations. These data were analysed by country, gender and level of parental education. 3.1 Travel to and from school Going to and from school on foot or by bicycle can contribute to physical activity. In addition, active travel has important social, environmental and economic benefits, such as reduced carbon emissions and cleaner air (1). Previous COSI data indicated that children in central Asian countries and the Russian Federation and, more generally, those with lower socioeconomic status were more likely to walk or cycle to and from school (8,30). For the fifth round, parents were asked how their child usually travelled to and from school. Data are presented on the healthy behaviour (walking, cycling, skating or non-motorized scooter) and compared with the less healthy behaviour (travel by motorized vehicle). 3.1.1 Proportion of children travelling actively to and from school Overall, in the 28 study locations that collected data, only 41% of 6–9-year-old children travelled to and from school actively (on foot, by bicycle, skating or by non-motorized scooter), while 50% travelled by motorized vehicle (car, school bus or public transport) (Fig. 24; Table A2.15). The percentage of children actively travelling to school ranged from 6% in San Marino to 98% in Tajikistan. More than half of children also actively travelled to school in Germany (Bremen), Kazakhstan, Russian Federation (Moscow and Yekaterinburg), North Macedonia, Armenia, Serbia, Croatia and Georgia. The percentage of children travelling to and from school by motorized vehicle ranged from 2% in Tajikistan to 88% in San Marino. In addition San Marino, more than three quarters of children travelled to school in motorized transport in Portugal (78%) and Malta (77%). In line with previous COSI data, it appeared that children were more likely to actively travel to school in central Asian countries and the Russian Federation (as well as in Germany). 24 WHO European Childhood Obesity Surveillance Initiative (COSI) 3.1.2 Active travel to and from school according to gender In most countries that collected data, the percentages actively travelling to school were similar in boys and girls, or slightly higher among boys (Fig. 25; Table A2.16). Sizeable differences were noted only in Greece (48% in boys versus 39% in girls) and Poland, which was unusual in reporting a higher level in girls (41% in girls versus 36% in boys). 3.1.3 Active travel to and from school according to parental education In the majority of study locations collecting data (20 of 27), children of parents with a low level of education were more likely to walk, ride or skate to school than those whose parents had a high level of education. (Fig. 26; Table A2.16). The largest differences were observed in Armenia (23 percentage points) and the lowest in Tajikistan (3 percentage points). A reverse or no relationship emerged in some countries, such as Austria, Croatia, Denmark, Germany, (Bremen), Italy, Montenegro and Serbia. Fig. 24. Transport to and from school (on foot/cycling/skating versus going by motorized vehicle) among 6–9-year-olds (%) TJ K GE R- BR KA Z RU S- M S RU S- YK M KD AR M SR B CR O GE O SP A RO M BU L GR E AU T PO L HU N DE N ES T M N E SV K LV A LT U IR E IT A M AT PO R SM R CO SI 100 80 60 40 20 0 % On foot/cycling/skating By motorized vehicle 25Report on the fifth round of data collection, 2018–2020 Fig. 25. Percentage of 6–9-year-old boys and girls going to and from school on foot/cycling/skating (%) and difference between genders (percentage points) a Fig. 26. Percentage of 6–9-year-olds going to and from school on foot/cycling/skating, by level of parental education (low, medium or high) (%) a a Variations, measured in percentage points, were calculated as the difference between the estimate for children with low parental education and the estimate for children with high parental education. AR M + 23 RO M + 22 M KD + 21 PO L +2 1 RU S- M S +1 8 LV A +1 5 SP A +1 5 KA Z +1 5 LT U +1 5 RU S- YK + 15 BU L +1 4 HU N + 12 GE O +1 2 GR E +1 2 ES T +1 0 M AT + 8 PO R +7 IR E +7 SM R +5 TJ K +3 M N E +0 CR O +0 IT A -1 SR B -2 AU T -8 GE R- BR -1 4 DE N -1 5 100 80 60 40 20 0 % MediumLow High a Variations, measured in percentage points, were calculated as the difference between the estimate for boys and the estimate for girls. 100 80 60 40 20 0 % GR E +9 RU S- YK + 4 SR B +4 M KD + 2 GE O: + 2 AU T +2 SV K +2 DE N + 2 M N E +2 M AT + 2 TJ K +1 KA Z +1 AR M + 1 RO M + 1 HU N + 1 LT U +1 IT A +1 SM R +1 GE R- BR + 0 CR O +0 SP A +0 ES T +0 LV A +0 IR E +0 BU L -1 PO R -1 RU S- M S -3 PO L -5 Boys Girls 26 WHO European Childhood Obesity Surveillance Initiative (COSI) 3.2 Time spent practising sports/dancing Participation in recreational physical activity – including sports, use of fitness clubs or gyms, dancing and outdoor pursuits – is important to help children meet the recommended level of at least 60 minutes per day of moderate- to vigorous-intensity physical activity (31). Previous COSI data suggested that children of parents with a low level of education were much less likely to spend two hours or more doing sports or dancing per week (30). For the fifth round of data collection, parents were asked how many hours, in a typical week, their child spent on sports and physical activities with sports clubs or on a dancing course. Data are presented for the percentage of children who spent at least two hours a week on sports/dancing and the percentage who never practised sports or dancing. 3.2.1 Proportion of children practising sports/dancing Overall, in the 27 study locations that collected data, more than half (53%) of 6–9-year-old children spent at least two hours a week doing sports or dancing (Fig. 27; Table A2.17). Four in 10 children (40%) did not spend any time doing sports or dancing. The percentage of children doing sports or dancing for at least two  hours a week ranged from 27%  in  Kazakhstan to 86% in San Marino, which was followed by Ireland (80%) and Greece (77%). The percentage of children who never did sports or dancing ranged from 7% in San Marino to 70% in Kazakhstan, which was followed by North Macedonia (60%) and Romania (57%). Fig. 27. Time spent practising sports/dancing (at least two hours a week versus never) among 6–9-year-olds (%) SM R IR E GR E ES T LV A GE R- BR IT A RU S- M S SP A CR O RU S- YK SR B LT U M AT DE N CZ H GE O AU T AR M PO L HU N M N E PO R BU L RO M M KD KA Z CO SI 100 80 60 40 20 0 % At least 2 hours a week Never 27Report on the fifth round of data collection, 2018–2020 3.2.2 Practising sports/dancing at least two hours a week according to gender In most countries, the percentage of boys practising sports/dancing for at least two  hours a week was higher than that of girls (Fig. 28; Table A2.18). The greatest differences were observed in Austria (14 percentage points), North Macedonia (12 percentage points), Portugal (11 percentage points), and Montenegro and Croatia (both 10 percentage points). Only in Greece, Armenia and Bulgaria were the levels slightly higher for girls, while in Hungary, Czechia and Lithuania they were the same. 3.2.3 Practising sports/dancing at least two hours a week according to parental education In all countries that collected data, the children of parents with a high level of education were more likely to spend at least two hours a week doing sports or dancing than those whose parents had a low level of education (Fig. 29; Table A2.18). The differences between were sizeable, reaching 43 percentage points in Bulgaria, 41 in Romania and 40 in North Macedonia. Also, in all countries except San Marino, a clear gradient can be seen, in which the levels are higher in children of parents with a high level of education than in children of parents with a medium level of education, which are, in turn, higher than in children of parents with a low level of education. Fig. 28. Percentage of 6–9-year-old boys and girls spending at least two hours a week practising sports/dancing (%) and difference between genders (percentage points) a a Variations, measured in percentage points, were calculated as the difference between the estimate for boys and the estimate for girls. AU T +1 4 M KD + 12 PO R +1 1 M N E +1 0 CR O +1 0 IT A +9 PO L +8 RU S- YK + 7 SP A +7 DE N + 6 SM R +5 KA Z +4 RO M + 4 LV A +4 M AT + 3 SR B +3 RU S- M S +3 GE R- BR + 3 GE O +2 ES T +2 IR E +2 CZ H +0 LT U +0 HU N + 0 BU L -1 AR M -2 GR E -3 100 80 60 40 20 0 % Boys Girls 28 WHO European Childhood Obesity Surveillance Initiative (COSI) 3.3 Time spent playing actively/vigorously Physically active play can also be an important way for children to meet the recommended level of 60 minutes of moderate or vigorous activity daily. Parents were asked how many hours their child usually spent playing actively or vigorously outside school hours, both on weekdays and at weekends. For the fifth round of COSI, data are presented for the percentage of children usually playing actively/vigorously for at least one hour a day on average, on weekdays and on weekend days. 3.3.1 Proportion of children playing actively/vigorously Overall, in the 27 study locations that collected data, a large majority of 6–9-year-olds (87%) spent at least one hour a day on average in active or vigorous play (Fig. 30; Tables A2.19 and A2.20). The figure was slightly lower on weekdays (86%) and markedly higher at weekends (96%). The percentage of children spending at least one hour a day on average playing actively or vigorously ranged from 65% (Tajikistan) to 96% (Montenegro). After Montenegro, the highest values were seen in Romania, Czechia and Bulgaria (all 95%). Values above 75% were found in the majority of countries. Fig. 29. Percentage of 6–9-year-olds spending at least two hours a week practising sports/dancing, by level of parental education (low, medium or high) (%) a a Variations, measured in percentage points, were calculated as the difference between the estimate for children with low parental education and the estimate for children with high parental education. BU L -4 3 RO M -4 1 M KD -4 0 LT U -3 5 PO R -3 4 RU S- YK -3 4 M N E -3 4 RU S- M S -3 2 SR B -3 1 PO L -3 1 CR O -3 0 HU N -2 7 AR M -2 6 AU T -2 6 LV A -2 5 GE R- BR -2 4 GR E -2 2 M AT -2 0 GE O -1 9 IT A -1 9 KA Z -1 8 CZ H -1 8 SP A -1 8 ES T -1 8 IR E -1 7 DE N -1 0 SM R -2 100 80 60 40 20 0 % MediumLow High 29Report on the fifth round of data collection, 2018–2020 3.3.2 Playing actively/vigorously for at least one hour daily according to gender In most countries, the percentage of children spending at least one hour daily in active or vigorous play was very similar in boys and girls, with a slight tendency for boys to play more than girls (Fig. 31; Table A2.21). In a few countries, the difference was more marked, notably in Greece (where boys were 10 percentage points higher) and Spain (9 percentage points). 3.3.3 Playing actively/vigorously for at least one hour daily according to parental education As in the previous round of COSI data collection (2015–2017), the relationship between active play and parental education was mixed (Fig. 32; Table A2.22). In 19 of the 26 study locations, children of parents with a low level of education were more likely to spend at least one hour in active or vigorous play than those with parents whose level of education was high. The largest difference was observed in Denmark, Estonia and Latvia (all 9 percentage points) and the smallest in Bulgaria, Georgia and Malta (1 percentage point). Among these study locations, only in 10 a gradual inverse association was observed. Conversely, in six locations, children of parents with a high level of education were more likely to spend at least one hour playing actively or vigorously than children of parents with a low level of education and in one country no difference was observed. Fig. 30. Percentage of 6–9-year-olds spending at least one hour a day on average playing actively/vigorously, on weekdays and at weekends (%) a a Time spent per day on average was calculated by weighting weekday hours (5/7) and weekend hours (2/7) spent playing actively/vigorously. M N E RO M CZ H BU L SR B AR M LT U AU T SV K RU S- YK CR O RU S- M S GE O M KD GE R- BR IR E KA Z LV A HU N PO R ES T PO L GR E SP A M AT DE N TJ K CO SI 100 80 60 40 20 0 % On weekdaysOn an average day At weekends 30 WHO European Childhood Obesity Surveillance Initiative (COSI) Fig. 31. Percentage of 6–9-year-old boys and girls spending at least one hour a day playing actively/vigorously (%) and difference between genders (percentage points) a Fig. 32. Percentage of 6–9-year-olds spending at least one hour a day playing actively/vigorously, by level of parental education (low, medium or high) (%) a a Variations, measured in percentage points, were calculated as the difference between the estimate for boys and the estimate for girls. a Variations, measured in percentage points, were calculated as the difference between the estimate for children with low parental education and the estimate for children with high parental education. TJ K -1 3 KA Z -5 M KD -4 RU S- M S -3 M N E -2 IR E -2 CZ H +0 BU L +1 GE O +1 M AT + 1 RO M + 2 SR B +2 AU T +2 SP A +2 AR M + 3 RU S- YK + 3 PO L +3 CR O +4 PO R +4 LT U +6 GE R- BR + 6 GR E +6 HU N + 8 LV A +9 ES T +9 DE N + 9 100 80 60 40 20 0 % MediumLow High GR E +1 0 SP A +9 M KD + 5 PO L +5 TJ K +5 IR E +4 DE N + 4 SR B +3 GE O +3 LV A +3 CZ H +2 AR M + 2 AU T +2 RU S- YK + 2 KA Z +2 M N E +1 SV K +1 CR O +1 GE R- BR + 1 HU N + 1 M AT + 1 RO M + 0 BU L +0 LT U +0 RU S- M S +0 PO R +0 ES T -2 100 80 60 40 20 0 % Boys Girls 31Report on the fifth round of data collection, 2018–2020 3.4 Time spent watching television or using electronic devices (screen time) The amount of time that children spend watching television or using electronic devices (screen time) increases sedentary behaviour, which has been correlated with a higher intake of energy-dense snacks, drinks and fast foods and with an overall higher energy intake (32). In the last round of COSI (2015–2017), children from families of lower socioeconomic status were found to be more likely to have more than two hours of screen time per day (30). For the fifth round, parents were asked how much time their child usually spent watching television or playing with electronic devices, either at home or outside home, on weekdays and at the weekend. Data are presented for the percentage of children spending at least two hours a day on average watching television or using electronic devices, on weekdays and on weekend days. 3.4.1 Proportion of children spending at least two hours a day watching television or using electronic devices Overall, in the 27 study locations that collected data, 43% of children aged 6–9 years spent at least two  hours a day on average watching television or using electronic devices (Fig. 33; Tables A2.22 and A2.23). At weekends, more than three quarters of children (76%) had two hours or more of screen time a day. The percentage of children having at least two  hours of screen time a day on average ranged from 18% (Austria) to 74% (San Marino), which was followed by Italy (72%) and Estonia (64%). At weekends, more than half the children in all study locations had two hours or more of screen time a day on average. 3.4.2 Spending at least two hours a day watching television or using electronic devices according to gender In all cases except Austria and the Russian Federation (Moscow), boys were more likely than girls to have at least two hours of screen time a day (Fig. 34; Table A2.24). The biggest differences were observed in San Marino and Estonia (both with a difference of 12 percentage points between boys and girls), and Italy and Malta (both 10 percentage points). 32 WHO European Childhood Obesity Surveillance Initiative (COSI) Fig. 33. Percentage of 6–9-year-olds spending at least two hours a day on average watching television or using electronic devices, on weekdays and at weekends (%) a a Time spent per day on average was calculated by weighting weekday hours (5/7) and weekend hours (2/7) spent watching television or using electronic devices. Fig. 34. Percentage of 6–9-year-old boys and girls spending at least two hours a day watching television or using electronic devices (%) and difference between genders (percentage points) a a Variations, measured in percentage points, were calculated as the difference between the estimate for boys and the estimate for girls. SM R IT A ES T RO M LV A DE N CR O M N E IR E BU L M AT RU S- YK M KD PO L SR B LT U GE O SV K KA Z CZ H AR M HU N SP A RU S- M S PO R GE R- BR AU T CO SI 100 80 60 40 20 0 % On weekdaysOn an average day At weekends SM R +1 2 ES T +1 2 IT A +1 0 M AT + 10 CR O +7 LT U +7 RO M + 6 DE N + 6 BU L +6 GE O +6 LV A +5 PO L +5 AR M + 5 M N E +4 M KD + 4 CZ H +3 HU N + 3 IR E +2 RU S- YK + 2 SR B +2 SV K +2 KA Z +2 SP A +2 PO R +2 GE R- BR + 2 RU S- M S -1 AU T -1 100 80 60 40 20 0 % Boys Girls 33Report on the fifth round of data collection, 2018–2020 3.4.3 Spending at least two hours a day watching television or using electronic devices according to parental education In 23 study locations, children of parents with a low level of education were more likely to watch television or use electronic devices for at least two hours a day than children of parents with a high level of education, with differences ranging from 28 percentage points, recorded in Hungary, to 4 percentage points in Denmark (Fig. 35; Table A2.24). In most countries, a clear gradient is visible, with the percentage of children having two hours screen time a day decreasing as the parental education level increased. A reverse or no relationship was observed in Georgia, Kazakhstan and North Macedonia. Fig. 35. Percentage of 6–9-year-olds spending at least 2 hours a day watching television or using electronic devices, by level of parental education (low, medium or high) (%) a a Variations, measured in percentage points, were calculated as the difference between the estimate for children with low parental education and the estimate for children with high parental education. HU N + 28 CZ H +2 4 RU S- YK + 20 PO L +2 0 IR E +2 0 GE R- BR + 20 RO M + 18 RU S- M S +1 7 LV A +1 7 BU L +1 7 IT A +1 6 AU T +1 6 M AT + 14 SP A +1 3 SM R +1 3 LT U +1 3 ES T +1 3 CR O +1 1 SR B +1 0 PO R +7 AR M + 6 M N E +5 DE N + 4 GE O +0 M KD -2 KA Z -5 100 80 60 40 20 0 % MediumLow High 34 WHO European Childhood Obesity Surveillance Initiative (COSI) Conclusion Data collected in the fifth round of COSI, conducted between 2018 and 2020 and encompassing over 400 000 children, indicate that, overall, in the 33 participating countries, 29% of children aged 7–9 years were living with overweight (including obesity) and 12% were affected by obesity. Both overweight and obesity tended to be more common in boys than girls and to increase with age. There continued to be large differences between countries, with overall prevalence of overweight ranging from 6% to 43% and of obesity from 1% to 19%. Taking into account all the latest available data, including from previous rounds of COSI for countries that did not participate in the fifth round, there were only six of 42 countries (43 study locations) where the proportion of children aged 7–9 years affected by overweight (including obesity) was less than one in five. There have been very few statistically significant changes in country prevalence of overweight or obesity since the fourth round of data collection in 2015–2017. While it is encouraging that there were only three countries in which significant increases were seen over this period, the stark reality is that nearly one in three children in this age group was living with overweight and one in eight with obesity. It is clear that childhood overweight and obesity remain a major public health challenge in the WHO European Region. Furthermore, there are serious concerns that the COVID-19 pandemic may have further exacerbated this problem. The pandemic – along with its attendant lockdowns, school closures and other mitigation strategies – may have increased unhealthy dietary habits and diminished physical activity levels. The impact of these factors is not yet visible in the COSI round  5 data reported here, which were predominantly collected in 2019. To investigate this issue further – taking advantage of the already established COSI network and methodology – a COSI COVID survey has been launched and will provide robust international data on the impact of COVID-19 on children’s daily routine and behaviours across the WHO European Region. Recognizing that urgent action on this issue is needed, the WHO Regional Director for Europe’s Advisory Council on Innovation for Noncommunicable Diseases included a signature initiative to tackle childhood overweight and obesity (1). The reliable and valid data reported here – based on standardized measurements of children’s height and weight – will contribute to these efforts, both by tracking progress and by informing and driving policy action on nutrition and physical activity. The WHO European regional report on obesity 2022 (1) highlighted the range of evidence-based policy tools available to Member States for the prevention and control of obesity and recommended an approach that addresses the structural drivers of obesity, along with a move away from solely individualist approaches. A comprehensive multisectoral approach is needed – one that targets unhealthy environments and their determinants while strengthening health systems to better prevent and manage obesity and overweight. In this way, countries will be able to halt or reverse the increase in childhood overweight and obesity, thus protecting the future health and well- being of European populations. 35Report on the fifth round of data collection, 2018–2020 References 5 1. WHO European regional obesity report 2022. Copenhagen: WHO Regional Office for Europe; 2022 (https://apps.who.int/ iris/handle/10665/353747). 2. Gao M, Piernas C, Astbury NM, Hippisley-Cox J, O’Rahilly S, Aveyard P et al. Associations between body-mass index and COVID-19 severity in 6.9 million people in England: a prospective, community-based, cohort study. Lancet Diabetes Endocrinol. 2021;9(6):350–9. doi: 10.1016/S2213-8587(21)00089-9. 3. European programme of work, 2020–2025: united action for better health in Europe. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/339209). 4. Report of the commission on ending childhood obesity. Geneva: World Health Organization; 2016 (https://apps.who.int/ iris/handle/10665/204176). 5. Breda J, McColl K, Buoncristiano M, Williams J, Abdrakhmanova Z, Abdurrahmonova Z et al. Methodology and implementation of the WHO childhood obesity surveillance initiative (COSI). Obes Rev. 2021;22(S6):e13215. doi: 10.1111/ obr.13215. 6. Breda J, Farrugia Sant’Angelo V, Duleva V, Galeone D, Heinen M, Kelleher CC et al. Mobilizing governments and society to combat obesity: reflections on how data from the WHO European childhood obesity surveillance initiative are helping to drive policy progress. Obes Rev. 2021;22(S6):e13217. doi: 10.1111/obr.13217. 7. Wickramasinghe K, Chatterjee S, Williams J, Weber MW, Rito AI, Rippin H et al. Childhood overweight and obesity abatement policies in Europe. Obes Rev. 2021;22(S6):e13300. doi: 10.1111/obr.13300. 8. WHO European childhood surveillance initiative: report on the fourth round of data collection 2015–2017. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/341189). 9. Buoncristiano M, Spinelli A, Williams J, Nardone P, Rito AI, Garcia-Solano M et al. Childhood overweight and obesity in Europe: changes from 2007 to 2017. Obes Rev. 2021;22(S6):e13226. doi: 10.1111/obr.13226. 10. Spinelli A, Buoncristiano M, Kovacs VA, Yngve A, Spiroski I, Obreja G et al. Prevalence of severe obesity among primary school children in 21 European countries. Obes Facts. 2019;12(2):244–58. doi: 10.1159/000500436. 11. Spinelli A, Buoncristiano M, Nardone P, Starc G, Hejgaard T, Júlíusson PB et al. Thinness, overweight and obesity in 6- to 9-year-old children from 36 countries: the World Health Organization European childhood obesity surveillance initiative: COSI 2015–2017. Obes Rev. 2021;22(S6):e13214. doi: 10.1111/obr.13214. 12. Buoncristiano M, Williams J, Simmonds P, Nurk E, Ahrens W, Nardone P et al. Socioeconomic inequalities in overweight and obesity among 6- to 9-year-old children in 24 countries from the World Health Organization European Region. Obes Rev. 2021;22(S6):e13213. doi: 10.1111/obr.13213. 13. GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of disease study 2019. Lancet. 2020;396(10258):1223–49. doi: 10.1016/S0140- 6736(20)30752-2. 14. Fismen A-S, Buoncristiano M, Williams J, Helleve A, Abdrakhmanova S, Bakacs M et al. Socioeconomic differences in food habits among 6- to 9-year-old children from 23 countries: WHO European childhood obesity surveillance initiative (COSI 2015/17). Obes Rev. 2021;22(S6):e13211. doi: 10.1111/obr.13211. 15. Van Lippevelde W, Te Velde SJ, Verloigne M, Van Stralen MM, Se Bourdeaudhuij I, Manios Y et al. Associations between family-related factors, breakfast consumption and BMI among 10- to 12-year old European children: the cross- sectional ENERGY-study. PLoS ONE. 2013;8(11):e79550. doi: 10.1371/journal.pone.0079550. 16. Monzani A, Ricotti R, Caputo M, Solito A, Archero F, Bellone S et al. A systematic review of the association of skipping breakfast with weight and cardiometabolic risk factors in children and adolescents. What should we better investigate in the future? Nutrients. 2019;11(2):387. doi: 10.3390/nu11020387. 17. Ma X, Chen Q, Pu Y, Guo M, Jiang Z, Huang W et al. Skipping breakfast is associated with overweight and obesity: a systematic review and meta-analysis. Obes Res Clin Pract. 2020;14(1):1–8. doi: 10.1016/j.orcp.2019.12.002. 5 All references were accessed 26 September 2022 unless otherwise stated. 36 WHO European Childhood Obesity Surveillance Initiative (COSI) 18. Diet, nutrition and the prevention of chronic diseases. Report of a joint WHO/FAO expert consultation. WHO technical report series 916. Geneva: World Health Organization; 2003 (https://apps.who.int/iris/handle/10665/42665). 19. Healthy diet: key facts [fact sheet]. 29 April 2020. Geneva: World Health Organization; 2020 (https://www.who.int/news- room/fact-sheets/detail/healthy-diet). 20. Better food and nutrition in Europe: progress report. Copenhagen: WHO Regional Office for Europe; 2018 (https://apps. who.int/iris/handle/10665/345370). 21. Incentives and disincentives for reducing sugar in manufactured foods: an exploratory supply chain analysis. Copenhagen: WHO Regional Office for Europe; 2017 (https://apps.who.int/iris/handle/10665/345828). 22. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84(2):274–88. doi: 10.1093/ajcn/84.1.274. 23. Luger M, Lafontan M, Bes-Rastrollo M, Winzer E, Yumuk V, Farpour-Lambert N. Sugar-sweetened beverages and weight gain in children and adults: a systematic review from 2013 to 2015 and a comparison with previous studies. Obes Facts. 2017;10:674–93. doi: 10.1159/000484566. 24. Valenzuela MJ, Waterhouse B, Aggarwal VR, Bloor K, Doran T. Effect of sugar-sweetened beverages on oral health: a systematic review and meta-analysis. Eur J Public Health. 2021;31(1):122–9. doi: 10.1093/eurpub/ckaa147. 25. Physical activity strategy for the WHO European Region 2016–2025. Copenhagen: WHO Regional Office for Europe; 2016 (https://apps.who.int/iris/handle/10665/329407). 26. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44203). 27. GBD 2016 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the global burden of disease study 2016. Lancet. 2017;390(10100):1345–1422. doi: 10.1016/S0140-6736(17)32366-8. 28. Sallis R, Young DR, Tartof SY, Sallis JF, Sall J, Li Qiaowu et al. Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients. Br J Sports Med. 2021;55(19):1099–1105. doi: 10.1136/ bjsports-2021-104080. 29. Physical activity: fact sheet on Sustainable Development Goals (‎SDGs)‎: health targets. World Health Organization. Regional Office for Europe; 2019 (https://apps.who.int/iris/handle/10665/340892). 30. Milanović SM, Buoncristiano M, Križan H, Rathmes G, Williams J, Hyska J et al. Socioeconomic disparities in physical activity, sedentary behaviour and sleep patterns among 6- to 9-year-old children from 24 countries in the WHO European Region. Obes Rev. 2021;22(6):e13209. doi: 10.1111/obr.13209. 31. WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization; 2020 (https://apps. who.int/iris/handle/10665/336656). 32. Whiting S, Buoncristiano M, Gelius P, Abu-Omar K, Pattison M, Hyska J et al. 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) 2015–2017. Obes Facts. 2021;14:32–44. doi: 10.1159/000511263. 37Report on the fifth round of data collection, 2018–2020 Annex 1. Methodology Data for the fifth round of the Childhood Obesity Surveillance Initiative (COSI), conducted between 2018 and 2020, were collected according to a common protocol devised by the WHO Regional Office for Europe and Member States. Originally devised in 2007 prior to the first round of data collection, the protocol has been amended slightly for subsequent rounds (1,2). Further details about COSI methodology and data collection procedures are provided elsewhere (3,4). Setting of enrolment Children were enrolled at primary schools in all countries except Czechia and Finland. In Czechia children were selected in paediatric clinics because COSI had been integrated into the mandatory health checks performed by paediatricians. In Finland the data source was the national register for primary health care. Integration of COSI into existing monitored measurement systems also took place in Denmark, Israel, North Macedonia, Slovenia and Sweden. Targeted population and sampling design Participating countries could select one or more of the following four age groups: 6.0–6.9, 7.0–7.9, 8.0–8.9 and 9.0–9.9 years. Thirteen countries targeted only 7-year-olds; five targeted only 8-year-olds; one targeted only 9-year-olds (Cyprus); and 15 targeted more than one age group (Table A1.1). Germany, Israel, Malta, San Marino and Sweden included the entire population of a particular school grade or of particular age groups, whereas all other countries selected a nationally representative sample. In Germany and the Russian Federation, the COSI sample was representative at subnational level as data were collected only in the City of Bremen (Germany) and in Moscow and Yekaterinburg (Russian Federation). Fifteen countries adopted a two-stage cluster sampling design with schools as the primary sampling units (PSUs) and classes as the secondary sampling units (SSUs) (Table A1.2). Ten countries adopted a cluster design with classes, schools, municipalities or paediatric units as sampling units, while a small number of countries adopted a cluster design with more than two stages. Seven countries decided to follow a sentinel approach, in which the same schools were selected and participated in multiple rounds of data collection, but most countries selected a new sample of schools for the fifth round of COSI (Table A1.1). 38 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A1.1. Main characteristics of the study design in each country collecting data in COSI round 5 Country Targeted age group(s) (years) Previous COSI rounds in which country participated a Sentinel approach b Data collection period (month/year) ARM 7 None – 04/2019–05/2019 AUT 8 4 Yes 09/2019–12/2019 BUL 7 1, 3, 4 Yes 04/2019–05/2019 CRO 8 4 No 02/2019–04/2019 CYP 9 4 No 01/2019–05/2019; 09/2019–12/2019 CZH 6, 7 1, 2, 3, 4 No 01/2019–12/2019 DEN 7 4 Yes 08/2019–02/2020 EST 7, 8 4 No 03/2019–06/2019 FIN 7, 8, 9 4 No 09/2019–10/2020 GEO 7 4 No 10/2019–12/2019 GER-BR 8 None – 10/2018–02/2019 GRE 7, 9 2, 3, 4 No 03/2019–06/2019 HUN 7 2, 4 No 09/2019–11/2019 IRE 7 1, 2, 3, 4 Yes 10/2018–02/2019 ISR 6, 7 None – 08/2018–07/2019 ITA 8, 9 1, 2, 3, 4 No 03/2019–05/2019 KAZ 7, 8 4 No 09/2020–12/2020 LTU 7 1, 2, 3, 4 No 04/2019–06/2019 LVA 7, 9 1, 2, 3, 4 No 10/2018–12/2018 MAT 7 1, 2, 3, 4 No 04/2019–06/2019 MKD 7 2, 3, 4 Yes 04/2019–06/2019 MNE 7 4 No 04/2019–06/2019 POL 8 4 No 10/2018–12/2018 POR 6, 7 1, 2, 3, 4 Yes 10/2018–03/2019 ROM 7, 8 3, 4 Yes 05/2019–06/2019 RUS-MS 7 4 No 10/2019–01/2020 RUS-YK 7 None – 02/2020–03/2020; 12/2020 SMR 8 4 No 03/2019 SPA 6, 7, 8, 9 2, 3, 4 No 10/2019–01/2020 SRB 7, 8, 9 4 No 02/2019–04/2019 SVK 7, 8 4 No 11/2018–12/2018 SVN 6, 7, 8, 9 1, 2, 3, 4 No 02/2019–05/2019 SWE 6, 7, 8 1, 4 No Not available TJK 7 4 No 05/2019–06/2019 a COSI round 1: 2007–2008; round 2: 2009–2010; round 3: 2012–2013; round 4: 2015–2017; round 5: 2018–2020. b Countries that participated in a previous round of data collection could choose to select a new sample of schools or follow a sentinel site approach – that is, involving the same schools that were selected previously. 39Report on the fifth round of data collection, 2018–2020 Table A1.2. Main features of the sampling design used in COSI round 5, by country a Country Sampling design Sampling unit (SU) definition Stratification variable ARM Two-stage stratified cluster sampling design PSU: primary schools SSU: 2nd and 3rd grades Region and degree of urbanization AUT Three-stage stratified cluster sampling design PSU: districts SSU: municipalities Tertiary SU: primary schools Federal province BUL Three-stage sampling design PSU: primary schools SSU: 1st grade Tertiary SU: 7-year-olds – CRO Cluster sampling design SU: 2nd and 3rd grades of primary school Region CYP Cluster sampling design SU: 1st and 4th grades of primary school – CZH Stratified cluster sampling design SU: paediatric clinics Region and degree of urbanization DEN Cluster sampling design SU: 2nd grade of primary school Region EST Stratified cluster sampling design SU: 1st grade of primary school County FIN All measurements of targeted children that had been taken in September and October 2017 were extracted from the national register for primary health care SSU: targeted children – GEO Two-stage stratified cluster sampling design PSU: primary schools SSU: 2nd and 3rd grades Region and degree of urbanization GRE Cluster sampling design SU: 2nd and 4th grades of primary school – HUN Two-stage stratified cluster sampling design PSU: primary schools SSU: 1st and 2nd grades County IRE Two-stage stratified cluster sampling design PSU: primary schools SSU: 2nd and 3rd grades Region and degree of urbanization ITA Stratified cluster sampling design SU: 3rd grade of primary school Region KAZ Two-stage cluster sampling design PSU: primary schoolsSSU: 2nd and 3rd grades Region and degree of urbanization LTU Stratified cluster sampling design SU: 1st grade of primary school County LVA Stratified cluster sampling design SU: 1st and 3rd grades of primary school Degree of urbanization andlanguage of instruction MKD Two-stage stratified cluster sampling design PSU: primary schools SSU: 2nd grade Public health authority MNE Two-stage stratified cluster sampling design PSU: primary schools SSU: 1st and 2nd grades Region and degree of urbanization POL Four-stage cluster sampling design PSU: regions SSU: subregions Tertiary SU: schools Quaternary SU: 3rd grade – POR Two-stage stratified cluster sampling design PSU: primary schools SSU: 1st and 2nd grades Region and school size ROM Two-stage stratified cluster sampling design PSU: primary schools SSU: 2nd and 3rd grades County and degree of urbanization RUS-MS Two-stage cluster sampling design PSU: primary schools SSU: 1st grade – RUS-YK Two-stage stratified cluster sampling design PSU: primary schools SSU: 1st grade City neighbourhoods SPA Two-stage stratified cluster sampling design PSU: primary schools SSU: 1st, 2nd, 3rd and 4th grades Region and degree of urbanization SRB Two-stage cluster sampling design PSU: primary schools SSU: 1st, 2nd and 3rd grades – SVK Stratified cluster sampling design SU: 1st, 2nd and 3rd grades of primary school Public health authority SVN Two-stage cluster sampling design PSU: primary schools SSU: 1st, 2nd and 3rd grades – TJK Two-stage stratified cluster sampling design PSU: primary schools SSU: 1st grade Region and degree of urbanization a Germany (Bremen), Israel, Malta, San Marino and Sweden included the entire population of a particular school grade or of particular age groups; they are therefore not included in this table because they did not apply a sampling approach. Dash (–) = not applicable. 40 WHO European Childhood Obesity Surveillance Initiative (COSI) In Finland all measurements performed between 1 September and 31 October 2019 were extracted from the national register for primary health care. In Israel all available measurements taken in the period August 2018–July 2019 were extracted from the national register. In Sweden all regions and municipalities were invited to participate in COSI. This was made possible by the Swedish Education Act, which offers all students health visits during their primary school years. The first visits occur during preschool and are followed by visits in grades 1, 2 and 3. Anthropometric measurements are collected for each child at all visits. Sixteen of 21 Swedish regions agreed to participate and contributed data. Malta and San Marino included the entire population of interest (all children in third-grade primary school classes). In Germany it was planned to include second-grade and third-grade students of all primary schools in the City of Bremen and of two schools in Bremerhaven. As a result of operational constraints that emerged during the fieldwork, it was not possible to include all schools in the City of  Bremen. Nevertheless, all school districts were represented in the final sample. Sample size and participation in the study The protocol specifies that the effective sample size – that is, the effective number of measured children – should be a minimum of 2800 children per target age group (1400 girls and 1400 boys), in order to have 80% power to detect a minimum difference of 0.10 Z-score in mean body mass index (BMI) per year at a two-sided 5% significance level, after adjusting for design effect of 1.2. In order to allow for the number of children not willing to participate in the study and/or not belonging to target age groups, the overall number of children approached should be higher than these minimum numbers. The sample size should be considerably increased in countries wishing to obtain estimates at subnational levels. Among countries that used a sampling approach, the number of children selected to participate in COSI round 5 varied because of differences in study design and sampling strategy: from over 50 000 in Italy (where a subregional representativeness of the estimates was chosen) to around  3200  in  Poland (Table  A1.3). Likewise, the effective sample size differed widely between countries. The number of measured children with complete information in each targeted age group was lowest in Czechia, Germany (Bremen) and Serbia (around 1000). Three countries almost reached the minimum effective sample size and 14 went beyond it. The highest sample sizes were recorded in Israel, Italy and Sweden. Children’s participation in the study was at least 80% of selected children in 13 countries, between 70% and 79% in eight countries, and between 60% and 69% in three countries (Table A1.3). Only in five countries did less than 60% of children take part in the study, with the lowest level recorded in Germany (Bremen) (39.8%). Twenty-seven countries used the family form in the fifth round of COSI (Table A1.3). Parent participation in the initiative was particularly high in Italy, San Marino and Tajikistan, where over 90% of the parents of selected children filled out and returned the family form. Percentages between 70% and 89% were recorded in nine countries, while in five countries parent participation was between 60% and 69%. Participation of parents was particularly low in Austria, Denmark, Germany (Bremen) and Hungary, where only around one in three parents took part in the survey. In Estonia, Greece, Ireland and the Russian Federation (Yekaterinburg) participation was even lower. 41Report on the fifth round of data collection, 2018–2020 Table A1.3. Participation of children and parents in COSI round 5, by country a Country Number of children invited to participate Number of measured children with complete information in each target age group b Total Proportion who participated in measurements (%) Proportion whose family form was filled in (%) 6-year-olds 7-year-olds 8-year-olds 9-year-olds ARM 3971 91.7 52.8 – 2384 – – AUT 5488 45.4 34.7 – – 1526 – BUL 3829 80.1 79.9 – 3068 – – CRO 7113 80.6 79.0 – – 2711 2746 CYP NA NA – – – – 1395 CZH NA NA – 1011 1250 – – DEN 3703 70.4 30.1 – 1841 – – EST 7115 84.9 23.9 – 2946 3096 – FIN NA NA – – 3622 3800 3424 GEO 4413 79.7 80.0 – 2806 – – GER-BR 5701 39.8 37.6 – – 1083 – GRE 6354 65.9 9.7 – 1202 – 1191 HUN 12 032 51.3 34.1 – 3091 – – IRE 7502 56.4 23.0 – 1412 – – ISR NA NA – 101 091 46 194 – – ITA 53 273 93.2 94.5 – – 29 621 16 279 KAZ 9441 72.6 67.8 – 2390 2933 – LTU 5384 60.5 66.9 – 2113 – – LVA 9575 73.4 73.1 – 2768 – 2896 MAT 4478 91.7 69.2 – 2683 – – MKD 3589 89.8 82.4 – 2082 – – MNE 4373 77.1 77.4 – 1652 – – POL 3228 83.4 75.9 – – 2690 – POR 8696 83.2 73.3 3078 3495 – – ROM 14 651 70.9 65.2 – 4111 4055 – RUS-MS 3435 74.6 55.5 – 2081 – – RUS-YK 3772 79.8 23.9 – 2686 – – SMR 348 93.7 96.0 – – 232 – SPA 24 428 68.2 68.2 4085 4280 4461 3839 SRB 4001 80.6 72.2 – 1019 1097 1085 SVK 11 802 50.9 45.4 – 2957 3023 – SVN 15 971 98.7 – 3228 5201 5324 1936 SWE NA NA – 24 504 12 658 19 707 – TJK 3721 92.8 90.5 – 2265 – – a Dash (–) = age group not targeted or family data were not collected; NA = not available. b The reported values include only those children with complete information on gender, age, body weight and height and who belonged to the targeted age group(s). These values are therefore lower than the total number of children who were measured in each country. 42 WHO European Childhood Obesity Surveillance Initiative (COSI) Data collection procedures Data were collected using two record forms. The child record form was filled in by the examiner to register a child’s age in months, gender, date and time of measurement, clothes worn when measured, and anthropometric measurements. The family form was completed by children’s parents or caregivers as a self-administered questionnaire, either on paper or online. It gathered data on simple indicators of children’s dietary intake, physical activity, sedentary behaviour and sleep patterns, as well as data on families’ socioeconomic characteristics and selected health conditions associated with overweight and obesity. Children’s bodyweight and height were measured in a private room at school by trained examiners using standardized procedures. Children were measured wearing normal, light indoor clothing. Countries were required to use the same highly accurate and precise anthropometric instruments. To measure weight, portable electronic (digital) scales calibrated to 0.1 kg (100 g) and measuring up to 150 kg were used. Height was measured in centimetres and the reading taken to the last completed millimetre (0.1 cm); a height board (preferably with a digital counter) mounted at a right angle between a level floor and a straight, vertical surface was used. Data cleaning and analysis Data quality assurance was first applied at the country level based on guidelines specifically developed for COSI data by the WHO Regional Office for Europe. All cleaned datasets were sent to the Regional Office’s COSI team, where they were first reviewed to assess completeness and identify any inconsistencies before being merged for intercountry analyses. Sampling weights were estimated by the WHO Regional Office, which adopted a common approach that considered the sampling design applied in each country (4). These weights were used in all analyses to infer results from sample to population. For Cyprus, the analysis was unweighted. In addition to presenting individual country prevalence for a range of indicators, overall values were estimated by pooling all countries with national representative data available at time of writing. Because of the heterogeneity in the number and type of age group(s) targeted by each country, the overall analysis included only one target age group per country in order to balance the contribution of each country to the pooled estimates and to limit, as much as possible, the differences in children’s age. For the pooled analysis, 7-year-olds were selected if they were targeted; otherwise, the nearest target age group was chosen. In the pooled analysis, an adjusting factor was applied to the sampling weights to take account of differences in population size of the countries involved. The adjusting factor was calculated based on the number of children belonging to the targeted age group according to Eurostat figures or national official statistics for 2019. Minor deviations from national results published elsewhere may occur for the following reasons: (i) data- checking procedures carried out by the WHO Regional Office; (ii) use of sampling weights to calculate estimates; (iii) differences in the inclusion criteria applied in data analysis; and (iv) differences in the way indicators were defined. Prevalence in children of overweight (including obesity), obesity, eating habits, and duration of physical activity and screen time were estimated by child’s gender and by parental education. 43Report on the fifth round of data collection, 2018–2020 Three categories of parental education were then created: (i) low parental education (both parents with lower education); (ii) medium parental education (one parent with lower education, one parent with higher education); and (iii) high parental education (both parents with higher education). We described parents as having lower education if they reported their educational attainment as “primary school or less”, “lower secondary education” or “upper secondary and post-secondary non-tertiary education”. We described parents as having higher education if they reported their educational attainment as “short-cycle tertiary education or bachelor’s or equivalent level” and “master’s or doctoral or equivalent level”. In the case of single-parent families, parental education was defined as low or high based on the single parent’s educational attainment. The classification of children’s weight status was based on the 2007 WHO-recommended growth reference for school-aged children and adolescents (5,6). According to WHO definitions, overweight and obesity are defined as a BMI-for-age value > +1 Z-score and > +2 Z-score, respectively (5). The estimated prevalence of overweight includes children with obesity (7). Children for whom a biologically implausible (or extreme) BMI- for-age value was estimated were excluded from the analysis (values below –5 or above +5 Z-scores relative to the 2007 WHO growth reference median) (6). As International Obesity Task Force (IOTF) cutoff points are widely used in the WHO European Region (8), prevalences were also calculated using these cutoffs and are presented in Annex 2. BMI was calculated using the formula: weight (kg) divided by height squared (m2). The prevalence of overweight and obesity among boys and girls was calculated by age group by country and by pooling data from all countries together. Children who were not in the defined target age groups were excluded from the analysis. Pooled estimates were calculated including the following age groups for each country: (i) 7-year-olds in Armenia, Bulgaria, Czechia, Denmark, Estonia, Finland, Georgia, Greece, Hungary, Ireland, Israel, Kazakhstan, Latvia, Lithuania, Malta, Montenegro, North Macedonia, Portugal, Romania, Serbia, Slovakia, Slovenia, Spain and Tajikistan; (ii) 8-year-olds in Austria, Croatia, Italy, Poland, San Marino and Sweden; and (iii) 9-year-olds in Cyprus. The report also describes country-specific values of overweight and obesity prevalence rates by parental education. As for children’s eating habits, the report focuses on the frequency of breakfast consumption and the frequency of consumption of fresh fruit and vegetables, which are generally considered to be healthy, and of soft drinks containing sugar, which are considered less healthy. Pooled estimates were calculated including only countries with available data on all eating habits; for these countries, the following age groups were used: (i) 7-year-olds in Bulgaria, Czechia, Denmark, Estonia, Georgia, Ireland, Kazakhstan, Latvia, Lithuania, Malta, Montenegro, North Macedonia, Portugal, Romania, Serbia, Spain and Tajikistan; and (ii) 8-year-olds in Austria, Croatia, Italy, Poland and San Marino. With respect to the physical activity and inactivity patterns of children, the report focuses on the following: transport to and from school; time spent practising sports and actively/vigorously playing; and time spent watching television or using electronic devices. The overall analysis for these indicators included the following age groups for each country: (i) 7-year-olds in Armenia, Bulgaria, Denmark, Estonia, Georgia, Ireland, Kazakhstan, Latvia, Lithuania, Malta, Montenegro, North Macedonia, Portugal, Romania, Serbia, Slovakia, Spain and Tajikistan; and (ii) 8-year-olds in Austria, Croatia, Italy, Poland and San Marino. For each of the above behaviours, an indicator of “healthy” or “less healthy” behaviour was defined to facilitate comparisons between countries and according to child’s gender and parents’ educational attainment. The indicators were calculated by aggregating answer options as reported in Table A1.4. Country-specific estimates were calculated including all children aged 6–9 years. Pooled values were estimated including only one age group for each country, as described above. In a few countries, data on some of the indicators were collected in a different way or not at all and were not included in the analysis. 44 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A1.4. Questions and answer options included in the COSI family record form on children’s eating habits, physical activity, screen time, and indicators of healthy and less healthy behaviour Family record form items and related questions Answer options Indicator Countries with no data Frequency of breakfast consumption Over a typical or usual week, how often does your child have breakfast (more than just a beverage e.g. milk, tea or juice)? “every day”; “most days (4–6 days)”; “some days (1–3 days)”; “never” “healthy” behaviour: 7 days = “every day” “less healthy” behaviour: “never” Frequency of fresh fruit, vegetables and soft drinks consumption Over a typical or usual week, how often does your child eat or drink the following kinds of foods or beverages? (i) “fresh fruit”; (ii) “vegetables (including vegetable soup, excluding potatoes)”; (iii) “soft drinks containing sugar” “every day”; “most days (4–6 days)”; “some days (1–3 days)”; “never” “healthy” behaviour for food items (i) and (ii): 7 days = “every day” Armenia, Hungary “less healthy” behaviour for food item (iii): > 3 days/week = “every day” or “most days (4–6 days)” Transport to and from school How does your child usually get to and from school? Please tick one option that he or she uses the most. To school: “Walking”; “Cycling, skating or non- motorized scooter”; “School bus or public transport”; “Private motorized vehicles” “healthy” behaviour: “Walking” or “Cycling, skating or non- motorized scooter” on both occasions (to and from school) Czechia From school: “Walking”; “Cycling, skating or non- motorized scooter”; “School bus or public transport”; “Private motorized vehicles” “less healthy” behaviour: “School bus or public transport” or “Private motorized vehicles” on both occasions (to and from school) Time spent practising sports/dancing Is your child a member of one or more sport clubs or dancing courses (e.g. football, running, hockey, swimming, tennis, basketball, gymnastics, ballet, fitness, ballroom dancing, etc.)? “yes”; “no” “healthy” behaviour: ≥ 2 hours/week = “2 hours a week”, “3 hours a week”; “4 hours a week”; “5 hours a week”; “6 hours a week”; “7 hours a week”; “8 hours a week”; “9 hours a week”; “10 hours a week”; “11 hours a week” Hungary, Slovakia, Tajikistan Over a typical week (including weekends), how many hours does your child spend on sports and physical activities with these sport clubs or dancing courses? “none”; “1 hour a week”; “2 hours a week”; “3 hours a week”; “4 hours a week”; “5 hours a week”; “6 hours a week”; “7 hours a week”; “8 hours a week”; “9 hours a week”; “10 hours a week”; “11 hours a week” “less healthy” behaviour: “none” Time spent playing actively/vigorously Outside school hours, during a normal week, how many hours per day is your child usually playing actively/vigorously (e.g. running, jumping outside or moving and fitness games inside)? Please tick one box for weekdays and one box for weekend. “never”; “less than 1 hour per day”; “about 1 hour per day”; “about 2 hours per day”; “about 3 or more hours per day” “healthy” behaviour: ≥ 1 hours/day a Italy, San Marino Screen time Outside school lessons, how much time does your child usually spend watching television or playing with electronic devices such as computer, tablet, smartphone or other electronic device (not including moving or fitness games), either at home or outside home (e.g. Internet cafes, game centres, etc.)? Please tick one for the weekdays and one for the weekend. “Not at all” “Number of hours and minute per day: Hours: ____ Minutes: ____” “less healthy” behaviour: ≥ 2 hours/day b Greece, Tajikistan a Numerical values are assigned to the items “playing actively/vigorously on a weekday” and “playing actively/vigorously on a weekend day”, allowing conversion of this item to a numerical scale (“never” = 0; “less than 1 hour per day” = 0.5; “about 1 hour per day” = 1; “about 2 hours per day” = 2; “about 3 or more hours per day” = 3). Usual play time per day is calculated weighting weekday hours (5/7) and weekend hours (2/7) accordingly. b Number of hours per day is calculated weighting weekday hours (5/7) and weekend hours (2/7) accordingly. 45Report on the fifth round of data collection, 2018–2020 References to Annex 1 1. Wijnhoven T, van Raaij J, Breda J. WHO European childhood obesity surveillance initiative: implementation of round 1 (2007/2008) and round 2 (2009/2010). Copenhagen: WHO Regional Office for Europe; 2014 (https://apps.who.int/iris/ handle/10665/344687). 2. Childhood obesity surveillance initiative (COSI): protocol: October 2016. Copenhagen: WHO Regional Office for Europe; 2017 (https://apps.who.int/iris/handle/10665/354793). 3. Childhood obesity surveillance initiative (COSI): data collection procedures: October 2016. Copenhagen: WHO Regional Office for Europe; 2017 (https://apps.who.int/iris/handle/10665/354792). 4. Breda J, McColl K, Buoncristiano M, Williams J, Abdrakhmanova Z, Abdurrahmonova Z et al. Methodology and implementation of the WHO childhood obesity surveillance initiative (COSI). Obes Rev. 2021;22(S6):e13215. doi: 10.1111/ obr.13215. 5. de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ. 2007;85:660–7. doi: 10.2471/blt.07.043497. 6. WHO AnthroPlus for personal computers manual: software for assessing growth of the world’s children and adolescents. Geneva: World Health Organization; 2009 (https://cdn.who.int/media/docs/default-source/child-growth/ growth-reference-5-19-years/who-anthroplus-manual.pdf?sfvrsn=ddd24b2_1). 7. Physical status: the use and interpretation of anthropometry. Report of a WHO expert committee. Geneva: World Health Organization; 1995 (https://apps.who.int/iris/handle/10665/37003). 8. Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatr Obes. 2012;7(4):284–94. doi: 10.1111/j.2047-6310.2012.00064.x. 46 WHO European Childhood Obesity Surveillance Initiative (COSI) Annex 2. Supplementary data tables Table  A2.1. Country-specific prevalence and 95% CIs of overweight (including obesity) and obesity according to WHO definitions among 6–9-year-olds, by age (%) a Country 6-year-olds 7-year-olds 8-year-olds 9-year-olds Overweight Obesity Overweight Obesity Overweight Obesity Overweight Obesity ARM 27.5 [24.7–30.5] 12.6 [11.0–14.4] AUT 25.3 [22.0–29.0] 9.1 [7.3–11.3] BUL 30.5 [28.6–32.5] 13.6 [12.3–15.1] CRO 35.0 [33.0–37.0] 14.8 [13.4–16.2] 36.8 [34.8–38.8] 16.7 [15.2–18.2] CYP 43.3 [40.3–46.3] 19.5 [17.1–22.1] CZH 20.0 [17.1–23.2] 8.2 [6.4–10.3] 21.0 [18.1–24.3] 8.5 [6.9–10.5] DEN 18.7 [16.5–21.2] 5.7 [4.8–6.9] EST 26.0 [24.7–27.4] 10.2 [9.3–11.2] 26.9 [25.6–28.2] 11.2 [10.3–12.1] FIN 28.3 [26.9–29.8] 11.2 [10.3–12.3] 31.9 [30.5–33.4] 12.8 [11.8–13.8] 36.6 [35.1–38.2] 16.2 [15.1–17.5] GEO 28.3 [26.3–30.3] 11.6 [10.4–12.9] GER-BR 25.9 [22.2–29.9] 10.3 [8.0–13.1] GRE 42.1 [38.4–46.0] 17.1 [14.5–20.0] 44.7 [40.7–48.7] 18.6 [15.8–21.7] HUN 29.8 [27.9–31.8] 13.7 [12.2–15.3] IRE 24.1 [21.4–27.1] 7.6 [5.9–9.8] ISR 19.7 [19.6–19.9] 6.9 [6.8–7.0] 19.4 [19.1–19.7] 7.1 [6.9–7.3] ITA 38.8 [38.0–39.6] 17.1 [16.6–17.7] 37.4 [36.4–38.4] 15.8 [15.0–16.5] KAZ 20.4 [17.9–23.2] 6.5 [5.2–8.2] 21.1 [18.8–23.7] 7.1 [5.9–8.5] LTU 24.9 [22.6–27.5] 9.2 [7.9–10.7] LVA 23.8 [22.0–25.6] 8.8 [7.8–9.9] 26.8 [25.2–28.5] 5.5 [4.3–7.0] MAT 33.0 [32.5–33.6] 14.9 [14.5–15.3] MKD 31.6 [28.0–35.5] 15.3 [12.8–18.1] MNE 31.1 [28.8–33.4] 13.0 [11.6–14.6] POL 32.3 [30.2–34.5] 13.6 [12.2–15.2] POR 27.7 [25.7–29.9] 10.7 [9.5–12.0] 31.0 [29.3–32.8] 12.5 [11.3–13.9] ROM 26.2 [24.0–28.6] 11.7 [10.5–13.0] 31.7 [30.0–33.6] 14.2 [13.0–15.5] RUS-MS 23.2 [21.2–25.4] 8.4 [7.1–9.9] RUS-YK 22.7 [21.2–24.2] 8.4 [7.2–9.9] SMR 33.2 [32.8–33.6] 11.2 [10.9–11.5] SPA 34.7 [32.2–37.3] 12.9 [11.4–14.4] 38.8 [36.9–40.8] 16.1 [14.7–17.6] 41.7 [39.4–44.1] 19.2 [17.5–21.1] 44.2 [41.7–46.7] 18.7 [16.9–20.7] SRB 31.3 [28.1–34.7] 12.3 [10.5–14.3] 36.2 [32.7–39.7] 15.6 [13.4–18.0] 36.4 [33.9–38.9] 14.3 [12.3–16.5] SVK 27.1 [25.0–29.4] 10.9 [9.4–12.5] SVN 19.0 [17.3–20.8] 6.1 [5.2–7.1] 24.5 [23.1–26.0] 9.1 [8.3–9.9] 29.9 [28.6–31.2] 11.3 [10.4–12.3] 31.9 [29.9–34.0] 12.1 [10.5–13.8] SWE 23.4 [22.8–23.9] 7.5 [7.1–7.8] 31.1 [30.4–31.8] 12.1 [11.6–12.6] 31.1 [30.5–31.8] 12.1 [11.6–12.6] TJK 6.1 [5.0–7.3] 1.4 [0.9–2.0] a Calculated only for the targeted age groups. 47Report on the fifth round of data collection, 2018–2020 Table A2.2. Country-specific prevalence and 95% CIs of overweight (including obesity) according to WHO definitions among 6–9-year-olds, by age and gender (%) a Country 6-year-olds 7-year-olds 8-year-olds 9-year-olds Boys Girls Boys Girls Boys Girls Boys Girls ARM 29.9 [25.7–34.4] 24.7 [22.0–27.6] AUT 25.5 [21.3–30.2] 25.1 [20.5–30.3] BUL 32.0 [29.6–34.6] 28.9 [26.5–31.5] CRO 36.8 [34.1–39.7] 33.2 [30.6–35.8] 39.8 [37.3–42.4] 33.5 [31.0–36.0] CYP 47.9 [43.8–52.0] 39.0 [35.7–42.5] CZH 20.5 [16.4–25.3] 19.5 [16.2–23.2] 22.4 [19.2–25.9] 19.6 [15.8–24.1] DEN 18.4 [16.0–21.1] 19.1 [15.9–22.8] EST 27.1 [25.1–29.2] 25.0 [23.0–27.0] 28.3 [26.6–30.1] 25.2 [23.4–27.1] FIN 28.6 [26.7–30.7] 28.1 [26.0–30.2] 34.4 [32.4–36.4] 29.3 [27.3–31.4] 37.7 [35.6–39.9] 35.5 [33.3–37.9] GEO 31.0 [28.2–33.9] 25.4 [23.1–27.7] GER-BR 28.2 [24.0–32.8] 23.5 [19.5–28.0] GRE 43.9 [39.0–48.9] 40.4 [35.6–45.3] 50.6 [45.5–55.8] 38.9 [33.8–44.4] HUN 29.7 [27.2–32.3] 29.9 [27.4–32.6] IRE 23.8 [20.7–27.3] 24.4 [20.3–29.1] ISR 18.9 [18.7–19.2] 20.6 [20.3–20.9] 19.5 [19.2–19.9] 19.2 [18.8–19.6] ITA 41.3 [40.2–42.4] 36.4 [35.3–37.4] 40.1 [38.7–41.4] 34.4 [33.0–35.8] KAZ 23.6 [20.0–27.5] 17.4 [14.7–20.5] 24.1 [21.2–27.4] 18.1 [15.5–21.2] LTU 24.6 [21.7–27.8] 25.3 [22.5–28.3] LVA 25.0 [23.0–27.0] 22.5 [20.0–25.1] 29.1 [26.8–31.4] 24.4 [21.8–27.1] MAT 34.9 [34.2–35.7] 31.1 [30.4–31.8] MKD 31.8 [28.0–36.0] 31.4 [26.6–36.7] MNE 33.9 [31.0–36.9] 28.1 [25.3–31.0] POL 35.9 [33.1–38.9] 28.6 [25.8–31.5] POR 29.0 [26.4–31.8] 26.5 [23.8–29.3] 29.6 [27.3–32.1] 32.5 [29.8–35.3] ROM 26.3 [23.6–29.2] 26.1 [23.7–28.7] 32.9 [30.6–35.3] 30.5 [28.0–33.1] RUS-MS 23.9 [21.3–26.7] 22.5 [19.8–25.6] RUS-YK 24.8 [22.8–26.9] 20.6 [18.7–22.6] SMR 35.8 [35.3–36.3] 30.4 [29.7–31.1] SPA 34.2 [31.0–37.5] 35.3 [32.1–38.6] 38.4 [36.2–40.7] 39.3 [36.5–42.1] 42.0 [38.9–45.2] 41.4 [38.7–44.2] 46.8 [43.4–50.3] 41.4 [38.4–44.4] SRB 35.3 [30.9–39.9] 27.1 [21.9–33.1] 36.1 [31.6–40.7] 36.2 [32.4–40.3] 39.6 [36.1–43.2] 32.9 [28.8–37.2] SVK 28.3 [25.7–31.2] 25.9 [23.3–28.7] 33.2 [30.1–36.5] 27.4 [24.7–30.3] SVN 20.6 [18.3–23.1] 17.4 [15.5–19.4] 25.3 [23.5–27.2] 23.7 [21.9–25.6] 31.4 [29.8–33.2] 28.2 [26.5–29.9] 33.6 [30.8–36.4] 30.0 [26.8–33.3] SWE 24.3 [23.6–25.1] 22.4 [21.6–23.2] 31.7 [30.8–32.7] 30.5 [29.5–31.6] 31.7 [30.8–32.7] 30.5 [29.6–31.5] TJK 6.7 [5.3–8.4] 5.5 [4.3–7.0] a Calculated only for the targeted age groups. 48 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.3. Country-specific prevalence and 95% CIs of obesity according to WHO definitions among 6–9-year-olds, by age and gender (%) a Country 6-year-olds 7-year-olds 8-year-olds 9-year-olds Boys Girls Boys Girls Boys Girls Boys Girls ARM 15.2 [12.7–18.1] 9.6 [7.8–11.7] AUT 11.3 [8.7–14.5] 7.1 [5.1–9.7] BUL 15.2 [13.3–17.2] 12.0 [10.4–14.0] CRO 17.7 [15.5–20.0] 11.8 [10.2–13.7] 19.7 [17.8–21.8] 13.3 [11.6–15.2] CYP 24.1 [20.6–28.0] 15.3 [12.7–18.1] CZH 8.5 [6.2–11.5] 7.8 [5.4–11.1] 10.4 [8.3–13.0] 6.6 [4.8–8.9] DEN 6.6 [5.0–8.5] 4.8 [3.4–6.8] EST 11.4 [10.1–12.9] 9.0 [7.9–10.3] 13.1 [11.7–14.6] 9.0 [8.0–10.2] FIN 12.4 [11.0–13.9] 10.0 [8.7–11.6] 15.7 [14.2–17.3] 9.7 [8.5–11.1] 19.5 [17.8–21.3] 12.9 [11.4–14.6] GEO 13.9 [11.9–16.1] 9.2 [7.8–10.8] GER-BR 12.3 [9.3–16.2] 8.2 [5.9–11.3] GRE 20.8 [17.2–24.9] 13.3 [10.3–17.1] 25.4 [21.4–29.9] 11.9 [9.2–15.3] HUN 15.0 [13.0–17.2] 12.3 [10.4–14.6] IRE 8.5 [6.3–11.4] 6.7 [4.4–9.8] ISR 7.0 [6.8–7.1] 6.9 [6.7–7.0] 7.8 [7.6–8.1] 6.3 [6.0–6.5] ITA 20.5 [19.7–21.4] 13.8 [13.1–14.5] 19.1 [18.0–20.2] 12.0 [11.0–13.0] KAZ 7.5 [5.6–10.1] 5.5 [4.0–7.6] 9.6 [7.8–11.8] 4.6 [3.5–6.0] LTU 9.3 [7.8–11.1] 9.1 [7.5–11.0] LVA 9.8 [8.3–11.5] 7.8 [6.5–9.3] 11.8 [10.2–13.6] 5.5 [4.3–7.0] MAT 17.5 [16.9–18.1] 12.2 [11.7–12.8] MKD 18.0 [14.7–21.7] 12.5 [9.8–15.9] MNE 15.5 [13.4–18.0] 10.4 [8.5–12.5] POL 17.6 [15.2–20.2] 9.4 [7.6–11.5] POR 12.6 [10.8–14.5] 8.8 [7.3–10.7] 12.9 [11.3–14.8] 12.1 [10.4–14.1] ROM 13.7 [12.1–15.3] 9.6 [8.4–11.0] 17.3 [15.3–19.4] 10.9 [9.3–12.7] RUS-MS 9.9 [8.1–12.0] 7.0 [5.7–8.5] RUS-YK 10.8 [9.0–12.8] 6.2 [4.9–7.7] SMR 13.3 [12.9–13.8] 8.9 [8.5–9.4] SPA 13.6 [11.8–15.7] 12.1 [10.3–14.1] 17.8 [16.0–19.8] 14.2 [12.5–16.1] 21.1 [18.6–23.7] 17.2 [15.4–19.3] 21.7 [19.2–24.5] 15.5 [13.3–18] SRB 15.0 [12.4–18.2] 9.3 [6.7–12.8] 17.7 [14.7–21.2] 13.3 [10.8–16.2] 19.4 [16.1–23.1] 8.8 [6.4–12.1] SVK 11.4 [9.5–13.7] 10.3 [8.4–12.6] 16.8 [14.1–20.0] 9.0 [7.3–11.1] SVN 7.9 [6.5–9.5] 4.4 [3.5–5.4] 10.3 [9.2–11.4] 7.8 [6.8–9.0] 12.8 [11.6–14.1] 9.8 [8.7–11.0] 15.2 [13.0–17.7] 8.3 [6.6–10.3] SWE 8.4 [7.9–8.9] 6.5 [6.1–7.0] 11.7 [11.0–12.5] 9.4 [8.7–10.2] 14.1 [13.4–14.9] 10.0 [9.3–10.6] TJK 1.8 [1.1–2.8] 1.0 [0.5–1.9] a Calculated only for the targeted age groups. 49Report on the fifth round of data collection, 2018–2020 Table  A2.4. Country-specific prevalence and 95% CIs of overweight (including obesity) and obesity according to WHO definitions among children aged 6–9, by parental education (%) Country Overweight (including obesity) Obesity Low parental education Medium parental education High parental education Low parental education Medium parental education High parental education ARM 22.6 [19.4–26.2] 28.7 [24.7–33.2] 30.0 [24.7–35.9] 11.0 [8.8–13.8] 14.0 [10.4–18.5] 15.4 [11.8–19.9] AUT 31.5 [28.4–34.7] 19.7 [14.9–25.5] 15.3 [11.2–20.5] 14.2 [11.5–17.3] 4.2 [2.4–7.3] 4.4 [2.5–7.8] BUL 31.4 [28.7–34.2] 30.7 [26.8–34.9] 27.8 [24.4–31.5] 15.4 [13.5–17.5] 12.7 [10.1–16.0] 10.4 [8.3–13.0] CRO 38.8 [36.9–40.7] 34.3 [31.6–37.2] 28.3 [25.7–31.1] 18.6 [17.2–20.1] 13.2 [11.1–15.6] 9.7 [8.1–11.5] CZH 24.6 [21.8–27.6] 17.7 [14.1–22.1] 13.3 [10.9–16.2] 11.5 [9.9–13.2] 5.7 [4.2–7.6] 3.3 [2.0–5.3] DEN 18.2 [14.3–22.8] 12.5 [8.6–17.8] 13.7 [10.1–18.2] 5.1 [3.3–7.8] 1.2 [0.4–3.8] 1.7 [0.6–4.7] EST 31.9 [28.4–35.6] 25.1 [22.2–28.2] 19.1 [16.6–22.0] 15.4 [12.9–18.2] 9.4 [7.5–11.7] 6.8 [5.4–8.6] GEO 24.8 [22.7–27.1] 34.8 [30.1–39.9] 33.0 [29.9–36.3] 10.4 [9.0–12.1] 15.5 [12.3–19.3] 13.4 [11.4–15.7] GER-BR 32.3 [28.8–36.0] 21.0 [17.5–25.0] 14.1 [11.5–17.2] 13.2 [11.1–15.8] 7.3 [5.1–10.5] 2.1 [1.1–3.7] GRE 41.7 [33.3–50.6] 50.6 [39.1–62.1] 39.4 [32.5–46.7] 21.5 [15.3–29.4] 31.9 [22.2–43.5] 13.3 [7.9–21.6] HUN 32.9 [30.4–35.6] 27.8 [24.3–31.6] 24.4 [20.9–28.1] 16.7 [14.7–18.9] 12.2 [9.9–14.8] 9.9 [8.0–12.2] IRE 31.0 [26.0–36.6] 26.1 [20.4–32.7] 16.7 [13.7–20.2] 10.0 [6.0–16.1] 8.6 [5.3–13.9] 5.2 [3.5–7.6] ITA 40.8 [40.0–41.5] 34.1 [32.8–35.5] 29.9 [28.4–31.5] 18.6 [18.1–19.3] 13.3 [12.4–14.2] 9.7 [8.8–10.8] KAZ 18.3 [15.7–21.2] 19.4 [16.8–22.4] 23.2 [20.0–26.6] 5.8 [4.8–6.9] 5.8 [4.5–7.4] 7.7 [5.8–10.2] LTU 32.3 [28.9–36.0] 29.7 [26.4–33.3] 19.8 [17.3–22.6] 13.5 [11.2–16.3] 12.5 [10.3–15.2] 6.7 [5.5–8.2] LVA 26.4 [24.5–28.5] 26.7 [24.7–28.7] 23.1 [21.7–24.6] 10.2 [9.1–11.5] 9.2 [7.8–10.8] 7.0 [6.0–8.2] MAT 36.8 [36.1–37.5] 32.4 [31.4–33.4] 24.6 [23.7–25.6] 18.1 [17.5–18.6] 13.4 [12.7–14.2] 9.6 [8.9–10.2] MKD 34.3 [31.1–37.5] 36.1 [31.8–40.6] 32.4 [25.3–40.3] 18.1 [15.7–20.8] 19.0 [15.8–22.7] 15.4 [11.9–19.7] MNE 30.3 [28.2–32.5] 31.8 [28.2–35.5] 32.7 [29.3–36.3] 13.1 [11.7–14.7] 12.6 [9.9–15.7] 11.9 [10.0–14.2] POL 34.0 [30.7–37.5] 37.7 [33.8–41.8] 27.5 [24.1–31.2] 16.8 [14.5–19.4] 15.5 [12.6–18.9] 8.6 [6.8–10.7] POR 33.6 [31.6–35.6] 26.8 [24.1–29.7] 22.8 [20.0–25.8] 14.6 [13.3–16.1] 9.8 [8.2–11.7] 6.8 [5.5–8.4] ROM 29.7 [27.6–31.9] 31.8 [28.7–35.0] 28.2 [25.3–31.4] 13.6 [12.4–14.9] 15.6 [13.5–18.0] 10.4 [9.1–11.8] RUS-MS 29.9 [23.7–37.0] 23.2 [18.5–28.5] 20.5 [18.4–22.9] 14.7 [10.8–19.7] 9.5 [6.4–13.8] 6.9 [5.5–8.5] RUS-YK 25.2 [21.4–29.3] 24.0 [19.5–29.2] 18.3 [15.4–21.5] 8.9 [5.8–13.5] 8.7 [6.3–12.0] 5.2 [3.3–8.1] SMR 33.1 [32.5–33.8] 35.3 [34.6–36.0] 29.3 [28.1–30.5] 14.2 [13.9–14.5] 11.8 [11.2–12.3] 7.3 [6.7–8.0] SPA 44.5 [43.0–46.1] 37.1 [35.1–39.1] 31.7 [29.5–34.0] 20.7 [19.5–21.9] 13.8 [12.4–15.5] 10.0 [8.8–11.4] SRB 35.4 [32.8–38.1] 34.5 [31.0–38.1] 35.1 [30.3–40.3] 16.1 [13.7–18.9] 13.2 [10.7–16.3] 12.1 [9.5–15.3] TJK 6.3 [5.2–7.6] 4.3 [2.9–6.4] 3.0 [1.1–7.9] 1.3 [0.8–2.0] 1.0 [0.4–2.4] 1.2 [0.3–4.9] 50 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.5. Country-specific prevalence and 95% CIs of overweight (including obesity) according to IOTF cutoffs among boys and girls, by age (%) a Country 6-year-olds 7-year-olds 8-year-olds 9-year-olds Boys Girls Boys Girls Boys Girls Boys Girls ARM 22.1 [18.3–26.4] 21.1 [18.6–24.0] AUT 15.7 [12.2–19.9] 20.4 [17.0–24.3] BUL 22.6 [20.6–24.8] 25.5 [23.1–28.0] CRO 26.6 [24.1–29.2] 27.6 [25.2–30.1] 29.2 [26.8–31.8] 27.2 [24.8–29.8] CYP 34.8 [31.1–38.7] 32.6 [29.1–36.2] CZH 13.7 [10.7–17.5] 16.4 [13.4–19.9] 15.1 [12.3–18.4] 16.4 [12.8–20.8] DEN 11.8 [9.8–14.2] 15.0 [12.1–18.5] EST 18.9 [17.1–20.7] 20.7 [18.8–22.7] 20.0 [18.4–21.8] 20.5 [18.9–22.1] FIN 20.9 [19.2–22.8] 23.3 [21.3–25.3] 24.4 [22.6–26.2] 23.8 [22.0–25.8] 28.4 [26.4–30.5] 28.4 [26.3–30.6] GEO 21.6 [19.1–24.2] 21.0 [18.9–23.3] GER-BR 19.6 [15.6–24.2] 18.6 [14.9–22.9] GRE 32.7 [28.0–37.8] 34.9 [30.4–39.8] 36.8 [32.2–41.8] 30.0 [25.5–34.8] HUN 21.8 [19.4–24.3] 26.4 [24.1–28.9] IRE 15.0 [12.4–18.1] 20.7 [16.7–25.4] ISR 12.0 [11.8–12.3] 17.2 [16.9–17.4] 12.9 [12.6–13.2] 15.9 [15.5–16.2] ITA 30.7 [29.7–31.7] 30.5 [29.6–31.5] 28.6 [27.3–29.8] 28.7 [27.4–30.1] KAZ 15.7 [12.7–19.2] 14.0 [11.6–16.9] 15.6 [13.3–18.2] 14.0 [11.6–16.7] LTU 16.0 [13.7–18.7] 21.3 [18.8–24.0] LVA 17.0 [15.2–19.1] 18.2 [16.3–20.2] 18.5 [16.7–20.5] 18.8 [16.4–21.5] MAT 25.9 [25.2–26.6] 25.4 [24.8–26.1] MKD 26.6 [23.3–30.3] 25.8 [22.4–29.6] MNE 25.5 [22.8–28.3] 23.2 [20.6–26.1] POL 26.6 [23.9–29.4] 23.9 [21.3–26.7] POR 20.5 [18.2–23.0] 22.4 [19.8–25.3] 20.3 [18.3–22.5] 27.4 [25.0–30.0] ROM 20.3 [18.3–22.5] 22.0 [19.0–25.3] 25.3 [23.4–27.4] 25.5 [22.9–28.4] RUS-MS 16.1 [13.7–18.9] 18.8 [16.3–21.5] RUS-YK 16.3 [14.5–18.3] 16.7 [14.9–18.7] SMR 22.5 [22.1–22.9] 25.9 [25.3–26.5] SPA 23.8 [21.2–26.7] 29.8 [26.8–32.9] 28.3 [26.1–30.5] 34.1 [31.4–36.8] 31.0 [28.1–34.0] 35.5 [32.9–38.2] 34.2 [31.2–37.4] 35.7 [32.7–38.8] SRB 25.1 [21.5–29.1] 22.3 [17.6–28.0] 28.3 [24.8–32.2] 30.8 [27.2–34.7] 29.3 [26.1–32.8] 25.5 [21.3–30.2] SVK 20.1 [17.9–22.6] 22.6 [19.9–25.4] 24.9 [22.0–28.0] 23.7 [21.2–26.4] SVN 14.0 [12.2–16.0] 13.7 [12.1–15.4] 16.9 [15.5–18.5] 19.7 [18.0–21.5] 21.4 [20.0–22.9] 22.5 [20.9–24.2] 24.4 [21.8–27.1] 23.8 [20.9–27.0] SWE 15.1 [14.5–15.8] 18.4 [17.7–19.2] 21.8 [20.9–22.7] 25.0 [24.1–26.0] 21.8 [20.9–22.6] 25.0 [24.1–26.0] TJK 3.4 [2.5–4.6] 4.5 [3.4–6.0] a Calculated only for the targeted age groups. 51Report on the fifth round of data collection, 2018–2020 Table A2.6. Country-specific prevalence and 95% CIs of obesity according to IOTF cutoffs among boys and girls, by age (%) a Country 6-year-olds 7-year-olds 8-year-olds 9-year-olds Boys Girls Boys Girls Boys Girls Boys Girls ARM 7.4 [5.9–9.2] 6.8 [5.3–8.8] AUT 4.1 [2.4–6.9] 4.3 [2.9–6.2] BUL 8.7 [7.2–10.4] 9.8 [8.3–11.6] CRO 9.6 [8.1–11.4] 8.4 [7.1–9.9] 9.9 [8.5–11.5] 8.8 [7.5–10.4] CYP 11.3 [9.0–14.0] 10.0 [7.6–13.1] CZH 5.2 [3.5–7.7] 6.8 [4.6–9.9] 4.9 [3.4–6.9] 5.6 [4.0–7.8] DEN 3.5 [2.3–5.3] 3.5 [2.5–5.0] EST 5.7 [4.8–6.7] 6.5 [5.5–7.7] 6.1 [5.2–7.2] 5.9 [5.0–6.8] FIN 6.9 [5.9–8.1] 7.9 [6.7–9.2] 8.1 [7.0–9.4] 7.3 [6.2–8.5] 10.3 [9.0–11.7] 9.1 [7.8–10.5] GEO 7.8 [6.4–9.4] 7.2 [6.0–8.7] GER-BR 6.9 [4.9–9.5] 6.2 [4.3–8.9] GRE 11.7 [8.9–15.2] 10.1 [7.5–13.6] 10.0 [7.3–13.7] 6.8 [4.9–9.4] HUN 8.5 [7.0–10.4] 10.2 [8.5–12.1] IRE 4.9 [3.2–7.3] 4.7 [3.0–7.1] ISR 3.8 [3.7–4.0] 5.7 [5.5–5.8] 4.3 [4.1–4.5] 5.0 [4.7–5.2] ITA 10.5 [9.8–11.1] 9.4 [8.8–10.0] 8.6 [7.9–9.4] 8.0 [7.2–8.8] KAZ 4.3 [2.7–6.7] 3.4 [2.3–4.9] 4.4 [3.3–5.9] 3.3 [2.4–4.5] LTU 4.2 [3.1–5.6] 6.9 [5.5–8.7] LVA 4.5 [3.8–5.5] 6.0 [4.8–7.3] 4.4 [3.5–5.6] 3.9 [2.9–5.1] MAT 10.7 [10.2–11.1] 9.6 [9.2–10.1] MKD 10.8 [8.7–13.4] 10.2 [7.5–13.7] MNE 7.2 [5.5–9.4] 7.2 [5.7–9.0] POL 8.0 [6.4–10.0] 6.1 [4.6–8.1] POR 6.3 [5.1–7.8] 7.5 [6.0–9.2] 5.9 [4.8–7.2] 9.1 [7.7–10.8] ROM 8.1 [7.0–9.4] 7.3 [6.0–8.8] 9.1 [7.7–10.7] 8.1 [6.7–9.9] RUS-MS 4.4 [3.3–5.9] 5.1 [3.9–6.8] RUS-YK 4.9 [3.8–6.3] 5.0 [3.9–6.5] SMR 6.7 [6.3–7.0] 8.0 [7.6–8.5] SPA 7.8 [6.3–9.5] 10.2 [8.7–12.1] 8.9 [7.7–10.3] 11.1 [9.4–12.9] 11.6 [9.9–13.6] 11.9 [10.1–13.9] 9.1 [7.5–11.2] 9.4 [7.6–11.5] SRB 8.5 [6.3–11.3] 6.4 [4.3–9.6] 9.0 [6.9–11.7] 8.5 [6.4–11.3] 9.3 [6.8–12.7] 5.4 [3.8–7.7] SVK 6.5 [5.2–8.0] 7.4 [6.0–9.2] 8.7 [6.8–11.0] 6.6 [5.0–8.6] SVN 3.4 [2.7–4.4] 3.6 [2.8–4.5] 4.8 [4.1–5.6] 5.6 [4.8–6.6] 6.5 [5.6–7.5] 7.0 [6.1–8.0] 7.1 [5.9–8.5] 5.6 [4.2–7.4] SWE 4.4 [4.0–4.7] 5.1 [4.7–5.6] 6.3 [5.8–6.8] 6.6 [6.1–7.1] 6.3 [5.8–6.8] 6.6 [6.1–7.1] TJK 0.7 [0.3–1.4] 0.4 [0.1–1.4] a Calculated only for the targeted age groups. 52 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.7. Frequency of consumption of breakfast among boys and girls aged 6–9 years (%) Country Boys Girls Total Never Some days (1–3 days) Most days (4–6 days) Every day Never Some days (1–3 days) Most days (4–6 days) Every day Never Some days (1–3 days) Most days (4–6 days) Every day ARM 11.9 28.7 16.5 43.0 9.8 29.8 15.1 45.4 10.9 29.2 15.8 44.1 AUT 5.6 17.1 12.2 65.1 7.5 21.4 15.1 56.0 6.5 19.2 13.7 60.6 BUL 1.6 13.1 11.6 73.7 1.2 12.3 10.9 75.6 1.4 12.7 11.2 74.6 CRO 3.0 14.4 15.3 67.2 3.6 14.4 14.7 67.4 3.3 14.4 15.0 67.3 CZH 2.6 11.4 12.5 73.5 2.2 12.3 13.8 71.6 2.4 11.9 13.1 72.6 DEN 0.0 1.4 3.9 94.8 0.3 2.1 5.1 92.5 0.2 1.7 4.4 93.7 EST 1.6 8.1 10.3 80.0 1.6 6.4 16.0 76.0 1.6 7.3 13.1 78.1 GEO 3.4 19.6 18.0 59.0 2.2 24.1 15.3 58.4 2.8 21.8 16.7 58.7 GER-BR 2.4 8.6 8.9 80.1 2.4 8.8 9.6 79.2 2.4 8.7 9.2 79.6 GRE 8.6 28.6 12.0 50.8 9.2 31.1 11.9 47.9 8.9 29.8 12.0 49.3 HUN 2.4 15.8 12.9 69.0 2.3 15.9 13.8 68.0 2.3 15.8 13.3 68.5 IRE 0.2 1.9 3.8 94.1 0.0 2.1 5.1 92.7 0.1 2.0 4.4 93.5 ITA 4.7 12.6 11.1 71.6 5.7 14.7 12.2 67.4 5.2 13.6 11.6 69.6 KAZ 2.1 11.2 12.5 74.2 2.1 10.5 12.6 74.7 2.1 10.8 12.6 74.5 LTU 4.8 21.6 8.6 65.0 5.9 22.1 8.2 63.9 5.3 21.8 8.4 64.5 LVA 2.9 12.0 11.3 73.8 3.0 13.3 11.9 71.8 2.9 12.6 11.6 72.8 MAT 8.4 20.7 15.5 55.4 8.0 22.3 16.3 53.4 8.2 21.5 15.9 54.4 MKD 2.4 12.4 8.6 76.6 1.6 12.5 9.3 76.6 2.0 12.5 8.9 76.6 MNE 0.3 3.0 5.3 91.5 0.4 3.7 5.0 91.0 0.3 3.3 5.1 91.3 POL 2.2 6.6 9.8 81.4 3.3 6.8 9.3 80.6 2.7 6.7 9.5 81.0 POR 0.5 2.2 3.0 94.3 0.6 2.7 3.6 93.0 0.6 2.5 3.3 93.7 ROM 8.1 21.3 10.0 60.6 7.8 22.9 10.0 59.3 8.0 22.1 10.0 59.9 RUS-MS 1.9 9.6 10.1 78.5 3.0 9.3 10.9 76.8 2.4 9.4 10.5 77.6 RUS-YK 5.9 14.3 10.7 69.1 9.2 14.3 14.1 62.4 7.6 14.3 12.5 65.6 SMR 3.1 6.8 10.6 79.5 3.4 6.8 7.4 82.4 3.2 6.8 9.1 80.9 SPA 2.1 15.5 12.1 70.4 2.3 19.2 12.8 65.7 2.2 17.3 12.4 68.1 SRB 2.1 6.6 6.5 84.8 1.5 6.5 7.7 84.3 1.8 6.6 7.1 84.6 SVK 7.9 16.8 8.9 66.4 10.1 17.5 10.1 62.4 9.0 17.1 9.5 64.4 TJK 2.2 11.4 9.2 77.3 2.0 11.4 7.7 78.9 2.1 11.4 8.5 78.1 53Report on the fifth round of data collection, 2018–2020 Table  A2.8. Country-specific prevalence and 95% CIs of daily breakfast consumption by child’s gender and parental education (%) Country Child’s gender Parental education No. of children included in the analysis Boys Girls Total No. of children included in the analysis Low Medium High ARM 2041 43.0 [39.1–47.0] 45.4 [41.3–49.5] 44.1 [40.9–47.4] 1776 41.0 [37.1–45.1] 43.4 [38.2–48.8] 52.3 [45.8–58.7] AUT 1841 65.1 [59.7–70.1] 56.0 [51.3–60.6] 60.6 [57.0–64.2] 1736 53.7 [49.5–57.9] 67.9 [60.4–74.6] 72.7 [66.9–77.7] BUL 3040 73.7 [70.4–76.7] 75.6 [73.0–78.0] 74.6 [72.2–76.9] 3008 71.0 [67.3–74.5] 77.4 [73.7–80.8] 80.2 [76.1–83.8] CRO 5406 67.2 [64.8–69.6] 67.4 [65.2–69.4] 67.3 [65.4–69.1] 5239 63.3 [61.0–65.5] 68.6 [65.7–71.3] 76.7 [73.9–79.3] CZH 2074 73.5 [70.1–76.6] 71.6 [68.0–75.1] 72.6 [69.7–75.3] 1998 66.2 [63.4–68.9] 76.5 [72.6–80.0] 85.7 [79.2–90.4] DEN 945 94.8 [92.2–96.5] 92.5 [89.2–94.9] 93.7 [91.3–95.4] 920 92.7 [89.7–94.9] 95.0 [88.8–97.9] 94.9 [92.1–96.8] EST 1437 80.0 [77.6–82.3] 76.0 [73.1–78.7] 78.1 [75.9–80.1] 1361 69.5 [65.4–73.3] 80.0 [76.9–82.8] 84.8 [81.9–87.3] GEO 3359 59.0 [56.0–62.0] 58.4 [55.7–61.1] 58.7 [56.4–61.1] 3081 53.7 [50.8–56.5] 56.7 [51.6–61.6] 67.7 [63.9–71.4] GER-BR 2062 80.1 [76.8–83.0] 79.2 [75.4–82.5] 79.6 [76.7–82.3] 1713 72.0 [68.6–75.1] 81.8 [77.1–85.7] 89.3 [86.6–91.5] GRE 513 50.8 [45.4–56.3] 47.9 [42.0–53.8] 49.3 [45.0–53.6] 498 48.2 [35.8–60.8] 44.9 [35.3–54.9] 53.0 [47.7–58.4] HUN 4056 69.0 [66.7–71.2] 68.0 [65.1–70.8] 68.5 [66.4–70.5] 3878 62.6 [59.6–65.4] 73.3 [69.5–76.8] 77.7 [75.0–80.1] IRE 1090 94.1 [91.5–96.0] 92.7 [89.8–94.9] 93.5 [91.5–95.0] 1017 87.0 [82.1–90.7] 93.7 [88.9–96.5] 96.2 [93.6–97.7] ITA 44 240 71.6 [70.8–72.4] 67.4 [66.6–68.3] 69.6 [68.9–70.2] 40 224 65.2 [64.4–66.0] 77.3 [76.1–78.4] 81.9 [80.5–83.3] KAZ 6051 74.2 [70.9–77.3] 74.7 [72.0–77.2] 74.5 [71.7–77.1] 5665 74.2 [70.3–77.7] 74.7 [71.1–77.9] 75.6 [70.9–79.8] LTU 3199 65.0 [61.7–68.2] 63.9 [60.3–67.3] 64.5 [61.4–67.4] 3024 47.9 [44.6–51.3] 60.6 [56.4–64.8] 73.3 [70.1–76.4] LVA 6815 73.8 [71.6–76.0] 71.8 [69.5–74.0] 72.8 [70.8–74.8] 6478 65.4 [62.8–67.8] 71.5 [69.1–73.7] 79.8 [77.5–82.0] MAT 3045 55.4 [54.7–56.2] 53.4 [52.6–54.1] 54.4 [53.9–54.9] 2886 49.3 [48.6–50.0] 55.3 [54.2–56.4] 65.6 [64.5–66.7] MKD 2801 76.6 [73.1–79.8] 76.6 [73.8–79.2] 76.6 [74.2–78.8] 2529 72.6 [69.9–75.1] 82.8 [78.2–86.6] 82.9 [78.6–86.5] MNE 3142 91.5 [89.8–92.9] 91.0 [89.2–92.5] 91.3 [90.0–92.4] 2946 90.7 [89.0–92.1] 91.7 [89.5–93.5] 93.8 [91.5–95.5] POL 2420 81.4 [79.0–83.5] 80.6 [77.8–83.1] 81.0 [79.2–82.7] 2313 77.9 [74.3–81.1] 82.2 [79.0–85.1] 83.9 [81.2–86.2] POR 6200 94.3 [93.3–95.2] 93.0 [91.8–94.1] 93.7 [92.9–94.5] 5800 92.0 [90.8–93.1] 95.8 [94.5–96.8] 96.2 [94.5–97.4] ROM 9305 60.6 [58.2–62.8] 59.3 [56.7–61.8] 59.9 [57.7–62.1] 8181 54.9 [52.8–57.0] 58.5 [52.5–64.2] 68.9 [65.5–72.0] RUS-MS 1844 78.5 [74.8–81.7] 76.8 [73.6–79.7] 77.6 [74.8–80.2] 1737 62.9 [55.7–69.5] 78.9 [73.1–83.7] 80.7 [78.1–83.1] RUS-YK 867 69.1 [64.1–73.7] 62.4 [57.8–66.9] 65.6 [61.5–69.4] 825 56.5 [51.2–61.7] 63.9 [55.1–71.8] 70.4 [65.4–75.0] SMR 309 79.5 [78.9–80.1] 82.4 [81.9–82.9] 80.9 [80.5–81.3] 292 74.0 [73.2–74.7] 91.6 [91.2–91.9] 92.5 [91.9–93.1] SPA 16 435 70.4 [69.0–71.7] 65.7 [64.1–67.3] 68.1 [66.9–69.3] 15 789 62.6 [61.0–64.0] 71.0 [69.2–72.8] 80.1 [78.6–81.6] SRB 2847 84.8 [82.8–86.6] 84.3 [80.7–87.2] 84.6 [82.4–86.5] 2756 83.0 [80.2–85.5] 86.1 [83.0–88.7] 86.2 [81.9–89.6] SVK 5070 66.4 [63.4–69.3] 62.4 [59.1–65.5] 64.4 [61.6–67.1] NA NA NA NA TJK 3291 77.3 [72.5–81.4] 78.9 [74.8–82.5] 78.1 [73.9–81.8] 3049 79.9 [75.8–83.5] 74.7 [68.3–80.2] 80.8 [70.1–88.3] 54 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.9. Frequency of consumption of fresh fruit among boys and girls aged 6–9 years (%) Country Boys Girls Total Never Less than once a week Some days (1–3 days) Most days (4–6 days) Every day Never Less than once a week Some days (1–3 days) Most days (4–6 days) Every day Never Less than once a week Some days (1–3 days) Most days (4–6 days) Every day AUT 1.1 5.0 24.1 25.3 44.4 1.6 2.5 18.6 28.7 48.6 1.4 3.8 21.4 27.0 46.5 BUL 1.0 5.4 28.0 29.8 35.9 0.8 5.3 25.5 29.2 39.1 0.9 5.3 26.8 29.5 37.5 CRO 1.6 4.6 31.3 31.8 30.6 1.5 3.2 29.3 32.6 33.5 1.6 3.9 30.3 32.2 32.0 CZH 1.5 3.1 17.4 31.4 46.7 0.4 2.2 16.1 33.6 47.6 1.0 2.6 16.8 32.5 47.1 DEN 0.8 3.6 9.7 28.4 57.5 0.2 1.5 8.6 26.8 62.9 0.5 2.6 9.2 27.6 60.1 EST 1.4 3.0 20.3 37.1 38.2 0.7 2.4 19.5 38.6 38.8 1.1 2.7 19.9 37.8 38.5 GEO 2.7 8.7 30.4 36.3 21.9 2.3 6.8 25.1 41.5 24.2 2.5 7.8 27.9 38.8 23.0 GER-BR 1.1 3.0 14.0 24.8 57.1 0.9 1.4 14.1 24.4 59.2 1.0 2.2 14.0 24.6 58.1 GRE 2.2 7.3 25.5 32.9 32.0 2.4 6.0 22.7 27.9 41.0 2.3 6.7 24.1 30.3 36.6 IRE 3.9 2.2 12.9 21.3 59.7 3.2 3.9 10.8 20.2 61.9 3.6 3.0 11.9 20.8 60.8 ITA 4.1 5.0 22.1 24.0 44.7 3.0 4.1 21.8 25.4 45.6 3.6 4.6 22.0 24.7 45.2 KAZ 1.5 7.6 26.2 29.1 35.7 1.1 8.0 24.4 28.5 38.0 1.3 7.8 25.3 28.8 36.9 LTU 1.2 5.2 30.1 33.0 30.5 1.0 4.2 25.0 35.8 34.0 1.1 4.7 27.7 34.3 32.2 LVA 0.7 7.0 36.0 30.9 25.5 0.7 4.3 33.1 33.1 28.8 0.7 5.7 34.6 32.0 27.1 MAT 8.6 7.2 21.0 21.6 41.6 5.6 5.7 18.4 24.2 46.1 7.1 6.5 19.7 22.9 43.9 MKD 1.4 4.7 27.3 23.7 42.9 1.1 3.6 24.5 29.6 41.2 1.2 4.2 26.0 26.6 42.1 MNE 0.7 2.7 21.4 30.7 44.4 0.7 1.7 17.9 30.1 49.5 0.7 2.3 19.7 30.4 46.9 POL 1.4 5.7 30.8 26.4 35.7 0.7 4.1 27.5 26.4 41.4 1.0 4.9 29.2 26.4 38.5 POR 1.3 1.5 13.6 20.0 63.6 1.1 1.8 12.6 22.1 62.3 1.2 1.7 13.1 21.1 63.0 ROM 1.5 5.7 28.7 23.9 40.2 0.7 4.5 25.8 24.5 44.6 1.1 5.1 27.3 24.2 42.3 RUS-MS 0.5 2.6 18.6 30.2 48.0 0.4 1.0 14.6 32.0 52.0 0.5 1.8 16.6 31.1 50.1 RUS-YK 0.4 1.9 16.6 32.1 49.0 0.8 1.6 16.3 36.4 45.0 0.6 1.7 16.4 34.4 46.9 SMR 1.9 5.0 17.0 28.9 47.2 5.3 1.3 15.3 31.3 46.7 3.6 3.2 16.2 30.1 46.9 SPA 2.7 4.3 26.3 29.7 37.0 2.4 3.9 25.3 31.8 36.6 2.5 4.1 25.8 30.8 36.8 SRB 1.1 4.5 23.6 31.9 39.0 0.5 2.6 22.8 31.6 42.4 0.8 3.6 23.2 31.7 40.7 SVK 1.5 5.1 25.0 28.8 39.6 0.8 3.1 24.3 28.1 43.8 1.2 4.1 24.7 28.4 41.6 TJK 4.1 7.0 23.8 20.6 44.5 3.7 8.5 22.5 22.8 42.5 3.9 7.7 23.2 21.7 43.5 55Report on the fifth round of data collection, 2018–2020 Table A2.10. Country-specific prevalence and 95% CIs of daily consumption of fresh fruit by child’s gender and parental education (%) Country Child’s gender Parental education No. of children included in the analysis Boys Girls Total No. of children included in the analysis Low Medium High AUT 1841 44.4 [40.3–48.7] 48.6 [43.1–54.1] 46.5 [43.0–50.0] 1740 38.6 [34.1–43.2] 53.8 [47.2–60.2] 58.9 [52.5–64.9] BUL 3044 35.9 [32.8–39.2] 39.1 [36.0–42.4] 37.5 [34.8–40.3] 3012 32.0 [28.2–36.1] 38.3 [34.4–42.4] 48.5 [43.5–53.5] CRO 5435 30.6 [28.8–32.5] 33.5 [31.5–35.5] 32.0 [30.6–33.5] 5268 28.8 [27.0–30.6] 34.3 [31.8–36.9] 37.9 [34.8–41.1] CZH 2084 46.7 [41.4–52.0] 47.6 [43.4–51.8] 47.1 [43.4–50.9] 2007 40.8 [37.0–44.7] 50.3 [44.2–56.3] 58.2 [53.8–62.4] DEN 944 57.5 [52.4–62.5] 62.9 [57.3–68.2] 60.1 [55.7–64.3] 919 57.3 [50.0–64.4] 65.4 [58.1–72.1] 59.5 [53.4–65.3] EST 1608 38.2 [35.2–41.2] 38.8 [36.1–41.7] 38.5 [36.5–40.5] 1530 29.1 [25.5–33.0] 42.6 [39.3–45.9] 41.6 [38.3–45.0] GEO 3417 21.9 [19.8–24.2] 24.2 [22.0–26.6] 23.0 [21.4–24.8] 3134 22.3 [20.2–24.6] 17.2 [14.0–20.9] 28.0 [24.9–31.4] GER-BR 2091 57.1 [53.8–60.4] 59.2 [55.3–62.9] 58.1 [55.1–61.1] 1741 51.1 [47.1–55.1] 57.3 [52.1–62.4] 68.1 [64.2–71.8] GRE 516 32.0 [27.0–37.5] 41.0 [31.7–50.9] 36.6 [31.0–42.7] 501 29.2 [19.6–41.1] 35.8 [26.7–46.0] 43.5 [36.3–50.9] IRE 1067 59.7 [52.7–66.3] 61.9 [56.2–67.3] 60.8 [55.6–65.7] 999 50.0 [41.5–58.6] 59.1 [51.1–66.7] 66.2 [59.3–72.4] ITA 44 209 44.7 [43.9–45.6] 45.6 [44.8–46.5] 45.2 [44.5–45.8] 40 177 41.1 [40.3–41.9] 50.4 [49.1–51.8] 57.6 [55.9–59.2] KAZ 6060 35.7 [33.3–38.2] 38.0 [35.4–40.8] 36.9 [34.7–39.1] 5672 32.4 [29.0–36.0] 37.1 [34.1–40.2] 42.7 [39.3–46.1] LTU 3195 30.5 [28.4–32.7] 34.0 [31.5–36.5] 32.2 [30.3–34.1] 3021 25.1 [21.9–28.6] 30.1 [26.8–33.6] 35.6 [33.4–37.9] LVA 6768 25.5 [23.7–27.3] 28.8 [27.0–30.7] 27.1 [25.5–28.8] 6445 24.3 [21.9–26.9] 26.6 [24.2–29.1] 28.7 [26.6–30.8] MAT 3056 41.6 [40.9–42.3] 46.1 [45.4–46.9] 43.9 [43.4–44.4] 2894 39.6 [38.9–40.3] 43.8 [42.7–45.0] 54.4 [53.3–55.5] MKD 2842 42.9 [38.8–47.1] 41.2 [37.9–44.5] 42.1 [39.1–45.0] 2563 41.7 [38.4–45.1] 40.6 [35.2–46.2] 44.4 [37.7–51.3] MNE 3126 44.4 [41.9–47.0] 49.5 [46.7–52.3] 46.9 [44.9–48.9] 2934 44.5 [41.4–47.7] 46.2 [42.7–49.7] 55.0 [51.9–58.0] POL 2422 35.7 [32.7–38.8] 41.4 [38.1–44.9] 38.5 [36.1–41.0] 2319 35.0 [31.4–38.9] 39.3 [34.9–43.8] 42.4 [38.7–46.2] POR 6218 63.6 [61.3–65.8] 62.3 [60.0–64.6] 63.0 [61.2–64.7] 5820 54.9 [52.9–56.9] 71.1 [67.6–74.4] 77.4 [74.6–80.0] ROM 9375 40.2 [37.5–42.9] 44.6 [42.7–46.4] 42.3 [40.7–43.9] 8248 41.8 [39.3–44.2] 40.3 [36.8–43.9] 42.3 [37.1–47.7] RUS-MS 1869 48.0 [44.4–51.7] 52.0 [48.4–55.5] 50.1 [47.2–52.9] 1759 39.5 [32.9–46.5] 50.5 [45.1–56.0] 51.9 [48.6–55.3] RUS-YK 871 49.0 [44.9–53.1] 45.0 [40.9–49.1] 46.9 [43.9–49.8] 829 38.7 [31.4–46.5] 46.5 [39.8–53.4] 50.3 [46.1–54.6] SMR 309 47.2 [46.7–47.6] 46.7 [46.0–47.3] 46.9 [46.5–47.4] 292 40.0 [39.4–40.6] 54.9 [54.1–55.7] 62.5 [61.4–63.6] SPA 16 307 37.0 [35.3–38.8] 36.6 [34.7–38.6] 36.8 [35.2–38.5] 15 677 28.2 [26.8–29.7] 41.1 [39.2–43.0] 53.7 [50.9–56.5] SRB 2832 39.0 [34.7–43.3] 42.4 [38.2–46.8] 40.7 [37.1–44.3] 2745 35.7 [32.1–39.4] 41.3 [36.0–46.8] 49.3 [45.0–53.6] SVK 5082 39.6 [36.9–42.4] 43.8 [40.9–46.7] 41.6 [39.3–44.0] NA NA NA NA TJK 3334 44.5 [39.6–49.5] 42.5 [38.0–47.1] 43.5 [39.1–48.1] 3098 43.1 [38.3–48.0] 42.4 [36.4–48.5] 48.6 [37.8–59.5] 56 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.11. Frequency of consumption of vegetables among boys and girls aged 6–9 years (%) Country Boys Girls Total Never Less than once a week Some days (1–3 days) Most days (4–6 days) Every day Never Less than once a week Some days (1–3 days) Most days (4–6 days) Every day Never Less than once a week Some days (1–3 days) Most days (4–6 days) Every day AUT 3.1 5.9 30.4 33.0 27.6 2.3 4.9 30.9 34.5 27.3 2.7 5.4 30.7 33.7 27.5 BUL 1.7 8.3 28.6 30.3 31.0 1.1 5.9 26.4 30.5 36.1 1.4 7.1 27.5 30.4 33.5 CRO 1.9 4.9 35.7 36.6 20.9 1.3 5.2 35.5 38.2 19.7 1.6 5.1 35.6 37.4 20.3 CZH 1.3 4.8 24.6 33.5 35.8 1.3 2.9 24.5 34.4 37.0 1.3 3.9 24.6 33.9 36.3 DEN 0.1 3.1 13.6 27.5 55.7 0.5 1.4 13.2 27.6 57.3 0.3 2.2 13.4 27.5 56.5 EST 1.8 8.7 38.3 31.3 19.9 0.7 8.5 37.3 35.0 18.5 1.3 8.6 37.8 33.1 19.2 GEO 4.5 14.5 35.8 33.6 11.6 2.9 12.7 35.3 35.1 14.0 3.7 13.6 35.6 34.3 12.8 GER-BR 1.6 3.2 23.6 32.9 38.6 1.0 3.4 20.3 32.7 42.6 1.3 3.3 22.0 32.8 40.5 GRE 5.5 13.7 41.6 20.6 18.6 4.0 9.7 46.0 22.3 18.1 4.7 11.7 43.8 21.5 18.3 IRE 3.8 3.9 18.0 32.0 42.3 2.2 5.6 17.5 27.2 47.5 3.0 4.7 17.8 29.7 44.8 ITA 7.1 8.4 32.4 22.0 30.1 4.9 7.1 31.2 24.3 32.4 6.0 7.8 31.8 23.2 31.3 KAZ 4.1 9.9 27.6 26.4 32.0 3.0 9.5 26.1 27.3 34.1 3.6 9.7 26.8 26.9 33.1 LTU 1.9 6.6 27.8 38.3 25.4 1.5 5.6 27.6 36.4 29.0 1.7 6.1 27.7 37.4 27.1 LVA 1.2 9.4 36.1 32.8 20.5 0.8 6.6 35.3 33.6 23.6 1.0 8.0 35.7 33.2 22.0 MAT 17.6 17.3 33.0 18.1 14.0 13.4 15.3 34.4 21.3 15.5 15.5 16.3 33.7 19.7 14.8 MKD 2.7 6.0 29.6 28.1 33.6 2.0 5.3 27.0 27.5 38.2 2.3 5.6 28.3 27.8 35.9 MNE 1.0 4.9 31.8 36.9 25.4 0.9 4.6 28.4 39.2 26.9 0.9 4.8 30.2 38.0 26.1 POL 1.8 8.9 34.6 28.8 25.9 1.4 7.6 31.1 32.3 27.7 1.6 8.2 32.9 30.5 26.8 POR 1.0 1.5 12.9 28.6 56.0 0.6 1.6 12.0 27.4 58.4 0.8 1.6 12.5 28.0 57.2 ROM 1.8 4.8 26.5 29.5 37.4 1.5 5.1 27.4 27.9 38.1 1.7 5.0 27.0 28.7 37.7 RUS-MS 1.6 3.5 21.6 32.3 41.0 0.3 3.4 21.4 34.2 40.8 0.9 3.5 21.5 33.3 40.9 RUS-YK 0.7 3.1 30.4 39.2 26.6 0.8 6.0 33.5 33.9 25.8 0.7 4.7 32.0 36.4 26.2 SMR 3.1 1.2 25.9 25.9 43.8 2.7 3.3 18.7 30.0 45.3 2.9 2.2 22.4 27.9 44.6 SPA 3.2 8.0 44.8 31.0 13.1 2.8 7.7 44.3 31.5 13.7 3.0 7.8 44.5 31.3 13.4 SRB 1.3 2.8 23.0 35.0 37.8 0.9 2.5 20.2 37.4 38.9 1.1 2.7 21.7 36.2 38.3 SVK 1.7 6.1 33.2 32.7 26.2 1.6 5.5 30.3 34.3 28.2 1.7 5.8 31.8 33.5 27.2 TJK 5.4 7.8 20.1 23.0 43.8 6.0 7.4 18.4 22.0 46.3 5.7 7.6 19.2 22.5 45.0 57Report on the fifth round of data collection, 2018–2020 Table A2.12. Country-specific prevalence and 95% CIs of daily consumption of vegetables by child’s gender and parental education (%) Country Child’s gender Parental education No. of children included in the analysis Boys Girls Total No. of children included in the analysis Low Medium High AUT 1838 27.6 [24.3–31.1] 27.3 [23.6–31.5] 27.5 [24.7–30.4] 1739 21.0 [17.7–24.7] 35.0 [30.0–40.4] 36.3 [30.2–42.8] BUL 3045 31.0 [28.2–34.0] 36.1 [32.8–39.6] 33.5 [31.0–36.2] 3013 28.0 [24.9–31.4] 34.2 [30.0–38.6] 44.5 [40.0–49.2] CRO 5432 20.9 [19.4–22.5] 19.7 [17.9–21.7] 20.3 [19.0–21.7] 5268 17.8 [16.4–19.4] 19.1 [16.9–21.4] 27.7 [24.8–30.9] CZH 2011 35.8 [30.8–41.0] 37.0 [33.0–41.1] 36.3 [32.4–40.5] 1940 31.4 [27.1–36.0] 35.9 [30.2–42.0] 48.7 [43.0–54.4] DEN 940 55.7 [50.3–61.1] 57.3 [52.7–61.8] 56.5 [52.5–60.4] 915 48.1 [42.6–53.7] 59.3 [52.0–66.2] 65.9 [59.0–72.3] EST 1611 19.9 [17.5–22.5] 18.5 [16.1–21.1] 19.2 [17.5–21.1] 1534 13.6 [11.2–16.4] 21.3 [18.4–24.6] 21.2 [18.6–24.1] GEO 3364 11.6 [10.1–13.4] 14.0 [12.2–16.0] 12.8 [11.5–14.1] 3084 12.8 [11.2–14.5] 11.8 [9.0–15.4] 13.1 [10.6–16.1] GER-BR 2089 38.6 [35.0–42.3] 42.6 [39.0–46.3] 40.5 [37.3–43.8] 1738 31.7 [28.6–35.0] 39.9 [35.3–44.7] 53.4 [48.9–57.8] GRE 515 18.6 [13.8–24.6] 18.1 [13.6–23.5] 18.3 [14.6–22.7] 499 14.7 [8.1–25.3] 18.3 [12.2–26.5] 21.5 [16.7–27.2] IRE 1071 42.3 [37.8–46.9] 47.5 [42.4–52.6] 44.8 [41.3–48.2] 1002 33.6 [27.3–40.4] 39.3 [32.7–46.4] 52.1 [47.5–56.6] ITA 44 299 30.1 [29.3–30.9] 32.4 [31.5–33.4] 31.3 [30.6–31.9] 40 264 26.5 [25.8–27.1] 38.0 [36.6–39.5] 45.0 [43.1–46.9] KAZ 5977 32.0 [29.3–34.8] 34.1 [31.5–36.8] 33.1 [30.7–35.5] 5600 33.0 [29.3–36.9] 31.9 [28.9–35.0] 33.7 [30.7–36.9] LTU 3161 25.4 [23.3–27.6] 29.0 [26.2–31.8] 27.1 [25.0–29.3] 2993 19.6 [16.7–22.9] 22.5 [19.7–25.6] 31.6 [29.0–34.3] LVA 6726 20.5 [18.4–22.8] 23.6 [21.6–25.7] 22.0 [20.1–24.1] 6402 20.4 [18.1–23.0] 20.4 [18.0–23.2] 24.3 [21.7–27.1] MAT 3036 14.0 [13.5–14.6] 15.5 [15.0–16.1] 14.8 [14.4–15.2] 2876 9.2 [8.8–9.7] 16.2 [15.3–17.0] 26.8 [25.8–27.8] MKD 2783 33.6 [30.5–36.9] 38.2 [34.6–41.9] 35.9 [33.3–38.5] 2519 34.6 [31.7–37.7] 37.7 [31.7–44.0] 40.6 [33.6–48.1] MNE 3079 25.4 [23.3–27.6] 26.9 [25.1–28.8] 26.1 [24.7–27.6] 2890 24.6 [22.7–26.6] 25.8 [22.5–29.4] 31.3 [27.9–34.9] POL 2404 25.9 [23.0–29.0] 27.7 [24.7–30.9] 26.8 [24.5–29.1] 2305 19.9 [17.2–23.0] 23.3 [20.0–26.9] 36.3 [32.8–40.0] POR 6196 56.0 [53.4–58.6] 58.4 [56.1–60.6] 57.2 [55.3–59.0] 5802 50.5 [48.1–52.8] 63.4 [60.3–66.4] 70.8 [68.0–73.5] ROM 9287 37.4 [35.5–39.3] 38.1 [35.2–41.1] 37.7 [35.6–39.9] 8189 37.1 [35.4–38.9] 34.4 [30.7–38.2] 41.1 [35.0–47.4] RUS-MS 1857 41.0 [37.6–44.4] 40.8 [36.7–44.9] 40.9 [38.1–43.7] 1752 33.7 [27.3–40.8] 35.4 [30.1–41.2] 43.5 [40.4–46.6] RUS-YK 858 26.6 [22.9–30.6] 25.8 [22.7–29.2] 26.2 [23.9–28.5] 819 25.1 [18.8–32.6] 24.9 [20.7–29.6] 27.2 [23.0–31.9] SMR 312 43.8 [43.2–44.5] 45.3 [44.8–45.9] 44.6 [44.1–45.1] 295 36.5 [35.8–37.2] 56.0 [55.3–56.6] 58.5 [57.4–59.7] SPA 16 154 13.1 [12.2–14.1] 13.7 [12.7–14.8] 13.4 [12.6–14.2] 15 536 10.5 [9.7–11.4] 13.3 [11.9–14.8] 19.6 [17.5–22.0] SRB 2813 37.8 [34.4–41.3] 38.9 [36.0–41.9] 38.3 [35.8–40.9] 2729 35.6 [32.5–38.8] 39.8 [35.3–44.5] 43.4 [38.7–48.2] SVK 5074 26.2 [23.8–28.8] 28.2 [25.8–30.7] 27.2 [25.1–29.4] NA NA NA NA TJK 3332 43.8 [38.9–48.7] 46.3 [41.4–51.2] 45.0 [40.5–49.6] 3096 44.5 [39.7–49.4] 43.3 [37.1–49.8] 52.8 [40.4–64.8] 58 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.13. Frequency of consumption of soft drinks among boys and girls aged 6–9 years (%) Country Boys Girls Total Never Less than once a week Some days (1–3 days) Most days (4–6 days) Every day Never Less than once a week Some days (1–3 days) Most days (4–6 days) Every day Never Less than once a week Some days (1–3 days) Most days (4–6 days) Every day ARM 27.1 20.2 30.0 14.6 8.2 29.4 20.5 28.2 14.3 7.5 28.2 20.4 29.2 14.5 7.9 AUT 19.5 46.4 25.9 5.6 2.7 25.6 42.7 24.2 5.4 2.1 22.5 44.5 25.1 5.5 2.4 BUL 26.8 31.6 19.8 9.3 12.5 28.6 34.6 20.6 7.5 8.7 27.7 33.1 20.2 8.4 10.6 CRO 5.9 21.3 31.7 17.5 23.5 6.9 26.5 31.4 16.1 19.1 6.4 23.8 31.6 16.8 21.3 CZH 6.2 20.8 31.8 18.9 22.4 4.8 20.9 32.9 18.9 22.5 5.5 20.9 32.3 18.9 22.4 DEN 9.4 37.5 45.1 5.8 2.2 10.9 40.2 40.7 5.6 2.5 10.1 38.8 43.0 5.7 2.4 EST 24.1 53.4 18.4 3.0 1.1 33.4 51.7 13.1 1.6 0.1 28.6 52.6 15.8 2.4 0.6 GEO 6.6 28.1 35.3 21.1 8.9 6.2 33.8 33.9 19.2 6.8 6.4 30.9 34.6 20.2 7.9 GER-BR 23.6 43.9 22.5 6.1 3.9 27.9 45.1 19.7 4.6 2.8 25.7 44.5 21.1 5.4 3.4 GRE 39.9 44.3 15.1 0.2 0.4 45.7 42.3 8.9 2.0 1.1 42.9 43.3 11.9 1.2 0.8 IRE 39.7 39.8 14.3 3.2 3.0 39.6 38.7 16.0 4.1 1.6 39.7 39.2 15.1 3.6 2.3 ITA 20.7 36.8 27.2 8.0 7.3 24.2 38.5 25.0 6.8 5.5 22.4 37.6 26.2 7.4 6.4 KAZ 12.6 28.3 28.3 14.4 16.4 13.6 28.9 26.7 13.8 17.0 13.1 28.6 27.5 14.1 16.7 LTU 14.9 55.8 22.6 5.3 1.4 18.0 53.9 22.7 4.0 1.4 16.4 54.9 22.7 4.7 1.4 LVA 6.5 43.9 34.4 8.7 6.5 8.4 45.3 32.1 8.2 6.0 7.4 44.6 33.2 8.4 6.3 MAT 30.7 33.4 19.5 8.4 8.0 32.7 33.7 19.0 7.4 7.2 31.7 33.6 19.2 7.9 7.6 MKD 12.0 16.3 31.3 14.5 25.9 15.3 16.5 31.4 15.4 21.5 13.6 16.4 31.3 15.0 23.8 MNE 13.4 26.1 32.7 15.0 12.8 14.7 29.6 31.5 14.7 9.5 14.0 27.8 32.1 14.9 11.2 POL 7.9 33.4 28.6 14.8 15.3 6.5 32.5 28.9 16.6 15.5 7.2 33.0 28.7 15.7 15.4 POR 14.2 38.4 31.8 8.6 7.0 15.0 40.7 31.6 7.4 5.4 14.6 39.5 31.7 8.0 6.2 ROM 11.8 41.1 30.1 7.3 9.6 14.2 42.6 29.2 5.7 8.3 13.0 41.9 29.7 6.5 9.0 RUS-MS 23.3 30.9 26.8 8.8 10.2 23.4 34.1 24.3 8.5 9.7 23.4 32.6 25.5 8.6 9.9 RUS-YK 21.1 33.5 27.2 7.8 10.4 21.7 34.2 27.4 8.6 8.1 21.4 33.9 27.3 8.2 9.2 SMR 21.6 50.0 21.0 3.1 4.3 36.9 36.2 21.5 3.4 2.0 28.9 43.4 21.2 3.2 3.2 SPA 48.2 35.2 12.5 2.6 1.5 53.5 32.0 11.4 2.2 0.9 50.8 33.7 12.0 2.4 1.2 SRB 10.3 25.3 36.6 15.2 12.6 11.2 28.5 34.2 13.6 12.5 10.7 26.9 35.4 14.4 12.5 SVK 7.6 23.5 32.9 16.7 19.3 7.5 24.8 32.2 17.0 18.5 7.5 24.1 32.6 16.8 18.9 TJK 9.9 22.2 36.7 18.6 12.6 9.9 24.4 38.0 15.5 12.2 9.9 23.3 37.3 17.1 12.4 59Report on the fifth round of data collection, 2018–2020 Table A2.14. Country-specific prevalence and 95% CIs of consumption of soft drinks on more than 3 days a week by child’s gender and parental education (%) Country Child’s gender Parental education No. of children included in the analysis Boys Girls Total No. of children included in the analysis Low Medium High ARM 1817 22.8 [19.1–27.0] 21.8 [17.7–26.5] 22.3 [19.6–25.3] 1602 24.5 [19.9–29.8] 19.7 [14.6–25.9] 18.9 [14.8–23.9] AUT 1838 8.3 [5.9–11.5] 7.5 [5.4–10.3] 7.9 [6.3–9.9] 1740 10.0 [7.7–13.0] 5.7 [3.5–9.2] 3.3 [1.8–6.0] BUL 3044 21.8 [18.1–26.0] 16.2 [13.2–19.6] 19.0 [16.0–22.6] 3013 29.1 [24.7–33.9] 8.3 [6.2–11.0] 6.3 [4.5–8.9] CRO 5439 41.1 [39.0–43.2] 35.2 [32.9–37.6] 38.2 [36.4–40.0] 5274 47.6 [45.4–49.7] 29.8 [26.9–32.8] 20.8 [18.2–23.8] CZH 2027 41.3 [36.9–45.8] 41.3 [37.4–45.4] 41.3 [37.6–45.1] 1955 47.5 [44.0–51.1] 36.1 [30.5–42.2] 31.6 [25.2–38.8] DEN 942 8.0 [5.8–11.1] 8.2 [6.0–11.0] 8.1 [6.4–10.2] 918 8.6 [6.2–11.8] 8.6 [5.0–14.4] 6.1 [3.7–9.8] EST 1612 4.1 [3.2–5.2] 1.7 [1.1–2.7] 3.0 [2.3–3.8] 1536 5.7 [4.1–7.8] 2.6 [1.6–4.2] 1.0 [0.5–1.8] GEO 3314 30.0 [27.8–32.4] 26.0 [23.9–28.3] 28.1 [26.3–30.0] 3044 30.9 [28.4–33.5] 27.2 [22.9–31.8] 23.5 [20.5–26.7] GER-BR 2084 10.0 [7.8–12.7] 7.4 [5.6–9.6] 8.7 [6.9–10.9] 1734 13.8 [11.5–16.5] 6.5 [4.6–9.3] 2.2 [1.2–4.0] GRE 517 0.6 [0.2–2.0] 3.1 [1.5–6.5] 1.9 [0.9–3.8] 502 4.6 [2.0–10.3] 0.4 [0.1–3.0] 0.5 [0.1–2.3] IRE 1063 6.2 [4.3–9.0] 5.6 [3.5–9.0] 6.0 [4.4–8.1] 992 10.4 [6.6–15.9] 8.1 [4.6–13.8] 3.8 [2.3–6.1] ITA 44 103 15.3 [14.6–15.9] 12.3 [11.6–13.0] 13.8 [13.3–14.3] 40 125 16.2 [15.6–16.9] 9.5 [8.8–10.4] 7.0 [6.2–7.9] KAZ 5906 30.8 [28.1–33.6] 30.8 [28.3–33.5] 30.8 [28.5–33.2] 5536 34.7 [31.2–38.3] 30.1 [26.7–33.6] 25.8 [23.0–28.8] LTU 3177 6.7 [5.5–8.2] 5.4 [4.4–6.6] 6.1 [5.1–7.2] 3010 12.8 [10.5–15.4] 5.6 [4.1–7.5] 3.5 [2.8–4.4] LVA 6727 15.2 [13.9–16.6] 14.2 [12.9–15.6] 14.7 [13.8–15.7] 6406 21.4 [19.7–23.2] 13.1 [11.7–14.6] 10.9 [9.6–12.2] MAT 3031 16.5 [15.9–17.0] 14.6 [14.1–15.2] 15.5 [15.2–15.9] 2870 21.5 [20.9–22.1] 9.0 [8.4–9.7] 6.7 [6.2–7.3] MKD 2773 40.5 [37.1–43.9] 36.9 [33.7–40.2] 38.7 [36.3–41.2] 2511 40.4 [37.4–43.5] 41.1 [35.8–46.7] 30.9 [24.8–37.6] MNE 2993 27.8 [25.1–30.6] 24.2 [22.0–26.7] 26.1 [24.2–28.0] 2810 30.3 [28.0–32.7] 24.1 [20.9–27.6] 14.9 [12.6–17.5] POL 2387 30.0 [26.7–33.6] 32.1 [29.1–35.2] 31.0 [28.5–33.7] 2286 37.7 [33.7–42.0] 32.1 [28.0–36.5] 23.1 [19.8–26.9] POR 6202 15.6 [14.1–17.2] 12.7 [11.4–14.2] 14.2 [13.1–15.3] 5805 17.5 [15.9–19.2] 10.3 [8.7–12.3] 7.1 [5.7–8.8] ROM 9233 16.9 [14.9–19.2] 14.0 [12.2–15.9] 15.5 [13.8–17.4] 8150 22.9 [20.7–25.3] 8.1 [5.8–11.2] 3.4 [2.6–4.4] RUS-MS 1854 19.0 [16.9–21.3] 18.2 [15.6–21.0] 18.6 [16.7–20.6] 1747 23.3 [18.4–29.0] 20.3 [15.8–25.8] 16.7 [14.4–19.4] RUS-YK 851 18.2 [14.3–22.9] 16.7 [12.4–22.0] 17.4 [13.9–21.5] 813 26.1 [17.2–37.5] 17.6 [13.7–22.3] 12.7 [10.1–15.8] SMR 311 7.4 [7.1–7.7] 5.4 [5.1–5.6] 6.4 [6.2–6.6] 294 8.3 [8.0–8.6] 6.0 [5.6–6.3] 0.0 SPA 15 803 4.1 [3.5–4.9] 3.1 [2.5–3.7] 3.6 [3.1–4.2] 15 219 5.7 [4.9–6.5] 1.3 [0.9–1.9] 0.4 [0.2–0.7] SRB 2771 27.8 [24.2–31.7] 26.1 [22.7–29.8] 26.9 [23.9–30.3] 2688 31.9 [28.3–35.8] 25.4 [21.6–29.7] 18.1 [15.2–21.4] SVK 4947 36.0 [33.3–38.8] 35.5 [32.1–39.1] 35.8 [33.1–38.5] NA NA NA NA TJK 3308 31.2 [27.6–35.0] 27.7 [24.5–31.0] 29.5 [26.4–32.7] 3072 27.7 [24.6–31.0] 36.5 [31.2–42.2] 31.7 [22.4–42.8] ARM 1817 22.8 [19.1–27.0] 21.8 [17.7–26.5] 22.3 [19.6–25.3] 1602 24.5 [19.9–29.8] 19.7 [14.6–25.9] 18.9 [14.8–23.9] 60 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.15. Means of transport to and from school among boys and girls aged 6–9 years (%) Country Boys Girls Total Walking, cycling, skating Motorized vehicles Combination Walking, cycling, skating Motorized vehicles Combination Walking, cycling, skating Motorized vehicles Combination ARM 64.5 20.5 15.0 64.1 19.6 16.2 64.3 20.1 15.5 AUT 44.4 38.8 16.8 42.1 41.0 16.9 43.2 39.9 16.9 BUL 44.4 45.1 10.5 45.4 42.0 12.6 44.9 43.6 11.5 CRO 51.2 37.7 11.1 50.9 39.3 9.9 51.0 38.5 10.5 DEN 35.8 57.6 6.5 34.5 56.4 9.2 35.2 57.0 7.8 EST 35.1 48.1 16.8 35.1 51.6 13.4 35.1 49.8 15.2 GEO 51.5 42.2 6.3 50.0 45.1 4.9 50.8 43.6 5.6 GER-BR 72.8 14.0 13.2 72.6 14.9 12.5 72.7 14.4 12.9 GRE 48.1 45.2 6.7 39.4 45.7 14.8 43.6 45.5 10.9 HUN 35.8 59.2 5.0 35.4 58.9 5.7 35.6 59.1 5.3 IRE 26.2 63.8 10.0 26.1 67.0 6.9 26.2 65.3 8.5 ITA 24.8 66.8 8.3 24.3 67.5 8.2 24.6 67.2 8.3 KAZ 71.6 23.7 4.7 71.3 23.3 5.4 71.4 23.5 5.1 LTU 29.5 57.3 13.2 29.1 57.5 13.4 29.3 57.4 13.3 LVA 32.6 52.4 15.0 32.9 52.5 14.6 32.7 52.5 14.8 MAT 19.6 76.7 3.7 17.5 78.1 4.4 18.5 77.4 4.1 MKD 66.4 24.4 9.2 63.5 26.0 10.5 65.0 25.2 9.8 MNE 35.6 40.0 24.4 34.4 40.8 24.8 35.0 40.4 24.6 POL 35.9 55.2 8.9 40.6 50.6 8.8 38.2 53.0 8.8 POR 15.5 78.3 6.2 15.6 78.4 6.0 15.5 78.3 6.1 ROM 45.9 44.7 9.4 45.5 44.3 10.2 45.7 44.5 9.8 RUS-MS 66.4 25.2 8.4 69.2 23.7 7.1 67.8 24.4 7.7 RUS-YK 69.1 15.7 15.2 64.6 21.2 14.2 66.7 18.6 14.7 SMR 6.3 88.1 5.7 4.9 88.2 6.9 5.6 88.1 6.3 SPA 48.8 40.8 10.4 48.9 40.5 10.6 48.9 40.6 10.5 SRB 61.7 29.3 9.1 58.5 31.8 9.7 60.1 30.5 9.4 SVK 36.2 44.2 19.6 33.7 48.7 17.5 35.0 46.4 18.6 TJK 97.8 1.8 0.4 97.2 2.4 0.5 97.5 2.1 0.4 61Report on the fifth round of data collection, 2018–2020 Table A2.16. Country-specific prevalence and 95% CIs of children going to and from school on foot, by bicycle or skating by child’s gender and parental education (%) Country Child’s gender Parental education No. of children included in the analysis Boys Girls Total No. of children included in the analysis Low Medium High ARM 2011 64.5 [59.7–69.0] 64.1 [59.2–68.8] 64.3 [60.3–68.2] 1748 72.2 [67.4–76.6] 59.6 [53.6–65.3] 49.1 [42.0–56.3] AUT 1704 44.4 [38.0–51.0] 42.1 [34.9–49.6] 43.2 [37.7–49.0] 1612 40.7 [34.9–46.8] 42.4 [35.1–49.9] 48.7 [39.5–57.9] BUL 3017 44.4 [39.4–49.4] 45.4 [41.0–49.8] 44.9 [40.6–49.3] 2985 51.8 [46.0–57.6] 34.3 [29.7–39.3] 38.5 [31.7–45.7] CRO 5121 51.2 [47.1–55.2] 50.9 [46.8–55.0] 51.0 [47.3–54.8] 4962 51.2 [47.3–55.0] 49.5 [44.5–54.4] 51.2 [44.9–57.4] DEN 946 35.8 [30.0–42.0] 34.5 [28.6–40.9] 35.2 [30.3–40.3] 916 31.0 [25.2–37.6] 30.5 [23.7–38.3] 45.6 [37.8–53.8] EST 1656 35.1 [31.5–38.9] 35.1 [31.5–38.8] 35.1 [31.9–38.4] 1537 41.0 [36.8–45.4] 36.4 [32.3–40.6] 31.2 [26.5–36.3] GEO 3281 51.5 [47.3–55.7] 50.0 [45.8–54.2] 50.8 [47.0–54.6] 3012 55.0 [51.0–58.8] 44.2 [38.4–50.2] 43.1 [37.0–49.4] GER-BR 1991 72.8 [67.7–77.4] 72.6 [68.3–76.5] 72.7 [68.4–76.6] 1655 66.0 [61.5–70.2] 76.3 [70.2–81.5] 80.4 [74.3–85.4] GRE 518 48.1 [37.6–58.8] 39.4 [26.6–53.9] 43.6 [33.4–54.5] 499 49.8 [36.4–63.2] 44.2 [33.8–55.2] 38.3 [23.9–55.1] HUN 4052 35.8 [31.1–40.7] 35.4 [31.5–39.6] 35.6 [31.6–39.8] 3862 42.2 [37.8–46.7] 25.3 [20.9–30.4] 29.6 [22.9–37.4] IRE 1047 26.2 [20.8–32.5] 26.1 [20.5–32.7] 26.2 [21.4–31.7] 953 33.5 [25.7–42.3] 18.6 [12.0–27.8] 26.9 [21.3–33.2] ITA 40 926 24.8 [23.8–25.9] 24.3 [23.2–25.4] 24.6 [23.6–25.5] 37 339 24.8 [23.8–25.9] 21.2 [19.8–22.7] 25.9 [23.4–28.5] KAZ 5926 71.6 [67.9–75.0] 71.3 [67.7–74.6] 71.4 [68.0–74.6] 5528 77.3 [73.4–80.7] 70.7 [66.4–74.7] 62.2 [57.5–66.7] LTU 2918 29.5 [26.0–33.3] 29.1 [25.5–33.0] 29.3 [26.1–32.8] 2762 39.0 [33.6–44.8] 31.2 [26.8–36.1] 24.1 [20.8–27.8] LVA 6684 32.6 [28.7–36.8] 32.9 [28.9–37.2] 32.7 [29.0–36.7] 6365 41.4 [37.0–45.9] 31.3 [27.3–35.6] 26.3 [22.4–30.6] MAT 2774 19.6 [19.0–20.2] 17.5 [16.9–18.1] 18.5 [18.1–19.0] 2633 22.6 [22.0–23.2] 11.5 [10.8–12.3] 14.7 [13.8–15.5] MKD 2827 66.4 [59.7–72.4] 63.5 [59.4–67.4] 65.0 [60.2–69.5] 2526 72.2 [68.2–75.9] 56.8 [49.7–63.7] 50.9 [41.1–60.6] MNE 3143 35.6 [32.2–39.1] 34.4 [31.0–38.0] 35.0 [31.9–38.3] 2947 35.6 [31.5–40.0] 32.2 [28.2–36.4] 35.6 [31.1–40.3] POL 2240 35.9 [31.1–41.0] 40.6 [35.9–45.5] 38.2 [34.0–42.6] 2140 49.2 [43.2–55.2] 33.1 [27.7–39.0] 28.0 [23.4–33.2] POR 5693 15.5 [13.5–17.6] 15.6 [13.4–18.1] 15.5 [13.8–17.4] 5349 18.3 [16.1–20.8] 10.1 [8.0–12.7] 10.6 [8.4–13.3] ROM 8944 45.9 [42.9–48.9] 45.5 [42.5–48.5] 45.7 [42.9–48.5] 7860 53.3 [49.8–56.9] 38.6 [34.1–43.4] 30.6 [26.3–35.3] RUS-MS 1797 66.4 [61.5–70.9] 69.2 [64.8–73.3] 67.8 [63.6–71.8] 1688 81.9 [75.6–86.8] 74.2 [68.2–79.4] 63.9 [58.8–68.7] RUS-YK 836 69.1 [61.6–75.6] 64.6 [56.3–72.1] 66.7 [59.4–73.3] 794 75.8 [68.1–82.0] 69.0 [62.1–75.1] 61.1 [50.7–70.5] SMR 303 6.3 [6.0–6.6] 4.9 [4.6–5.1] 5.6 [5.4–5.8] 286 4.9 [4.6–5.1] 7.3 [6.7–8.0] 0.0 SPA 15 316 48.8 [45.3–52.3] 48.9 [45.6–52.2] 48.9 [45.6–52.1] 14 713 54.5 [51.4–57.5] 43.3 [39.9–46.8] 39.4 [33.6–45.4] SRB 2721 61.7 [56.2–66.9] 58.5 [53.4–63.4] 60.1 [55.2–64.8] 2638 60.1 [53.2–66.7] 57.2 [50.9–63.3] 62.1 [55.1–68.7] SVK 5272 36.2 [33.0–39.5] 33.7 [31.1–36.4] 35.0 [32.4–37.7] NA NA NA NA TJK 3366 97.8 [96.6–98.6] 97.2 [95.2–98.4] 97.5 [96.2–98.4] 3117 98.3 [97.1–99.0] 94.6 [91.1–96.8] 95.1 [90.3–97.6] 62 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.17. Hours per week spent by boys and girls aged 6–9 years in sport clubs or on dancing courses (%) Country Boys Girls Total 0 hours/ week 1 hour/ week 2 hours/ week 3 hours/ week 4 hours/ week 5 hours/ week or more 0 hours/ week 1 hour/ week 2 hours/ week 3 hours/ week 4 hours/ week 5 hours/ week or more 0 hours/ week 1 hour/ week 2 hours/ week 3 hours/ week 4 hours/ week 5 hours/ week or more ARM 46.7 1.1 5.6 22.4 0.9 23.4 44.7 1.7 13.3 21.2 1.5 17.5 45.8 1.4 9.2 21.9 1.2 20.6 AUT 30.2 8.7 11.2 11.2 11.7 27.1 35.9 16.7 16.2 13.1 5.5 12.5 33.0 12.6 13.7 12.1 8.7 20.0 BUL 57.3 2.2 10.7 7.8 6.7 15.3 54.9 4.5 14.2 7.4 7.2 11.8 56.1 3.3 12.4 7.6 7.0 13.6 CRO 25.8 3.3 13.1 20.1 17.0 20.8 33.7 5.1 21.0 17.2 11.7 11.2 29.7 4.2 17.0 18.7 14.4 16.1 CZH 33.1 11.8 20.2 16.6 8.9 9.4 28.4 16.8 23.8 14.3 9.3 7.4 30.8 14.3 22.0 15.5 9.1 8.5 DEN 21.0 20.4 22.0 17.3 8.6 10.6 18.9 28.3 30.8 12.7 4.9 4.4 20.0 24.2 26.2 15.1 6.8 7.6 EST 21.0 3.1 16.1 19.3 16.4 24.0 19.7 6.0 20.1 21.4 11.5 21.3 20.4 4.5 18.1 20.3 14.0 22.7 GEO 42.2 2.3 8.2 14.2 7.7 25.5 43.5 2.6 10.3 17.4 9.6 16.7 42.8 2.4 9.2 15.7 8.6 21.2 GER-BR 24.8 0.9 9.2 17.9 14.3 32.9 29.1 0.3 16.0 22.0 13.9 18.7 26.9 0.6 12.5 19.9 14.1 26.1 GRE 19.3 5.9 9.6 18.4 16.2 30.5 16.2 5.6 13.8 25.3 16.2 22.9 17.7 5.7 11.8 22.0 16.2 26.6 IRE 9.8 8.7 16.0 18.8 16.2 30.6 10.0 10.7 20.6 20.4 16.0 22.3 9.9 9.7 18.2 19.5 16.1 26.6 ITA 19.5 6.0 21.0 19.8 14.8 18.9 24.4 9.9 27.3 18.1 10.0 10.3 21.9 7.9 24.1 19.0 12.4 14.7 KAZ 67.7 3.2 6.5 7.8 3.1 11.7 71.9 3.4 7.9 6.6 3.1 7.1 69.8 3.3 7.2 7.2 3.1 9.4 LTU 33.0 6.1 15.0 15.1 11.3 19.5 31.5 7.6 26.5 13.7 9.5 11.3 32.3 6.8 20.4 14.4 10.4 15.6 LVA 18.6 5.1 13.5 15.5 14.4 32.9 20.8 7.5 19.3 15.7 13.9 22.9 19.7 6.3 16.3 15.6 14.1 28.0 MAT 30.6 11.0 12.7 14.8 11.8 19.1 31.3 14.1 19.7 15.0 8.9 11.1 31.0 12.5 16.2 14.9 10.3 15.1 MKD 54.7 1.9 12.1 12.8 6.6 11.9 66.6 2.5 12.5 9.0 3.9 5.6 60.4 2.2 12.3 11.0 5.3 8.8 MNE 44.0 0.9 4.0 18.4 9.9 22.8 54.0 1.3 11.8 13.0 5.8 14.1 48.9 1.1 7.8 15.7 7.9 18.6 POL 36.1 7.6 13.9 15.3 10.2 16.9 39.5 12.9 13.3 12.6 8.8 12.9 37.8 10.2 13.6 14.0 9.5 14.9 POR 40.6 8.5 18.1 13.5 10.3 9.0 45.6 14.1 18.4 10.8 6.2 4.9 43.1 11.2 18.2 12.2 8.3 7.0 ROM 56.6 3.4 13.3 8.8 7.2 10.7 58.2 5.7 15.5 8.6 5.6 6.5 57.3 4.5 14.4 8.7 6.4 8.6 RUS-MS 27.1 3.2 16.8 16.7 12.1 24.0 30.4 2.7 18.9 13.0 11.3 23.8 28.8 2.9 17.9 14.8 11.7 23.9 RUS-YK 29.8 2.2 15.2 13.5 9.8 29.5 36.3 2.6 13.4 10.8 8.6 28.2 33.2 2.4 14.3 12.0 9.2 28.8 SMR 2.7 8.8 16.3 21.1 17.0 34.0 11.2 5.6 20.3 26.6 17.5 18.9 6.9 7.2 18.3 23.8 17.2 26.6 SPA 24.8 4.8 17.6 16.4 14.3 22.1 29.0 8.0 23.6 15.7 10.5 13.2 26.9 6.3 20.5 16.1 12.4 17.8 SRB 34.7 1.4 11.6 21.4 11.7 19.2 36.9 2.2 18.5 17.6 10.0 14.8 35.8 1.8 15.0 19.5 10.9 17.0 SVK 29.2 6.6 13.7 18.3 10.6 21.7 34.5 10.2 20.2 12.2 6.5 16.4 31.6 8.3 16.7 15.4 8.7 19.3 63Report on the fifth round of data collection, 2018–2020 Table A2.18. Country-specific prevalence and 95% CIs of children practising sports/dancing for at least 2 hours a week by child’s gender and parental education (%) Country Child’s gender Parental education No. of children included in the analysis Boys Girls Total No. of children included in the analysis Low Medium High ARM 2000 52.3 [47.2–57.3] 53.5 [48.6–58.4] 52.8 [48.9–56.8] 1742 44.5 [39.8–49.3] 58.8 [51.2–65.9] 70.2 [64.9–75.1] AUT 1816 61.1 [57.1–65.0] 47.4 [41.1–53.8] 54.5 [50.2–58.7] 1714 47.4 [42.2–52.7] 57.0 [49.8–63.9] 72.8 [68.1–77.1] BUL 3035 40.5 [35.5–45.7] 40.7 [36.2–45.3] 40.6 [36.2–45.1] 3002 22.9 [19.7–26.4] 55.6 [49.6–61.5] 66.2 [61.4–70.7] CRO 5393 71.0 [68.7–73.1] 61.2 [58.3–63.9] 66.2 [64.0–68.2] 5227 55.1 [52.6–57.7] 76.3 [73.6–78.8] 85.3 [82.6–87.6] CZH 2073 55.1 [50.1–60.0] 54.7 [51.0–58.5] 54.9 [51.1–58.7] 1998 48.2 [43.5–53.0] 60.9 [54.5–66.9] 66.1 [59.7–72.0] DEN 950 58.6 [53.0–64.0] 52.8 [47.3–58.3] 55.8 [51.5–60.1] 920 51.6 [46.7–56.5] 57.5 [49.5–65.1] 61.5 [53.9–68.6] EST 1653 75.9 [73.5–78.2] 74.3 [71.6–76.8] 75.1 [73.3–76.9] 1534 64.1 [60.5–67.6] 77.1 [73.9–79.9] 81.5 [79.0–83.8] GEO 3370 55.6 [52.7–58.4] 54.0 [50.8–57.1] 54.8 [52.4–57.1] 3085 48.6 [45.6–51.5] 54.6 [49.0–60.0] 68.4 [65.1–71.6] GER-BR 2067 74.4 [69.9–78.3] 70.6 [65.4–75.3] 72.5 [68.2–76.5] 1719 62.4 [57.3–67.3] 77.5 [72.0–82.1] 86.3 [82.6–89.4] GRE 520 74.8 [65.5–82.4] 78.2 [69.4–85.0] 76.6 [71.1–81.3] 502 62.0 [50.0–72.7] 81.3 [70.5–88.8] 84.5 [75.8–90.4] IRE 1113 81.5 [76.8–85.3] 79.3 [74.0–83.8] 80.4 [76.5–83.9] 1015 70.2 [62.4–76.9] 74.2 [66.8–80.4] 87.4 [82.9–90.8] ITA 40 218 74.6 [73.7–75.4] 65.7 [64.7–66.8] 70.2 [69.5–70.9] 36 696 65.4 [64.5–66.3] 79.7 [78.5–80.9] 83.5 [82.0–84.9] KAZ 6005 29.1 [26.3–32.0] 24.7 [22.2–27.4] 26.9 [24.6–29.3] 5612 18.8 [16.3–21.5] 29.5 [26.5–32.6] 37.0 [33.3–40.8] LTU 3148 60.9 [56.5–65.1] 60.9 [57.4–64.3] 60.9 [57.4–64.3] 2984 37.3 [33.8–41.0] 59.7 [55.0–64.1] 72.1 [68.4–75.6] LVA 6788 76.3 [73.0–79.3] 71.7 [68.4–74.7] 74.0 [71.1–76.8] 6461 59.2 [55.9–62.3] 77.4 [75.0–79.6] 84.0 [81.7–86.0] MAT 3020 58.4 [57.7–59.2] 54.6 [53.9–55.3] 56.5 [56.0–57.0] 2860 48.8 [48.0–49.5] 64.9 [63.8–66.0] 69.4 [68.3–70.4] MKD 2638 43.4 [38.4–48.5] 30.9 [25.4–37.1] 37.4 [32.7–42.3] 2386 23.2 [19.5–27.4] 50.4 [45.9–54.8] 63.3 [55.7–70.3] MNE 3120 55.1 [51.2–58.9] 44.7 [41.1–48.3] 50.0 [46.7–53.4] 2926 39.2 [36.3–42.3] 58.8 [54.3–63.1] 72.7 [68.3–76.8] POL 2388 56.3 [52.2–60.4] 47.6 [43.1–52.2] 52.0 [48.7–55.3] 2284 37.4 [33.6–41.3] 55.7 [50.6–60.8] 67.8 [63.5–71.8] POR 6166 50.9 [48.2–53.6] 40.3 [37.7–42.9] 45.7 [43.4–48.0] 5774 34.1 [31.8–36.4] 59.1 [55.7–62.4] 68.2 [64.9–71.4] ROM 8813 40.0 [36.9–43.3] 36.1 [32.5–39.9] 38.1 [35.0–41.4] 7766 22.0 [19.7–24.6] 47.7 [43.2–52.3] 62.8 [59.2–66.2] RUS-MS 1863 69.7 [65.1–73.9] 66.9 [62.2–71.4] 68.3 [64.3–72.0] 1750 42.7 [34.3–51.6] 64.1 [58.9–69.0] 75.3 [71.4–78.8] RUS-YK 863 68.0 [60.2–74.9] 61.1 [52.0–69.4] 64.3 [56.3–71.6] 819 42.0 [30.5–54.4] 63.0 [53.1–71.8] 75.7 [71.7–79.3] SMR 290 88.4 [87.9–88.9] 83.2 [82.8–83.6] 85.9 [85.5–86.2] 274 84.2 [83.6–84.7] 91.1 [90.7–91.6] 86.5 [85.6–87.3] SPA 16 310 70.4 [68.4–72.4] 62.9 [60.9–64.9] 66.8 [65.0–68.6] 15 670 59.2 [57.3–61.2] 76.4 [74.5–78.3] 77.1 [74.6–79.4] SRB 2818 63.9 [58.3–69.1] 60.9 [55.8–65.7] 62.4 [57.6–67.0] 2730 49.3 [44.4–54.1] 71.3 [66.6–75.7] 80.2 [75.9–83.9] 64 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.19. Hours per day spent by boys and girls aged 6–9 years playing actively/vigorously on weekdays (%) Country Boys Girls Total Never Less than 1 hour/ day About 1 hour/ day About 2 hours/ day About 3 or more hours/ day Never Less than 1 hour/ day About 1 hour/ day About 2 hours/ day About 3 or more hours/ day Never Less than 1 hour/ day About 1 hour/ day About 2 hours/ day About 3 or more hours/ day ARM 1.6 4.8 21.0 37.7 34.9 2.8 6.4 25.1 37.3 28.5 2.1 5.5 22.9 37.5 31.9 AUT 0.8 7.2 28.7 43.7 19.6 0.1 9.4 34.0 37.8 18.6 0.5 8.3 31.3 40.8 19.1 BUL 0.8 6.7 22.3 43.8 26.4 1.0 6.5 26.8 41.2 24.5 0.9 6.6 24.5 42.5 25.5 CRO 0.6 9.1 35.0 40.6 14.7 1.3 9.6 39.4 37.8 11.9 1.0 9.3 37.2 39.2 13.3 CZH 0.5 4.0 33.1 39.9 22.5 0.4 6.9 34.1 39.4 19.3 0.4 5.4 33.6 39.7 20.9 DEN 1.1 26.3 40.2 23.4 9.0 2.4 28.3 49.4 16.0 4.0 1.7 27.2 44.6 19.9 6.6 EST 1.8 17.6 34.3 34.2 12.0 1.2 16.8 38.3 31.5 12.2 1.5 17.3 36.2 32.9 12.1 GEO 1.4 10.3 22.3 43.3 22.7 3.0 11.2 24.7 41.6 19.5 2.2 10.7 23.4 42.5 21.2 GER-BR 0.5 11.8 34.4 37.3 16.0 1.2 12.1 36.1 35.9 14.6 0.9 11.9 35.3 36.6 15.3 GRE 3.2 15.8 44.2 24.9 11.9 1.4 27.5 43.0 23.4 4.7 2.3 21.7 43.6 24.1 8.2 HUN 2.0 15.5 42.0 28.8 11.7 2.5 16.8 40.4 30.0 10.4 2.2 16.1 41.2 29.4 11.1 IRE 0.5 11.2 43.3 31.9 13.2 0.7 15.3 38.7 31.5 13.8 0.6 13.2 41.1 31.7 13.5 KAZ 2.8 10.2 22.5 42.1 22.4 2.6 12.8 25.4 40.0 19.2 2.7 11.5 23.9 41.0 20.8 LTU 1.0 8.3 26.2 37.4 27.2 0.9 8.3 27.7 38.2 25.0 0.9 8.3 26.9 37.7 26.1 LVA 1.1 15.5 32.3 32.5 18.6 1.7 17.2 33.5 31.4 16.2 1.4 16.3 32.9 32.0 17.4 MAT 5.5 27.4 39.6 20.0 7.5 5.1 28.1 39.0 20.4 7.4 5.3 27.8 39.3 20.2 7.4 MKD 2.4 8.7 23.4 36.8 28.7 3.1 12.8 25.2 35.4 23.5 2.8 10.7 24.3 36.1 26.2 MNE 0.2 4.5 21.6 42.7 31.1 0.4 5.4 22.2 43.7 28.4 0.3 4.9 21.9 43.2 29.8 POL 2.0 15.0 39.3 29.7 14.0 3.3 17.1 38.1 30.3 11.2 2.6 16.0 38.7 30.0 12.6 POR 2.2 17.8 36.1 32.4 11.4 2.3 18.0 36.3 31.8 11.7 2.3 17.9 36.2 32.1 11.6 ROM 0.9 5.3 18.5 39.1 36.2 0.5 5.5 21.0 39.7 33.2 0.7 5.4 19.7 39.4 34.8 RUS-MS 1.0 9.1 29.0 37.0 23.8 1.6 9.8 33.0 34.5 21.1 1.3 9.5 31.0 35.7 22.4 RUS-YK 0.0 8.9 22.8 38.8 29.6 1.4 9.8 28.9 36.5 23.4 0.7 9.4 26.0 37.6 26.3 SPA 4.2 13.9 38.7 28.7 14.5 6.6 18.6 39.7 23.8 11.2 5.4 16.1 39.2 26.4 12.9 SRB 0.4 5.1 22.2 47.5 24.8 1.2 7.5 25.4 45.8 20.0 0.8 6.3 23.8 46.7 22.5 SVK 0.7 9.2 33.6 40.9 15.6 1.1 9.8 34.8 38.8 15.5 0.9 9.5 34.2 39.9 15.6 TJK 4.9 30.2 24.0 28.3 12.6 6.3 32.7 24.7 26.2 10.0 5.6 31.4 24.4 27.3 11.3 65Report on the fifth round of data collection, 2018–2020 Table A2.20. Hours per day spent by boys and girls aged 6–9 years playing actively/vigorously at weekends (%) Country Boys Girls Total Never Less than 1 hour/ day About 1 hour/ day About 2 hours/ day About 3 or more hours/ day Never Less than 1 hour/ day About 1 hour/ day About 2 hours/ day About 3 or more hours/ day Never Less than 1 hour/ day About 1 hour/ day About 2 hours/ day About 3 or more hours/ day ARM 0.5 0.5 3.2 13.9 81.9 0.3 1.0 4.2 17.0 77.4 0.4 0.7 3.7 15.4 79.9 AUT 0.4 2.3 8.0 27.8 61.5 0.1 0.9 9.6 28.8 60.7 0.3 1.6 8.8 28.3 61.1 BUL 0.5 0.8 2.1 13.6 83.0 0.4 1.0 3.0 15.2 80.5 0.4 0.9 2.5 14.4 81.7 CRO 0.5 1.9 7.8 30.6 59.2 0.7 2.2 8.7 32.9 55.5 0.6 2.1 8.3 31.7 57.4 CZH 0.5 1.0 5.1 20.0 73.3 0.3 0.9 8.0 23.0 67.8 0.4 1.0 6.5 21.4 70.6 DEN 0.2 8.8 26.9 36.2 27.9 1.1 12.8 32.8 30.4 22.9 0.6 10.7 29.7 33.4 25.5 EST 0.0 3.2 9.3 23.7 63.8 0.3 1.9 9.0 27.5 61.3 0.1 2.6 9.2 25.5 62.6 GEO 1.1 3.2 5.8 23.9 66.0 1.3 4.5 7.4 24.2 62.5 1.2 3.8 6.6 24.1 64.3 GER-BR 0.3 3.4 12.0 32.9 51.3 1.2 4.5 14.0 29.2 51.0 0.8 3.9 13.0 31.1 51.2 GRE 0.2 6.5 14.1 31.3 47.8 0.2 8.9 26.5 37.9 26.5 0.2 7.8 20.4 34.7 36.9 HUN 0.5 1.2 7.4 25.6 65.4 0.4 1.5 7.8 25.3 65.0 0.4 1.3 7.6 25.4 65.2 IRE 0.2 2.8 12.0 31.8 53.2 0.0 3.5 10.5 33.0 52.9 0.1 3.1 11.3 32.4 53.1 KAZ 1.4 4.1 9.1 22.7 62.7 0.9 4.1 10.3 25.5 59.2 1.2 4.1 9.7 24.1 60.9 LTU 0.2 1.2 3.7 17.5 77.4 0.1 0.8 4.9 18.4 75.8 0.2 1.0 4.3 17.9 76.6 LVA 0.1 2.3 6.7 25.5 65.3 0.2 2.5 10.1 26.3 60.9 0.1 2.4 8.4 25.9 63.2 MAT 1.5 7.1 20.7 31.4 39.3 1.8 6.5 19.3 30.6 41.8 1.6 6.8 20.0 31.0 40.6 MKD 2.8 3.4 4.9 20.2 68.7 2.9 5.3 7.5 26.2 58.1 2.8 4.3 6.2 23.1 63.6 MNE 0.3 0.9 2.9 15.6 80.3 0.2 1.0 2.6 16.8 79.4 0.3 1.0 2.8 16.1 79.9 POL 1.5 4.9 19.7 34.5 39.4 2.9 6.8 23.4 33.2 33.7 2.2 5.8 21.5 33.9 36.6 POR 0.4 3.4 11.3 25.5 59.5 0.8 4.0 10.7 23.5 61.0 0.6 3.7 11.0 24.5 60.2 ROM 0.8 1.2 3.0 15.3 79.7 0.4 1.4 4.6 15.7 78.0 0.6 1.3 3.8 15.5 78.9 RUS-MS 0.2 2.4 7.0 26.4 64.0 0.5 1.8 7.4 32.1 58.2 0.3 2.1 7.2 29.4 61.0 RUS-YK 0.5 1.9 7.6 27.5 62.6 0.8 1.5 9.1 24.8 63.8 0.7 1.7 8.4 26.0 63.2 SPA 3.1 8.5 23.5 34.4 30.5 5.3 13.6 24.7 31.4 24.9 4.1 11.0 24.1 33.0 27.8 SRB 0.1 0.5 3.0 16.1 80.3 0.3 1.4 3.7 18.9 75.8 0.2 0.9 3.3 17.5 78.1 SVK 0.2 2.1 8.1 25.0 64.6 0.5 1.9 9.6 27.2 60.9 0.3 2.0 8.8 26.1 62.8 TJK 3.6 8.6 17.3 32.5 37.9 4.0 10.9 19.2 33.3 32.7 3.8 9.8 18.2 32.9 35.3 66 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.21. Country-specific prevalence and 95% CIs of children playing actively/vigorously for at least 1 hour a day by child’s gender and parental education (%) Country Child’s gender Parental education No. of children included in the analysis Boys Girls Total No. of children included in the analysis Low Medium High ARM 1947 95.1 [93.2–96.5] 93.0 [90.7–94.7] 94.1 [92.7–95.2] 1705 95.0 [92.7–96.6] 95.2 [91.4–97.4] 91.6 [88.3–94.0] AUT 1777 92.5 [89.9–94.4] 91.0 [86.7–94.1] 91.8 [89.3–93.7] 1680 92.8 [89.8–95.0] 89.5 [83.9–93.4] 91.2 [86.8–94.2] BUL 2988 94.9 [93.7–95.8] 95.0 [93.4–96.2] 94.9 [93.9–95.8] 2955 95.5 [94.0–96.6] 95.2 [92.9–96.8] 93.8 [90.9–95.8] CRO 5223 91.2 [89.9–92.4] 90.3 [89.0–91.4] 90.8 [89.7–91.7] 5070 91.8 [90.6–92.9] 90.6 [88.8–92.1] 88.4 [86.0–90.5] CZH 1936 95.9 [94.2–97.1] 94.2 [92.4–95.5] 95.0 [93.8–96.1] 1870 94.8 [92.6–96.3] 96.2 [94.0–97.6] 95.1 [92.1–97.0] DEN 914 71.1 [66.7–75.2] 67.4 [61.7–72.7] 69.4 [66.0–72.5] 888 72.8 [68.2–77.0] 67.6 [60.8–73.7] 64.3 [58.1–70.1] EST 1631 83.5 [81.0–85.7] 85.0 [82.7–87.0] 84.2 [82.4–85.8] 1518 87.9 [85.3–90.1] 85.3 [82.4–87.7] 79.1 [76.0–81.9] GEO 3323 90.6 [88.7–92.2] 87.9 [85.9–89.6] 89.3 [87.9–90.5] 3056 89.0 [87.1–90.7] 92.1 [88.9–94.5] 88.5 [85.9–90.7] GER-BR 1954 87.7 [85.5–89.7] 87.1 [84.8–89.0] 87.4 [85.5–89.1] 1639 89.7 [87.5–91.5] 86.6 [82.5–89.9] 84.2 [80.6–87.2] GRE 512 80.7 [74.2–85.8] 71.1 [63.7–77.6] 75.8 [70.8–80.2] 495 80.5 [68.1–88.9] 71.5 [63.8–78.1] 74.6 [66.6–81.2] HUN 3679 85.6 [83.3–87.6] 85.5 [83.3–87.4] 85.5 [84.1–86.8] 3530 88.5 [86.5–90.1] 83.8 [80.4–86.8] 80.0 [76.5–83.0] IRE 1065 88.6 [85.1–91.4] 85.4 [81.1–88.8] 87.1 [84.4–89.3] 974 86.4 [79.8–91.0] 85.2 [78.6–90.0] 88.3 [84.9–91.0] KAZ 5951 87.9 [86.2–89.4] 85.9 [83.9–87.6] 86.8 [85.2–88.3] 5573 84.3 [81.9–86.4] 89.4 [87.4–91.2] 89.3 [86.5–91.5] LTU 2852 93.0 [91.3–94.4] 92.9 [91.2–94.2] 92.9 [91.6–94.0] 2696 97.0 [95.5–98.0] 93.5 [91.6–95.0] 90.8 [88.7–92.4] LVA 6547 87.9 [86.3–89.2] 84.8 [83.2–86.3] 86.4 [85.1–87.6] 6225 90.8 [89.5–91.9] 87.2 [85.5–88.7] 82.1 [80.5–83.6] MAT 2783 71.3 [70.6–72.0] 70.1 [69.4–70.8] 70.7 [70.2–71.2] 2644 70.8 [70.1–71.5] 70.1 [69.0–71.2] 70.0 [68.9–71.1] MKD 2648 90.0 [87.0–92.4] 85.2 [82.1–87.8] 87.7 [85.2–89.8] 2417 85.7 [82.7–88.3] 91.2 [87.3–94.0] 90.5 [86.6–93.3] MNE 3083 96.1 [94.9–97.1] 95.5 [94.2–96.5] 95.8 [95.0–96.5] 2893 94.9 [93.8–95.9] 96.4 [94.7–97.6] 97.3 [95.6–98.3] POL 2231 82.6 [79.5–85.3] 78.2 [75.1–80.9] 80.4 [78.0–82.6] 2138 82.1 [78.6–85.1] 79.5 [75.8–82.8] 79.1 [74.6–83.0] POR 5999 85.0 [83.4–86.4] 84.7 [83.1–86.1] 84.8 [83.8–85.9] 5641 86.4 [85.1–87.6] 83.1 [80.6–85.3] 81.6 [78.4–84.3] ROM 8991 94.9 [94.2–95.5] 95.3 [94.3–96.2] 95.1 [94.5–95.6] 7937 96.3 [95.5–97.0] 95.6 [93.8–96.9] 94.0 [92.0–95.5] RUS-MS 1822 90.5 [88.3–92.3] 89.6 [87.4–91.4] 90.0 [88.4–91.4] 1717 87.1 [80.1–91.9] 90.4 [86.8–93.1] 90.0 [88.0–91.8] RUS-YK 847 92.0 [89.1–94.2] 90.2 [87.4–92.4] 91.0 [89.0–92.7] 809 92.7 [89.7–94.9] 90.0 [83.4–94.2] 90.3 [86.7–93.0] SPA 14 743 79.7 [78.5–80.8] 70.9 [69.5–72.2] 75.5 [74.5–76.4] 14 179 75.9 [74.5–77.2] 76.5 [74.8–78.2] 74.4 [72.5–76.3] SRB 2743 95.9 [94.5–97.0] 92.9 [90.7–94.6] 94.4 [93.1–95.5] 2660 95.4 [93.8–96.5] 93.8 [91.0–95.7] 93.2 [90.8–95.1] SVK 4976 92.1 [90.8–93.3] 91.0 [89.3–92.5] 91.6 [90.4–92.7] NA NA NA NA TJK 3179 67.6 [63.5–71.6] 62.5 [58.3–66.6] 65.1 [61.5–68.6] 2974 63.3 [59.2–67.3] 70.8 [65.7–75.5] 75.9 [67.8–82.5] 67Report on the fifth round of data collection, 2018–2020 Table A2.22. Hours per day spent by boys and girls aged 6–9 years watching TV or using electronic devices on weekdays (%) Country Boys Girls Total Never or less than 1 hour/day About 1 hour/day About 2 hours/day About 3 or more hours/day Never or less than 1 hour/day About 1 hour/day About 2 hours/day About 3 or more hours/day Never or less than 1 hour/day About 1 hour/day About 2 hours/day About 3 or more hours/day ARM 31.7 36.5 23.1 8.6 33.5 39.8 20.5 6.3 32.6 38.0 21.9 7.5 AUT 37.2 45.8 12.9 4.2 35.6 46.6 13.6 4.2 36.4 46.2 13.2 4.2 BUL 11.6 42.1 32.3 14.0 12.4 47.1 31.2 9.2 12.0 44.6 31.8 11.7 CRO 9.9 43.2 34.4 12.5 12.7 47.0 30.2 10.2 11.3 45.0 32.3 11.4 CZH 17.5 49.2 26.7 6.6 19.0 51.3 23.3 6.4 18.2 50.2 25.0 6.5 DEN 2.1 52.6 24.7 20.6 4.5 55.7 23.2 16.6 3.2 54.1 24.0 18.7 EST 5.3 25.5 39.8 29.4 7.0 34.2 40.9 17.9 6.1 29.7 40.4 23.8 GEO 16.9 43.0 27.4 12.7 20.7 46.1 24.1 9.0 18.7 44.5 25.8 10.9 GER-BR 43.8 37.7 13.4 5.1 50.1 33.7 10.7 5.5 46.9 35.7 12.1 5.3 HUN 26.4 47.3 20.3 6.0 30.8 46.2 18.3 4.7 28.5 46.8 19.3 5.4 IRE 19.4 41.8 29.8 9.0 21.8 43.0 28.1 7.1 20.5 42.4 29.0 8.1 ITA 7.8 28.0 31.5 32.8 11.3 34.3 29.2 25.2 9.5 31.1 30.4 29.1 KAZ 24.7 39.1 24.7 11.5 27.0 38.7 24.2 10.1 25.9 38.9 24.4 10.8 LTU 16.5 43.4 30.3 9.8 19.4 47.1 26.4 7.1 17.8 45.1 28.5 8.6 LVA 13.6 39.0 32.2 15.1 16.6 41.1 29.6 12.7 15.1 40.0 30.9 13.9 MAT 11.7 41.0 30.7 16.6 14.8 46.6 28.3 10.2 13.3 43.8 29.5 13.4 MKD 16.0 38.8 31.9 13.4 17.2 43.7 30.0 9.1 16.6 41.2 30.9 11.3 MNE 5.3 45.1 35.6 13.9 6.1 49.1 33.3 11.6 5.7 47.1 34.5 12.8 POL 17.5 42.4 27.5 12.6 24.8 39.4 27.9 8.0 21.1 40.9 27.7 10.3 POR 32.8 48.7 15.4 3.2 35.9 46.9 14.5 2.7 34.3 47.8 14.9 3.0 ROM 14.2 35.4 35.1 15.2 15.3 40.1 34.0 10.6 14.7 37.7 34.6 13.0 RUS-MS 30.3 43.7 20.2 5.8 32.0 41.7 20.2 6.1 31.2 42.7 20.2 6.0 RUS-YK 18.9 36.8 27.6 16.7 20.1 37.6 32.6 9.7 19.5 37.2 30.3 13.0 SMR 2.1 32.6 39.0 26.2 7.7 35.4 35.4 21.5 4.8 33.9 37.3 24.0 SPA 26.0 46.8 20.3 6.8 26.1 48.1 19.5 6.4 26.0 47.4 19.9 6.6 SRB 15.2 45.3 29.7 9.9 17.2 44.7 28.9 9.3 16.1 45.0 29.3 9.6 SVK 11.6 52.9 27.2 8.3 13.3 52.9 25.8 8.0 12.4 52.9 26.5 8.2 68 WHO European Childhood Obesity Surveillance Initiative (COSI) Table A2.23. Hours per day spent by boys and girls aged 6–9 years watching TV or using electronic devices at weekends (%) Country Boys Girls Total Never or less than 1 hour/day About 1 hour/day About 2 hours/day About 3 or more hours/day Never or less than 1 hour/day About 1 hour/day About 2 hours/day About 3 or more hours/day Never or less than 1 hour/day About 1 hour/day About 2 hours/day About 3 or more hours/day ARM 11.5 19.7 29.0 39.8 11.4 22.3 31.3 34.9 11.5 20.9 30.1 37.6 AUT 11.8 30.3 38.0 19.8 12.5 31.3 32.5 23.7 12.2 30.8 35.3 21.7 BUL 7.0 13.1 31.9 48.0 7.9 16.4 31.0 44.6 7.4 14.7 31.5 46.4 CRO 2.6 14.7 36.8 45.9 4.0 19.0 38.6 38.5 3.3 16.8 37.7 42.3 CZH 4.1 25.4 35.3 35.2 4.1 28.0 36.6 31.3 4.1 26.6 35.9 33.4 DEN 0.4 12.9 26.7 60.0 0.2 17.5 30.2 52.1 0.3 15.1 28.4 56.3 EST 3.1 12.3 26.9 57.8 3.7 15.7 36.2 44.4 3.4 13.9 31.4 51.3 GEO 9.0 20.7 30.9 39.4 9.9 23.5 34.2 32.4 9.4 22.1 32.5 36.0 GER-BR 12.8 32.6 30.3 24.4 18.4 35.2 25.6 20.8 15.5 33.9 28.0 22.6 HUN 4.6 20.6 32.2 42.5 5.8 22.2 33.2 38.8 5.2 21.4 32.7 40.7 IRE 2.6 12.3 31.1 53.9 1.7 11.4 38.2 48.7 2.2 11.9 34.5 51.4 ITA 2.1 5.1 11.1 81.7 3.3 7.6 16.0 73.2 2.7 6.3 13.5 77.5 KAZ 15.5 22.4 32.1 30.0 16.3 25.4 29.3 29.0 15.9 23.9 30.7 29.5 LTU 5.8 21.6 36.0 36.6 7.7 24.2 38.0 30.1 6.7 22.8 36.9 33.5 LVA 3.2 14.2 32.5 50.0 4.2 15.4 34.1 46.3 3.7 14.8 33.3 48.2 MAT 4.3 17.3 32.1 46.3 5.4 22.7 36.1 35.8 4.9 20.0 34.1 41.0 MKD 8.9 19.9 34.9 36.4 9.3 25.1 35.0 30.6 9.1 22.4 34.9 33.6 MNE 4.9 26.9 37.6 30.5 5.0 29.3 37.7 28.0 4.9 28.1 37.7 29.3 POL 3.4 14.9 34.6 47.2 4.8 20.4 36.2 38.6 4.1 17.6 35.4 42.9 POR 3.3 20.5 36.9 39.3 6.3 25.3 33.9 34.5 4.8 22.9 35.4 36.9 ROM 6.6 17.0 31.9 44.5 6.7 19.1 37.6 36.6 6.6 18.0 34.7 40.7 RUS-MS 11.6 25.6 32.1 30.7 12.6 26.0 33.4 28.1 12.1 25.8 32.7 29.4 RUS-YK 9.3 23.1 30.7 36.9 9.0 24.1 35.4 31.6 9.1 23.6 33.2 34.1 SMR 0.7 2.1 10.6 86.5 2.3 3.8 15.4 78.5 1.5 3.0 12.9 82.7 SPA 4.8 18.3 36.1 40.8 6.1 19.8 36.6 37.4 5.4 19.1 36.4 39.1 SRB 7.9 22.8 38.5 30.8 8.5 25.6 37.4 28.5 8.2 24.2 38.0 29.7 SVK 2.7 18.0 36.8 42.5 3.0 20.7 36.6 39.7 2.9 19.3 36.7 41.1 69Report on the fifth round of data collection, 2018–2020 Table A2.24. Country-specific prevalence and 95% CIs of children watching TV or using electronic devices for at least 2 hours a day by child’s gender and parental education (%) Country Child’s gender Parental education No. of children included in the analysis Boys Girls Total No. of children included in the analysis Low Medium High ARM 1939 33.3 [30.2–36.5] 28.1 [23.7–32.9] 30.9 [28.1–33.8] 1698 34.3 [29.5–39.4] 26.8 [21.2–33.4] 28.3 [24.2–32.8] AUT 1804 17.2 [14.0–21.0] 18.4 [15.0–22.3] 17.8 [15.5–20.3] 1707 23.4 [20.4–26.6] 12.1 [8.7–16.6] 7.1 [4.7–10.6] BUL 3018 46.2 [42.4–50.0] 40.3 [36.8–44.0] 43.3 [40.2–46.5] 2986 50.3 [45.9–54.7] 37.2 [32.5–42.2] 32.8 [28.8–37.0] CRO 5314 48.0 [45.7–50.3] 41.2 [39.2–43.2] 44.7 [43.0–46.4] 5165 49.2 [47.2–51.2] 40.0 [37.3–42.8] 37.7 [34.6–40.9] CZH 1896 34.0 [29.9–38.3] 30.8 [27.1–34.8] 32.4 [29.2–35.9] 1837 41.3 [37.5–45.3] 26.2 [22.4–30.5] 16.7 [12.7–21.7] DEN 826 47.9 [42.8–53.1] 42.1 [37.9–46.5] 45.2 [41.8–48.6] 804 46.3 [40.8–51.9] 46.2 [38.5–54.1] 42.1 [37.3–47.1] EST 1557 69.7 [66.6–72.5] 58.3 [55.5–61.0] 64.1 [61.7–66.5] 1456 69.9 [66.0–73.5] 70.7 [66.9–74.3] 57.3 [53.7–60.9] GEO 3160 39.4 [36.6–42.3] 32.6 [30.0–35.3] 36.1 [34.1–38.2] 2917 35.9 [33.3–38.6] 36.8 [31.6–42.3] 36.1 [32.5–39.8] GER-BR 2046 19.4 [15.7–23.6] 17.5 [13.9–21.8] 18.5 [15.1–22.3] 1714 26.8 [23.2–30.7] 16.4 [12.6–21.1] 6.7 [4.8–9.3] HUN 3761 28.8 [25.6–32.2] 25.7 [22.4–29.4] 27.3 [24.6–30.1] 3597 39.9 [36.4–43.4] 16.0 [13.3–19.1] 12.1 [9.4–15.4] IRE 1096 44.3 [40.2–48.5] 42.2 [36.4–48.3] 43.3 [39.5–47.3] 1004 54.8 [48.1–61.3] 50.5 [43.9–57.0] 34.8 [29.5–40.5] ITA 35 308 76.9 [76.0–77.7] 67.1 [66.1–68.0] 72.1 [71.4–72.8] 32 439 76.0 [75.2–76.8] 69.2 [67.7–70.6] 60.3 [58.2–62.3] KAZ 5753 34.9 [32.4–37.5] 32.9 [30.6–35.3] 33.9 [31.8–36.1] 5410 31.1 [28.3–34.1] 36.6 [33.2–40.1] 36.0 [32.6–39.5] LTU 3134 39.6 [36.2–43.1] 32.9 [29.9–36.1] 36.4 [33.7–39.2] 2968 44.3 [40.5–48.3] 41.2 [37.7–44.7] 30.7 [27.2–34.5] LVA 6755 48.0 [45.4–50.7] 42.8 [40.3–45.4] 45.5 [43.1–47.9] 6432 55.3 [53.0–57.6] 44.8 [42.0–47.6] 38.5 [35.5–41.6] MAT 2949 47.7 [46.9–48.4] 38.0 [37.3–38.7] 42.8 [42.3–43.3] 2800 46.5 [45.7–47.2] 43.8 [42.7–45.0] 31.5 [30.5–32.6] MKD 2567 44.5 [40.2–48.9] 39.6 [35.0–44.4] 42.1 [38.3–46.0] 2340 40.7 [36.6–44.9] 45.2 [38.3–52.3] 43.2 [36.5–50.2] MNE 3070 45.7 [42.6–48.9] 41.9 [39.3–44.5] 43.9 [41.5–46.3] 2888 44.8 [42.0–47.5] 44.4 [40.0–48.8] 39.8 [34.5–45.4] POL 2389 41.8 [38.6–45.1] 36.7 [33.0–40.5] 39.3 [36.6–42.0] 2290 48.0 [44.7–51.4] 40.5 [36.2–45.0] 27.7 [24.7–30.9] POR 6051 21.2 [19.4–23.1] 19.2 [17.5–21.0] 20.2 [18.9–21.5] 5680 22.5 [20.8–24.3] 19.0 [16.5–21.7] 15.0 [12.8–17.5] ROM 8875 50.1 [47.7–52.6] 43.9 [41.4–46.5] 47.2 [44.9–49.5] 7881 53.4 [51.0–55.7] 48.8 [44.4–53.1] 35.1 [30.6–40.0] RUS-MS 1816 26.4 [22.8–30.3] 26.7 [23.0–30.8] 26.5 [23.5–29.8] 1718 38.8 [32.1–46.0] 35.2 [30.0–40.9] 21.8 [19.1–24.8] RUS-YK 853 43.3 [38.5–48.3] 41.5 [36.7–46.4] 42.3 [39.3–45.5] 814 55.5 [49.5–61.4] 40.0 [34.0–46.4] 36.4 [31.3–41.8] SMR 271 80.1 [79.6–80.6] 67.7 [67.1–68.3] 74.2 [73.8–74.5] 256 77.6 [77.0.1–78] 72.2 [71.3–73.1] 64.9 [63.7–66.0] SPA 16 537 28.0 [26.2–29.9] 25.7 [24.1–27.4] 26.9 [25.4–28.5] 15 857 32.1 [30.4–33.9] 22.3 [20.5–24.2] 18.8 [16.8–20.9] SRB 2762 38.8 [35.1–42.7] 37.1 [33.8–40.4] 38.0 [35.0–41.0] 2681 42.2 [39.0–45.6] 35.9 [31.5–40.6] 31.8 [27.6–36.3] SVK 4892 35.9 [32.7–39.3] 33.6 [30.7–36.6] 34.8 [32.1–37.6] NA NA NA NA 70 WHO European Childhood Obesity Surveillance Initiative (COSI)

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