WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children: report of the third round of data collection 2012–2013

WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Report of the third round of data collection 2012–2013 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Report of the third round of data collection 2012–2013 Abstract Surveillance data on the prevalence of overweight and obesity among children and adolescents are essential to inform the development of effective policies and strategies to tackle the challenge of childhood obesity in the WHO European Region. In response to this need, the WHO Regional Office for Europe established the WHO European Childhood Obesity Surveillance Initiative (COSI) in 2007. The third round of data collection took place during the 2012–2013 school year and included assessment of more than 250 000 primary school-aged children in 19 countries and collection of information about the participating schools. In addition, 17 of the countries collected further data on the school environment, and 11 countries collected data on fami- ly diet and physical activity. The systematic collection of these data and their analysis enable intercountry comparisons and a better understanding of the progression of childhood overweight and obesity in Europe, clearly showing that childhood obesity remains a ma- jor public health problem in the WHO European Region. Keywords Child nutritional sciences Obesity-prevention and control Public health surveillance Body height Body weight Nutrition policy Schools - education Cross-sectional studies Health plan implementation Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). Document number: WHO/EURO:2018-2980-42738-59613 © World Health Organization 2018 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by au- thors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. iii Contents Abstract ii Contents iii Abbreviations and acronyms iv Acknowledgements iv Contributors vi Executive summary 1 1. Introduction 3 2. Methods 4 2.1 Study design and sampling strategy 4 2.2 Data collection forms and procedures 8 3. Overweight and obesity among children aged 6–9 years 13 3.1 Data elaboration 13 3.2 Prevalence by age group, sex and country 14 4. Eating habits and physical activity among children aged 6–9 years 16 4.1 Data elaboration 16 4.2 Dietary behaviour 20 4.3 Physical activity behaviour 26 5. School environment 36 5.1 Data elaboration 36 5.2 School characteristics 37 6. References 43 Annex 1. Prevalence of overweight (including obesity) and obesity (definition of the International Obesity Task Force) in boys and girls aged 6–9 years, by age and country 46 Annex 2. COSI record forms 47 iv WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Abbreviations and acronyms BMI body mass index COSI Childhood Obesity Surveillance Initiative SD standard deviation PSU primary sampling unit SSU secondary sampling unit SU sampling unit TSU tertiary sampling unit Acknowledgements This document is the official report of the third round of data collection in the WHO European Childhood Obesity Sur- veillance Initiative (COSI). This report was prepared by a drafting group including Wolfgang Ahrens, Joao Breda, Marta Buoncristiano, Ana Rito, Angela Spinelli, Stephen Whiting and Norman Wirsik. Implementation of COSI during the 2012– 2013 school year was made possible by the following partners and institutions: Albania: Institute of Public Health Belgium: The Flemish Agency for Care and Health Bulgaria: Ministry of Health, the National Centre for Public Health and Analyses and Regional Health Inspections; bien- nial collaborative agreement between the Ministry of Health and the WHO Regional Office for Europе Czechia: Institute of Endocrinology; biennial collaborative agreement between the Ministry of Health and the WHO Regional Office for Europе Greece: Hellenic Medical Association for Obesity; Alexander Technological Educational Institute, Thessaloniki Ireland: National Nutrition Surveillance Centre, University College Dublin; Healthy Eating and Active Living Programme, Health Service Executive Italy: Ministry of Health Latvia: Centre for Disease Prevention and Control, Ministry of Health Lithuania: Department of Preventive Medicine, Lithuanian University of Health Sciences Malta: Primary Health Care Norway: Norwegian Institute of Public Health; Ministry of Health and Care Services Portugal: Ministry of Health Institutions: Directorate General of Health; National Institute of Health Dr Ricardo Jorge; regional health directorates of Algarve, Alentejo, Açores, Centro, Lisbon and Tagus Valley, Madeira and Norte Republic of Moldova: National Agency for Public Health Romania: National Institute of Public Health; public health directorates of counties San Marino: State Secretariat for Health and Social Security Slovenia: Faculty of Sport, University of Ljubljana vSpain: Spanish Agency of Consumers Affairs, Food Safety and Nutrition The former Yugoslav Republic of Macedonia: Ministry of Health; Institute of Public Health Turkey: Public Health Institution, Ministry of Health; World Bank in Turkey The WHO Regional Office for Europe gratefully acknowledges the financial support of the Government of the Russian Federation for the preparation of this report by the WHO European Office for Prevention and Control of Noncommu- nicable Diseases; the European Commission for financial support for round 3 of COSI; and the ministries of health of Croatia, Greece, Malta and the Russian Federation for financial support for the meetings at which the data collection procedures and analyses were discussed. The WHO Regional Office for Europe also sincerely thanks Dr Harry Rutter, Oxford, United Kingdom, for overall advice on the design of COSI and its protocol. vi WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Contributors Albania Jolanda Hyska, Arjan Bregu, Genc Burazeri, Institute of Public Health Belgium Laurence Doughan, Federal Public Service of Public Health, Food Security Chain and Environment Machtel Wauters, Flemish Agency for Care and Health Bulgaria Vesselka Duleva, Ekaterina Chikova-Iscener, National Centre of Public Health and Analyses Czechia Marie Kunesova, Institute of Endocrinology Greece Maria Hassapidou, Hellenic Medical Association for Obesity; Alexander Technological Educational Institute of Thessaloniki Ireland Cecily Kelleher, Mirjam Heinen, National Nutrition Surveillance Centre at University College Dublin; Healthy Eating and Active Living Programme, Health Service Executive Italy Angela Spinelli, Paola Nardone, National Centre for Disease Prevention and Health Promotion, National Institute of Health Daniela Galeone, General Directorate of Prevention, Ministry of Health Latvia Iveta Pudule, Biruta Velika, Centre for Disease and Prevention Control Lithuania Ausra Petrauskiene, Department of Preventive Medicine, Lithuanian University of Health Sciences Malta Victoria Farrugiaa Sant’Angelo, Primary Health Care Norway Anna Biehl, Jorgen Meisfjord, Ragnhild Hovengen, Norwegian Institute of Public Health Portugal Ana Rito, Pedro Graça, National Institute of Health Dr Ricardo Jorge Republic of Moldova Galina Obreja, National Agency for Public Health, State University of Medicine and Pharmacy Romania Constanta Huidumac Petrescu, Rodica Nicolescu, National Institute of Public Health San Marino Andrea Gualtieri, State Secretariat for Health and Social Security Slovenia Gregor Starc, Faculty of Sport, University of Ljubljana vii Spain Napoleon Perez-Farinos, M Angeles Dal Re, Spanish Agency of Consumers Affairs, Food Safety and Nutrition The former Yugoslav Republic of Macedonia Igor Spiroski, Physiology and Monitoring of Nutrition, Institute of Public Health Turkey Nazan Yardim, Sibel Gogen, Şeniz Ilgaz, Faika Betül Aydin, Public Health Institution, Ministry of Health WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow João Breda, Head Enrique Loyola, Noncommunicable Diseases Surveillance Coordinator Stephen Whiting, Technical Officer Karen McColl, Consultant Marta Buoncristiano, Consultant Leibniz Institute for Prevention Research and Epidemiology, WHO Collaborating Centre, Germany Wolfgang Ahrens, Deputy Director, Head of Department Norman Wirsik, Scientific Manager WHO Regional Office for Europe, Copenhagen Gauden Galea, Division Director, Noncommunicable Diseases and Promoting Health through the Life-course Ms Liza Jane Villas, Programme Assistant, Nutrition, Physical Activity and Obesity Ms Jelena Jakovljevic, Consultant 1 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Executive summary Childhood obesity is associated with a wide range of serious health and social consequences in childhood and higher risks of premature death and disability in adulthood. Prevention is recognized as the only feasible option for curbing the epidemic, and surveillance data on the prevalence of overweight and obesity among children and adolescents are es- sential to inform the development of effective policies and strategies. In response to the critical need for standardized surveillance data, the WHO Regional Office for Europe established the WHO European Childhood Obesity Surveillance Initiative (COSI) in 2007. This population-based system consists of stan- dardized, harmonized, systematic monitoring of the prevalence of overweight and obesity (based on measurements) among primary-school children (aged 6.0–9.9 years). The common COSI protocol establishes the main characteristics of study design and sampling strategy but, by including a combination of mandatory and voluntary components, also affords participating countries some flexibility for adapting the system to their national context. This enables the moni- toring of trends in the epidemic as well as comparisons of countries in the European Region. Thirteen Member States participated in the first round of COSI data collection in 2007–2008, and a further four coun- tries joined the second round in 2009–2010. In the first and second rounds, the prevalence of overweight among boys ranged from 19.3% and 18.0% of 6-year-olds in Belgium to 49.0% of 8-year-olds in Italy and 57.2% of 9-year-olds in Greece, respectively. In girls, the prevalence varied from 18.4% in Belgium to 42.6% of 8-year-olds in Italy and 50.0% of 9-year-olds in Greece, respectively. Data were collected for the third round of COSI in 19 countries during the 2012–2013 school year.1 All participating countries collected anthropometrics, and most (17/19) collected data about the schools on a mandatory record form. In addition, 17 countries collected data about the school environment on an optional record form. Furthermore, 11 coun- tries provided data on simple indicators of children’s dietary intakes and physical and inactivity patterns, family socioeco- nomic characteristics and co-morbid conditions associated with obesity collected on a voluntary family record form. Over 250 000 children were measured and weighed according to the COSI protocol. The prevalences of overweight and obesity were calculated by age group for children in the defined target group, with the cut-offs recommended by WHO to compute Z-scores for body mass index (BMI) for age. The prevalence of overweight (including obesity) and obesity in boys and girls aged 6–9 years in the 19 countries that participated in the third round of COSI is presented in Fig. 1. The prevalence of overweight ranged from 18% to 52% in boys and from 13% to 43% in girls, and the prevalence of obesity ranged from 6% to 28% among boys and from 4% to 20% among girls. The data suggest an increasing north−south gradient, with the highest prevalences of overweight and obesity in south- ern European countries. In the countries that collected data for more than one age group, the prevalence of overweight and obesity tended to increase with age. According to WHO definitions, more boys than girls were overweight and obese in most age groups, particularly at older ages, and in most countries. Data were also collected on eating habits and physical activity patterns, which are closely linked to the energy imbalance that results in children becoming overweight and obese. There was considerable variation among countries in the fre- quency of consumption of healthy and less healthy food items, with less difference between boys and girls within coun- tries. Countries also varied considerably in indicators of physical activity, such as going to school on foot or by bicycle, attending a sports or dance club and time spent playing outside, media consumption and sleep duration. There was little variation between boys and girls within countries. The frequency of walking or cycling to school appeared to be associat- ed with parents’ perceptions of the safety of the route and the distance to school. Given the importance of schools for promoting child health and establishing lifelong habits, data were also collected on aspects of the school environment related to nutrition and physical activity. Countries varied widely in the school nu- trition environment score, which is based on the possibility of obtaining two healthy food items and three less healthy items. The mean duration of physical education classes per week varied from 62 to 187 min, and the provision of at least 1 h of physical education per week was not realized in all schools in several countries. The proportion of schools that in- troduced healthy lifestyle initiatives or projects varied by country, ranging from 57% to over 90%. 1 Albania, Belgium (Flanders only), Bulgaria, Czechia, Greece, Ireland, Italy, Latvia, Lithuania, Malta, Norway, Portugal, Republic of Moldova, Romania, San Marino, Spain, Slovenia, the former Yugoslav Republic of Macedonia and Turkey. 2Systematic data collection for COSI provides a better understanding of the progression of childhood overweight and obesity in Europe and of related factors, such as eating habits, physical activity patterns and school environments. As- sessment of more than 250 000 primary school-aged children in 19 countries during the third round of data collection clearly shows that childhood obesity remains a major public health problem in the European Region. Fig. 1. Prevalence of overweight (including obesity) and obesity (WHO definition) in boys and girls aged 6-9 years, by age and country, COSI round 3 (2012–2013) 37 43 44 32 52 28 25 34 48 42 28 24 44 22 24 25 27 43 33 19 33 25 26 24 38 23 30 23 25 28 18 31 33 37 29 43 29 22 31 42 33 23 24 40 23 20 23 26 40 36 13 33 21 22 25 43 20 27 25 22 26 19 16 19 21 12 28 12 9 15 24 21 14 7 23 8 10 12 12 19 15 7 18 9 11 8 22 10 14 10 10 13 6 10 7 13 8 20 10 8 10 16 17 8 7 15 7 5 7 9 15 13 4 16 7 7 7 16 6 11 9 7 10 5 60 50 40 30 20 10 0 10 20 30 40 50 60 SVN SMR ITA IRE GRE BEL TUR SVN SPA SMR ROM NOR ITA BEL ALB TUR SVN SPA POR MDA MAT LVA LTU IRE GRE CZH BUL BEL SVN MKD BEL 9- ye ar- ol ds 8- ye ar- ol ds 7- ye ar- ol ds 6- ye ar- ol ds Percentage Boys Girls Girls obese Boys obese Girls overweight Boys overweight 3 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children 1. Introduction Obesity in children remains an important public health problem in the WHO European Region. It is unequally distributed within and between countries and population groups (1,2). Childhood obesity is a multifactorial disease associated with a wide range of serious health and social consequences, including higher risks for premature death and disability in adulthood (3). Children with a high body mass index (BMI) often become obese adults (4). Obesity is strongly associated with risk factors for cardiovascular disease and diabetes (5), orthopaedic problems and mental health problems (3). Underachievement at school and lower self-esteem have also been linked to childhood obesity (6). Obesity arises from a combination of exposure of the child to an unhealthy, obesogenic environment (7), in which there is an imbalance between energy intake and energy expenditure, and inade- quate behavioural and biological responses to the environment (2). Prevention is recognized as the only feasible option for curbing the epidemic. Nutritional surveillance data are essential to effectively design, implement and evaluate policies and strategies for counteracting obesity (8). At the first consulta- tion of Member States (Copenhagen, October 2005) that led to the WHO European Ministerial Conference on Counter- acting Obesity (Istanbul, 15–17 November 2006), it was recognized that standardized, harmonized surveillance systems were required as a basis for policy development in the WHO European Region (8). It was acknowledged that regular assessments, based on measured weight and height, of the prevalence of overweight and obesity among children and adolescents were not commonly conducted in the Member States of the Region (9-11). In response, the WHO Regional Office for Europe and 13 Member States established the WHO European Childhood Obesity Surveillance Initiative (COSI) in 2007, for systematic collection, analysis, interpretation and dissemination of descriptive information for use in monitoring excess bodyweight and in programme planning and evaluation (12). The importance of such surveillance was reinforced in the Vienna Declaration on Nutrition and Noncommunicable Diseases in the Context of Health 2020 (13) and in the Report of the Commission on Ending Childhood Obesity (2). The establishment of COSI was the beginning of population-based monitoring of measured overweight and obesity among primary-school children in the WHO European Region. This age group (6.0–9.9 years) is important because it precedes puberty and can predict the condition in adulthood. Moreover, at the age of about 6 years, the “adiposity re- bound”, the onset of the second period of a rapid increase in body fat, begins (14,15). The aim of COSI is to measure trends in childhood overweight and obesity routinely in order to obtain a correct under- standing of the progress of the disease in this population group. Such measurements allow intercountry comparisons within the European Region, which are important for identifying effective policies to reverse the trend. Although each country is free to develop a system appropriate to its local circumstances, data must be collected according to an agreed common protocol (16) that includes a number of stipulated core items. The protocol was developed for the first COSI round (2007–2008) by 13 Member States – Belgium, Bulgaria, Cyprus, Czechia, Ireland, Italy, Latvia, Lithuania, Malta, Norway, Portugal, Slovenia and Sweden – and has been continually updated. Four new countries joined COSI for the sec- ond round (2009–2010): Greece, Hungary, Spain and the former Yugoslav Republic of Macedonia. In the first and second rounds, the prevalence of childhood overweight among boys varied from 19.3% and 18.0% of 6-year-olds in Belgium to 49.0% of 8-year-olds in Italy and 57.2% of 9-year-olds in Greece. In girls, the prevalence varied from 18.4% in Belgium to 42.6% of 8-year-olds in Italy and 50.0% of 9-year-olds in Greece (17). In both rounds, multi-country comparisons suggested the presence of a north−south gradient, with the highest prevalence of over- weight in southern European countries. Between rounds 1 and 2, the highest significant decrease in the prevalence of overweight was found in countries in which there were higher absolute BMI values in round 1 (i.e. Italy, Portugal and Slovenia), and the highest significant increase was found in countries in which there were lower BMI values in round 1 (i.e. Latvia and Norway) (18). This document is the official WHO report of the third round of COSI data collection in the 2012–2013 school year. It de- scribes the methods used and presents the main results, including trends in overweight and obesity in relation to previ- ous data collection rounds. 42. Methods 2.1 Study design and sampling strategy The third COSI data collection round was conducted in 19 countries in the 2012–2013 school year. Surveillance was conducted for the first time in five countries (Albania, Republic of Moldova, Romania, San Marino and Turkey), while the other 14 countries had participated in at least one of the two previous rounds (Belgium (only Flanders), Bulgaria, Cze- chia, Greece, Ireland, Italy, Latvia, Lithuania, Malta, Norway, Portugal, Spain, Slovenia and the former Yugoslav Republic of Macedonia).2 Data were collected by a common protocol devised in 2007 by the WHO Regional Office for Europe and Member States (19), which was slightly amended for COSI 2 and 3 (16,17). The protocol defines the limits within which each participat- ing country can create a surveillance system that both matches its own national characteristics and allows comparisons with those of the other countries. The main characteristics of the study design and sampling strategy in the COSI protocol are:3 • The surveillance system target population is primary school-age children. More specifically, participating countries can select one or more of the following four age groups: 6.0–6.9, 7.0–7.9, 8.0–8.9 or 9.0–9.9 years. • Primary schools are the settings for enrolment. As education is compulsory in all countries in the European Region, most children can easily be reached through the education system. Moreover, primary schools are of interest be- cause they play an important role in influencing children’s behaviour regarding nutrition and physical activity and can be settings for the promotion of healthy lifestyles. • Given the differences among school systems, age at starting school, number of children held back and level of pu- pils’ advancement in countries, it appeared at first that it would be difficult to find a uniform – and equally appli- cable – approach to the selection of children. It was therefore suggested that age be the first inclusion criterion. If all children in the targeted age group are in the same grade, only that grade should be included. If the targeted age group is spread across grades, however, all grades in which the majority are children in the selected age group should participate. • COSI has a semi-longitudinal design repeated at defined intervals. For each data collection round, a new cross-sec- tional sample of children of the same age group is selected. Countries may opt for a prospective cohort design, in which the initial sample of children is followed up for one round. Countries may also choose to include all children in the target age group, instead of selecting a sample. • Countries that participated in a previous round of data collection can choose to select a new sample of schools or fol- low a sentinel site approach, i.e. involve the same schools that were selected previously. • COSI should be integrated into existing surveillance systems if possible, to avoid duplication or an additional burden for countries. Table 1 provides an overview of the main characteristics of the study design in each country that participated in COSI round 3. Children were enrolled at primary schools in all countries except Czechia, where they were selected in paedi- atric clinics because COSI had been integrated into the mandatory health checks performed by paediatricians. Belgium and Slovenia targeted all four age groups, while most countries selected 7-year-old children (Bulgaria, Czechia, Greece, Ireland, Latvia, Lithuania, Malta, Portugal, Republic of Moldova, Spain and Turkey). Albania, Italy, Norway, Romania and San Marino targeted only older children. The former Yugoslav Republic of Macedonia is the only country that studied only 6-year-old children. Belgium included the entire population of interest (all children in first and third grade prima- ry-school classes), as did Malta and San Marino (all children in third-grade primary-school classes). Other countries se- lected a nationally representative sample. Of the 14 countries that had participated in the first or second round of COSI data collection, six adopted a sentinel approach (Bulgaria, Ireland, Lithuania, Norway, Portugal and the former Yugoslav Republic of Macedonia). COSI was integrated into routinely monitored measurements in Belgium, Czechia, Malta and Slovenia but was newly established in the other countries. 2 Only Flanders participated in COSI round 3, while the data collected in all the other countries are nationally representative. 3 More details on the COSI 2012 protocol and on previous versions are provided elsewhere (15,18). 5 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Table 1. Main characteristics of study design in each country participating in COSI round 3 Country Targeted age groups Inclusion of a sample or of all children in targeted grades of primary school Participation in previous COSI rounds of data collection Sentinel approach Albania 8 Sample No – Belgiuma 6, 7, 8, 9 All children in target grades Yes, in 2007/8 and 2009/10 – Bulgaria 7 Sample Yes, in 2007/8 Yes Czechia 7 Sample Yes, in 2007/8 and 2009/10 No Greece 7, 9 Sample Yes in 2009/10 No Ireland 7, 9 Sample Yes, in 2007/8 and 2009/10 Yes Italy 8, 9 Sample Yes, in 2007/8 and 2009/10 No Latvia 7 Sample Yes, in 2007/8 and 2009/10 No Lithuania 7 Sample Yes, in 2007/8 and 2009/10 Yes Malta 7 All children in target grades Yes, in 2007/8 and 2009/10 – Republic of Moldova 7 Sample No – Norway 8 Sample Yes, in 2007/8 and 2009/10 Yes Portugal 7 Sample Yes, in 2007/8 and 2009/10 Yes San Marino 8, 9 All children in target grades No – Romania 8 Sample No – Spain 7, 8 Sample Yes, in 2009/10 No Slovenia 6, 7, 8, 9 Sample Yes, in 2007/8 and 2009/10 No The former Yugoslav Republic of Macedonia 6 Sample Yes, in 2009/10 Yes Turkey 7, 8 Sample No – The setting in all countries was primary schools. –, not applicable. aOnly Flanders was involved in COSI round 3. Table 2 shows the main features of the sampling design used in countries that did not include the whole population of targeted children. All countries used cluster sampling; 10 of 16 used a two-stage sampling design, with primary schools as the primary and classes as the secondary sampling units. Norway also adopted a two-stage cluster sampling design but with counties as the primary and schools as the secondary sampling unit. Four countries implemented a simple clus- ter sampling design: Italy selected third-grade classes, Greece and Latvia primary schools and Czechia paediatric clinics. Spain used provinces as the primary sampling units, schools as the secondary sampling units and classes as tertiary sampling units. Stratification was applied in 10 of 16 countries. Although they used different variables, many considered a geographical or administrative division of the national territory and the degree of urbanization of the child’s place of residence or school location. 6All primary schools in Malta and San Marino participated in COSI round 3. The number of schools in Belgium that partici- pated in COSI round 3 was not available. Table 2. Main features of sampling design used in COSI round 3, by country Country Cluster sampling design Sampling unit definition Stratification Sampling units approached and proportion that participated (%) PSU/SU SSU Albania Two-stage stratified PSU: primary schools SSU: 2nd and 3rd grades By degree of urbanization 104 (100.0) 208 (100.0) Bulgaria Two-stage PSU: primary schools SSU: 1st grade No 185 (100.0) 191 (100.0) Czechia Stratified SU: paediatric clinics By region and degree of urbanization 91 (100.0) – Greece Cluster sampling SU: primary schools (2nd and 4th grades) No 186 (97.3) – Ireland Two-stage stratified PSU: primary schools SSU: 1st and 3rd grades By school size 194 (82.0) 330 (81.2) Italy Stratified SU: 3rd grade By region 2 622 (100.0) – Latvia Stratified SU: primary schools (1st grade) By degree of urbanization and language of instruction 140 (100.0) – Lithuania Two-stage stratified PSU: primary schools SSU: 1st grade By district and degree of urbanization 122 (NA)a 249 (NA)a Norway Two-stage PSU: counties SSU: primary schools (3rd grade) No 10 (100.0) 131 (96.2) Portugal Two-stage PSU: primary schools SSU: 1st and 2nd grades No 200 (100.0) 440 (NA)a Republic of Moldova Two-stage PSU: primary schools SSU: 1st grade No 203 (100.0) 203 (100.0) Romania Two-stage stratified PSU: primary schools SSU: 1st and 2nd grade By county and degree of urbanization 205 (100.0) 507 (NA)a Spain Three-stage stratified PSU: provinces SSU: schools TSU: classes (2nd and 3rd grades) By region and size of municipal population 130 (53.8) 250 (NA) Slovenia Two-stage PSU: primary schools SSU: 1st, 2nd and 3rd grades No 232 (100.0) 1333 (100.0) The former Yugoslav Republic of Macedonia Two-stage stratified PSU: primary schools SSU: 1st grade By regional, centres of public health and degree of urbanization 113 (96.5) 237 (NA)a Turkey Two-stage stratified PSU: primary schools SSU: 2nd grade By region 216 (100.0) 216 (100.0) –, not applicable; NA, not available; PSU, primary sampling unit; SSUs, secondary sampling unit; TSUs, tertiary sampling unit; SU, sampling unit. a Number of sampling units that participated in the survey; the number of units approached was not available. 7 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Table 3 shows, for each country, the number of children who were invited to participate in COSI round 3, the proportion who took part in measurements and whose parents completed the family form and the numbers of measured children in the targeted age groups. According to the COSI protocol, the minimum final effective sample size4 should be 2800 children per target age group (1400 girls and 1400 boys). In order to compensate for the eventual loss of children who do not participate in the study or are not in the target age group, the overall number of children to be sampled should be higher. The sample size should be considerably increased in countries that choose to make estimates for subnational levels. In COSI round 3, the number of children selected differed by country because of differences in study design and sam- pling strategy. The level of participation in the study was high: at least 90% of selected children took part in five coun- tries (Albania, Italy, Malta, San Marino and Slovenia) and 80–87% in Bulgaria, Latvia, Norway, Portugal, Republic of Mol- dova and Turkey. Ireland had the lowest level of participation (59%).5 The effective sample size varied widely among countries that used a sampling approach, ranging from around 1000 measured children per target age group in Ireland to more than 15 000 in Italy. Moreover, the sample size was much lower than that recommended in the COSI protocol in Czechia, Ireland and Spain (1000–1800 measured children per age group instead of 2800). In Greece, Lithuania, Portugal, Republic of Moldova, the former Yugoslav Republic of Mace- donia and Turkey, 2100–2700 children were measured per age group; in Bulgaria and Latvia more than 3000 children; in Romania more than 4000; and in Slovenia more than 20 000 children. Eleven countries used the family form in the 2012–2013 data collection:6 Bulgaria, Czechia, Ireland, Italy, Lithuania, Mal- ta, Portugal, Republic of Moldova, San Marino, Spain and Turkey. Parents’ participation in the surveillance was particu- larly high in Italy and San Marino, where more than 95% of the parents of the selected children filled out and returned the family form. Bulgaria and Turkey also registered a good level of participation (around 85%), followed by the Republic of Moldova, Portugal and Lithuania (79%, 76% and 70%, respectively). Parents’ participation was nearly 70% in Lithuania and Malta, while, in Ireland, the family form was filled in for only one in two children (50%). Table 3. Numbers of children who were invited to participate in COSI round 3, proportions who took part in measurements (%) and whose parents completed the family form and numbers of measured children in the targeted age groups, by country Country No. of children invited to participate No. of measured children with complete information and were in the target age groups 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 Albania 6 117 95.0 – – – 3 312 – Belgiuma 138 322b NA – 56 245 15 208 48 470 18 395 Bulgaria 3 923 85.5 85.5 – 3 348 – – Czechia 2 650 95.0 91.6 – 1 457 – – Greece 11 912 78.1 – – 2 728 – 2 642 Ireland 6 270 58.6 50.3 – 1 012 – 1 129 Italy 5 1145 90.9 95.2 – – 29 045 16 502 Latvia 5 082 85.8 – – 3 481 – – Lithuania 5 392 71.2 69.9 – 2 594 – – Malta 3 832 91.0 68.6 – 2 064 – – Norway 4 078 86.1 – – 2 873 – 4 The minimal effective sample size is the number of children in the targeted age group who should be measured during data collection. 5 Data on children’s participation was not available for Belgium, Czechia, Romania, Spain and the former Yugoslav Republic of Macedonia. 6 More details on the COSI family form are provided in section 2.2 and Annex 2. 8Country No. of children invited to participate No. of measured children with complete information and were in the target age groups 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 Portugal 7 430 79.9 76.4 – 2 649 – – Republic of Moldova 4 426 87.1 78.9 – 2 575 – – Romania 4 348b NA NA – – 4 278 – San Marino 305 91.8 97.4 – – 160 118 Spain 3 426b NA NA – 1 820 1 606 – Slovenia 24 958 95.8 – 5 523 7 861 7 829 2 634 The former Yugoslav Republic of Macedonia 3 176b NA NA 2 210 – – – Turkey 5 739 86.4 87.4 – 2 613 2 345 – –, not applicable; NA, not available; PSU, primary sampling unit; SSU, secondary sampling unit; TSU, tertiary sampling unit; SU, sampling unit. a Only Flanders was involved in COSI round 3. b Number of children who participated in the survey; the number of children approached is not available. 2.2 Data collection forms and procedures In accordance with the agreed common protocol of the WHO Regional Office for Europe and Member States (16) for the third round, standardized data collection procedures were followed and adapted by each country to suit its local circumstances. 2.2.1 Organization Each country was responsible for collecting and analysing its data, and a country coordination team was established. This usually consisted of: • a principal investigator responsible for overall coordination; • supervisor(s) responsible for data collection in each sampled school; • a data manager responsible for overall data management; • examiners responsible for administration of the examiner’s record form and taking anthropometrics; • data clerks responsible for entering the data into electronic data files; and • school personnel responsible for the completing the school record forms and other relevant tasks. In each country, these teams met regularly during the surveillance initiative to review progress, ensure uniform data col- lection and discuss any issues that arose. Table 3. contd 9 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children 2.2.2 Period In most countries, data were collected in the 2012–2013 school year. Countries were requested to make measurements of all sampled children over as short a time as possible, preferably within 4 weeks and no longer than 10 weeks, avoiding data collection during the first 2 weeks of a school term or immediately after a major holiday. Table 1 shows the period of data collection in each country. 2.2.3 Examiners and training In most countries, surveillance was conducted in the sampled schools in collaboration with teachers and other school personnel. Depending on the local arrangements, circumstances and budget, countries appointed examiners to collect the core data. The examiners were: • school nurses, physicians or paediatricians linked to the school health system; • other suitable school personnel, such as physical education teachers during physical education classes; • health professionals who were taking measurements during routine comprehensive health screening or specifically for the surveillance initiative; or • other examiners, such as university students in the fields of health, nutrition and sports. For the third round data collection, examiners were trained in making standardized measurements as accurately and precisely as possible, according to the prescribed measurement techniques and instructions for examiners included in the protocol (16). Training included a review of the background and objectives of the surveillance system, standardized use of the forms, making measurements as described in the protocol, supporting children who are anxious, calibrating instruments, re- cording measurements immediately after reading them and writing legibly to reduce mistakes during data entry. Strict adherence to the measurement techniques and recording procedures was emphasized. Attention was also paid to con- fidentiality, the prevention of stigmatization or bullying of vulnerable children and answering questions from children, school staff and parents. 2.2.4 Ethical considerations The protocol (16) was in accordance with the International Ethical Guidelines for Biomedical Research Involving Human Subjects (20) and was approved by ethical committees in each country. All study procedures were fully explained to parents, in a letter or at a school information meeting, and they gave informed consent for the measurements and data treatment (written in the local language) before the child was enrolled. In accor- dance with the local legal requirements, countries could choose passive or active informed consent (see Table 4). Although parents have the right to know their child’s body height and body weight, these were communicated only upon request. The children’s assent was always obtained before the measurements were made. Children were never told the measure- ments of other children. The confidentiality of all collected and archived data was assured. The children’s names and, in some cases, the entire date of birth were not included in the electronic data files sent by the countries to the WHO Region- al Office. 2.2.5 Data collection forms Four data collection forms (see Annex 2) are included in the COSI manual of data collection procedures (21): • a mandatory examiner’s record form, • a mandatory school record form, • a voluntary school record form and • a voluntary family record form. 10 The forms include closed questions with pre-coded answers (when applicable). The child’s record form and the school record form were accompanied by detailed instructions. The voluntary school record form was used if the country de- cided to collect data on the schools. Table 1 shows use of each record form by country. As the original data collection forms and instructions for their administration were prepared in English, countries were advised to have them translated into their local languages by a professional translator. The forms were then translated back into English and carefully checked for discrepancies with the original English version. Mandatory examiner’s record form Variables The mandatory variables collected on the examiner’s record form are: date of birth (or age in months), sex, place of res- idence, school grade, date and time of measurement, clothes worn when measured, school address, body weight and body height. Administration Preparation of a private room with specific requirements, organization and preparation of children for the study, the an- thropometric instruments and calibration and maintenance procedures, measurement techniques and administration of the forms are described in the manual of data collection procedures (21). Examiners are advised to follow the guidance strictly. Anthropometric measurements The mandatory anthropometric measures are body weight and height. These two measures are often used as they are easy to measure (16) and provide anthropometric indices such as the BMI, which is a well-recognized indicator of whether a child is underweight, of normal weight, at risk for overweight, overweight or obese (22). Examiners are advised not to calculate the BMI at the point of measurement, because it requires time and special tools. It is recommended that waist and hip circumferences be measured to characterize a population in terms of abdominal fat distribution, independently of total fat (23). Of the 19 countries, seven collected additional data on waist circumfer- ence and four on hip circumference. Children’s weight and height are measured in a private room at school by trained examiners, preferably in the morning before lunch, by standardized procedures (21). Countries are required to use the same anthropometric instruments everywhere and to calibrate them, preferably every day when measurements are being made. The instruments must be highly accurate and precise. Body weight is measured on portable electronic (digital) scales calibrated to 0.1 kg (100 g) and measuring up to 150 kg. These are easy to use and transport and reduce observer measurement error, as the weight is displayed electronically. Body weight is measured and recorded in kilograms to the nearest 100 g (0.1 kg). Height is measured on a height board mounted at a right angle between a level floor and a straight, vertical surface (if possible with a digital counter). The height board should be made of smooth, moisture-resistant (varnished or polished) wood, and the horizontal and vertical pieces should be firmly joined at right angles, with a movable piece as the head- board. Height is measured in centimetres and the reading taken to the last completed millimetre (0.1 cm). After assent, children should be measured wearing normal, light, indoor clothing. If they are not wearing light indoor clothing, the clothes worn should be recorded. Examiners are advised to communicate with the child in a sensitive way and to explain the measurement procedures. Mandatory school record form The school record form was completed by the school principal (head teacher), by the teachers in the sampled classes or by someone else who could document and report the variables required. The variables were: the location of the school, the number of children registered and measured (examined) per sampled class, those whose parents refused to allow their child to be measured and children who were absent on the measuring day. Furthermore, a few school (environ- mental) characteristics were included, such as the frequency of physical education lessons, the availability of school 11 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children playgrounds, the possibility of purchasing a number of listed food items and beverages on the school premises and cur- rent organized school initiatives to promote a healthy lifestyle (healthy eating, physical activity). It was strongly recommended that the form be given to the relevant school representative on the day of the measure- ments and that it be completed in the presence of the examiner. Most of the countries (17/19) provided data on the mandatory school form; only Belgium and Spain did not use the form. Voluntary school record form Of the 19 participating countries, 13 collected additional data on the voluntary school record form, which contained optional questions about the school environment on, for example, the availability of safe routes to school, transport to school, the school curriculum, school meals, vending machines and the availability of fruit, vegetable or milk schemes. Each country could decide to answer some or all the questions on this form, and the replies could be appended to the mandatory school form. School principals or teachers of the classes sampled were asked to complete the form. Again, it was strongly recom- mended that the form be completed in the presence of the examiner. Voluntary family record The family form was completed by 11 countries. Submission of the form was voluntary, and all or only some of the items could be completed. The forms were filled in by parents or caregivers, and countries had to attach the letter sent to the parents to inform them about the initiative and request their consent. The form contains data on simple indicators of the children’s dietary intake and physical activity or inactivity patterns, the family’s socioeconomic characteristics and comorbid conditions associated with obesity. Table 4. Data collection period, informed consent and use of record forms in COSI round 3, by country Country Data collection period Informed consent Examiner’s record form Mandatory school record form Voluntary school record form Family record form Albania February–March 2013 Active ✔ ✔ ✔ Belgium September 2012–July 2013 NA ✔ Bulgaria April–May 2013 Passive ✔ ✔ ✔ ✔ Czechia January–June 2013 Active ✔ ✔ ✔ ✔ Greece January–June 2013 Active ✔ ✔ ✔ Ireland November 2012–February 2013 Active ✔ ✔ ✔ Italy April–June 2012; October– November 2012 Passive ✔ ✔ ✔ ✔ Latvia October–December 2012 Passive ✔ ✔ ✔ Lithuania March–May 2013 Active ✔ ✔ ✔ ✔ Malta February–June 2013 Passive ✔ ✔ ✔ ✔ Norway September–December 2012 Active ✔ ✔ Portugal May–June 2013; October– November 2013 Active ✔ ✔ ✔ ✔ 12 Country Data collection period Informed consent Examiner’s record form Mandatory school record form Voluntary school record form Family record form Republic of Moldova May 2013 Active ✔ ✔ ✔ ✔ Romania April–May 2013 Active ✔ ✔ San Marino May 2012 Passive ✔ ✔ ✔ ✔ Spain October–December 2013 Active ✔ ✔ Slovenia April 2013 Active ✔ ✔ ✔ The former Yugoslav Republic of Macedonia March–June 2013 Passive ✔ ✔ Turkey May–June 2013 Active ✔ ✔ ✔ ✔ NA, not applicable Table 4. contd 13 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children 3. Overweight and obesity among children aged 6–9 years 3.1 Data elaboration The cut-offs recommended by WHO in 2007 for data on school-aged children and adolescents were used to compute BMI-for-age Z-scores and to estimate the prevalence of overweight and obesity (24,25). BMI was calculated from the formula: weight (kg) divided by height squared (m2). Overweight and obesity were defined as a BMI-for-age value > +1 Z-score and > +2 Z-scores, respectively (24). According to WHO definitions, the estimated prevalence of overweight includes children who are obese (26). Children for which 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 ref- erence median) (24). For comparison, prevalence calculated with the International Obesity Task Force cut-offs (27) are presented in Annex 1. All cleaned country datasets were sent to the WHO Regional Office, where they were reviewed for inconsistencies and completeness in a standard manner and then merged for intercountry analyses. The final anthropometric dataset in- cluded measurements for children who had given informed consent and for whom complete information on age, sex, weight and height was available. The prevalence of overweight and obesity among boys and girls was calculated by age group (see Table 5). Children who were not in the defined target age groups were excluded from the analysis. As sampling weights to adjust for the sampling design, oversampling and non-response were available for only a few countries, the analysis was performed unweighted.7 Table 5. Numbers of children included in the analysis of overweight and obesity in COSI round 3, by coun- try, age group and sex Country Age group Boys (N) Girls (N) Total (N) Albania 8-year-olds 1 706 1 606 3 312 Belgium 6-year-olds 28 372 27 810 56 182 7-year-olds 8 020 7 159 15 179 8-year-olds 24 534 23 915 48 449 9-year-olds 9 411 8 978 18 389 Bulgaria 7-year-olds 1 671 1 676 3 347 Czechia 7-year-olds 759 693 1 452 Greece 7-year-olds 1 346 1 375 2 721 9-year-olds 1 320 1 320 2 640 Ireland 7-year-olds 508 504 1 012 9-year-olds 579 550 1 129 Italy 8-year-olds 14 502 14 500 29 002 9-year-olds 8 590 7 902 16 492 Latvia 7-year-olds 1 803 1 677 3 480 Lithuania 7-year-olds 1 273 1 311 2 584 Malta 7-year-olds 1 014 1 037 2 051 7 For Greece, values were calculated by applying a weighting factor in order to correct for the unbalanced distribution of the sample by geographical area. 14 Country Age group Boys (N) Girls (N) Total (N) Norway 8-year-olds 1 492 1 381 2 873 Portugal 7-year-olds 1 331 1 313 2 644 Republic of Moldova 7-year-olds 1 309 1 264 2 573 Romania 8-year-olds 2 134 2 140 4 274 San Marino 8-year-olds 85 75 160 9-year-olds 63 55 118 Slovenia 6-year-olds 2 769 2 735 5 504 7-year-olds 4 015 3 823 7 838 8-year-olds 3 975 3 834 7 809 9-year-olds 1 370 1 261 2 631 Spain 7-year-olds 870 944 1 814 8-year-olds 804 800 1 604 The former Yugoslav Republic of Macedonia 6-year-olds 1 125 1 070 2 195 Turkey 7-year-olds 1 266 1 341 2 607 8-year-olds 1 212 1 132 2 344 3.2 Prevalence by age group, sex and country The prevalence of overweight (including obesity) and obesity according to the WHO definition among boys and girls aged 6–9 years in the 19 countries participating in COSI round 3 is presented in Fig. 1 in the Executive summary. The prevalence of overweight ranged from 18% to 52% in boys and from 13% to 43% in girls and that of obesity from 6% to 28% among boys and from 4% to 20% among girls. The data suggest the presence of an increasing north−south gradient, with the highest prevalence of overweight and obesity in southern European countries. In the countries in which data were collected on more than one age group, there was a tendency for an increase in the prevalence of overweight and obesity by age. According to WHO definitions, more boys than girls were overweight and obese in most age groups, particularly at older ages, and in most countries. Table 5. contd 15 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Fig. 1. Prevalence of overweight (including obesity) and obesity (WHO definition) in boys and girls aged 6-9 years, by age and country, COSI round 3 (2012/2013) 37 43 44 32 52 28 25 34 48 42 28 24 44 22 24 25 27 43 33 19 33 25 26 24 38 23 30 23 25 28 18 31 33 37 29 43 29 22 31 42 33 23 24 40 23 20 23 26 40 36 13 33 21 22 25 43 20 27 25 22 26 19 16 19 21 12 28 12 9 15 24 21 14 7 23 8 10 12 12 19 15 7 18 9 11 8 22 10 14 10 10 13 6 10 7 13 8 20 10 8 10 16 17 8 7 15 7 5 7 9 15 13 4 16 7 7 7 16 6 11 9 7 10 5 60 50 40 30 20 10 0 10 20 30 40 50 60 SVN SMR ITA IRE GRE BEL TUR SVN SPA SMR ROM NOR ITA BEL ALB TUR SVN SPA POR MDA MAT LVA LTU IRE GRE CZH BUL BEL SVN MKD BEL 9- ye ar- ol ds 8- ye ar- ol ds 7- ye ar- ol ds 6- ye ar- ol ds Percentage Boys Girls Girls obese Boys obese Girls overweight Boys overweight 16 4. Eating habits and physical activity among children aged 6–9 years Eating habits and physical activity patterns are closely linked to the energy imbalance that results in overweight and obese (2). COSI collects information on some eating and physical activity behaviour to provide the information necessary for policy-makers to design, implement and evaluate the effectiveness of policies and strategies to improve diets and increase physical activity. The greater availability and affordability of energy-dense, nutrient-poor foods and drinks has contributed to the obe- sogenic environment in which many children now grow up, which encourages weight gain (2). Eating breakfast regularly is associated with a better-quality diet and a lower risk of becoming overweight or obese (28-31). Daily consumption of fruit and vegetables is an important component of a healthy diet, while consumption of foods such as savoury or sweet snacks, fast foods, processed meat products and sugary soft drinks, which tend to be high in saturated fats, free sugars or salt, should be limited (32). The benefits of physical activity, such as active play, walking, cycling and participation in sports, for children’s physical and mental health as well as for their academic achievement are well documented (33-35): higher levels of habitual physical activity are associated with less overweight in children (36). WHO recommends that children have at least 60 min of moderate-to-vigorous physical activity every day (33), but only a small proportion of children currently meet this recommendation (37,38). Active transport – walking or cycling – involves more physical activity and cardiovascular fit- ness (39), but in many countries the proportion of children who walk or cycle to and from school has been decreasing (37). Concern has been raised that the time children spend watching television or using electronic media (screen time) is dis- placing unstructured play and resulting in more sedentary time and less physical activity (37,40,41). This has prompted some national authorities to issue guidance for parents to limit their children’s screen or sedentary time (37,42-44). Short sleep duration is another energy-related behaviour that is independently associated with weight gain and adiposi- ty in childhood (45,46). 4.1 Data elaboration As mentioned in section 2.2, COSI collects limited information on eating habits and the physical activity and inactivity of children from the questionnaire filled in by parents. Table 6 lists the items included in the analysis and the availability of information by country. This section presents the frequency of eating breakfast and some food and beverages items generally accepted as healthy or as having high contents of salt, sugar, fat or trans fats and therefore unhealthy. The following eating habits were analysed: • eating breakfast every day; • eating fresh fruit daily; • eating vegetables daily; • eating foods like potato crisps, corn crisps, popcorn or peanuts on more than 3 days a week; • eating foods like pizza, French fries (chips), hamburgers, sausages or meat pies on more than 3 days a week; • eating sweets or chocolate on more than 3 days a week; • eating foods like biscuits, cakes, doughnuts or pies on more than 3 days a week; • drinking soft drinks containing free sugar on more than 3 days a week; and 17 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children • drinking 100% fruit juice on more than 3 days a week. The following aspects of physical activity and sedentary behaviour were investigated: • travelling to or from school on foot or by bicycle; • going to a sports or dancing club on at least 2 days a week; • playing outside for at least 1 h a day; • watching television or videos or playing computer games for at least 2 h a day; and • sleeping at least 9 h a day. Table 6. Data on children’s lifestyle and categorization of answer options for behavioural analyses Question Answer options Categorization of answer options Countries that provided information Breakfast frequency “Over a typical or usual week, how often does your child have breakfast?’ “Every day”; “most days (4–6 days)”; “some days (1–3 days)”; “never” Every day=“every day” < 7 days/week=“most days (4–6 days)”; “some days (1–3 days)” or “never” Bulgaria, Czechia, Ire- land, Lithuania, Malta, Portugal, Republic of Moldova, Spain and Turkey Food and beverage consumption frequency “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 (excluding potatoes); (iii) foods like pota- to crisps, corn crisps, popcorn or peanuts; (iv) foods like piz- za, French fries, hamburgers, sausages or meat pies; (v) foods like sweets or choco- late; (vi) foods like biscuits, cakes, doughnuts or pies; (vii) soft drinks containing sugar; (viii) 100% fruit juice”? “Every day”; “most days (4–6 days)”; “some days (1–3 days)”;” never” Food items (i) to (ii): Every day=“every day” < 7 days/week=“most days (4–6 days)”; “some days (1–3 days)” or “never”. Bulgaria, Czechia, Ire- land, Italy (items (i) and (ii) only), Lithuania, Republic of Moldova, San Marino (only items (i) and (ii)), Spain and Turkey Food items (iii) to (viii): > 3 days/week=“every day” or “most days (4–6 days)” ≤ 3 days/week=“some days (1–3 days)” or “never” 18 Question Answer options Categorization of answer options Countries that provided information Physical activity 1.1.2 “How does your child usually get to and from school? Please tick one box for “Going to school” and one box for “Coming from school”” “S/he usually takes the school bus”; “s/he usually goes by public transport”; “s/he is usually brought by car”; “s/he usually rides a bicycle”; “s/he usually walks”; “other” Going to or from school on foot or by bicycle = “s/he usually rides a bicycle” or “s/he usually walks” (on at least one route) Going to or from school not on foot or by bicycle=“s/ he usually takes the school bus”, “s/he usually goes by public transport”, “s/he is usually brought by car” or “other” (on both routes) Bulgaria, Czechia, Ire- land, Lithuania, Malta, Portugal, Republic of Moldova, Spain and Turkey “Is your child a member of one or more sports or dancing clubs (e.g. football, running, hockey, swimming, tennis, basketball, gymnastics, ballet, fitness, ballroom dancing, etc.)?” “Yes”; “No” “0 days a week”; “1 day a week”; “2 days a week”; “3 days a week”; “4 days a week”; “5 days a week”; “6 days a week”; “7 days a week” ≥ 2 days/week=“2 days a week”, “3 days a week”, “4 days a week”, “5 days a week”, “6 days a week” or “7 days a week” < 2 days/week=“0 days a week”, “1 day a week” or “not a member of one or more sports or dancing club(s)” Bulgaria, Czechia, Ire- land, Lithuania, Malta, Portugal, Republic of Moldova, Spain and Turkey “Over a typical or usual week, on how many days does your child go to this/these sports or dancing club(s)?” “In his/her free time, about how many hours a day does your child usually play out- side, at home or somewhere else? Please tick one box for weekdays and one box for weekends.” “Never”; “less than 1 h per day”; “about 1 h per day”; “about 2 h per day”; “about ≥ 3 h per day” ≥ 1 h/daya < 1 h/daya Bulgaria, Czechia, Ire- land, Lithuania, Portu- gal, Republic of Moldo- va, Spain and Turkey Screen time 1.1.4 “In his/her free time, about how many hours per day does your child usually spend watching television (including videos), at home or somewhere else? Please tick one box for weekdays and one box for weekends.” “Never”; “less than 1 h per day”; “about 1 h per day”; “about 2 h per day”; “about ≥ 3 h per day” < 2 h/dayb ≥ 2 h/dayb Bulgaria, Czechia, Ire- land, Italy, Lithuania, Malta, Portugal, Repub- lic of Moldova, San Ma- rino, Spain and Turkey Table 6. contd 19 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Question Answer options Categorization of answer options Countries that provided information “In his/her free time, about how many hours per day does your child usually spend using a computer for playing games (other than home- work), at home or somewhere else? Please tick one box for weekdays and one box for weekends.” “Never”; “less than 1 h per day”; “about 1 hour per day”; “about 2 h per day”; “about ≥ 3 h per day” < 2 h/dayb ≥ 2 h/dayb Bulgaria, Czechia, Ire- land, Italy, Lithuania, Malta, Portugal, Repub- lic of Moldova, San Ma- rino, Spain and Turkey Sleep duration “How long does your child usually sleep each day?” ___ h and __min (both night sleep and naps) ≥ 9 h/day < 9 h/day Bulgaria, Czechia, Ire- land, Lithuania, Portu- gal, Republic of Moldo- va, Spain and Turkey a Numerical values were assigned to the items “playing outside on a weekday” and “playing outside on a weekend day” in order to convert this item to a numerical scale (“never”=0; “< 1 h per day” =0·5; “about 1 h per day” =1; “about 2 h per day”=2; “about ≥ 3 h per day” =3). Usual outside play time per day was calculated by weighing weekday (5/7) and weekend hours (2/7) accordingly. b Numerical values were assigned to the items “using a computer” and “watching television” on a weekday or a weekend day in order to convert these two items to a numerical scale (“never”=0; “< 1 h per day”=0·5; “about 1 h per day”=1; “about 2 h per day” =2; “about ≥ 3 h per day” =3). Total screen time per day was calculated as the sum of the two items by weighing weekday (5/7) and weekend hours (2/7) accordingly. The analysis included children aged 6–9 years for whom family forms had been completed (see Table 7). Sampling weights to adjust for the sampling design, oversampling and non-response were available only for a few countries, and the analysis was therefore performed unweighted. Table 7. Children included in the analysis of eating habits and physical activity and sedentary behaviour in COSI round 3, by country, age group and sex Country No. of children included in the analysis Boys (%) Age (%) 6-year-olds 7-year-olds 8-year-olds 9-year-olds Bulgaria 3 352 49.9 0.0 100.0 0.0 0.0 Czechia 2 400 51.5 40.0 58.6 1.4 0.0 Ireland 1 001 47.8 29.7 68.3 1.7 0.3 Italy 45 897 50.8 0.0 0.7 63.3 36.0 Lithuania 3 761 50.1 0.3 68.4 31.2 0.1 Malta 2 622 51.0 0.0 58.9 40.6 0.5 Portugal 5 583 49.8 29.5 43.7 24.7 2.1 Republic of Moldova 3 488 51.8 3.7 68.0 28.0 0.3 San Marino 278 53.2 0.0 0.0 57.5 42.5 Spain 3 363 49.2 0.0 53.0 47.0 0.0 Turkey 4 998 49.7 0.0 52.5 47.5 0.0 The number of children differs by item because of missing data. Table 6. contd 20 4.2 Dietary behaviour Breakfast, food and beverage consumption frequency was assessed from the answers to nine questions. Fig. 2 shows the proportion of children who ate breakfast, fresh fruits and vegetables every day by country. The majority of children had breakfast every day, the proportions ranging from 58% in Malta to 94% in Portugal. Fresh fruit was eaten daily by only 27% of Moldovan children; the highest proportions were observed in Italy (72%) and San Marino (75%). In San Marino, over 70% of children ate vegetables daily, while in Turkey this proportion was only 18%. Fig. 2. Eating habits by country, COSI round 3 (2012–2013) 0 10 20 30 40 50 60 70 80 90 100 TUR SPA SMR POR* MDA MAT* LTU ITA IRE CZH BUL TUR SPA SMR POR* MDA MAT* LTU ITA IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL Ea tin g ve ge ta bl es e ve ry d ay Ea tin g fru it ev er y da y H av in g br ea kf as t ev er y da y Proportion (%) * Question not asked in this country. 21 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Fig. 3 presents the eating habits of boys and girls by country. Boys and girls in each country had similar eating habits. Fig. 3. Eating habits by sex and country, COSI round 3 (2012–2013) 100 90 80 70 60 50 40 30 20 10 0 10 20 30 40 50 60 70 80 90 100 TUR SPA SMR POR* MDA MAT* LTU ITA IRE CZH BUL TUR SPA SMR POR* MDA MAT* LTU ITA IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL Ea tin g ve ge ta bl es e ve ry d ay Ea tin g fru it ev er y da y H av in g br ea kf as t ev er y da y Proportion (%) Boys Girls * Question not asked in this country. 22 Fig. 4 shows the frequency distribution of eating fresh fruit and vegetables by country. Fresh fruits were consumed on all or most days by 63–95% of children and vegetables by 45–93%. Fig. 4. Frequency distribution of indicators of healthy nutritional behaviour by country. COSI round 3 (2012/2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TUR SPA SMR POR* MDA MAT* LTU ITA IRE CZH BUL TUR SPA SMR POR* MDA MAT* LTU ITA IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL Ve ge ta bl es , e xc lu di ng p ot at oe s Fr es h fru it Br ea kf as t Proportion (%) Every day Most days Some days Never * Question not asked in this country. 23 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Fig. 5 presents the proportions of children who ate less healthy foods like potato chips, corn crisps, popcorn and pea- nuts and unhealthy beverages on more than 3 days per week. The proportion ranged from < 5% in Czechia and Spain to 31% in Bulgaria. In Bulgaria also, the highest proportion of children ate foods like pizza, French fries, hamburgers, sau- sages, meat pies, sweets or chocolate on more than 3 days a week. The proportion of children who drank soft drinks containing free sugar on more than 3 days per week ranged from 6% in Spain to 44% in Czechia. The proportion of children who drank 100% fruit juice on more than 3 days per week was high- est in Bulgaria (37%) and Ireland (38%). Fig. 5. Proportions of children who frequently ate selected less healthy foods, by country, COSI round 3 (2012–2013) 0 10 20 30 40 50 60 70 80 90 100 TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL 10 0% fr uit ju ice >3 da ys/ we ek So ft dr ink s c on ta ini ng fre e s ug ar >3 da ys/ we ek Bis cu its , c ak es , d ou gh nu ts or pi es >3 da ys/ we ek Ca nd y b ar s o r c ho co lat e >3 da ys/ we ek Piz za , F re nc h f rie s, ha mb ur ge rs, sa us ag es o r m ea t p ies >3 da ys/ we ek Po ta to ch ips , c or n c ris ps , p op co rn , pe an ut s > 3 d ay s/w ee k Proportion (%) * Question not asked in this country. 24 Fig. 6 presents the consumption of selected food items for which frequent consumption is considered to be less healthy, by country. No strong sex difference in the consumption patterns was observed. Fig. 6. Proportions of children who frequently ate selected less healthy food items, by sex and country, COSI round 3 (2012–2013) 100 90 80 70 60 50 40 30 20 10 0 10 20 30 40 50 60 70 80 90 100 TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL 10 0% fr ui t ju ic e >3 d ay s/ w ee k So ft d rin ks c on ta in in g fre e su ga r > 3 da ys /w ee k Bi sc ui ts , c ak es , d ou gh nu ts or p ie s > 3 d ay s/ w ee k Ca nd y ba rs o r c ho co la te >3 d ay s/ w ee k Pi zz a, F re nc h fri es , ha m bu rg er s, sa us ag es o r m ea t pi es > 3 da ys /w ee k Po ta to c hi ps , c or n cr isp s, po pc or n, p ea nu ts >3 d ay s/ w ee k Proportion (%) Boys Girls * Question not asked in this country. 25 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Fig. 7 shows the frequency distribution of foods and beverages that are less healthy if consumed too often, by country. Between 78% of the children (Turkey) and 95% in Spain and Czechia consumed foods like potato chips, corn crisps, pop- corn or peanuts only on some days of the week or never. Foods containing high amounts of sugar were consumed daily or on most days by 11% of children in Spain and up to 59% of children in Bulgaria. Fig. 7. Frequency distribution of consumption of selected less healthy food items by country, COSI round 3 (2012–2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL TUR SPA SMR* POR* MDA MAT* LTU ITA* IRE CZH BUL 10 0% fr ui t ju ic e So ft d rin ks w it h su ga r Fo od s lik e ca nd y ba rs o r c ho co la te Fo od s lik e bi sc ui ts , ca ke s, d ou gh nu ts Fo od s lik e pi zz a, F re nc h fri es , ha m bu rg er s, s au sa ge s or m ea t pi es Fo od s lik e po ta to c hi ps , co rn c ris ps , p op co rn , p ea nu ts Proportion (%) Every day Most days Some days Never * Question not asked in this country. 26 4.3 Physical activity behaviour Physical activity behaviour was assessed from the answers to up to five questions, including screen time and length of sleeping per day. Participating countries did not use all the questions, as described in section 4.1. Fig. 8 shows indicators of physical activity, screen time and sleep duration for all children by country. It indicates con- siderable variation among countries. In Ireland, Malta and Portugal, less than 30% of children used active transport to and from school, while in the Republic of Moldova this proportion was over 80%. In the Republic of Moldova, only 23% of children went to a sports or dancing club at least 2 days a week, while in Turkey this proportion was 7%. In Portugal, only 54% of children played at least 1 h per day outside, while in Bulgaria, Czechia and the Republic of Moldova the pro- portion was > 93%. The smallest proportion of children who had ≥ 2 h of screen time per day was in Czechia (37%). In Bulgaria, Italy, Lithuania and San Marino, more than 60% of children had a daily screen time of ≥ 2 h. The proportion of children who had < 9 h of sleep per day ranged from 4% in Ireland to 26% in Bulgaria. Fig. 8. Indicators of physical activity, screen time and sleep duration by country, COSI round 3 (2012–2013) 0 10 20 30 40 50 60 70 80 90 100 TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL Sl ee p du ra ti on a t le as t 9 h ou rs /d ay Sc re en ti m e at le as t 2 ho ur s/ da y Pl ay in g ou ts id e at le as t 1 h ou r/ da y G oi ng to a s po rt s or d an ci ng cl ub a t l ea st 2 d ay s/ w ee k G oi ng to o r fr om s ch oo l on fo ot o r by b ic yc le Proportion (%) * Italy and San Marino used only the question on screen time. 27 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Fig. 9 shows indicators of the physical activity, screen time and sleep duration of boys and girls by country. In each coun- try, boys and girls had very similar patterns of physical activity and inactivity. Fig. 9. Indicators of physical activity, screen time and sleep duration by sex and country, COSI round 3 (2012–2013) 100 90 80 70 60 50 40 30 20 10 0 10 20 30 40 50 60 70 80 90 100 TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL Sl ee p du ra tio n at le as t 9 h ou rs /d ay Sc re en ti m e at le as t 2 h ou rs /d ay Pl ay in g ou ts id e at le as t 1 h ou r/ da y G oi ng to a s po rt s or d an ci ng cl ub a t l ea st 2 d ay s/ w ee k G oi ng to o r f ro m s ch oo l on fo ot o r b y bi c y cl e Proportion (%) Boys Girls * Italy and San Marino used only the question on screen time. 28 Mode of transport to and from school Fig. 10 shows the distribution of the usual mode of transport to school, by country. In the Republic of Moldova, 75% of children used an active mode of transport (walking or riding a bike) regularly to go to school. In San Marino, only 9% of children walked to school, and none went by bike. Fig. 10. Distribution of usual mode of transport to school, by country, COSI round 3 (2012–2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TUR SPA SMR POR MDA MAT LTU ITA IRE CZH BUL Usually walks Usually rides a bicycle Usually takes the school bus Usually goes by public transport Usually brought by car Other 29 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children The distribution of usual mode of transport between home and school is shown by country in Fig. 11. Generally, the proportions were similar, but fewer children were picked up by car after school than those taken to school by car. Correspondingly, the proportion of children who walked home was higher than that of children who walked to school, except in Malta, where the proportions were about equal, i.e. 22.5% walked to school and 22.0% walked home. Fig. 11. Distribution of usual mode of transport between home and school, by country, COSI round 3 (2012–2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TUR SPA SMR* POR MDA MAT LTU ITA* IRE CZH BUL Usually walks Usually rides a bicycle Usually takes the school bus Usually goes by public transport Usually brought by car Other * Question not asked in this country. 30 Fig. 12 presents parents’ opinions about the safety of the route to school for walking or riding a bicycle, by country. In Spain, 75% of parents considered that the route to school was safe, as did over 50% of parents in Czechia, Lithuania and the Republic of Moldova. In Malta, only 19% of parents agreed. In Bulgaria, the Republic of Moldova and Spain, over 80% of children lived less than 2 km from their schools. In Malta, 46% of children lived ≥ 3 km from school. Fig. 12. Safety of route to school for walking or cycling and distance by country, COSI round 3 (2012–2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Distance from child's school to home Route to school - safe to walk or ride a bicycle Distance from child's school to home Route to school - safe to walk or ride a bicycle Distance from child's school to home Route to school - safe to walk or ride a bicycle Distance from child's school to home Route to school - safe to walk or ride a bicycle Distance from child's school to home Route to school - safe to walk or ride a bicycle Distance from child's school to home Route to school - safe to walk or ride a bicycle Distance from child's school to home Route to school - safe to walk or ride a bicycle Distance from child's school to home Route to school - safe to walk or ride a bicycle Distance from child's school to home Route to school - safe to walk or ride a bicycle TU R SP A PO R M D A M AT LT U IR E CZ H BU L Yes No < 1 km 1–2 km ≥ 3 km The perceived safety of the route to and from school and the distance to school appeared to be associated with the mode of transport, i.e. whether the child walked to school or rode a bicycle, as indicated in Figs 13 and 14. In all coun- tries, the proportion of children who walked or cycled to school was higher when the route was perceived as safe than when it was perceived as unsafe (Fig. 13). The proportion of children who walked or cycled to school decreased with distance from the school, although differenc- es were observed between countries. While in Czechia only 2% of children walked or cycled to school if the distance was ≥ 3 km, in Turkey < 30% used active transport (Fig. 14). 31 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Fig. 13. Proportion of children who walked or cycled to and from school by perceived safety of the route, by country, COSI round 3 (2012–2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes TU R SP A PO R M D A M AT LT U IR E CZ H BU L Ro ut e to s ch oo l - s af e to w al k or ri de a b ic yc le b y ch ild Proportion of children walking or riding a bicycle to school, if route is perceived to be safe Proportion of children walking or riding a bicycle to school, if route is perceived to be unsafe 32 Fig. 14. Proportion of children who walked or cycled to and from school and distance to school by coun- try, COSI round 3 (2012–2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% ≥3 km 1-2 km < 1 km ≥3 km 1-2 km < 1 km ≥3 km 1-2 km < 1 km ≥3 km 1-2 km < 1 km ≥3 km 1-2 km < 1 km ≥3 km 1-2 km < 1 km ≥3 km 1-2 km < 1 km ≥3 km 1-2 km < 1 km ≥3 km 1-2 km < 1 km TU R SP A PO R M D A M AT LT U IR E CZ H BU L D is ta nc e fr om c hi ld 's s ch oo l t o ho m e Walking/bicycle Other mode of transport Playing outside and membership in sports or dancing clubs In all countries, more time was spent playing outside on weekends than during the week, with considerable variation among countries (Fig. 15). In Portugal, 55% of children played outside on a week day for < 1 h or never (28%). This pro- portion was only 12% during the weekend. Thus, Portugal was the country in which the highest proportion of children spent < 1 h playing outdoors. 33 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Fig. 15. Distribution of daily duration of playing outside by country, COSI round 3 (2012–2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Playing outside on weekend days Playing outside on week days Playing outside on weekend days Playing outside on week days Playing outside on weekend days Playing outside on week days Playing outside on weekend days Playing outside on week days Playing outside on weekend days Playing outside on week days Playing outside on weekend days Playing outside on week days Playing outside on weekend days Playing outside on week days Playing outside on weekend days Playing outside on week days TU R SP A PO R M D A LT U IR E CZ H BU L Never < 1 h per day About 1 h per day About 2 h per day About 3 h per day or more Membership in a sports or dancing club varied from 21% in Turkey to 83% in Ireland (Fig. 16). Correspondingly, 53% of Turkish children had zero or at least one day attendance in a sport or dancing club per week. In Lithuania over 16% of the children attended sport or dancing clubs on four or more days per week. 34 Fig. 16. Membership in sports or dancing clubs and distribution of weekly frequency by country, COSI round 3 (2012–2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Frequency sports or dancing weekly Membership sports or dancing clubs Frequency sports or dancing weekly Membership sports or dancing clubs Frequency sports or dancing weekly Membership sports or dancing clubs Frequency sports or dancing weekly Membership sports or dancing clubs Frequency sports or dancing weekly Membership sports or dancing clubs Frequency sports or dancing weekly Membership sports or dancing clubs Frequency sports or dancing weekly Membership sports or dancing clubs Frequency sports or dancing weekly Membership sports or dancing clubs Frequency sports or dancing weekly Membership sports or dancing clubs TU R SP A PO R M D A M AT * LT U IR E CZ H BU L Yes No 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days * Question not asked in this country. Screen time As observed for playing outside, children used a computer or watched television less often on weekdays than on week- ends (Fig. 17). Nearly 85% of children in Portugal used a computer never or for < 1 h per day on a weekday. In Lithuania, about 71% of children used a computer for about 1 h or more on weekends and 53% on weekdays. The same trend was observed for watching television. Fewer children watched television for < 1 h per day on weekends than on weekdays. 35 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Fig. 17. Distribution of frequency of computer usage and watching television on week days and weekends by country, COSI round 3 (2012–2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Watching television on a weekend day Watching television on a weekday Using a compter on a weekend day Using a computer on a weekday Watching television on a weekend day Watching television on a weekday Using a compter on a weekend day Using a computer on a weekday Watching television on a weekend day Watching television on a weekday Using a compter on a weekend day Using a computer on a weekday Watching television on a weekend day Watching television on a weekday Using a compter on a weekend day Using a computer on a weekday Watching television on a weekend day Watching television on a weekday Using a compter on a weekend day Using a computer on a weekday Watching television on a weekend day Watching television on a weekday Using a compter on a weekend day Using a computer on a weekday Watching television on a weekend day Watching television on a weekday Using a compter on a weekend day Using a computer on a weekday Watching television on a weekend day Watching television on a weekday Using a compter on a weekend day Using a computer on a weekday Watching television on a weekend day Watching television on a weekday Using a compter on a weekend day Using a computer on a weekday TU R SP A PO R M D A M AT LT U IR E CZ H BU L Never < 1 h per day About 1 h per day About 2 h per day About 3 h per day or more 36 5. School environment The important role of schools in promoting child health and establishing lifelong healthy habits is widely recognized (2,47-49). The third round of COSI data collection therefore sought information on school characteristics relating to nu- trition and physical activity. Schools can promote healthy lifestyles both in the teaching curriculum and the school environment, and comprehen- sive, multifaceted initiatives are likely to have the best results (50,51). Creating a healthier school nutrition environ- ments, by, for example, increasing access to fruit, vegetables or milk or limiting access to sugar-sweetened beverages and sweet or salty snacks, can change children’s eating habits and improve the nutritional quality of their diets, with some evidence of an effect on bodyweight (51-53). Schools can also promote physical activity, by providing physical education classes and creating an environment that supports active play and other forms of activity. There is good evidence that school programmes can increase children’s moderate-to-vigorous physical activity (54), and more frequent physical education sessions are a common component of effective interventions for preventing childhood obesity (51). More specifically, regular, good-quality physical education can help children to meet the global recommendations for physical activity and may also improve fitness and reduce adiposity (55). 5.1 Data elaboration As described in section 2.2, the third round of COSI data collection included a mandatory form for collection of infor- mation on the school environment with respect to nutrition and physical activity. The analysis presented in this report includes the following characteristics: possibility of obtaining five specific food items and beverages on the school prem- ises (fresh fruit, cold drinks containing sugar, sweet snacks, salted snacks and milk), frequency of physical education classes and organization of school initiatives to promote a healthy lifestyle (e.g. physical activity and/or healthy eating). These aspects are potentially modifiable by national or local governments or by the schools themselves and thus pres- ent opportunities for improving children’s eating and physical activity patterns (56). In accordance with Wijnhoven et al. (56), the answers to the five items on food and beverages were used to calculate a school nutrition environment score. A score of 0 or 1 was given according to whether each of the items could be ob- tained on the school premises: the answer was graded 1 when it was considered supportive of a healthy school nutrition environment (presence of fresh fruit and milk; absence of cold drinks containing sugar, sweet snacks and salted snacks) and 0 when it was considered unsupportive (absence of fresh fruit and milk; presence of cold drinks containing sugar, sweet snacks and salted snacks). A nutrition environment score was calculated by adding the five food and beverage item scores for each school that provided information on all the characteristics. A school score of 0 indicates that all the characteristics were graded as unsupportive, while a score of 5 indicates that all the characteristics were graded as supportive. Table 8 shows the number of schools included in the analysis and the data available on school nutrition environment by country. All the countries except Belgium and Spain used the mandatory school form in the third round of COSI data collection. 37 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Table 8. Schools included in the analysis and availability of data on school nutrition environment, COSI round 3 (2012–2013), by country Country No. of schools Physical education lessons Food items and beverages that could be obtained on the school premises School initia- tives to pro- mote a healthy lifestyle Fresh fruit Milk Cold drinks with sugar Sweet snacks Salted snacks Albania 104 ✔ ✔ ✔ ✔ ✔ ✔ ✔ Bulgaria 185 ✔ ✔ ✔ ✔ ✔ ✔ ✔ Czechiaa 810 ✔ ✔ ✔ ✔ ✔ ✔ Greece 181 ✔ ✔ ✔ ✔ ✔ ✔ ✔ Ireland 159 ✔ ✔ ✔ ✔ ✔ ✔ ✔ Italy 2 355 ✔ ✔ Lithuaniab 122 ✔ ✔ ✔ ✔ Latvia 140 ✔ ✔ ✔ ✔ ✔ ✔ ✔ Malta 92 ✔ ✔ ✔ ✔ ✔ ✔ ✔ Norway 126 ✔ ✔ ✔ ✔ ✔ ✔ ✔ Portugal 196 ✔ ✔ ✔ ✔ ✔ ✔ ✔ Republic of Moldova 203 ✔ ✔ ✔ ✔ ✔ ✔ ✔ Romania 205 ✔ ✔ ✔ ✔ ✔ ✔ ✔ San Marino 14 ✔ ✔ Slovenia 232 ✔ ✔ ✔ ✔ ✔ ✔ ✔ The former Yugoslav Republic of Macedonia 109 ✔ ✔ ✔ ✔ ✔ ✔ ✔ Turkey 216 ✔ ✔ ✔ ✔ ✔ ✔ ✔ a Data on school initiatives to promote a healthy lifestyle were not included in the analysis because of many missing responses. b Data on milk, sweet snacks and salted snacks were not included in the analysis because of many missing responses. 5.2 School characteristics Nutrition environment The school nutrition environment score based on the possibility of obtaining two “healthy” items (milk, fresh fruit) and three “unhealthy” food items (cold drinks containing sugar, sweet snacks and salted snacks) at school varied widely by country (Fig. 18). Schools in Ireland, Malta, Norway, Portugal and Slovenia all had medium to high nutritional environ- ment scores, while 97% of Albanian schools had low scores. 38 Fig. 18. School nutrition environment score, by country, COSI round 3 (2012–2013) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TUR SVN ROM POR NOR MKD MDA MAT LVA IRE GRE CZH BUL ALB Low Medium High The score is based on the possibility of obtaining five food and beverage items at school (fresh fruit, milk, cold drinks containing sugar, sweet snacks and salted snacks). The score ranges from 0 to 5. A higher score corresponds to a more supportive school environment for healthy behaviour. Values 0 and 1 correspond to a low score, values 2 and 3 to a medium score and 4 and 5 to a high score. Fig. 19 shows the proportions of food items that were available on school premises by country. The lowest proportions of schools that provided fresh fruit on their premises were in Albania (0%), the former Yugoslav Republic of Macedonia (17%) and Ireland (23%) and the highest in Malta (100%) and Slovenia (97%). Albania is the only country in which milk could not be purchased on any school premises. In the other countries, milk could be obtained in 22–95% of schools. There was wide variation in the availability of cold drinks containing sugar on school premises, from < 5% in Ireland (1%), Portugal (2%), Malta (3%) and Norway (4%) to > 50% in Latvia (51%), Lithuania (59%) and Albania (68%). Heterogeneity among countries was also observed for sweet and salted snacks. The highest proportions of schools in which sweet snacks were accessible were in Albania (96%), Turkey (75%), Latvia (65%) and Bulgaria (50%) and the lowest in Ireland (2%), Malta (2%) and Portugal (3%). Fewer schools made salted snacks available on their premises than sweet snacks (none in Norway, Portugal and the Republic of Moldova and about 1% in Ireland, Malta and Slovenia), with the exception of Albania, where 97% of schools made salted snacks available on their premises, the former Yugoslav Repub- lic of Macedonia (38%) and Latvia (19%). Norway was the only country that did not make sweet and salted snacks avail- able to pupils on school premises. 39 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Fig. 19. Proportions of schools in which healthy and unhealthy food and beverage items were available, by country, COSI round 3 (2012–2013) 0 10 20 30 40 50 60 70 80 90 100 ALB BUL CZH GRE IRE LTU LVA MAT MDA MKD NOR POR ROM SVN TUR ALB BUL CZH GRE IRE LVA MAT MDA MKD NOR POR ROM SVN TUR ALB BUL CZH GRE IRE LTU LVA MAT MDA MKD NOR POR ROM SVN TUR ALB BUL CZH GRE IRE LVA MAT MDA MKD NOR POR ROM SVN TUR ALB BUL CZH GRE IRE LVA MAT MDA MKD NOR POR ROM SVN TUR Sa lte d sn ac ks Sw ee t sn ac ks Co ld d ri nk s co nt ai ng s ug ar M ilk Fr es h fr ui t Proportion (%) 40 Physical activity environment In Albania, the Republic of Moldova and the former Yugoslav Republic of Macedonia, the duration of physical education lessons was the same in all schools (90 min in the first two countries and 120 min in the last). In all other countries, the mean ranged from 62 min in Ireland to 187 min in Slovenia (Fig. 20). Fig. 20. Mean duration of physical education classes per week by country, COSI round 3 (2012–2013) 0 20 40 60 80 100 120 140 160 180 200 ALB BUL CZH GRE IRE ITA LTU LVA MAT MDA MKD NOR POR ROM SMR SVN TUR Ph ys ic al e du ca tio n (m in ut es p er w ee k) In Albania, the Republic of Moldova and the former Yugoslav Republic of Macedonia, the duration of physical education lessons was the same in all schools. 41 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children In, San Marino, Slovenia and the former Yugoslav Republic of Macedonia, all pupils received at least 2 h of physical ed- ucation per week (Fig. 21), while in Albania, Ireland and the Republic of Moldova, no schools provided this amount of physical education. In several countries, not all schools provided at least 1 h per week, Malta and Ireland having the low- est percentages of schools that met this goal (84% and 86%, respectively). Fig. 21. Weekly provision of physical education classes: percentage of schools providing at least 60, 90 and 120 min of physical education, by country, COSI round 3 (2012–2013) 0 20 40 60 80 100 ALB BUL CZH GRE IRE ITA LTU LVA MAT MDA MKD NOR POR ROM SMR SVN TUR ALB BUL CZH GRE IRE ITA LTU LVA MAT MDA MKD NOR POR ROM SMR SVN TUR ALB BUL CZH GRE IRE ITA LTU LVA MAT MDA MKD NOR POR ROM SMR SVN TUR At le as t 1 20 m in At le as t 9 0 m in At le as t 6 0 m in Percentage 42 Promotion of a healthy lifestyle The proportion of schools that introduced initiatives or projects to promote a healthy lifestyle (with a focus on physical activity and/or healthy eating) was as low as 57% in Norway, followed by the former Yugoslav Republic of Macedonia (62%) and Albania (64%) (Fig. 22). In Italy, Malta, Romania and San Marino, over 90% of schools had introduced initia- tives or projects to promote a healthy lifestyle. Fig. 22. Proportion of schools with initiatives or projects to promote a healthy lifestyle, by country, COSI round 3 (2012–2013) 0 20 40 60 80 100 TUR SVN SMR ROM POR NOR MKD MDA MAT LVA LTU ITA IRE GRE BUL ALB Proportion (%) 43 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children 6. References 1. Action plan for the prevention and control of noncommunicable diseases in the WHO European Region. Copenha- gen: World Health Organization, 2016 (http://www.euro.who.int/__data/assets/pdf_file/0011/315398/66wd11e_ NCDActionPlan_160522.pdf?ua=1, accessed 13 February 2018). 2. Report of the Commission on Ending Childhood Obesity. Geneva: World Health Organization, 2016 (http://apps. who.int/iris/bitstream/10665/204176/1/9789241510066_eng.pdf?ua=1, accessed 13 February 2018). 3. Pulgaron ER. Childhood obesity: a review of increased risk for physical and psychological comorbidities. Clin Ther. 2013;35(1):18–32. 4. Mamun AA, O’Callaghan MJ, Cramb SM, Najman JM, Williams GM, Bor W. Childhood behavioral problems predict young adults’ BMI and obesity: evidence from a birth cohort study. Obesity. 2009;17(4):761–6. 5. Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr. 2007; 150 (1):12–17. 6. Health policy for children and adolescents, No. 7: Growing up unequal: gender and socioeconomic differences in young people’s health and well-being. Health Behaviour in School-aged Children (HBSC) study: international report from the 2013/2014 survey. Copenhagen: World Health Organization Regional Office for Europe; 2016 (http:// www.euro.who.int/__data/assets/pdf_file/0003/303438/HSBC-No.7-Growing-up-unequal-Full-Report.pdf, ac- cessed 13 February 2018). 7. Lake A, Townshend T. Obesogenic environments: exploring the built and food environments. J R Soc Promot Health. 2006;126:262–7. 8. European Charter on counteracting obesity. WHO Ministerial Conference on Counteracting Obesity. Istanbul. Co- penhagen: World Health Organization Regional Office for Europe; 2006 (http://www.euro.who.int/__data/assets/ pdf_file/0009/87462/E89567.pdf, accessed 13 February 2018). 9. Cattaneo A, Monasta L, Stamatakis E, Lioret S, Castetbon K, Frenken F et al. Overweight and obesity in infants and pre-school children in the European Union: a review of existing data. Obesity Rev. 2010;11(5):389–98. 10. Lien N, Henriksen HB, Nymoen LL, Wind M, Klepp KI. Availability of data assessing the prevalence and trends of overweight and obesity among European adolescents. Public Health Nutr. 2010;13(10A):1680–7. 11. Olds T, Maher C, Zumin S, Péneau S, Lioret S, Castetbon K et al. Evidence that the prevalence of childhood over- weight is plateauing: data from nine countries. Int J Pediatr Obes. 2011;6(5–6):342–60. 12. Branca F, Nikogosian H, Lobstein T, editors. The challenge of obesity in the WHO European Region and the strate- gies for response. Copenhagen: WHO Regional Office for Europe, 2007 (http://www.euro.who.int/__data/assets/ pdf_file/0010/74746/E90711.pdf, accessed 13 February 2018). 13. Vienna declaration on nutrition and noncommunicable diseases in the context of Health 2020. Copenhagen: World Health Organization Regional Office for Europe; 2013 (http://www.euro.who.int/__data/assets/pdf_ file/0005/193253/CONSENSUS-Vienna-Declaration-5-July-2013.pdf, accessed 13 February 2018). 14. Janssen I, Katmarzyk PT, Srinivasan SR, Chen W, Malina RM, Bouchard C et al. Utility of childhood BMI in the predic- tion of adulthood disease: comparison of national and international references. Obes Res. 2005;13(6):1106–15. 15. Rolland-Cachera MF, Deheeger M, Bellisle F, Sempé M, Guilloud-Bataille M, Patois E. Adiposity rebound in children: a simple indicator for predicting obesity. Am J Clin Nutr. 1994;39(1):129–35. 16. WHO European Childhood Obesity Surveillance Initiative. Protocol, version October 2012. Copenhagen: World Health Organization Regional Office for Europe; 2012. 17. Wijnhoven T, van Raaij J, Breda J, editors. WHO European Childhood Obesity Surveillance Initiative – implementa- tion of round 1 (2207/2008) and round 2 (2009/2010). Copenhangen: World Health Organization Regional Office for Europe; 2014 (http://www.euro.who.int/__data/assets/pdf_file/0004/258781/COSI-report-round-1-and-2_fi- nal-for-web.pdf). 18. Wijnhoven TM, van Raaij JM, Spinelli A, Starc G, Hassapidou M, Spiroski I et al. WHO European Childhood Obesity Surveillance Initiative: body mass index and level of overweight among 6–9-year-old children from school year 2007/2008 to school year 2009/2010. BMC Public Health. 2014;14:806. 44 19. Wijnhoven T, Branca F. WHO European Childhood Obesity Surveillance Initiative. Protocol, version January 2008. Copenhagen: World Health Organization Regional Office for Europe; 2008. 20. Council for International Organizations of Medical Sciences, World Health Organization. International Ethical Guidelines for Biomedical Research Involving Human Subjects. Geneva: Council for International Organizations of Medical Sciences; 2002 (https://cioms.ch/shop/product/international-ethical-guidelines-for-biomedical-re- search-involving-human-subjects-2/, accessed 12 December 2017). 21. WHO European Childhood Obesity Surveillance Initiative (COSI). Manual of data collection procedures, version Oc- tober 2012. Copenhagen: WHO Regional Office for Europe; 2012. 22. Prentice AM, Jebb SA. Beyond body mass index. Obes Rev. 2001;2(3):141–7. 23. Lobstein T, Baur L, Uauy R, IASO International Obesity TaskForce. Obesity in children and young people: a crisis in public health. Obes Rev. 2004;5(Suppl. 1):4–104. 24. 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. 25. WHO AnthroPlus for personal computers manual: software for assessing growth of the world’s children and ado- lescents. Geneva: World Health Organization; 2009 (http://www.who.int/entity/growthref/tools/who_anthroplus_ manual.pdf, accessed 8 December 2017). 26. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. Geneva: World Health Organization; 1995 (WHO Technical Report Series, No. 854; http://whqlibdoc.who.int/trs/WHO_TRS_854. pdf, accessed 8 December 2017). 27. Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatr Obes. 2012=;7(4):284–94. 28. Szajewska H, Ruszczynski M. Systematic review demonstrating that breakfast consumption influences body weight outcomes in children and adolescents in Europe. Crit Rev Food Sci Nutr. 2010;50(2):113-9. 29. de la Hunty A, Gibson S, Ashwell M. Does regular breakfast cereal consumption help children and adolescents stay slimmer? A systematic review and meta-analysis. Obes Facts. 2013;6(1):70–85. 30. Affenito SG. Breakfast: a missed opportunity. J Am Diet Assoc. 2007;107(4):565–9. 31. Kesztyus D, Traub M, Lauer R, Kesztyus T, Steinacker JM. Skipping breakfast is detrimental for primary school chil- dren: cross-sectional analysis of determinants for targeted prevention. BMC Public Health. 2017;17:258. 32. Healthy diet (Fact sheet No. 394, updated September 2015). Geneva: World Health Organization; 2015 (http:// www.who.int/mediacentre/factsheets/fs394/en/, accessed 13 February 2018). 33. Global recommendations on physical activity for health. Geneva: World Health Organization; 2010 (http://www. who.int/dietphysicalactivity/factsheet_recommendations/en/, accessed 13 February 2018). 34. Janssen I, Leblanc AG. Systematic review of the health benefits of physical activity and fitness in school-aged chil- dren and youth. Int J Behav Nutr Phys Act. 2010;11(7):40. 35. The association between school based physical activity, including physical education, and academic performance. Atlanta (GA): Centers for Disease Control and Prevention; 2010 (https://www.cdc.gov/healthyyouth/health_and_ academics/pdf/pa-pe_paper.pdf, accessed 13 February 2018). 36. Jiménez-Pavon D, Kelly J, Reilly JJ. Associations between objectively measured habitual physical activity and adipos- ity in children and adolescents: systematic review. Int J Pediatr Obes. 2010;5(1):3–18. 37. Tremblay MS, Gray CE, Akinroye K, Harrington DM, Katzmarzyk PT, Lambert EV et al. Physical activity of children: a global matrix of grades comparing 15 countries. J Physical Activity Health. 2014;11(1):S113–25. 38. Inchley J, Currie D, Jewell J, Breda J, Barnekow V, editors. Adolescent obesity and related behaviours: trends and inequalities in the WHO European Region 2002–2014. Copenhagen: World Health Organization Regional Office for Europe; 2017 (http://www.euro.who.int/__data/assets/pdf_file/0019/339211/WHO_ObesityReport_2017_v3.pdf, accessed 13 February 2018). 39. Larouche R, Saunders TJ, Edward G, Faulkner GEJ, Colley R, Tremblay M. Associations between active school trans- port and physical activity, body composition and cardiovascular fitness: a systematic review of 68 studies. J Physical 45 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Activity Health. 2014;11(1):206–27. 40. Pearson N, Braithwaite RE, Biddle SJ, van Sluijs EM, Atkin AJ. Associations between sedentary behaviour and physi- cal activity in children and adolescents: a meta-analysis. Obes Rev. 2014 Aug;15(8):666-75. doi: 10.1111/obr.12188 41. Carson V, Hunter S, Kuzik N, Gray CE, Poitras VJ, Chaput JP et al. Systematic review of sedentary behaviour and health indicators in school-aged children and youth: an update. Appl Physiol Nutr Metab. 2016;41:S240–65. 42. American Academy of Pediatrics Committee on Public Education. Children, adolescents and television. Pediatrics. 2001;107(2):423–6. 43. Start active, stay active: a report on physical activity from the four home countries’ chief medical officers. London: Department of Health; 2011 (https://www.gov.uk/government/publications/start-active-stay-active-a-report-on- physical-activity-from-the-four-home-countries-chief-medical-officers, accessed 13 February 2018). 44. Australia’s physical activity and sedentary behaviour guidelines for children (5–12 years). Canberra: Department of Health; 2014 (http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act- guidelines, accessed 13 February 2018). 45. Patel SR, Hu FB. Short sleep duration and weight gain: a systematic review. Obesity. 2008;16(3):643–53. 46. Taveras EM, Gillman MW, Pena MM, Redline S, Rifas-Shiman SL. Chronic sleep curtailment and adiposity. Pediat- rics. 2014;133(6):1013–22. 47. European Food and Nutrition Action Plan 2015–2020. Copenhagen: World Health Organization Regional Office for Europe; 2014 (www.euro.who.int/__data/assets/pdf_file/0008/.../64wd14e_FoodNutAP_140426.pdf, accessed 13 February 2018). 48. Physical activity strategy for the WHO European Region 2016–2025. Copenhagen: World Health Organization Regional Office for Europe; 2015 (http://www.euro.who.int/en/publications/abstracts/physical-activity-strate- gy-for-the-who-european-region-20162025, accessed 13 February 2018). 49. Food and nutrition policy for schools: a tool for the development of school nutrition programmes in the European Region. Copenhagen: World Health Organization Regional Office for Europe; 2006 (http://www.euro.who.int/en/ health-topics/disease-prevention/nutrition/publications/guidance-and-tools/school-age-children-and-adolescents/ food-and-nutrition-policy-for-schools-a-tool-for-the-development-of-school-nutrition-programmes-in-the-who-eu- ropean-region, accessed 13 February 2018). 50. Better food and nutrition in Europe: a progress report monitoring policy implementation in the WHO European Region. Copenhagen: World Health Organization Regional Office for Europe; 2017 (http://www.euro.who.int/en/ health-topics/disease-prevention/nutrition/publications/2017/better-food-and-nutrition-in-europe-progress-re- port-2017, accessed 13 February 2018). 51. Waters E, de Silva-Sanigorski A, Burford BJ, Brown T, Campbell KJ, Gao Y et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2011; 12:CD001871. 52. Driessen CE, Cameron AJ, Thornton LE, Lai SK, Barnett LM. Effect of changes to the school food environment on eating behaviours and/or body weight in children: a systematic review. Obes Rev. 2014;15(12):968–82. 53. Vézina-Im L, Beaulieu D, Bélanger-Gravel A, Boucher D, Sirois C, Dugas M et al. Efficacy of school-based interven- tions aimed at decreasing sugar-sweetened beverage consumption among adolescents: a systematic review. Public Health Nutr. 2017;20(13):2416–31. 54. Dobbins M, De Corby K, Robeson P, Husson H, Tirilis D. School-based physical activity programs for promoting phys- ical activity and fitness in children and adolescents aged 6–18. Cochrane Database Syst Rev. 2009;1:CD007651. 55. Institute of Medicine. The effectiveness of physical activity and physical education policies and programs: summary of the evidence. In: Committee on Physical Activity and Physical Education in the School Environment, editors. Edu- cating the student body: taking physical activity and physical education to school. Washington DC: National Acade- mies Press; 2013 (https://www.ncbi.nlm.nih.gov/books/NBK201508/, accessed 13 February 2018). 56. Wijnhoven TMA, van Raaij JMA, Sjoberg A, Eldin N, Yngve A, Kunesova M et al. WHO European Childhood Obesity Surveillance Initiative: school nutrition environment and body mass index in primary schools. Int J Environ Res Pub- lic Health. 2014;11(11):11261–85. 46 Annex 1. Prevalence of overweight (including obesity) and obesity (International Obesity Task Force definition) in boys and girls aged 6–9 years, by age and country, COSI round 3 (2012–2013) 26 30 32 20 42 19 17 24 36 35 21 14 34 14 16 18 19 30 23 11 25 16 18 14 30 16 21 16 17 20 11 25 27 31 22 37 24 18 25 35 32 19 19 33 18 15 19 21 34 30 11 30 18 18 21 39 17 23 22 19 22 16 8 8 10 4 12 6 5 8 11 11 7 3 12 4 4 6 6 10 7 3 9 4 5 2 14 6 9 6 6 8 3 8 4 9 5 11 7 5 7 11 13 5 4 11 4 3 4 6 11 10 3 13 5 5 6 12 5 9 7 6 8 4 60 50 40 30 20 10 0 10 20 30 40 50 60 SVN SMR ITA IRE GRE BEL TUR SVN SPA SMR ROM NOR ITA BEL ALB TUR SVN SPA POR MDA MAT LVA LTU IRE GRE CZH BUL BEL SVN MKD BEL 9- ye ar -o ld s 8- ye ar -o ld s 7- ye ar -o ld s 6- ye ar -o ld s Percentage Boys Girls Girls obese Boys obese Girls overweight Boys overweight 47 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Annex 2. COSI record forms Examiner’s record form, page 1: mandatory items only European Childhood Growth Surveillance Initiative Examiner’s Record Form Page 1/3 October 2012 IDENTIFICATION, CHILD (1) Form code EXAMINER (2) Country code (3) What is your name? First name Surname (4) Child’s code (5) Child’s sex Boy Girl (6) Child’s date of birth / / Day / Month / Year (7) Categorize the child’s place of residence according to the country’s urbanization grade. Urban Semi-urban Rural IDENTIFICATION, CHILD’S SCHOOL (8) In what grade/class level are you? (9) Class code (10) School code REMARKS 48 Examiner’s record form, page 2: mandatory items only European Childhood Growth Surveillance Initiative Examiner’s Record Form Page 2/3 October 2012 (2) Country code (4) Child’s code (9) Class code (10) School code ANTHROPOMETRIC EXAMINATION (11) Date of measurement / / Day / Month / Year (12) Time of measurement Before lunch After lunch (13) Now I would like to weigh you and measure your height. I will explain to you how I am going to do this. May I take these measurements? Yes, child agrees to be measured (take the measurements and continue with question 15) No, child does not agree to be measured (complete question 14, enter your (18) code and sign the form) (14) Can you tell me why you don’t want to be measured? Child is not feeling well or is in pain Child is anxious/nervous Child has a physical disability Other reason (please specify) Measurement items (15) Body weight kg . (16) Body height cm . (17) Describe the clothes the child is wearing when measured (select one option only). Please, remember to take off any kind of shoes, socks or stockings as well as any heavy objects (phone, wallet, belt, etc.). Underwear only Gym clothes (e.g. shorts and t-shirt only) Light clothing (e.g. t-shirt, cotton trousers or skirt) Heavy clothing (e.g. sweater and jeans) Other (please specify) 49 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Examiner’s record form, page 3: mandatory items only European Childhood Growth Surveillance Initiative Examiner’s Record Form Page 3/3 October 2012 (2) Country code (4) Child’s code (9) Class code (10) School code (18) Weight scale code (19) Height stadiometer code (20) Examiner’s code Signature Date OBSERVATIONS BY SUPERVISOR 50 Examiner’s record form, page 1: mandatory and voluntary items European Childhood Growth Surveillance Initiative Examiner’s Record Form Page 1/3 October 2012 IDENTIFICATION, CHILD (1) Form code EXAMINER (2) Country code (3) What is your name? First name Surname (4) Child’s code (5) Child’s sex Boy Girl (6) Child’s date of birth / / Day / Month / Year (7) Categorize the child’s place of residence according to the country’s urbanization grade. Urban Semi-urban Rural (7a) Child’s place of residence (7b) Child’s postal code IDENTIFICATION, CHILD’S SCHOOL (8) In what grade/class level are you? (9) Class code (10) School code REMARKS 51 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Examiner’s record form, page 2: mandatory and voluntary items European Childhood Growth Surveillance Initiative Examiner’s Record Form Page 2/3 October 2012 (2) Country code (4) Child’s code (9) Class code (10) School code ANTHROPOMETRIC EXAMINATION (11) Date of measurement / / Day / Month / Year (12) Time of measurement Before lunch After lunch (12a) Hour / Minute / Hour / Minute (13) Now I would like to weigh you, measure your height and take your waist and hip circumferences. I will explain to you how I am going to do this. May I take these measurements? Yes, child agrees to be measured (take the measurements and continue with question 15) No, child does not agree to be measured (complete question 14, enter your (21) code and sign the form) (14) Can you tell me why you don’t want to be measured? Child is not feeling well or is in pain Child is anxious/nervous Child has a physical disability Other reason (please specify) Measurement items (15) Body weight kg . (16) Body height cm . (17) Waist circumference cm . (18) Hip circumference cm . (19) Weight scale code (20) Height stadiometer code 52 Examiner’s record form, page 3: mandatory and voluntary items European Childhood Growth Surveillance Initiative Examiner’s Record Form Page 3/3 October 2012 (2) Country code (4) Child’s code (9) Class code (10) School code (21) Describe the clothes the child is wearing when measured (select one option only). Please remember to take off any kind of shoes, socks or stockings as well as any heavy objects (phone, wallet, belt, etc.). Underwear only Gym clothes (e.g. shorts and t-shirt only) Light clothing (e.g. t-shirt, cotton trousers or skirt) Heavy clothing (e.g. sweater and jeans) Other (please specify) (22) Did you have breakfast this morning? Yes No (23) Examiner’s code Signature Date OBSERVATIONS BY SUPERVISOR 53 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children School return form, page 1: mandatory items European Childhood Growth Surveillance Initiative School Record Form Page 1 October 2012 IDENTIFICATION, CHILD (1) Form code School (2) Country code (3) School code (4) School name (5) School address – street (6) School address – city/town/village (7) School address – region/province (8) What is your function at the school? Headmaster/Headmistress/Principal Teacher Other (please specify) (9) Date of completion of this form / / Day / Month / Year IDENTIFICATION, CHILD’S SCHOOL (8) In what grade/class level are you? (9) Class code (10) School code Class No. Grade/level of class No. of pupils registered No. of pupils examined No. of pupils absent No. of pupils who themselves declined to be examined No. of pupils whose parents did not give consent 1. Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys 2. Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys 3. Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys 54 School return form, page 2: mandatory items European Childhood Growth Surveillance Initiative School Return Form Page 2 October 2012 (2) Country code (3) School code INFORMATION ON SCHOOL ENVIRONMENT (12) For each participating class, please complete the columns below: Participating Class No. In this current school year and as part of the school curriculum, for how much time each week does your school provide physical educa- tion lessons (including e.g. dancing) to the pupils of each class participating in this project? In this current school year, have any initiatives/ projects been organized in each participating class to promote a healthy lifestyle (e.g. to pro- mote physical activity and/or healthy eating)? 1. Minutes per week Yes No 2. Minutes per week Yes No 3. Minutes per week Yes No (13) Does your school have outside playgrounds or inside play areas where children can usually play during school breaks? Yes No (14) Which of the following kinds of food/beverage can pupils obtain on the school premises? Please tick all items that apply. Fresh fruit Vegetables 100% fruit juices without sugar Yoghurt Fruit juices containing sugar Milk Cold drinks without sugar Flavoured milk Cold drinks containing sugar Water Hot drinks without sugar Candy bars, chocolate, cakes or other sweet snacks Hot drinks containing sugar Potato chips, corn chips, popcorn, peanuts or other savoury snacks Diet or “light” soft drinks Other (please specify below): 55 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children School record form, page 3: voluntary items European Childhood Growth Surveillance Initiative School Record Form Page 3 October 2012 (2) Country code (3) School code INFORMATION ON SCHOOL ENVIRONMENT (15) Does your school have any vending machines with foods or beverages on its premises? Yes No (16) Does your school have a shop or cafeteria where foods or beverages can be purchased? Yes No (17) Does your school have a canteen? Yes please continue with the next question No please continue with question 19 (18) Do the meals served in the school canteen meet your country’s nutrition (or healthy eating) guidelines? Yes No Don’t know (19) Does your school provide pupils with fresh fruit for free? Yes, to all pupils Only to pupils in some grade levels (please specify the grade): No, to nobody (20) Does your school provide pupils with vegetables for free? Yes, to all pupils Only to pupils in some grade levels (please specify the grade): No, to nobody (21) Does your school provide pupils with milk for free? Yes, to all pupils Only to pupils in some grade levels (please specify the grade): No, to nobody 56 School record form, page 4: voluntary items European Childhood Growth Surveillance Initiative School Record Form Page 4 October 2012 (2) Country code (3) School code INFORMATION ON SCHOOL ENVIRONMENT (22) Does your school provide pupils with milk at a low price? Yes, to all pupils Only to pupils in some grade levels (please specify the grade): No, to nobody (23) Does your school curriculum include nutrition education; either as a separate lesson or integrated into lessons on, for example, health education, biology or home economics? Yes, for all grade levels Only to pupils in some grade levels (please specify the grade): No, for none (24) Is your school free from advertising and marketing of any energy-dense and nutrient-poor foods and beverages that could undermine the promotion of a healthy, balanced diet? Yes No (25) Does your school provide school bus transport? Yes, to all pupils Only to pupils in some grade levels (please specify the grade): Only to pupils from rural areas Only to pupils living far away (please specify the distance): No, to nobody (26) In your opinion, are the routes to and from school safe for most pupils to walk or ride a bicycle? Yes No (27) Does your school curriculum include physical education lessons? Yes, for all grade levels Only for pupils in some grade levels (please specify the grade): No, for none 57 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children School record form, page 5: voluntary items European Childhood Growth Surveillance Initiative School Record Form Page 5 October 2012 (2) Country code (3) School code INFORMATION ON SCHOOL ENVIRONMENT (28) Does your school provide pupils with milk at a low price? Yes, to all pupils Only to pupils in some grade levels (please specify the grade): No, to nobody REMARKS You may write down any remarks you would like to make in this box: ***********END OF QUESTIONNAIRE*********** THANK YOU VERY MUCH FOR COMPLETING THIS QUESTIONNAIRE. PLEASE RETURN IT TO THE PROJECT COORDINATOR. 58 Family record form, page 1: voluntary items European Childhood Growth Surveillance Initiative Family Record Form Page 1 October 2012 INTRODUCTION TO CAREGIVERS This survey is conducted by the [insert name of coordinating institute] in collaboration with the World Health Orga- nization and is called the European Childhood Growth Surveillance Initiative. Its aim is to promote the health and well-being of primary-school children and is taking place in several countries in Europe. Your child’s class has been selected to participate. This questionnaire is about your child’s health and the things s/he does that may influence his or her health. We would like to ask you to complete this form, possibly together with your child. The information you give will be used to develop better health programmes for children like yours. Your child can return the completed form to his or her teacher in the enclosed envelope, which you can seal. The information you provide is totally confidential and will not be disclosed to anyone at the school. It will be made anonymous and will only be used for research and monitoring purposes. Your name, address and other personal information will be removed from the database. Only a code will be used to connect your name and your answers, without identifying you. Your participation is voluntary and you are free to refuse to answer any of the questions in this questionnaire. If you have any queries about this survey you may contact [insert coordinating institution and contact details, or name the Principal Investigator]. We would like to thank you very much in advance for your kind cooperation. Form code FAMILY Country code GENERAL IDENTIFICATION, CHILD (1) What is your child’s name? First name Surname (2) What is your child’s date of birth? / / Day / Month / Year (3) Child’s sex Boy Girl (4) What was the approximate birth weight of your child (in grams)? grams 59 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Family record form, page 2: voluntary items European Childhood Growth Surveillance Initiative Family Record Form Page 2 October 2012 GENERAL IDENTIFICATION, CHILD (5) Was your child born at full term (in general after 37 weeks of pregnancy)? Yes No Don’t know (6a) What is your place of residence? (6b) Postal code? GENERAL IDENTIFICATION, SCHOOL (7) What is the name of your child’s school? (8) What is the location/address of your child’s school? (9) In which class/grade level is your child now? CHILD’S LIFESTYLE CHARACTERISTICS The following are questions about some lifestyle characteristics of your child. (10) How does your child usually get to and from school? Please tick one box for “Going to school” and one box for “Coming from school”. Going to school Coming from school S/he usually takes the school bus S/he usually takes the school bus S/he usually goes by public transport S/he usually goes by public transport S/he is usually brought by car S/he is usually brought by car S/he usually rides a bicycle S/he usually rides a bicycle S/he usually walks S/he usually walks Other (please specify): Other (please specify): (11) In your opinion, are the routes to and from school safe for your child to walk or ride a bicycle? Yes No 60 Family record form, page 3: voluntary items European Childhood Growth Surveillance Initiative Family Record Form Page 3 October 2012 CHILD’S LIFESTYLE CHARACTERISTICS (12) How far is your child’s school from your home? Less than 1 kilometre 1–2 kilometres 3–4 kilometres 5–6 kilometres More than 6 kilometres (13) Is your child a member of one or more sport or dancing clubs (e.g. football, running, hockey, swimming, tennis, basketball, gymnastics, ballet, fitness, ballroom dancing, etc.)? Yes please continue with the next question No please continue with question 15 (14) Over a typical or usual week, on how many days does your child go to this/these sport or dancing club(s)? 0 days a week 4 days a week 1 day a week 5 days a week 2 days a week 6 days a week 3 days a week 7 days a week (15) What is your child’s usual amount of sleep each day? hours and minutes (combining night-time sleep and naps) (16) In his/her free time, about how many hours per day does your child usually play outside, at home or some- where else? Please tick one box for weekdays and one box for weekends. Weekdays Weekends Never Never Less than 1 hour per day Less than 1 hour per day About 1 hour per day About 1 hour per day About 2 hours per day About 2 hours per day About 3 or more hours per day About 3 or more hours per day 61 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Family record form, page 4: voluntary items European Childhood Growth Surveillance Initiative Family Record Form Page 4 October 2012 CHILD’S LIFESTYLE CHARACTERISTICS (17) In his/her free time, about how many hours per day does your child usually spend doing homework or reading a book, at home or somewhere else? Please tick one box for weekdays and one box for weekends. Weekdays Weekends Never Never Less than 1 hour per day Less than 1 hour per day About 1 hour per day About 1 hour per day About 2 hours per day About 2 hours per day About 3 or more hours per day About 3 or more hours per day (18) Do you have a computer at home? Yes No (19) In his/her free time, about how many hours per day does your child usually spend using a computer for playing games (other than homework), at home or somewhere else? Please tick one box for weekdays and one box for weekends. Weekdays Weekends Never Never Less than 1 hour per day Less than 1 hour per day About 1 hour per day About 1 hour per day About 2 hours per day About 2 hours per day About 3 or more hours per day About 3 or more hours per day (20) In his/her free time, about how many hours per day does your child usually spend watching television (including videos), at home or somewhere else? Please tick one box for weekdays and one box for weekends. Weekdays Weekends Never Never Less than 1 hour per day Less than 1 hour per day About 1 hour per day About 1 hour per day About 2 hours per day About 2 hours per day About 3 or more hours per day About 3 or more hours per day 62 Family record form, page 5: voluntary items European Childhood Growth Surveillance Initiative Family Record Form Page 5 October 2012 CHILD’S LIFESTYLE CHARACTERISTICS (21) Over a typical or usual week, how often does your child have breakfast? Every day Most days (4-6 days) Some days (-3 days) Never (22) Over a typical or usual week, how often does your child eat or drink the following kinds of foods or beverages? Please tick one box for each line. Every day Most days Some days Never (4–6 days) (1–3 days) Fresh fruit Vegetables (excluding potatoes) 100% fruit juice Soft drinks containing sugar Diet or “light” soft drinks Low-fat/semi-skimmed milk Whole-fat milk Flavoured milk Cheese Yoghurt, milk pudding, cream cheese/ quark or other dairy products Meat Fish Foods like potato chips (crisps), corn chips, popcorn or peanuts Foods like candy bars or chocolate Foods like biscuits, cakes, doughnuts or pies Foods like pizza, french fries (chips), hamburgers, sausages or meat pies (23) Was your child ever breastfed? Yes please continue with the next question No please continue with question 25 63 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Family record form, page 6: voluntary items European Childhood Growth Surveillance Initiative Family Record Form Page 6 October 2012 CHILD’S LIFESTYLE CHARACTERISTICS (24) In his/her first year of life, for how long was your child breastfed? Less than 1 month About 4 months About 1 month About 5 months About 2 months About 6 months About 3 months More than 6 months FAMILY HEALTH CHARACTERISTICS The following are questions about some health characteristics of yourself and your family. (25) During the past 12 months, have you or anyone else in your household been told by a doctor or other health worker that one of you has high blood pressure (hypertension)? Yes No Don’t know (26) During the past 12 months, have you or anyone else in your household been told by a doctor or other health worker that one of you has diabetes? Yes No Don’t know (27) During the past 12 months, have you or anyone else in your household been told by a doctor or other health worker that one of you has a high cholesterol level? Yes No Don’t know FAMILY GENERAL CHARACTERISTICS The last set of questions asks about some general characteristics of yourself and your family. 64 Family record form, page 7: voluntary items European Childhood Growth Surveillance Initiative Family Record Form Page 7 October 2012 FAMILY GENERAL CHARACTERISTICS (28) How many people aged 18 years or older, including yourself, live in your household? (29) How many people younger than 18 years live in your household? (30) What is the highest level of education you and/or your spouse/partner have completed? Please select one answer only for each of you. You Your spouse/partner Primary school Primary school Secondary school Secondary school Undergraduate/Bachelor degree Undergraduate/Bachelor degree Masters degree or higher Masters degree or higher (31) During the past calendar year, what was the gross income of your household? Please express it in your local currency. (32) Which of the following best describes your and/or your spouse’s/partner’s main work over the last 12 months? Please select one answer only for each of you. You Your spouse/partner Government employed Government employed Non-government employed Non-government employed Self-employed Self-employed Student Student Homemaker Homemaker Unemployed, able to work Unemployed, able to work Unemployed, unable to work Unemployed, unable to work Retired Retired (33) In what type of housing are you currently living? House/bungalow, detached House, semi-detached/terraced Apartment Shared house Shared apartment Other (please specify) 65 WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children Family record form, page 8: voluntary items European Childhood Growth Surveillance Initiative Family Record Form Page 8 October 2012 FAMILY GENERAL CHARACTERISTICS (34) Is this accommodation: Owned by you? Rented by you? Other (please specify) (35) What is your relationship to the child? I am the mother I am the father Other (please specify), I am Date of completion of this form / / Day / Month / Year Signature REMARKS You may write down any remarks you would like to make in this box: The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Document number: WHO/EURO:2018-2980-42738-59613 World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: euwhocontact@who.int Website: www.euro.who.int