Conceived and designed the experiments: JB STV AS MC EB YM. Performed the experiments: JB MVS STV MC IDB NL EB VM AS L. Maes L. Moreno NJ EK TL YM. Analyzed the data: JB MVS STV. Contributed reagents/materials/analysis tools: JB MVS STV MC IDB NL EB VM AS L. Maes L. Moreno NJ EK TL YM. Wrote the paper: JB. Provided feedback on drafts of the manuscript: MVS STV MC IDB NL EB VM AS L. Maes L. Moreno NJ EK TL YM.
The authors have declared that no competing interests exist.
Current data on the prevalence of overweight and energy-balance behaviors among European children is necessary to inform overweight prevention interventions.
A school-based survey among 10–12 year old children was conducted in seven European countries using a standardized protocol. Weight, height, and waist circumference were measured; Engagement in physical activity, sedentary and dietary behaviors, and sleep duration were self-reported. Descriptive analyses were conducted, looking at differences according to country, gender, and parental education. 7234 children (52%girls; 11.6±0.7 years) participated. 25.8% and 5.4% of boys, and 21.8% and 4.1% of girls were overweight (including obese) and obese (according to International Obesity Task Force criteria), respectively. Higher prevalence of overweight/obesity was observed in Greece, Hungary, Slovenia and Spain than in Belgium, Netherlands and Norway. Large differences between countries were found in intakes of sugar-sweetened beverages, breakfast, active transport, TV and computer time. More favorable overweight status and behavior patterns were found in girls than boys and in children of higher educated parents than in children of lower educated parents.
High levels and striking differences in overweight status and potential risk behaviors were found among schoolchildren across Europe.
Overweight and obesity are important determinants of avoidable burden of disease
Recent reviews suggest that high intakes of sugar sweetened beverages, breakfast skipping, lack of physical activity, high levels of ‘screen time’ (e.g. watching TV, or playing e-games), and lack of sleep
What are the distributions and differences in body mass index (BMI), waist circumference (WC), overweight and obesity in schoolchildren in seven countries across Europe?
What are the distribution and differences in dietary, physical and sedentary activities and sleeping duration in these countries across Europe?
What are differences in anthropometrics and EBRB according to sex and parental education across different countries in Europe?
A description of the rationale and organization of the ENERGY-project
Ghent; in Greece the survey was approved by the Bioethics Committee of Harokopio University; in Hungary the survey was approved by the Scientific and Ethics Committee of Health Sciences Council; in The Netherlands the survey was approved by the Medical Ethics Committee of the VU University medical center; in Norway the survey was approved by the National Committees for Research Ethics in Norway; in Slovenia the survey was approved by the National Medical Ethics Committee of the Republic of Slovenia; and in Spain the survey was approved by Clinical Research Ethics Committee of the Government of Aragón. Furthermore, research permission was, if necessary, obtained from local school authorities (local school boards and/or headmasters).
The school-based survey was carried out between March and July 2010 in Belgium, Greece, Hungary, the Netherlands, Norway, Slovenia, and Spain, among pupils in the final years of primary education (aged 10–12 years). These seven countries were selected to provide variation across regions in Europe and thus variation in potential obesogenic behaviors and prevalence of overweight and obesity. Inclusion of more countries across Europe was not possible because of budgetary restraints. Based on previous cross-European studies (e.g. the Pro-Children study
A school recruitment letter was sent to the headmaster or principal of the sampled schools, followed by a personal telephone call. Following the school’s agreement, parents received a letter explaining the study purpose and were asked for written consent for their child’s and own participation.
Measurements were conducted according to standardized protocols. Dietary, physical activity and screen viewing behaviors were assessed by the child questionnaire. Child’s sleep duration was reported by the parent. The children completed questionnaires and anthropometric measurements during school time. Test-retest reliability was tested by administrating the questionnaire twice with a one week interval among 720 schoolchildren across the participating countries. The intraclass coefficients and percentage agreement was good to excellent for 77% of items and construct validity was moderate to excellent for 73% of the items
Body height, weight, and WC were measured by trained research assistants. The children were measured in light clothing without shoes. Body height was measured with Seca Leicester Portable stadiometer (accuracy of 0.1 cm). Weight was measured with a calibrated electronic scale SECA 861 (accuracy of 0.1 kg), WC with the SECA 201 measuring band (accuracy 0.1 cm). Two readings of each measurement were obtained. If the two readings differed more than 1%, a third measurement was taken. Body mass index (BMI) and overweight status (overweight, obesity) based on the International Obesity Task Force criteria (IOTF)
Intakes of soft drinks and fruit juices were each assessed with two food frequency questions (FFQ). First children were asked on how many days per week they drank the beverage on a seven point scale ranging from never to more than once every day (ICC soft drink = 0.72; ICC fruit juice = 0.64). Subsequently they were asked to indicate how much they drank on days they consumed the beverage by ticking the number of glasses (or small bottles, i.e. 250 ml; ICC = 0.59), cans (i.e. 330 ml; ICC = 0.53)) and/or large bottles (i.e. 500 ml; ICC = 0.59) for soft drinks, or glasses/small cartons (250 ml; ICC = 0.54) and/or regular cartons (330 ml; ICC = 0.52) for fruit juices. Pictures of the serving sizes were printed in the questionnaire. Mean intake in ml per day was calculated from the FFQ by multiplication of number of days per week and amount per day in ml divided by 7. Additionally, children were asked to indicate how much of the beverages they had consumed on the day before questionnaire administration, again by ticking the number of glasses (ICC = 0.58), cans (ICC = 0.53) and/or bottles (ICC = 0.55) for soft drinks, and glasses (ICC = 0.48) and/or cartons (ICC = 0.35) for juice.
Breakfast habits were assessed by two questions asking the children on how many schooldays per week (ICC = 0.73) and on how many weekend days (ICC = 0.52) they normally had breakfast. Breakfast frequency per week was calculated by adding up the answers of the two questions. The frequency score was recoded into a skipping breakfast score ([0] had breakfast 7 days/week;
Transport to school was assessed by two questions about how many days per week the child cycled (ICC = 0.94) or walked (ICC = 0.91) to school (from never [0] to 5 days/week
Regarding organized sports participation, questions were included on how many hours per week children participated in sports for two sports (ICC = 0.74 for sport 1; ICC = 1.00 for sport 2). Based on the answers average time of sport participation per week was calculated for each child.
Screen time questions (i.e. TV and computer time) were asked about time spent watching TV (including video and DVD;) and computer (PC) activities for weekdays (ICCs = 0.67 for TV and for PC) and weekend days (ICCs = 0.68 for TV and 0.67 for PC) separately using a categorical scale ([0] not at all, [0.5] 30 minutes per day…
The child’s sleep habits were reported by the parent about how many hours the child sleeps on average per night, separately for weekdays (ICC = 0.81) and weekend days (ICC = 0.78). A mean number of hours of sleep per day was calculated.
Parental education was also assessed in the Parent Questionnaire. Parents were asked to report their own level of education and that of the other parent/caregiver. Both scores were combined, and dichotomized into low (0, both parent/caregivers with fewer than 14 years of education) and high (at least one parent/caregiver with 14 or more years of education).
Multivariate Analyses of Variance (MANOVA) were performed to assess differences in means or proportions according to country, gender and parental education with anthropometrics (i.e. BMI, WC, % overweight/obese, according to IOTF as well as WHO criteria) and potential risk behaviors as dependent variables and country, sex and parental education as factors, and with age as a covariate. For the dependent variables that showed significant results, subsequent pairwise comparisons by means of ANOVAS with Bonferoni correction were conducted. For EBRBs means and standard deviations are reported, but because of skewed distributions, a table with median values is made available as an additional file (see
Between 15 (Slovenia) and 37 (Greece) schools participated, with a wide range in response rates at school level (see
Belgium | Greece | Hungary | Netherlands | Norway | Slovenia | Spain | |
Schools recruited, N | 26 | 37 | 29 | 23 | 21 | 15 | 24 |
% response | 29% | 54% | 71% | 5% | 36% | 100% | 72% |
Completed child questionnaires, N | 1003 | 1077 | 1022 | 926 | 1004 | 1178 | 1024 |
% response |
82% | 94% | 100% | 93% | 99% | 100% | 100% |
% response |
77% | 64% | 33% | 92% | 45% | 98% | 43% |
Completed child anthropometrics, N | 1005 | 1077 | 1022 | 898 | 980 | 1146 | 1012 |
% response | 82% | 94% | 100% | 86% | 97% | 97% | 99% |
Completed parent questionnaires, N | 763 | 1008 | 932 | 404 | 903 | 1028 | 964 |
% response |
62% | 83% | 91% | 41% | 89% | 87% | 94% |
% response |
59% | 60% | 67% | 40% | 41% | 86% | 40% |
response rate is the percentage of children that completed the child questionnaire of the children with parental consent.
response rate is the percentage of children that completed to child questionnaire of the total number of eligible children.
response rate is the percentage of children with completed parent questionnaire of the children with parental consent.
response rate is the percentage of children with completed parent questionnaire of the total number of eligible children.
Multivariate Analyses of Variance revealed a significant multivariate main effect on the antropometric variables for country (Willk’s λ = 0.88, F (36, 30878.0) = 25.07, p<0.00), gender (Willk’s λ = 0.93, F(6.0, 7036.00) = 91.31, p<0.00), and parental education (Willk’s λ = 0.98, F(6.0, 5082.00) = 14.85, p<0.00).
Across the countries, 25.8 and 5.4% of the boys, and 21.8 and 4.1% of the girls were overweight (including obesity) and obese, respectively (
Belgium | Greece | Hungary | Netherlands | Norway | Slovenia | Spain | Differences between countries |
|||||||||
(B) | (Gr) | (Hu) | (Nl) | (N) | (Sl) | (Es) | ||||||||||
Gender | Boys | Girls | Boys | Girls | Boys | Girls | Boys | Girls | Boys | Girls | Boys | Girls | Boys | Girls | Boys | Girls |
N = 481 | N = 522 | N = 503 | N = 588 | N = 458 | N = 562 | N = 453 | N = 448 | N = 470 | N = 508 | N = 559 | N = 589 | N = 485 | N = 523 | |||
BMI (mean, SD) |
18.3 (3.2) | 18.1 (3.0) | 20.6 (3.7) | 20.3 (3.9) | 19.7 (3.8) | 19.3 (3.5) | 18.4 (3.2) | 18.5 (3.0) | 18.4 (2.4) | 18.7 (3.0) | 19.4 (3.5) | 18.9 (3.2) |
19.1 (2.8) | 19.2 (3.0) | B,Nl,N<Gr,Hu,Sl,EsHu,Sl,Es<Gr | B<Gr,Hu,Sl,EsN,Nl<Gr,Sl,EsHu,Sl,Es<Gr |
WC (mean, SD) |
64.1 (8.5) | 62.6 (7.6) |
71.8 (10.2) | 69.4 (9.2) |
70.1 (11.0) | 66.9 (9.2) |
64.0 (7.9) | 62.6 (7.0) |
65.0 (6.7) | 63.9 (7.3) |
68.9 (9.6) | 65.9 (8.3) |
66.3 (7.4) | 64.9 (7.2) |
B,N,Nl<Gr,Hu,Sl,EsHu,Sl<GrEs<Gr,Hu,Sl | B,N,Nl<Gr,Hu,Sl,EsHu,Sl,Es<Gr |
% Overweight |
16.9 | 13.5 | 44.4 | 37.7 |
27.7 | 22.6 |
16.8 | 15.4 | 15.1 | 13.8 | 31.7 | 22.5 |
25.8 | 23.8 | B,N<Gr,Hu,Sl,EsHu,Sl,Es<GrNl<Gr,Hu,Sl | B,N<Gr,Hu,Sl,EsHu,Sl,Es<GrNl<Gr,Hu,Es |
% Obese |
3.7 | 2.3 | 11.2 | 9.7 | 6.8 | 4.1 |
4.5 | 2.5 | 0.4## | 2.4 | 7.5 | 3.9 |
2.9 | 3.1 | B,Nl<GrN<Gr,Hu,SlEs<Gr,Sl | B,Hu,Nl,N,Sp,Es<Gr |
%Overweight WHO |
24.5 | 17.9 |
55.4 | 44.1 |
35.5 | 26.2 |
26.0 | 18.5 |
21.2 | 17.8 | 39.5 | 28.3 |
37.6 | 30.8 |
B,Nl,N<Gr,Hu,Sl,EsHu,Sl,Es<Gr | B,N<Gr,Hu,Sl,EsNl<Gr,Sl,EsHu,Sl,Es<Gr |
%Obese WHO |
8.0 | 4.1 |
27.6 | 14.8 |
14.0 | 6.8 |
7.2 | 4.2 | 3.9 | 4.2 | 16.8 | 6.2 |
10.7 | 6.1 |
Es,Hu,Sl<GrB,Nl,N<Gr,Hu,Sl | B,Hu,Nl.N.Sl.Es<Gr |
P<0.05;
p<0.01;
p<0.001 girls significantly lower than boys, adjusted for age;
p<0.05 boys significantly lower than girls, adjusted for age;
p<0.05;
p<0.01;
P<0.001 high educated significantly lower than low educated, adjusted for age;
pairwise comparison between countries using Bonferroni correction, adjusted for age;
pairwise comparison between countries using Bonferroni correction, adjusted for age and height;
overweight categories based on the IOTF criteria, including both overweight and obesity;
Weight categories based on WHO criteria, overweight including obese stands for BMI+1SD; obese stands for BMI+2SD.
MANOVA showed a significant multivariate main effect on the energy balance related behaviors for country (Willk’s λ = 0.242, F(102.00, 28716.63) = 79.626, p<0.00), gender (Willk’s λ = 0.921, F(17.00, 5041.00) = 25.276, p<0.00), and parental education (Willk’s λ = 0.937, F(17.0, 4456.00) = 17.59, p<0.00).
Belgium | Greece | Hungary | Netherlands | Norway | Slovenia | Spain | Differences between countries |
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(B) | (Gr) | (Hu) | (Nl) | (N) | (Sl) | (Es) | ||||||||||
Gender | Boys N = 477 | Girls N = 516 | Boys N = 500 | Girls N = 586 | Boys N = 459 | Girls N = 563 | Boys N = 456 | Girls N = 463 | Boys N = 450 | Girls N = 518 | Boys N = 570 | Girls N = 601 | Boys N = 493 | Girls N = 529 | Boys | Girls |
Soft drink FFQ (ml/day) | 502±593 | 408±515 |
139±216 | 92±186 |
608±648 | 496±576 |
700±633 | 565±525 |
275±328 | 174±233 |
413±557 | 249±432 |
239±348 | 133±246 |
B.Hu<NlGr<B,Hu,Nl,N,Sl,EsN,Es<B,Hu,Nl,SlSl<Hu,Nl | B,Hu<NlGr,N,Es<B,Hu,Nl,SlSl<B,Hu,Nl |
Soft drink-24 h recall (ml/day) | 381±466 | 309±390 |
179±259 | 133±226 |
641±630 | 591±600 | 689±586 | 599±443 |
240±379 | 168±264 |
498±604 | 354±447 |
203±319 | 123±249 |
B<Hu,Nl,SlGr,N,Es<B,Hu.Nl,SlSl<Hu,Nl | B,Sl<Hu,NlGr,N,Es<B,Hu,Nl,Sl |
Fruit Juice FFQ (ml/day) | 265±300 | 251±297 | 286±292 | 241±238 |
349±442 | 345±397 | 384±434 | 385±399 | 217±281 | 159±207 |
415±v569 | 355±389 |
250±258 | 223±270 | B,N,Es<Hu,Nl,SlGr<Nl,SL | B,Gr,Es<Hu,Nl,SlN<B,Gr,Hu,Nl,Sl,Es |
Fruit juice-24 h recall (ml/day) | 271±323 | 226±264 |
254±300 | 224±232 | 305±416 | 331±420 | 388±413 | 391±390 | 175±284 | 132±209 |
413±468 | 370±382 | 220±278 | 207±234 | B,Gr,Hu<Nl,SlN<B,Gr,Hu,Nl,SlEs<Hu,Nl,Sl | B,Gr,Es<Hu,Nl,SlHu<NlN<B,Gr,Hu,Nl,Sl,Es |
Breakfast (days/week) | 6.2±1.6 | 6.2±1.6 | 5.4±2.1 | 5.4±2.2 | 5.8±1.9 | 5.6±1.9 | 6.4±1.4 | 6.3±1.6 | 6.3±1.6 | 6.5±1.3 | 5.1±2.2 | 5.1±2.2 | 6.6±1.1 | 6.7±1.0 | B<EsGr,Hu<B,Nl,N,EsSl<B,Hu,Nl,N,Es | B<N,EsGr,Hu<B,Nl,N,EsSl<B,Hu,Nl,N,Es |
Skipped breakfast ≥ 1/week (%) | 30.4 | 30.4 | 47.8 | 46.1 | 38.1 |
47.5 | 24.1 | 22.1 | 21.8 | 19.8 | 51.7 | 51.3 | 16.9 | 12.0 |
B,Hu<Gr,SlNlN<Gr,Hu,SlEs<B,Gr,Hu,Sl | B<Gr,Hu,SlNl,N,Es<B,Gr,Hu,Sl |
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Soft drink FFQ (ml/day) | 565±559 | 350±473 |
119±194 | 86±152 |
654±679 | 469±565 |
631±608 | 505±491 | 251±303 | 208±277 | 344±550 | 257±393 |
256±411 | 163±269 |
Gr<B,Hu,Nl,Sl,EsN,Sl,Es<B,Hu,Nl | B<Hu,NlGr<B,Hu,Nl,N,Sl,EsN,Sl<B,Hu,NlEs<B,Hu,Nl,Sl |
Soft drink-24 h recall (ml/day) | 472±465 | 279±358 |
174±249 | 121±200 |
633±595 | 564±604 | 638±476 | 559±460 | 233±291 | 167±315 |
379±560 | 319±446 |
216±377 | 143±254 |
Gr,N,Es<B,Hu,Nl,SlSl<Hu | B,Sl<Hu,NlGr,N,Es<B,Hu,Nl,Sl |
Fruit Juice FFQ (ml/day) | 297±342 | 233±274 | 259±270 | 258±246 | 371±469 | 338±396 | 437±431 | 303±325 |
165±213 | 199±257 | 405±446 | 336±385 |
285±338 | 226±241 |
Gr,N<Hu,Nl,SlEs<Sl | B,Es<Hu,Nl,SlGr<Hu,SlN<Gr,Hu,Nl,Sl |
Fruit juice-24 h recall (ml/day) | 264±334 | 229±269 | 240±246 | 219±234 | 330±408 | 300±405 | 455±394 | 294±304 |
128±232 | 162±256 | 423±473 | 336±370 |
264±336 | 200±222 |
B,Es<Nl,SlGr<Hu,Nl,SlHu<SlN<Gr,Hu,Nl,Sl,Es | B<Hu,SlGr,Es<Hu,Nl,SlN<B,Hu,Nl,Sl |
Breakfast (days/week) | 5.8±1.9 |
6.2±1.5 | 5.3±2.1 |
5.7±2.0 | 5.7±1.9 | 5.6±2.0 | 6.5±1.2 | 6.6±1.1 | 6.3±1.5 | 6.5±1.3 | 5.0±2.2 |
5.5±2.1 | 6.5±1.1 | 6.7±1.0 | Gr<Hu,Nl,N,EsHu<Nl,N,EsSl<B,Hu,Nl,N,Es | B<Nl,N,EsGr,Hu,Sl<B,Nl,N,Es |
Skipped breakfast ≥ 1/week (%) | 40.8 | 27.2 |
50.5 | 40.7 |
42.6 | 41.6 | 19.7 | 14.8 | 23.5 | 17.1 | 56.1 | 42.9 |
21.6 | 11.8 |
Hu<,SlN,Es<B,Gr,Hu,SlNl<Gr,Hu,Sl | B<Gr,Hu,SlNl,N,Es<B,Gr,Hu,Sl |
P<0.05;
p<0.01;
p<0.001 girls significantly lower than boys, adjusted for age;
p<0.05.
p<0.01;
p<0.001 boys significantly lower than girls, adjusted for age;
p<0.05;
p<0.01;
P<0.001 high educated significantly lower than low educated, adjusted for age;
p<0.05;
p<0.01;
p<0.001 lower educated significantly lower than higher educated, adjusted for age.
pair wise comparison between countries using Bonferroni correction adjusted for age;
Mean number of days/week having breakfast ranged from 6.7 among Spanish girls to 5.1 among Slovenian girls. In Slovenia the highest prevalence (>50%) of skipping breakfast on one or more days per week was reported.
Children of lower educated parents reported less favorable intakes regarding soft drink, fruit juice, and breakfast than children of higher educated parents (
With an average of more than 40 minutes/week, children in Norway and Netherlands spent much more time cycling to school than children in other countries (
Belgium | Greece | Hungary | Netherlands | Norway | Slovenia | Spain | Differences between countries |
|||||||||
(B) | (Gr) | (Hu) | (Nl) | (N) | (Sl) | (Es) | ||||||||||
Gender | Boys N = 477 | Girls N = 516 | Boys N = 500 | Girls N = 586 | Boys N = 459 | Girls N = 563 | Boys N = 456 | Girls N = 463 | Boys N = 450 | Girls N = 518 | Boys N = 570 | Girls N = 601 | Boys N = 493 | Girls N = 529 | Boys | Girls |
Total active transport (days/week) | 3.22.4 | 3.1±2.5 | 4.0±1.9 | 3.9±1.9 | 2.4±2.5 | 2.3±2.4 | 4.8±1.2 | 4.8±1.1 | 5.8±2.5 |
6.3±2.6 | 3.0±2.4 | 2.8±2.4 | 4.0±1.8 | 4.1±1.7 | B,Sl<Gr,Nl,N,EsGr,Es<Nl,NHu<B,Gr,Nl,N,Sl,EsNl<N | B,Sl<Gr,Nl,N,EsGr,Es<Nl,NHu<B,Gr,Nl,N,Sl,EsNl,<N |
Total active transport (min/week) | 43±44 | 43±50 | 41±41 | 40±34 | 44±57 | 41±56 | 55±44 | 60±44 | 94±72 |
111±80 | 45±51 | 46±53 | 59±48 | 61±50 | Gr,Hu<Nl,N,EsB,Sl<N,EsNl,Es<N | B,Gr,Hu,Sl<Nl,N,EsNl,Es<N |
Active transport 24 h (min/day) | 6.5±8.8 | 6.3±9.4 | 7.7±7.7 | 7.4±7.3 | 5.3±9.8 | 5.5±9.8 | 10.2±9.0 | 11.1±9.6 | 12.5±1 | 13.7±12 | 6.6±9.8 | 6.6±10 | 10.4±10 | 11.1±10 | B,Gr,Sl,<Nl,N,EsHu<Gr,Nl,N,Sl,EsNl<N | B,Gr,Sl<Nl,N,EsHu<Gr,Nl,N,EsNl,Es<N |
Cycling to school(days/week) | 2.0±2.2 | 1.8±2.1 | 0.1±0.6 | 0 1±0.4 | 0.4±.2 | 0.2±0.8 |
3.3±2.1 | 3.2±2.1 | 3.4±2.1 | 3.2±2.0 | 0.4±1.0 | 0.2±0.8 |
0.1±0.4 | 0.0±0.1 |
B<Nl,NGr,Es<B,Nl,N,SlHu,Sl<B,Nl,N | B<Nl,NGr,Hu,Sl,Es<B,Nl,N |
Cycling to school(min/week) | 27±39 | 25±41 | 1.5±12 | 0.3±2.6 |
6.3±24 | 3.8±18 | 42±47 | 46±50 | 46±45 | 49±48 | 6.7±23 | 4.6±21 | 0.8±7.4 | 0.2±1.9 | B<Nl.NEs<B,NL,N,SlGr,Hu,Sl<B,Nl,N | B<Nl,NGr,Hu,Sl,Es<B,Nl,N |
Walking to school (days/week) | 1.3±2.0 | 1.3±2.0 | 3.9±1.9 | 4.0±1.9 | 2.0±2.3 | 2.1±2.3 | 1.5±2.1 | 1.6±2.1 | 2.5±2.2 |
3.1±2.1 | 2.5±2.3 | 2.6±2.3 | 3.9±1.8 | 4.1±1.8 | Hu<Gr,N,Sl,EsB,Nl<Gr,Hu,N,Sl,EsN,Sl<Gr,Es | B,Nl<Gr,Hu,N,Sl,EsHu<Gr,N,Sl,EsN,Sl<Gr,Es |
Walking to school (min/week) | 16±30 | 18±35 | 40±36 | 39±34 | 38±53 | 37±53 | 13±22 | 14±22 | 48±56 |
62±60 | 38±46 | 42±50 | 58±47 | 61±50 | B,Nl<Gr,Hu,N,Sl,EsGr,N,Sl<EsHu<N,Es | B,Nl<Gr,Hu,N,Sl,EsGr,Hu,Sl<N,Es |
Sport participation (min/week) | 229±148 | 191±145 |
190±154 | 139±137 |
282±179 | 236±161 |
248±159 | 174±138 |
310±166 | 238±154 |
292±171 | 246±173 |
249±166 | 148±139 |
B<Hu,N,SlGr<B,Hu,Nl,N,Sl,EsNl,Es<N,SL | B,Nl<Hu,N,SlGr,Es<B,Hu,Nl,N,Sl |
P<0.05;
p<0.01;
p<0.001 girls significantly lower than boys, adjusted for age;
p<0.05;
p<0.01;
p<0.001 boys significantly lower than girls, adjusted for age;
pair wise comparison between countries using Bonferroni correction adjusted for age.
Belgium | Greece | Hungary | Netherlands | Norway | Slovenia | Spain | Differences between countries |
|||||||||
(B) | (Gr) | (Hu) | (Nl) | (N) | (Sl) | (Es) | ||||||||||
Parental education | Low N = 105 | High N = 561 | Low N = 430 | High N = 461 | Low N = 320 | High N = 443 | Low N = 78 | High N = 271 | Low N = 183 | High N = 533 | Low N = 392 | High N = 503 | Low N = 171 | High N = 708 | Low | High |
Total active transport (days/week) | 3.4±2.3 | 3.0±2.4 | 4.1±1.8 | 3.8±2.0Λ | 2.3±2.5 | 2.2±2.4 | 4.7±1.3 | 4.8±0.9 | 5.9±2.7 | 6.1±2.5 | 2.7±2.4 | 2.8±2.4 | 4.3±1.5 |
4.0±1.9 | Sl<Gr,Nl,N,EsB<Nl,N,EsGr,Nl,Es<NHu<B,Gr,Nl,N,Es | B,Sl<Gr,Nl,N,EsGr,Nl<NHu<B,Gr,Nl,N,Sl,EsEs<Nl,N |
Total active transport (min/week) | 46±46 | 41±48 | 43±41 | 36±32ΛΛ | 42±58 | 39±52 | 52±38 | 59±43 | 107±84 | 104±76 | 43±52 | 44±52 | 67±51 | 59±49 ˆ | B,Gr,Hu,Sl<N,EsNl,Es<N | B,Gr,Sl<Nl,N,EsHu<Nl,N,Sl,EsNl,Es<N |
Active transport 24 h (min/day) | 63.2±7.5 | 6.7±97 | 8.3±8.0 | 6.6±6.8ΛΛ | 5.8±10.8 | 4.9±9.2 | 9.9±8.2 | 10.9±9.8 | 13.6±11.8 | 13.3±11.7 | 6.8±10.7 | 6.1±9.6 | 11.9±10 | 10.6±10 | B,Gr<N,EsHu<Gr,Nl,N,EsSl<N,Es | B,Gr,Sl<Nl,N,EsHu<B,Gr,Nl,N,EsEs<N |
Cycling to school(days/week) | 23.0±2.2 | 1.8±2.1 | 0.1±0.5 | 0.1±0.5 | 0.3±1.1 | 0.2±0.9 | 2.8±2.2 | 3.2±2.1 | 3.2±2.1 | 3.4±2.0 | 0.3±0.8 | 0.3±0.9 | 0.1±0.4 | 0.0±0.3 | B<Nl,NGr,Hu,Sl,Es<B,Nl,N | B<Nl,NEs<B,Nl,N,SlGr,Hu,Sl<B,Nl,N |
Cycling to school(min/week) | 26±37 | 27±42 | 0.8±1.0 | 0.5±3.9 | 5.9±24 | 4.1±18 | 37±45 | 44±49 | 51±47 | 49±48 | 4.0±18 | 6.1±23 | 0.8±8 | 0.5±5.0 | B,Nl<NGr,Hu,Sl,Es<B,Nl,N | B<Nl,NEs<B,Nl,N,SlGr,Hu,Sl<B,Nl,N |
Walking to school (days/week) | 1.4±2.1 | 1.2±1.9 | 4.0±1.8 | 3.7±2.0Λ | 2.0±2.3 | 2.0±2.3 | 2.0±2.3 | 1.6±2.1 | 2.7±2.2 | 2.7±2.2 | 2.4±2.3 | 2.4±2.3 | 4.3±1.5 | 3.9±1.9 ˆ | B,<Gr,N,Sl,EsHu<Gr,N,EsNl,N,Sl<Gr,Es | B<Gr,Hu,N,Sl,EsHu,Nl<Gr,N,Sl,EsN,Sl<Gr,Es |
Walking to school (min/wk) | 19±35 | 14±30 | 43±38 | 36±32ΛΛ | 36±53 | 34±50 | 15±17 | 14±21 | 56±62 | 55±59 | 39±50 | 38±47 | 66±50 | 58±48 ˆ | B,Nl<Gr,Hu,N,Sl,EsGr,Hu,Sl<N,Es | B,Nl<Gr,Hu,N,Sl,EsGr,Hu,Sl<N,Es |
Sport participation (min/week) | 187±148 | 212±144 | 144±146 |
183±145 | 234±169 |
282±171 | 225±165 | 205±136 | 240±160 |
283±160 | 258±173 | 274±170 | 173±163 |
207±158 | Es<Hu,N,SlB<SlGr<Hu,Nl,N,Sl | B,Gr,Nl,Es<Hu,N,Sl |
P<0.001 high educated significantly lower than low educated, adjusted for age;
p<0.05;
p<0.01;
p<0.001 lower educated significantly lower than higher educated, adjusted for age.
pair wise comparison between countries using Bonferroni correction adjusted for age.
For engagement in sport activities, boys reported on average 260 minutes/week ranging from more than 300 minutes/week in Norway to less than 200 minutes/week in Greece. Girls reported on average almost 200 minutes/week, ranging from 250 minutes/week in Slovenia to less than 150 minutes/week in Greece. Girls reported lower engagement in sport across all countries. Children of higher educated parents participated significantly more in sports than those from lower educated parents.
Across the countries boys reported spending about 2½ hours and girls somewhat less than 2 hours on screen-viewing activities (TV and computer-time combined) in 24-h recall; girls in Spain reported the lowest screen time (
Belgium | Greece | Hungary | Netherlands | Norway | Slovenia | Spain | Differences between countries |
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(B) | (Gr) | (Hu) | (Nl) | (N) | (Sl) | (Es) | ||||||||||
Gender | Boys N = 477 | Girls N = 516 | Boys N = 500 | Girls N = 586 | Boys N = 459 | Girls N = 563 | Boys N = 456 | Girls N = 463 | Boys N = 450 | Girls N = 518 | Boys N = 570 | Girls N = 601 | Boys N = 493 | Girls N = 529 | Boys | Girls |
Screen time FQ (min/day) | 205±102 | 178±95 |
214±103 | 179±85 |
233±108 | 198±103 |
223±115 | 185±101 |
196±97 | 168±91 |
213±112 | 174±103 |
193±102 | 160±90 |
N,Es<Gr,Hu,Nl,Sl | N<B,Gr,Hu,Nl,SlEs<,Gr,Hu |
Screen time -24 h recall (min/day) | 124±92 | 107±83 |
155±103 | 122±87 |
166±113 | 131±100 |
153±105 | 112±88 |
132±95 | 101±80 |
131±104 | 100±88 |
122±95 | 89±73 |
B,N,Es<Gr,Hu,NlSl<Gr,Hu | B<GrEs<B,Gr,Hu,NlSl,N<Gr,Hu |
TV time FQ(min/day) | 116±61 | 110±63 | 126±61 | 120±56 | 123±62 | 116±61 | 116±65 | 104±60 |
105±56 | 97±54 |
120±65 | 108±64 |
109±56 | 97±54 |
Nl<GrN<B,Gr,Hu,Nl,SlEs<Gr,Sl | B,Hu,Nl,Sl<GrN<B,Gr,Hu,SlEs<B,Gr,Sl |
TV time 24 h recall (min/day) | 78±57 | 77±60 | 99±63 | 89±62 |
90±63 | 85±62 | 83±64 | 67±54 |
72±58 | 62±50 |
78±63 | 68±60 |
77±54 | 64±52 |
B,Hu,Nl,Sl,Es<GrN<Gr,Hu | B,Hu,Sl<GrNl,Es<B,Gr,HuN<B,Gr,Hu,Sl |
Computer time Q (min/day) | 89±62 | 69±53 |
88±61 | 60±51 |
110±66 | 82±60 |
106±66 | 81±59 |
91±60 | 71±53 |
93±65 | 64±57 |
85±61 | 6350 |
N,Es<Hu,NlB<Nl | Gr,Es<Hu,NlN,Sl<Nl |
Computer time- 24 h recall (min/day) | 47±60 | 29±56 |
55±63 | 33±48 |
75±73 | 46±59 |
71±65 | 45±56 |
60±61 | 40±48 |
52±64 | 33±47 |
45±57 | 25±39 |
Es<HuB<Hu,NlN,Sl<Nl | B<Hu,NlSl<NlEs<Hu.Nl.N |
Sleeping habits(hr/night) | 9.6±0.7 | 9.7±0.8 | 8.7±0.8 |
8.8±0.8 | 9.0±0.7 | 9.1±0.7 | 9.5±0.8 | 9.7±0.8 | 9.2±0.6 | 9.2±0.6 | 9.1±0.7 | 9.1±0.7 | 9.3±0.7 |
9.4±0.7 | Gr<B,Hu,Nl,N,Sl,EsN,Es<B,NlSl,Hu<B,Nl,N,Es | Gr<B,Hu,Nl,N,Sl,EsHu<B,NLEsN,Es<Bl,NSl<B,Nl,N,Es |
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Screen time FQ (min/day) | 184±90 | 181±93 | 201±98 | 190±87 | 230±110 | 198±100 ̂̂̂ | 224±123 | 177±106̂̂ | 184±95 | 174±90 | 208±111 | 175±101 ˆˆˆ | 191±106 | 171±92ˆ | N<Hu,Nl,Sl | N<B,Gr,HuEs<Gr |
Screen time −24 h recall (min/day) | 115±96 | 109±81 | 142±98 | 130±93 | 162±109 | 125±98 |
162±125 | 112±92 |
116±91 | 109±80 | 126±98 | 95±82 |
121±92 | 100±82 |
N<Gr,Hu,Nl | B,Hu,Nl,N,Sl,Es<Gr |
TV time FQ(min/day) | 105±63 | 111±61 | 130±58 | 119±55 |
130±65 | 112±60 |
124±65 | 96±61 |
103±53 | 97±52 | 121±65 | 106±60 |
108±59 | 102±53 | B,Es<GrN<Gr,Hu,,Sl | Nl,<B,GrN<B,Gr,Hu,Sl,Hu,Sl,Es<Gr |
TV time 24 h recall (min/day) | 72±59 | 76±56 | 98±61 | 88±61ˆ | 99±64 | 75±58ˆˆˆ | 90±65 | 65±57ˆˆ | 68±49 | 63±51 | 79±61 | 63±56 ˆˆˆ | 76±54 | 69±52 | B,N<Gr,HuSl,Es<Gr | B,Hu,Nl,Es<GrSl<B,GrN<B,Gr,Es |
Computer time FQ (min/day) | 80±60 | 71±52 | 71±59 | 72±52 | 101±66 | 87±59 |
109±72 | 80±59 |
80±58 | 77±54 | 86±64 | 68±58 |
83±62 | 70±53 |
Gr<Hu,Nl,SlN<Hu,Nl | |
Computer −24 h recall (min/day) | 44±61 | 34±49 | 44±560 | 41±53 | 62±70 | 51±59 |
72±75 | 47±54 |
48±57 | 46±51 | 46±57 | 32±48 |
44±59 | 32±46 |
Gr,N<Nl | Es<Gr,Hu,Nl,NB,Sl<Nl |
Sleeping habits(hr/night) | 9.5±0.8 |
9.7±0.7 | 8.8±0.8 | 8.7±0.7 |
9.1±0.8 | 9.1±0.7 | 9.5±0.9 | 9.7±0.7 | 9.2±0.7 | 9.2±0.6 | 9.2±0.8 | 9.1±0.7 | 9.4±0.8 | 9.3±0.6 | Gr<B,Hu,Nl,N,Sl,EsHu,Sl<B,Nl | Gr<B,Hu,Nl,N,Sl,EsHu,N,Es<B,NlSl<B,Nl,N,Es |
P<0.05;
p<0.01;
p<0.001 girls significantly lower than boys, adjusted for age;
p<0.05;
p<0.01;
p<0.001 boys significantly lower than girls, adjusted for age;
p<0.05;
p<0.01;
P<0.001 high educated significantly lower than low educated, adjusted for age;
p<0.05;
p<0.01;
p<0.001 lower educated significantly lower than higher educated, adjusted for age.
pair wise comparison between countries using Bonferroni correction adjusted for age.
Parents of boys and girls reported on average that their child slept 9.2 hours/night. This varied between 8.7 hours for Greek boys to 9.7 hours for Belgian girls. Significantly less hours of sleep were reported for Greek boys and girls than in all the other countries (
The prevalence of measured overweight -including obesity- across seven countries from different regions in Europe was 25.8% and 21.8% (IOTF) or 34.6% and 26.8% (WHO) for boys and girls respectively. The patterns in differences in overweight and obesity were similar for IOTF and WHO criteria, but WHO criteria resulted in somewhat to substantially higher prevalence rates. The prevalence of overweight was much higher than reported for the same seven countries in the Health Behavior in School-aged Children (HBSC) report
Across all countries children engage frequently in dietary, (lack of) physical activity and sedentary behaviors that are regarded as potential risk behaviors for becoming overweight obese, with large differences between countries. Many children skipped breakfast on one or more days per week, especially in Greece and Slovenia, and the mean intakes of sugar-sweetened beverages in the Netherlands, Hungary and Slovenia was high. Low levels of active transport were reported especially in Belgium, Slovenia and Hungary, while low levels of sports were reported in Greece. Norwegian children reported the most minutes of cycling and walking to school. This is probably partly due to over-reporting due to the large seasonal differences in Norway. Norwegian children tend to cycle to school in summer, and walk to school in winter
For sedentary behaviors, screen activities were high in all countries, wherein children spent on average more than 2 hours/day in TV and computer activities. The results also indicate that children’s screen time is quite close to being equally divided between TV and other screen-viewing behaviors, confirming that sedentary behavior interventions should not be restricted to TV time only.
Furthermore, we found that overweight and participation in the potential risk behavior was more prevalent in boys than girls, with the exception of sports activities. In addition, overweight and potential risk behaviors are generally more likely in children of parents with fewer years of formal education. The difference in prevalence of overweight and risk behaviors according to parental education in Slovenia appeared to be especially worrisome and the educational disparities and differences in these disparities across Europe requires further research. In-depth analyses (not presented in this study) showed that these patterns were similar for both boys and girls. This supports earlier studies
The study has some limitations. First, differences in response rates at school and student level were apparent, which may have reduced the external validity of the findings. The fact that schools were especially difficult to recruit in the Netherlands is in line with other school-based research in this country in recent years. There is a great emphasis on youth health research. Some school-based research is obligatory (i.e. as conducted by municipal health services
Furthermore, data on dietary, physical activity and sedentary behavior were based on self-reports, and thus possibly biased. Nevertheless, the measures showed good test-retest reliability and construct validity
Strengths of the present study include the large multinational sample from different regions across Europe, the standardized data collection protocol across the different countries, measured weight, height and waist circumference, and the inclusion of a large range of potential EBRBs, including sedentary behaviors and sleep duration.
In conclusion, prevalence of overweight is high across Europe among school-aged children, with especially worrisome prevalence in Greece. Many children engage frequently in dietary, physical activity and sedentary behaviors that are associated with the likelihood of becoming overweight and obese, with large differences in such behaviors between countries and region. Region or country-specific policies and interventions are needed to contribute to curbing the overweight epidemic in European schoolchildren.
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