A Snapshot of European Children's Eating Habits: Results from the Fourth Round of the WHO European Childhood Obesity Surveillance Initiative (COSI)

Associations between restrictive feeding practices and children's dietary intake: Systematic review and meta-analyses

BACKGROUND

Parents' attempt to limit or restrict children's intake of 'unhealthy' or discretionary foods has been widely considered as a counterproductive feeding practice associated with poorer dietary outcomes, but empirical evidence is varied.

AIM

The present systematic literature review aimed to investigate the association between parental restriction and children's dietary intake.

METHOD

Studies were identified through PsycInfo, MEDLINE, CINAHL, Web of Science, and Scopus databases on April 29th, 2022. Included were peer-reviewed, English-language articles published between 2001 and 2022, with an effect size between restriction and children's intake of foods that are 'healthy' (i.e., fruit, vegetables, other general healthy foods) or 'discretionary' (i.e., sweet or savoury energy-dense/nutrient poor foods, high-sugar foods, high-salt/fat foods, and high-energy/sugar-sweetened beverages), or overall diet quality. Risk of bias was assessed using a quality assessment checklist designed to evaluate survey studies.

RESULTS

Included studies (n = 44) were most often conducted in the USA, cross-sectional, and participants were mothers. Effect sizes (k = 59) from 21 studies were used in nine meta-analyses investigating various healthy and discretionary dietary intake variables. No meta-analytic effects were statistically significant. Qualitative synthesis of effect sizes ineligible for meta-analysis (k = 91) identified patterns of associations between restriction and increased intake of healthy foods, and decreased intake of discretionary foods.

CONCLUSIONS

Studies used a diverse selection of measures of restriction and dietary intake, limiting the ability of this review to make accurate cross-study comparisons. However, results suggest that instead of restriction being detrimental for children's dietary outcomes, it may be unrelated, or associated with more beneficial dietary outcomes. Research that utilises validated measures of restriction and dietary outcomes and a longitudinal design is needed to clarify this association.

Association between protein-to-energy ratio and overweight/obesity in children and adolescents in the United States: a cross-sectional study based on NHANES

Background

The dietary protein proportion may be crucial in triggering overweight and obesity among children and adolescents.

Methods

Cross-sectional data from 4,336 children and adolescents who participated in the National Health and Nutrition Survey (NHANES) between 2011 and March 2020 were analyzed. Multivariate logistic regression was used to calculate odds ratio (OR) and 95% confidence interval (CI). Restricted cubic splines assessed the nonlinear relationships between dietary protein intake and the prevalence of overweight and obesity.

Results

Adjusted logistic regression models showed that each 1% increase in dietary protein proportion was associated with a 4% higher risk of overweight and obesity (OR = 1.04, 95% CI: 1.01-1.07). A nonlinear relationship was noted in children aged 6-11 years (P < 0.05), as demonstrated by restricted cubic spline analysis. After dividing dietary protein intake into quartiles, the highest quartile had an adjusted OR of 2.07 (95% CI: 1.35, 3.16, P = 0.001) compared to the lowest, among children aged 6-11 years.

Conclusion

Dietary protein intake is positively linked to overweight and obesity in American children, irrespective of individual characteristics and total energy consumption.

Associations between household food environment and daily intake of regular and diet soft drinks per BMI status of European children: Feel4Diabetes Study

The objective of this study was to investigate how the availability of food in the household environment is associated with a daily intake of regular and diet soft drinks in European children, considering BMI status. This cross-sectional study utilised baseline data from 12 211 schoolchildren participating in the Feel4Diabetes European lifestyle modification intervention. Sociodemographics, soft drink intake and household food availability data were collected using parent-completed questionnaires. Anthropometry was recorded, and children were classified into BMI categories according to the International Obesity Task Force cut-offs. In the multivariate logistic regression analysis controlled for children's sex, mother's BMI, and educational level, frequent household availability of fruit juice (sugar added), regular soft drinks and salty snacks compared to less frequent were positively associated with daily regular soft drink intake in children, regardless of BMI group (ORs range 1.59-6.69). Conversely, frequent availability of fruit juice (no added sugar) was inversely related to regular soft drink intake in both BMI groups, as was the availability of fresh fruit in the overweight/obesity group, and the availability of diet soft drinks in the underweight/normal-weight (ORs range 0.31-0.54). In conclusion, habitual household availability of selected energy-dense foods/beverages was positively associated with a daily intake of regular soft drinks in European children, regardless of BMI status. Contrastingly, household availability of fresh fruit, fruit juice (no added sugar) and diet soft drinks were inversely associated with regular soft drink intake. Programmes focusing on reducing children's soft drink intake should consider reducing the availability of sugar-added beverages in the household food environment and encouraging water consumption, as a practical, healthier alternative suggestion.

Reframing interventions for optimal child nutrition and childhood obesity: the importance of considering psychological factors

This review aims to emphasise the impact of poor nutrition on children's health and psychological well-being, urging those involved in childhood obesity or nutrition services to broaden their intervention approach. Poor nutrition and childhood obesity affect physical and psychological health. The stress of living with obesity further impacts quality of life, well-being and self-esteem. Children living with obesity may experience adverse childhood events and stress, and young people are able to recall the impact of psychosocial issues such as experiencing stigma and discrimination. Food is often a coping mechanism for managing negative emotions, perpetuating cycles of emotional coping and unhealthy eating behaviours. UK guidelines recommend family-based, multi-component weight management interventions for children living with obesity. Interventions mainly target health behaviours and utilise behaviour change techniques attempting to directly improve diet and physical activity as behavioural outcomes. Whilst these interventions may show some improvements in psychological well-being, there is limited consideration or understanding of the underlying mechanisms of action which indirectly influence engagement and the sustainability of the behaviour change. Lack of attention and inclusion of psychosocial variables in intervention implementation may help explain the variable effectiveness reported across childhood obesity interventions. In conclusion, enhancing the effectiveness of childhood obesity interventions requires a broader approach that fully incorporates psychosocial factors. Those responsible for commissioning, designing and implementing these interventions should adopt a holistic approach that addresses psychological and emotional needs while incorporating underlying mechanisms of action. This shift in focus could result in more sustainable and comprehensive treatment for childhood obesity.

Children's exposure to television advertising of unhealthy foods and beverages across four countries of WHO European Region

OBJECTIVE

To compare the frequency and healthfulness of foods being advertised to children and adolescents in four countries of WHO European region.

DESIGN

Cross-sectional quantitative study, guided by an adapted version of the WHO protocol. All recorded food advertisements were categorised by categories and as either 'permitted' or 'not permitted' for advertising to children in accordance with WHO Regional Office for Europe Nutrient Profile Model.

SETTINGS

Four countries: Russia, Turkey, Kazakhstan and Kyrgyzstan.

PARTICIPANTS

TV channels most popular among children and adolescents.

RESULTS

Analysis included 70 d of TV broadcasting for all channels, during which time there were 28 399 advertisements. The mean number of advertisements per hour varied from eleven in Turkey and Kazakhstan to eight and two in Russia and Kyrgyzstan. In all countries, the majority of the food and beverages advertised should not be permitted for advertising to children according to the WHO Nutrient Profile Model. The mean number of non-permitted food and beverage advertisements per hour was high in Turkey and Kazakhstan (8·8 and 8·5 ads) compared with Russia (5·1) and Kyrgyzstan (1·9). Turkey was the only country where nutritional information was fully available, and no values were missing that prevented coding for some product categories.

CONCLUSIONS

Results revealed that children and adolescents in four countries are exposed to a considerable volume of food and beverage advertisements, including sugary products on broadcast television. As such, policymakers should consider protecting youth by developing regulations to restrict these marketing activities within media popular with children.

Effects of "Football and Nutrition for Health" program on body composition, physical fitness, eating behaviours, nutritional knowledge, and psychological status among 7 to 10 years school children

Introduction

Noncommunicable diseases and obesity are between the major health threat due to consumption of unhealthy foods and limited time spent on physical activities, a situation of particular concern among children. Since children spend most of their time at school, this study intends to investigate the effect of a school intervention program, which combines recreational football and nutrition education, on body composition, physical fitness, physical activity, blood pressure and heart rate, eating behaviours, nutritional knowledge, and psychological status in elementary school children.

Methods

A total of 67 children, between 7 and 10 years old, were allocated into three groups: the Football Group (FG) which held 2 weekly sessions of 60 min of recreational football, the Nutrition and Football Group (NFG) which held 2 sessions per week of 60 min of recreational football plus 60 min of nutritional education and the Control Group (CG) which maintained its usual curriculum. The intervention lasted 12 weeks. All measurements were collected before and after the intervention.

Results

Intervention groups significantly (p < 0.05) improved BMI Z-score, rest heart rate, horizontal jump and shuttle test, physical activity level, and psychosocial health. The NFG group significantly decreased (p < 0.05) waist-to-height ratio and blood pressure, and significantly increased (p < 0.05) nutritional knowledge, fruit, and fish consumption. While FG significantly decreased (p < 0.05) the percentage of fat mass and significantly increased (p < 0.05) muscle mass and performance in the 20 m sprint.

Discussion

The results have shown to improve nutritional status, explosive strength, aerobic and neuromuscular fitness, as well as increase the level of physical activity. The nutritional education sessions contributed to increase nutritional knowledge and to improve the consumption of healthy food groups in a ludic-educational way. The "Football and Nutrition for Health" program was able to induce short-term improvements in several health markers, highlighting the role of the school curriculum in children's health.

Child characteristic correlates of food rejection in preschool children: A narrative review

Dietary habits formed in early childhood are key for establishing a healthy diet later in life. Picky eating and food neophobia - the two main forms of food rejection in young children - form an important barricade to establishing such healthy habits. Understanding these types of food rejection is thus essential for promoting healthy eating behaviour in both children and adults. To this end, the present narrative review aims to provide an overview of food rejection research in preschool-aged children, focusing on recent advances in the cognitive literature. Specifically, we evaluate the link between children's cognitive development, chemosensory perception and affective evaluation of food, food knowledge, decision-making strategies, anxiety and disgust sensitivity, and food rejection behaviour. Longitudinal and experimental studies are necessary to establish how the relationships between food rejection and cognitive processes develop over time and to determine their causal directions.

Trend in Breakfast Consumption among Primary School Children in Italy

Eating breakfast daily improves cognitive function, may contribute to learning and academic performance in children and can decrease the risk of childhood obesity. The aim of this study was to analyse how breakfast consumption changed in the period from 2008/9 to 2019 in Italy among children aged 8-9 years old participating in the OKkio alla SALUTE surveys and to explore the associations with some socio-demographic and lifestyle factors. Information about children's daily breakfast consumption (adequate, inadequate, and no breakfast) and the socio-demographic characteristics of the children and their mothers was collected through four questionnaires addressed to parents, children, teachers and head teachers. Data were analysed for the 272,781 children from 21 Italian regions from 2008/9 to 2019. The prevalence of adequate breakfast decreased from 60.7% in 2008/9 to 55.7% in 2019 and no breakfast from 10.9 to 8.7%; conversely, inadequate breakfast increased from 28.4 to 35.6%. Logistic regression models showed that the occurrence of inadequate or no breakfast consumption was significantly higher among girls, children living in the southern regions and children with less educated mothers. These findings highlight the need for effective interventions to increase daily breakfast consumption and its adequacy among children.

Lifestyle interventions to change trajectories of obesity-related cardiovascular risk from childhood onset to manifestation in adulthood: a joint scientific statement of the task force for childhood health of the European Association of Preventive Cardiology and the European Childhood Obesity Group

There is an immediate need to optimize cardiovascular (CV) risk management and primary prevention of childhood obesity to timely and more effectively combat the health hazard and socioeconomic burden of CV disease from childhood development to adulthood manifestation. Optimizing screening programs and risk management strategies for obesity-related CV risk in childhood has high potential to change disease trajectories into adulthood. Building on a holistic view on the aetiology of childhood obesity, this document reviews current concepts in primary prevention and risk management strategies by lifestyle interventions. As an additional objective, this scientific statement addresses the high potential for reversibility of CV risk in childhood and comments on the use of modern surrogate markers beyond monitoring weight and body composition. This scientific statement also highlights the clinical importance of quantifying CV risk trajectories and discusses the remaining research gaps and challenges to better promote childhood health in a population-based approach. Finally, this document provides an overview on the lessons to be learned from the presented evidence and identifies key barriers to be targeted by researchers, clinicians, and policymakers to put into practice more effective primary prevention strategies for childhood obesity early in life to combat the burden of CV disease later in life.

Translating and Testing a Digital Game Promoting Vegetable Consumption in Young Children: Usability Study

BACKGROUND

Promoting healthy eating in children is key to preventing chronic diseases, and vegetable consumption is notably lower than recommended in this population. Among the interventions tested, gamification has shown promise in promoting familiarization, increasing knowledge, and potentially increasing vegetable intake.

OBJECTIVE

This pilot study aimed first to translate the digital game "Veggies4myHeart" into French and to assess its influence on young children's preferences and willingness to taste vegetables when combined with repeated tasting and education. We also aimed to investigate the acceptability and applicability of the game in 2 classrooms.

METHODS

During 5 consecutive weekly sessions, children from 2 elementary classes played the digital game consisting of 5 mini games on different vegetables (lettuce, carrot, red cabbage, cucumber, and tomato) in pairs for 10-15 minutes. In addition, they discussed one of the vegetables and tasted the 5 vegetables in each session. Pretest and posttest food preferences and willingness to taste the vegetables were compared. Teachers participated in a semistructured interview.

RESULTS

A total of 45 children aged 5 to 6 years tested the French version of the digital game. The children's declared food preferences were already high for carrot, cucumber, and tomato, with scores higher than 4 out of a maximum of 5. The scores did not change significantly after the intervention, except for red cabbage (pretest: mean 2.52, SD 1.49; posttest: mean 3.29, SD 1.67; P=.006) and a composite score (pretest: mean 3.76, SD 1.06; posttest: mean 4.05, SD 1.03; P=.001). Before the intervention, 18 (44%), 30 (73%), 16 (39%), 29 (71%), and 26 (63%) children out of 41 were willing to taste lettuce, carrot, red cabbage, cucumber, and tomato, respectively. After the intervention, no significant statistical differences were observed, with 23 (51%), 36 (80%), 24 (53%), 33 (73%), and 29 (64%) children out of 45 willing to taste lettuce, carrot, red cabbage, cucumber, and tomato, respectively. Teachers supported this tool combined with repeated tasting and education and highlighted facilitators and barriers that should be anticipated to improve implementation in schools.

CONCLUSIONS

In this study, we translated an existing digital game applicable and acceptable to both children and teachers. A larger study is warranted to confirm the effectiveness of interventions using the digital game to promote vegetable preference, willingness to taste, and intake.

Three-Year School-Based Multicomponent Intervention May Change Fruit and Vegetable Preferences in Primary School Children-A Quasi-Randomized Trial

Preference could be the trigger for fruit and vegetable (FV) consumption in children and could be modified by appropriate intervention to increase the acceptance of FVs. The primary objective of this study was to investigate the effects of the three-year school-based multicomponent intervention "Nutri-školica" on the FV preferences of primary school children. It also aimed to explore whether a positive change in FV preferences could lead to an increase in actual FV consumption. The study was conducted in 14 primary schools from the city of Zagreb on 193 children (52.3% boys; age, 7.7 ± 0.4 years; n = 85 in the control group and n = 108 in the intervention group) who completed a preference questionnaire before and after the intervention with a 5-point hedonic smiley-face scale, where 5 means "I like it a lot." The per-protocol approach was used for data analysis (28.3% of children from the study sample). After the intervention, children in the intervention group (before: 3.1 ± 0.8; after: 3.5 ± 0.8) increased their FV preferences significantly more than children in the control group (before: 3.2 ± 0.8; after: 3.3 ± 0.7). Children's FV preferences changed most toward the varieties for which they had the least preferences at the beginning of the study. Participation in the intervention had a stronger effect on changing FV intake than change in FV preferences among primary school children. In summary, the present study highlighted that a targeted intervention can increase children's FV preferences, but that participation in the intervention is substantial for increasing FV intake.

Socioeconomic and gender inequalities in childhood obesity in Spain

INTRODUCTION

Childhood obesity is inversely associated with household socioeconomic status in high-income countries. Our aim was to explore the association between childhood weight status and household socioeconomic status in Spain in relation to family characteristics, perceptions and lifestyle habits and the school environment.

METHODS

We performed a descriptive analysis of child weight status according to family socioeconomic factors and mediating variables based on data from the ALADINO 2019 study in a sample of 16,665 schoolchildren representative of the population aged 6-9 years in Spain.

RESULTS

The prevalence of childhood obesity in households with low socioeconomic status (26.8% boys; 20.4% girls) was, in both sexes, twice as high as in those with higher socioeconomic status (12.1% boys; 8.7% girls). Unhealthy eating habits, sedentary lifestyles (mainly in girls) and the presence of screens in the bedroom (more prevalent in boys) were more frequent in school-aged children from low-income households. On the other hand, in the most disadvantaged households, a history of breastfeeding and physical activity (especially in girls) were less frequent. Similarly, schools attended by children from low-income households were less likely to have their own kitchens and indoor gymnasiums or offer sports activities.

CONCLUSION

A lower household socioeconomic status was associated with poorer dietary and physical activity habits and certain characteristics of the family and school environments that mediate the inverse association between household socioeconomic status and the prevalence of childhood obesity. Girls were less physically active and reported more sedentary lifestyles, while boys had greater access to screens. Interventions to combat childhood obesity should address the identified inequalities.

Healthcare and socioeconomic costs of NAFLD: A global framework to navigate the uncertainties

Left unaddressed, non-alcoholic fatty liver disease (NAFLD) will continue to have substantial health, economic and social implications. To address the challenge, a paradigm shift is needed in the way NAFLD is conceptualised. Concerted, collaborative action across medical specialities, industry sectors and governments will be vital in tackling this public health threat. To drive this change, in this review, we present data on the current global healthcare and socioeconomic costs of NAFLD and highlight priority actions. The estimated healthcare costs of patients with NAFLD are nearly twice as high as their age-matched counterparts without the disease and are highest in those with advanced fibrosis and end-stage liver disease. NAFLD is accountable for the highest increase in DALYs (disability-adjusted life years) among all liver diseases globally. NAFLD and non-alcoholic steatohepatitis (NASH)-specific drug therapies are not yet available and there is considerable uncertainty regarding cost, optimal length of treatment, and their impact on liver-related outcomes and mortality. Among the currently available bariatric procedures, sleeve gastrectomy is reported to be the most cost-effective for NASH resolution. Gastric bypass remains very expensive, while data on bariatric endoscopy are limited. Lastly, we propose a global NAFLD/NASH investment framework to guide the development of achievable yet ambitious country-specific targets and strategic actions to optimise resource allocation and reduce the prevalence of NAFLD and NASH. Its focus on high-level inputs will be critical to enabling a political and financial environment that supports clinical-level implementation of NAFLD prevention, treatment and care efforts, across all settings.

Toward an Integrated Consideration of 24 h Movement Guidelines and Nutritional Recommendations

While physical activity, sleep and sedentary behaviors are almost always considered independently, they should be considered as integrated human behaviors. The 24 h Movement approach proposes a concomitant consideration of these behaviors to promote overall health. Not only do these behaviors impact energy expenditure, but they have also been shown to separately impact energy intake, which should be further explored when considering the entire integration of these movement behaviors under the 24 h movement approach. After an evaluation of the prevalence of meeting the 24 h Movement and dietary recommendations, this review summarizes the available evidence (using English publications indexed in PubMed/MEDLINE) regarding the association between the 24 h Movement Guidelines and eating habits. Altogether, the results clearly show the beneficial impact of promoting the 24 h guidelines simultaneously, highlighting that the higher the number of respected movement recommendations, the better eating behaviors in both children and adults. Importantly, our results point out the importance of emphasizing the need to reach sedentary guidelines for better eating habits. Movement and dietary behaviors appear closely related, and giving recommendations on one might impact the other. Combining the 24 h Movement with dietary Guidelines might be more efficient than promoting them separately in public health strategies.

Post-Pandemic Feeding Patterns and Mediterranean Diet Adherence in Spanish Toddlers

During the last decade, feeding patterns, more specifically those of children, have worsened-affecting dietary habits and Mediterranean diet adherence. Here, we examine the post-pandemic feeding habits of Spanish toddlers. A total of 2465 parents of children aged between 12 and 36 months completed an online 25-item multiple-choice survey asking about dietary habits and Mediterranean diet adherence. Only 34 children (1.38%) had an adequate intake of all of the food groups included in the questionnaire. Adherence worsened as toddlers grew (p < 0.0001). Further, lower compliance was found in children with a higher intake of fast food (p < 0.001), those with siblings (p = 0.0045), and children who were the second or third child (p = 0.0005). The food group with the most commonly reported adequate intake was fish (88% of children), followed by pulses (80%), water (79%), and meat (78%). Cow's milk was the most commonly consumed dairy product among all age groups analyzed. Half of the children exhibited a low consumption of milk and dairy products. These results showed that a lack of adherence to a balanced diet is common among Spanish toddlers in the post-pandemic period and that greater parent education could improve the nutrition of toddlers.

Malnutrition Patterns in Children with Chronic Kidney Disease

Malnutrition is frequent in children with chronic kidney disease (CKD). Apart from undernutrition and protein energy wasting (PEW), overnutrition prevalence is rising, resulting in fat mass accumulation. Sedentary behavior and unbalanced diet are the most important causal factors. Both underweight and obesity are linked to adverse outcomes regarding renal function, cardiometabolic risk and mortality rate. Muscle wasting is the cornerstone finding of PEW, preceding fat loss and may lead to fatigue, musculoskeletal decline and frailty. In addition, clinical data emphasize the growing occurrence of muscle mass and strength deficits in patients with fat mass accumulation, attributed to CKD-related wasting processes, reduced physical activity and possibly to obesity-induced inflammatory diseases, leading to sarcopenic obesity. Moreover, children with CKD are susceptible to abdominal obesity, resulting from high body fat distribution into the visceral abdomen compartment. Both sarcopenic and abdominal obesity are associated with increased cardiometabolic risk. This review analyzes the pathogenetic mechanisms, current trends and outcomes of malnutrition patterns in pediatric CKD. Moreover, it underlines the importance of body composition assessment for the nutritional evaluation and summarizes the advantages and limitations of the currently available techniques. Furthermore, it highlights the benefits of growth hormone therapy and physical activity on malnutrition management.

The Association between Breakfast Macronutrient Composition and Body Weight, in Preadolescence: An Epidemiological Study among Schoolchildren

Over the last few decades, childhood overweight and obesity tend to reach epidemic proportions. The present study aimed to examine whether the composition of breakfast, through the prism of its macronutrient content, could play a part in the development of excess body weight in children. A sample of 1728 Greek students from 47 primary schools was enrolled for the purposes of this study. Their weight and height were measured and their Body Mass Index was calculated and classified according to the International Obesity Task Force criteria. Their dietary habits, breakfast foods of choice, and physical activity were assessed through the use of a self-completed questionnaire. Further assessment of breakfast composition was carried out in order to evaluate its macronutrient content. Initial analysis, which was only energy-adjusted, showed a negative association between body weight and breakfast protein content and a positive association for lipid content. After further adjustment for age, sex, level of adherence to the Mediterranean diet, and physical activity, there was a significant negative association between breakfast protein and excess body weight in children (p = 0.029), as well as a significant positive association of breakfast lipid content (p = 0.028). Breakfast macronutrient content seems to have an effect on body composition in children, independently of overall adherence to the Mediterranean diet and physical activity, however further research is needed in order to elucidate potential pathways.

The Impact of Physical Activity at School on Eating Behaviour and Leisure Time of Early Adolescents

(1) Background: Diet and physical activity (PA) significantly impact health. The aim of this study was to evaluate the impact of long-term increase in organized PA level at school on the eating behaviour and leisure time of early adolescences in the period from the age of 10 to 12. (2) Methods: Children born in 2007 (n = 278) in groups with a standard (control group) and increased level of organized PA at school (4 and 10 h a week) were subjected to an anonymous follow-up survey. The questionnaire included 22 questions related to the eating behaviour and ways and frequency of leisure time PA. The study was conducted in the same groups in three assessment sessions in September 2017, 2018 and 2019. (3) Results: During the course of the study, it was shown improvement of eating behaviour in the increased PA group whereas decline in the standard PA one. The share of children with good and very good scores of eating behaviour decreased in the standard PA group from 56.89% to 54.54% and increased in the increased PA from 58.06% to 60.29%. In the increased PA group children more frequently than standard PA ate vegetables, fruits, fish, poultry meat, wholemeal bakery products, milk, dairy products and drinking tea without sugar, as well as ate breakfast. The standard PA children more frequently than increased PA ate high sugar and/or fat content food as sweets, savoury snacks and drank fizzy drinks as well as fast foods. The frequency of often undertaken leisure time PA increased in the increased PA group from 67% to 74%, while decreased in the standard PA from 58% to 52%. (4) Conclusions: Increase in organized PA at school beneficially influenced early adolescents' eating behaviour and frequency of leisure time PA during 2 years observation. It also increased early adolescents' awareness of healthy diet. Increased PA at school helps shaping healthy lifestyle among early adolescents.

Public health interventions tackling childhood obesity at European level: A literature review

Childhood obesity pandemic, a form of malnutrition including undernutrition, and other food-regime associated risks, has universally been on the rise during the chronic period of the past 4-5 decades and is now acknowledged as one of the most "toxic fuel" accounting for poor health in the majority of countries. In order to find remedies to heal this alarming issue, a corpus of European interventions have been brought to light in the recent years. Since the vague influence and effectiveness of these measures / policies is to be further identified, their evaluation screening is underlined as a pivotal necessity. Within this framework this paper aims to critically report on the development and evaluation of the implementation of the European Union, World Health Organization Regional Office for Europe, and European Union countries' national public health policy interventions and action plans in the fight against childhood obesity. Thus, this is a narrative review synthesizing the results -following a qualitative interpretation and analysis- of recent scientific epidemiological research and review studies evidence concerning European public health interventions tackling childhood obesity, through computer-assisted literature search -via PubMed, Scopus, and Google Scholar- scientific databases. According to the literature data, it is concluded that despite the unprecedented public health challenge of addressing childhood obesity, the extent to which related European policies and programs targeting healthy nutrition, increased physical activity, and healthy lifestyle ethos are truly efficacious is still under inquiry.

Dietary behaviour and physical activity policies in Europe: learnings from the Policy Evaluation Network (PEN)

The European Policy Evaluation Network (PEN), initiated in autumn 2018, aimed at advancing the evidence base for public policies impacting dietary behaviour, physical activity and sedentary behaviours in Europe. This is needed because non-communicable diseases-the leading cause of global mortality-are substantially caused by physical inactivity and unhealthy dietary behaviours, which in turn are driven by upstream factors that have not yet been addressed effectively by prevention approaches. Thus, successful policy interventions are required that target entire populations and tackle the 'causes of the causes'. To advance our knowledge on the effective implementation of policies and their impact in terms of improving health behaviours, PEN focused on five research tasks: (i) Adaptation and implementation of a Food Environment Policy Index (Food-EPI) and development of a Physical Activity Environment Policy Index (PA-EPI); (ii) Mapping of health-related indicators needed for policy evaluation and facilitating a harmonized pan-European approach for surveillance to assess the impact of policy interventions; (iii) Refining quantitative methods to evaluate the impact of public policies; (iv) Identifying key barriers and facilitators of implementation of policies; and (v) Advance understanding the equity impact of the development, implementation and evaluation of policies aimed at promoting physical activity and a healthy diet. Finally, and in order to provide concrete evidence for policymaking, existing exemplary policies, namely sugar-sweetened beverages taxation, active transport policies and school policies on nutrition and physical activity were assessed in consideration of these five tasks. At the end of the PEN project's formal runtime, considerable advancements have been made. Here, we present an overview of the most important learnings and outputs.

Applying a systems perspective to understand the mechanisms of the European School Fruit and Vegetable Scheme

BACKGROUND

For the past two decades, the percentage of European children who consume fruit daily has remained at around 40%, despite numerous school-based policy efforts and interventions. This study aimed to apply a systems approach to provide an integrated perspective of the mechanisms of the European School Fruit and Vegetable Scheme (the Scheme) to understand better how to increase its long-term impact on children's fruit and vegetable consumption.

METHODS

We developed a causal loop diagram by synthesizing peer-reviewed articles and national government documents related to the Scheme, following the conceptualization steps of system dynamics. The initial causal loop diagrams were then validated in three stages by consulting with experts (two individuals and a group) in school-based fruit and vegetable programmes, children's fruit and vegetable consumption and the Scheme, using disconfirmatory interview guidelines.

RESULTS

The findings suggest that a central self-reinforcing mechanism through which children socialize during fruit and vegetable consumption is critical in the habituation process. Additionally, the initial increase in children's fruit and vegetable consumption following the Scheme implementation is due to growth in three self-reinforcing loops related to motivation and capability mechanisms; however, this trend gradually slows and stops due to four balancing feedback loops with alternative goals related to opportunity mechanisms that reach their limits.

CONCLUSIONS

The scheme's design should incorporate activities that align the objectives of the implementers and recipients of the Scheme at all levels. This alignment should provide children with ongoing opportunities to consume fruits and vegetables and strengthen the motivation and capability mechanisms.

Contribution of home availability, parental child-feeding practices and health beliefs on children's sweets and salty snacks consumption in Europe: Feel4Diabetes-Study

Adoption of healthy dietary and snacking habits could support optimum physical and mental development in children as they define health in adulthood. This study assessed parameters associated with children's snacking such as food home availability, parenting practices, and parents' health beliefs. In this cross-sectional study 12 039 children, 49·4% boys 5-12 years, participating in the European Feel4Diabetes-Study were included. Children's weekly consumption of sweets and salty snacks, home availability of snacks, food parenting practices, and health beliefs were assessed via questionnaires. Logistic regression was applied to explore associations of a) home availability of snacks, b) food parenting practices (permissiveness and rewarding with snacks) and c) parent's opinions on deterministic health beliefs with children's consumption of sweets and salty snacks. Results showed that home availability (sweets: OR_adj: 4·76, 95 % CI: 4·32, 5·23; salty snacks: OR_adj: 6·56, 95 % CI: 5·64, 7·61), allowing to consume (sweets: OR_adj: 3·29, 95 % CI: 2·95, 3·67; salty snacks: OR_adj: 3·41, 95 % CI: 2·98, 3·90) and rewarding with sweets/salty snacks (sweets: OR_adj: 2·69, 95 % CI: 2·23, 3·24; salty snacks: OR_adj: 4·34, 95 % CI: 3·57, 5·28) 'sometimes/or less frequently' compared to 'always/or often' were associated with lower weekly consumption of sweets and snacks. Parents' disagreement compared to agreement with deterministic health beliefs and inattentive eating were associated with lower consumption of salty snacks and sweets in children. Overall, the findings of this study indicate that attempts to promote healthy snacking habits in children should aim to improve parental dietary habits, food parenting practices, health beliefs, and reducing home availability of unhealthy foods and snacks.

Parent, child, and environmental predictors of vegetable consumption in Italian, Polish, and British preschoolers

This study compared the vegetable intake of preschool children from three European countries [Italy, Poland, and the United Kingdom (UK)] and explored the parent, child, and environmental factors that predicted intake in each country. A total of 408 parents of preschoolers (Italy: N = 61, Poland: N = 124, and UK: N = 225; child mean age = 32.2 months, SD = 9.47) completed an online survey comprising a set of standardised questionnaires. For all three countries, the questionnaires included measures of children's vegetable intake (VegFFQ), child eating behaviour (CEBQ-FF), parents' mealtime goals (FMGs), and sociodemographic questions about family background and environment. In the UK and Italy, additional questionnaires were used to assess child temperament (EAS-T) and parents' feeding practices (CFPQ). The results showed that the number of child-sized portions of vegetables consumed per day varied significantly across countries; Polish children consumed the most (∼3 portions) and Italian children the least (∼1.5 portions). Between-country differences were seen in parents' goals for family mealtimes; compared to Italian parents, Polish and UK parents were more motivated to minimise mealtime stress, increase family involvement in meal preparation, and share the same foods with family members. British and Italian parents also adopted different feeding practices; parents in the UK reported more use of healthy modelling behaviours and more use of foods to support their child's emotion regulation. In terms of child factors, Italian children were reported to be more emotional and more sociable than British children. Analyses of the relationships between the parent, child, and environmental factors and children's vegetable intake revealed both similarities and differences between countries. Negative predictors of vegetable intake included child food fussiness in the UK and Poland, child temperament (especially, shyness) in Italy, and the use of food as a reward and child emotionality in the UK. Positive predictors included the parental mealtime goal of 'family involvement' in the UK. These results highlight differences in the extent to which European preschoolers achieve recommended levels of vegetable intake, and in the factors that influence whether they do. The results suggest a need to develop healthy eating interventions that are adopted to meet the specific needs of the countries in which they are implemented.

Increasing Fruit and Vegetable Intake of Primary School Children in a Quasi-Randomized Trial: Evaluation of the Three-Year School-Based Multicomponent Intervention

Insufficient consumption of fruit and vegetables was found in primary school children. To address this problem, a three-year school-based multicomponent intervention was conducted in 14 primary schools in the City of Zagreb. The aim of the study was therefore to evaluate one of the primary goals of the intervention—the increase in fruit and vegetable intake among primary school children. A total of 681 children were allocated to the intervention (n = 300 in the control group and n = 381 in the intervention group). The intervention included 23 interactive classroom workshops, 10 cross-curricular activities, 13 homework challenges, visual exposure with educational posters in classrooms, parent education via the website, and the implementation of new dishes into the school food system. Fruit and vegetable intake was assessed using a semi-quantitative food frequency questionnaire at baseline and after the intervention. Data were analyzed by per-protocol analysis. The study involved 259 children (50.2% girls; age 7.7 ± 0.4 years; n = 116 in the control group and n = 143 in the intervention group) who completed a food intake frequency questionnaire at both time points. Children in the intervention group showed a significant increase (p < 0.001) in total daily fruit and vegetable intake (before: 332.1 ± 164.9 g; after: 430.1 ± 186.7 g) compared to the control group (before: 350.2 ± 187.5; after: 382.6 ± 196.8) after the intervention. The increase in fruit and vegetable intake was achieved in 89% of children, while 25% more children reached the daily recommendation of 400 g. The use of the multicomponent intervention showed potential to increase fruit and vegetable intake in primary school children.

Toward Systems Models for Obesity Prevention: A Big Role for Big Data

The relation among the various causal factors of obesity is not well understood, and there remains a lack of viable data to advance integrated, systems models of its etiology. The collection of big data has begun to allow the exploration of causal associations between behavior, built environment, and obesity-relevant health outcomes. Here, the traditional epidemiologic and emerging big data approaches used in obesity research are compared, describing the research questions, needs, and outcomes of 3 broad research domains: eating behavior, social food environments, and the built environment. Taking tangible steps at the intersection of these domains, the recent European Union project "BigO: Big data against childhood obesity" used a mobile health tool to link objective measurements of health, physical activity, and the built environment. BigO provided learning on the limitations of big data, such as privacy concerns, study sampling, and the balancing of epidemiologic domain expertise with the required technical expertise. Adopting big data approaches will facilitate the exploitation of data concerning obesity-relevant behaviors of a greater variety, which are also processed at speed, facilitated by mobile-based data collection and monitoring systems, citizen science, and artificial intelligence. These approaches will allow the field to expand from causal inference to more complex, systems-level predictive models, stimulating ambitious and effective policy interventions.

Relative validity and reproducibility of a semi-quantitative food frequency questionnaire to assess fruit and vegetable consumption in school-aged children

Background

Since the beneficial effects of fruit and vegetable (FV) consumption on health are well known due to the synergy of their nutrients and non-nutrients, it is crucial to have good tools to assess the FV intake. A food frequency questionnaire (FFQ) is an adequate method to estimate FV consumption, but it is necessary to relate this dietary method to the geographic and cultural environment. Therefore, this study presented the development of a semi-quantitative FFQ to estimate the FV intake in school-aged children who usually consume cooked homemade and school meals. It also aimed to evaluate the relative validity and reproducibility of the FFQ.

Methods

School-aged children (baseline age 8 years) from 14 primary schools in the city of Zagreb participated in the study during the 2019/2020 school year. Parents/caregivers, together with the children, completed the FFQs and 3-day dietary records (3DDRs). The FFQ was designed to assess the consumption of eight food categories. The FFQ was validated using the 3DDR of 141 children (51.4% of boys), whereas the reproducibility test included the FFQ of 161 children (53.4% of boys).

Results

Of the eight food categories, FFQ overestimates the consumption of three and underestimates the consumption of three food categories (p &lt; 0.05; Wilcoxon signed rank test) compared to the 3DDR. De-attenuated correlation coefficients estimated a significant relationship (0.217–0.384) between the FFQ and 3DDR. Cross-classification analysis revealed that overall, 28–41% of children were classified in the same quartile, whereas less than 10% of children were extremely misclassified for all food categories obtained from 3DDR and FFQ1. κw values showed fair agreement for all food categories. The Bland–Altman analysis results showed a relatively small bias for all food categories (median between -11.7 and -54.8 g), with no systematic patterns between the FFQ and 3DDR. No differences were found between food categories estimated with the FFQs on both occasions, and Spearman’s correlation coefficients ranged from 0.664 to 0.712 (p &lt; 0.01). Cronbach’s alpha values (α &gt; 0.700) indicate good internal consistency, and ICCs (range 0.724–0.826; p &lt; 0.01) indicate good reproducibility of the FFQ.

Conclusion

The results indicate reasonable relative validity and acceptable reproducibility of the FFQ for estimating FV consumption among school-aged children.

School Fruit and Vegetables Scheme: Characteristics of Its Implementation in the European Union from 2009/10 to 2016/17

The “School Fruit and Vegetables Scheme” (SFVS) was proposed in 2009/10 as a strategy to support the consumption of Fruit and Vegetables (FV), decrease rates of obesity, improve agricultural income, stabilize markets, and ensure the current and future supply of these foods. However, there is little information about how it was carried out in the EU. Given the potential of the SFVS to support healthier, more sustainable food systems, the objective of this study was to identify the characteristics of SFVS implementation from 2009/10 to 2016/17 in the EU. A longitudinal, observational, and retrospective study was carried out based on secondary data. A total of 186 annual reports of the Member States (MS) participating in the SFVS from 2009/10 to 2016/17 were consulted: European and national budget, funds used from the EU, participating schools and students, duration of the SFVS, FV offered, and application of sustainability criteria, expenditure per student, days of the week, the quantity of FV offered per student and other indicators were calculated. The majority of MS participated in the SFVS during the study period with a heterogeneous implementation pattern in terms of funds used, coverage, duration, quantity (totals and by portion), and cost of FV distributed per student. The sustainability criteria for the FV distribution were also not applied uniformly in all the MS. Establishing minimum recommendations for SFVS implementation are recommended to maximize the benefits of the SFVS. The results may be useful for planning new strategies to help address and improve current health and environmental problems.

Exploring the Use of a Web-Based Menu Planning Tool in Childcare Services: Qualitative Cross-sectional Survey Study

Background

Early childhood is a critical period for supporting the development of healthy eating habits, which may affect lifelong health. Childcare services are important settings for promoting early childhood nutrition; however, food provision in childcare frequently does not align with dietary guidelines. Web-based menu planning tools are well suited to support healthy food provision in childcare, although little is known about their use. Research is needed to understand how web-based menu planning tools are used in the childcare setting and how they can effectively support healthy menu planning and food provision for children in childcare.

Objective

We aimed to explore the use of a web-based menu planning tool called FoodChecker, which is available to childcare services in Victoria, Australia. We also aimed to gain insights and perspectives from childcare staff involved in menu planning about their use of the tool to plan healthy menus and guide healthy food provision for children.

Methods

We conducted a qualitative descriptive study using a cross-sectional web-based survey completed by the staff involved in menu planning in childcare services. Thematic analysis was performed using NVivo software. Emergent themes were mapped against constructs of the Technology Acceptance Model regarding perceived usefulness, perceived ease of use, and external variables influencing perceptions and use.

Results

The participants included 30 cooks and 34 directors from 53 childcare services. Participants perceived the web-based menu planning tool as useful for supporting child nutrition and health, improving organizational processes, and aiding the menu planner role. Perceptions regarding ease of use were mixed. External variables influencing perceptions and use included awareness of the tool, perceived need, time, resources, organizational support, and the food budget. Participants made recommendations to improve the tool, particularly the need to integrate functionality to make it easier and faster to use or to include more links to resources to support healthy menu planning.

Conclusions

The web-based menu planning tool was perceived as useful for cooks and directors in childcare services. Areas for improvement were identified; for example, the need for integrated digital features to make the tool easier and faster to use. As the first qualitative study to explore childcare staff experiences with a web-based menu planning tool, these findings inform future research and development of such tools to aid scalable and sustainable support for healthier food provision in the childcare sector.

Prospective Association of Maternal Educational Level with Child's Physical Activity, Screen Time, and Diet Quality

Evidence has identified unhealthy lifestyle behaviors as the main contributors to obesity in children, so it is essential to identify factors that could influence children’s lifestyles. The objective of the present study was to analyze the association of baseline maternal educational level with child’s physical activity, screen time, and dietary habits at follow-up. This community-based cohort study was carried out between 2012 and 2014 and included 1405 children aged 8 to 10 years old. Maternal educational level was used as an indicator of child’s socioeconomic status. Physical activity, screen time, and dietary habits were assessed by validated questionnaires. The odds of having commercially baked goods for breakfast [OR 1.47 (95% CI 1.03 to 2.10)], going more than once a week to a fast-food restaurant [OR 1.64 (95% CI 1.20 to 2.26)], and taking sweets and candys several times a day [OR 3.23 (95% CI 2.14 to 4.87) were significantly higher among children whose mothers had a lower educational level compared to their peers whose mothers had a higher level. These associations held for taking sweets and candy several times a day after additional adjustment for the corresponding dietary behavior at baseline. Maternal educational level was inversely associated (p < 0.001) with child’s screen time at follow up and being in the lowest maternal educational category was associated with an increased odds of surpassing the maximum recommended time of screen time of 120 min per day (OR (95% CI) 1.43 (1.07 to 1.90), p = 0.016). Maternal education is a predictor for unhealthy dietary habits and high screen time in children.

Urban and rural differences in frequency of fruit, vegetable, and soft drink consumption among 6-9-year-old children from 19 countries from the WHO European region

In order to address the paucity of evidence on the association between childhood eating habits and urbanization, this cross-sectional study describes urban-rural differences in frequency of fruit, vegetable, and soft drink consumption in 123,100 children aged 6-9 years from 19 countries participating in the fourth round (2015-2017) of the WHO European Childhood Obesity Surveillance Initiative (COSI). Children's parents/caregivers completed food-frequency questionnaires. A multivariate multilevel logistic regression analysis was performed and revealed wide variability among countries and within macroregions for all indicators. The percentage of children attending rural schools ranged from 3% in Turkey to 70% in Turkmenistan. The prevalence of less healthy eating habits was high, with between 30-80% and 30-90% children not eating fruit or vegetables daily, respectively, and up to 45% consuming soft drinks on >3 days a week. For less than one third of the countries, children attending rural schools had higher odds (OR-range: 1.1-2.1) for not eating fruit or vegetables daily or consuming soft drinks >3 days a week compared to children attending urban schools. For the remainder of the countries no significant associations were observed. Both population-based interventions and policy strategies are necessary to improve access to healthy foods and increase healthy eating behaviors among children.

Socioeconomic differences in food habits among 6- to 9-year-old children from 23 countries-WHO European Childhood Obesity Surveillance Initiative (COSI 2015/2017)

BACKGROUND

Socioeconomic differences in children's food habits are a key public health concern. In order to inform policy makers, cross-country surveillance studies of dietary patterns across socioeconomic groups are required. The purpose of this study was to examine associations between socioeconomic status (SES) and children's food habits.

METHODS

The study was based on nationally representative data from children aged 6-9 years (n = 129,164) in 23 countries in the World Health Organization (WHO) European Region. Multivariate multilevel analyses were used to explore associations between children's food habits (consumption of fruit, vegetables, and sugar-containing soft drinks) and parental education, perceived family wealth and parental employment status.

RESULTS

Overall, the present study suggests that unhealthy food habits are associated with lower SES, particularly as assessed by parental education and family perceived wealth, but not parental employment status. We found cross-national and regional variation in associations between SES and food habits and differences in the extent to which the respective indicators of SES were related to children's diet.

CONCLUSION

Socioeconomic differences in children's food habits exist in the majority of European and Asian countries examined in this study. The results are of relevance when addressing strategies, policy actions, and interventions targeting social inequalities in children's diets.

Dietary Patterns and Weight Status of Primary School Children in Serbia

The purpose of the present cross-sectional study was to examine dietary patterns and the prevalence of underweight, overweight, and obesity among Serbian children. Furthermore, the study analyzed the association between dietary patterns and weight status. A nationally representative sample of 6–9-year-old children (n = 3,067) was evaluated as part of the Fifth Round World Health Organization European Childhood Obesity Surveillance Initiative. The children's height and weight were measured by trained field examiners, while their parents or guardians filled paper versions of the food frequency questionnaire to collect information related to the child's breakfast habits and food and beverage intake. According to the International Obesity Task Force cut-off points, the overall prevalence of overweight (including obesity) and underweight were 28.9 and 8.1%, respectively. The majority of parents reported that their children (84.5%) had breakfast every day, while only 39.5 and 37% of children had daily fruit and vegetable consumption, respectively. The children who do not eat breakfast every day are more likely to be obese (OR = 1.50), while a higher intake frequency of nutrient-poor beverages such as soft drinks increases the risk of being not only overweight (OR = 1.32) but also underweight (OR = 1.39). Regular monitoring and understanding of dietary patterns and weight status is crucial to inform, design, and implement strategies to reduce national and global diet and obesity-related diseases. Urgent actions need to be taken from public policymakers to stop and reverse the increasing trend of overweight (including obesity) among Serbian children.

Investigating the Effectiveness of an Educational Escape Game for Increasing Nutrition-Related Knowledge in Young Adolescents: A Pilot Study

Objective: As a pilot trial under the Games of Food consortium, this study assessed the effectiveness of an educational escape game alongside a self-study method as a nutrition knowledge intervention. Furthermore, this study explored the use of an escape game as an educational tool for young adolescents.

Materials and Methods: Altogether three schools participated, one from Finland and two from the UK. Baseline questionnaires assessing knowledge were administered before intervention day. Participants from each class were randomly allocated by the researchers into either the escape game condition, where participants played a nutrition education escape game with a focus on plant-based protein sources, or the self-study condition, where participants received an educational leaflet with identical content. In addition to the knowledge post-assessment, the educational escape game condition answered an enjoyment and intrinsic motivation questionnaire to evaluate the game experience. Paired t-tests were used to determine significant changes within intervention conditions and ANCOVA was used to estimate the differences in knowledge.

Results: The participants were 130 children (11–14 years), divided into educational escape game (n = 68) and self-study (n = 62) conditions. Both the educational escape game (20.7 vs. 23, p < 0.001) and self-study (21.1 vs. 23.1, p = 0.002) had improved overall knowledge scores. No significant differences in gained knowledge existed between groups. Of the educational escape game participants, 60% reported the game as mostly enjoyable and 46% reported added use and value for learning.

Conclusion: The educational escape game condition was comparable to the self-study method for nutrition education in adolescents. However, since the educational escape game provides an enjoyable experience that may enhance intrinsic motivation to promote learning and possible behavior change, the use of escape games for nutrition education warrant further investigation.

Physical Education and the Adoption of Habits Related to the Mediterranean Diet

Childhood obesity and sedentary lifestyles are now gaining a foothold in the Western world. The aim of this research was to analyse the influence of physical education classes on a healthy diet (i.e., Mediterranean diet). To this end, psychological constructs derived from the theory of self-determination and the theory of planned behaviour were taken into account, such as the satisfaction and frustration of basic psychological needs, motivation in physical education classes, and social cognition and intention. A total of 3415 secondary school students (13-19 years) participated in this study. A structural equation model was proposed that would explain the relationships between the variables mentioned above and the adherence to a Mediterranean diet. The results provide adequate fit indexes for the proposed model. Based on the results of the study, it was concluded that a high satisfaction perceived in the physical education classes would help to reinforce the intention of having a healthy diet and therefore help to generate a perdurable commitment to this habit.

Establishing consensus on key public health indicators for the monitoring and evaluating childhood obesity interventions: a Delphi panel study

BACKGROUND

Childhood obesity is influenced by myriad individual, societal and environmental factors that are not typically reflected in current interventions. Socio-ecological conditions evolve and require ongoing monitoring in terms of assessing their influence on child health. The aim of this study was to identify and prioritise indicators deemed relevant by public health authorities for monitoring and evaluating childhood obesity interventions.

METHOD

A three-round Delphi Panel composed of experts from regions across Europe, with a remit in childhood obesity intervention, were asked to identify indicators that were a priority in their efforts to address childhood obesity in their respective jurisdictions. In Round 1, 16 panellists answered a series of open-ended questions to identify the most relevant indicators concerning the evaluation and subsequent monitoring of interventions addressing childhood obesity, focusing on three main domains: built environments, dietary environments, and health inequalities. In Rounds 2 and 3, panellists rated the importance of each of the identified indicators within these domains, and the responses were then analysed quantitatively.

RESULTS

Twenty-seven expert panellists were invited to participate in the study. Of these, 16/27 completed round 1 (5 9% response rate), 14/16 completed round 2 (87.5% response rate), and 8/14 completed the third and final round (57% response rate). Consensus (defined as > 70% agreement) was reached on a total of 45 of the 87 indicators (49%) across three primary domains (built and dietary environments and health inequalities), with 100% consensus reached for 5 of these indicators (6%).

CONCLUSION

Forty-five potential indicators were identified, pertaining primarily to the dietary environment, built environment and health inequalities. These results have important implications more widely for evaluating interventions aimed at childhood obesity reduction and prevention.