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

      research-article
      1 , * , 1 , 2 , 3 , 2 , 4 , 5 , 6 , 7 , 8 , 9 , 9 , 10 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 1 , 1 , 1 , 33 , 34 , 1
      Nutrients
      MDPI
      nutrition, child, obesity, surveillance, health, noncommunicable diseases, children, fruit, vegetables, soft drinks

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          Abstract

          Consuming a healthy diet in childhood helps to protect against malnutrition and noncommunicable diseases (NCDs). This cross-sectional study described the diets of 132,489 children aged six to nine years from 23 countries participating in round four (2015–2017) of the WHO European Childhood Obesity Surveillance Initiative (COSI). Children’s parents or caregivers were asked to complete a questionnaire that contained indicators of energy-balance-related behaviors (including diet). For each country, we calculated the percentage of children who consumed breakfast, fruit, vegetables, sweet snacks or soft drinks “every day”, “most days (four to six days per week)”, “some days (one to three days per week)”, or “never or less than once a week”. We reported these results stratified by country, sex, and region. On a daily basis, most children (78.5%) consumed breakfast, fewer than half (42.5%) consumed fruit, fewer than a quarter (22.6%) consumed fresh vegetables, and around one in ten consumed sweet snacks or soft drinks (10.3% and 9.4%, respectively); however, there were large between-country differences. This paper highlights an urgent need to create healthier food and drink environments, reinforce health systems to promote healthy diets, and continue to support child nutrition and obesity surveillance.

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          The impact of non-response bias due to sampling in public health studies: A comparison of voluntary versus mandatory recruitment in a Dutch national survey on adolescent health

          Background In public health monitoring of young people it is critical to understand the effects of selective non-response, in particular when a controversial topic is involved like substance abuse or sexual behaviour. Research that is dependent upon voluntary subject participation is particularly vulnerable to sampling bias. As respondents whose participation is hardest to elicit on a voluntary basis are also more likely to report risk behaviour, this potentially leads to underestimation of risk factor prevalence. Inviting adolescents to participate in a home-sent postal survey is a typical voluntary recruitment strategy with high non-response, as opposed to mandatory participation during school time. This study examines the extent to which prevalence estimates of adolescent health-related characteristics are biased due to different sampling methods, and whether this also biases within-subject analyses. Methods Cross-sectional datasets collected in 2011 in Twente and IJsselland, two similar and adjacent regions in the Netherlands, were used. In total, 9360 youngsters in a mandatory sample (Twente) and 1952 youngsters in a voluntary sample (IJsselland) participated in the study. To test whether the samples differed on health-related variables, we conducted both univariate and multivariable logistic regression analyses controlling for any demographic difference between the samples. Additional multivariable logistic regressions were conducted to examine moderating effects of sampling method on associations between health-related variables. Results As expected, females, older individuals, as well as individuals with higher education levels, were over-represented in the voluntary sample, compared to the mandatory sample. Respondents in the voluntary sample tended to smoke less, consume less alcohol (ever, lifetime, and past four weeks), have better mental health, have better subjective health status, have more positive school experiences and have less sexual intercourse than respondents in the mandatory sample. No moderating effects were found for sampling method on associations between variables. Conclusions This is one of first studies to provide strong evidence that voluntary recruitment may lead to a strong non-response bias in health-related prevalence estimates in adolescents, as compared to mandatory recruitment. The resulting underestimation in prevalence of health behaviours and well-being measures appeared large, up to a four-fold lower proportion for self-reported alcohol consumption. Correlations between variables, though, appeared to be insensitive to sampling bias.
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            Health Effects of Overweight and Obesity in 195 Countries over 25 Years.

            Background While the rising pandemic of obesity has received significant attention in many countries, the effect of this attention on trends and the disease burden of obesity remains uncertain. Methods We analyzed data from 67.8 million individuals to assess the trends in obesity and overweight prevalence among children and adults between 1980 and 2015. Using the Global Burden of Disease study data and methods, we also quantified the burden of disease related to high body mass index (BMI), by age, sex, cause, and BMI level in 195 countries between 1990 and 2015. Results In 2015, obesity affected 107.7 million (98.7-118.4) children and 603.7 million (588.2- 619.8) adults worldwide. Obesity prevalence has doubled since 1980 in more than 70 countries and continuously increased in most other countries. Although the prevalence of obesity among children has been lower than adults, the rate of increase in childhood obesity in many countries was greater than the rate of increase in adult obesity. High BMI accounted for 4.0 million (2.7- 5.3) deaths globally, nearly 40% of which occurred among non-obese. More than two-thirds of deaths related to high BMI were due to cardiovascular disease. The disease burden of high BMI has increased since 1990; however, the rate of this increase has been attenuated due to decreases in underlying cardiovascular disease death rates. Conclusions The rapid increase in prevalence and disease burden of elevated BMI highlights the need for continued focus on surveillance of BMI and identification, implementation, and evaluation of evidence-based interventions to address this problem.
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              Food Marketing Influences Children’s Attitudes, Preferences and Consumption: A Systematic Critical Review

              Exposure to the marketing of unhealthy foods and beverages is a widely acknowledged risk factor for the development of childhood obesity and noncommunicable diseases. Food marketing involves the use of numerous persuasive techniques to influence children’s food attitudes, preferences and consumption. This systematic review provides a comprehensive contemporary account of the impact of these marketing techniques on children aged 0–18 years and critically evaluates the methodologies used. Five electronic academic databases were searched using key terms for primary studies (both quantitative and qualitative) published up to September 2018; 71 eligible articles were identified. Significant detrimental effects of food marketing, including enhanced attitudes, preferences and increased consumption of marketed foods were documented for a wide range of marketing techniques, particularly those used in television/movies and product packaging. Together, these studies contribute strong evidence to support the restriction of food marketing to children. However, the review also signposted distinct gaps: Firstly, there is a lack of use of qualitative and physiological methodologies. Secondly, contemporary and sophisticated marketing techniques used in new media warrant increased research attention. Finally, more research is needed to evaluate the longer-term effects of food marketing on children’s weight.
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                Author and article information

                Journal
                Nutrients
                Nutrients
                nutrients
                Nutrients
                MDPI
                2072-6643
                17 August 2020
                August 2020
                : 12
                : 8
                : 2481
                Affiliations
                [1 ]WHO European Office for the Prevention and Control of Noncommunicable Diseases, 125009 Moscow, Russian Federation; buoncristianom@ 123456who.int (M.B.); giuliarathmes@ 123456icloud.com (G.R.); anne-charlotte.bunge@ 123456charite.de (A.C.B.); rakovaci@ 123456who.int (I.R.); rodriguesdasilvabred@ 123456who.int (J.B.)
                [2 ]Italian National Institute of Health (Istituto Superiore Di Sanità), 00161 Rome, Italy; paola.nardone@ 123456iss.it (P.N.); angela.spinelli@ 123456iss.it (A.S.)
                [3 ]National Institute of Health Dr. Ricardo Jorge, 1600 560 Lisbon, Portugal; ana.rito@ 123456insa.min-saude.pt
                [4 ]Danish Health Authority, 2300 Copenhagen S, Denmark; thv@ 123456sst.dk
                [5 ]National Institute of Public Health, University of Southern Denmark, 1455 Copenhagen K, Denmark; leki@ 123456sdu.dk
                [6 ]Department of Nutrition Research, National Institute for Health Development, 11619 Tallinn, Estonia; eha.nurk@ 123456tai.ee
                [7 ]Institute of Endocrinology, Obesity Unit, 116 94 Prague, Czechia; mkunesova@ 123456endo.cz
                [8 ]Croatian Institute of Public Health, University of Zagreb, School of Medicine, 10000 Zagreb, Croatia; sanja.music@ 123456hzjz.hr
                [9 ]Spanish Agency for Food Safety and Nutrition, 28014 Madrid, Spain; mgarcias@ 123456mscbs.es (M.G.-S.); egutierrez@ 123456mscbs.es (E.G.-G.)
                [10 ]Department of Public Health and Management, University of Medicine and Pharmacy Carol Davila, 030167 Bucharest, Romania; lbrinduse@ 123456gmail.com (L.A.B.); alexandra.cucu@ 123456insp.gov.ro (A.C.)
                [11 ]Department of Cardiology, Institute of Mother and Child, 01-211 Warsaw, Poland; anna.fijalkowska@ 123456imid.med.pl
                [12 ]Primary Health Care, Ministry for Health, 1940 Floriana, Malta; victoria.farrugia-santangelo@ 123456gov.mt
                [13 ]National Center of Public health, Ministry of Health of the Republic of Kazakhstan, 010000 Nur-Sultan City, Kazakhstan; shynar_a@ 123456mail.ru
                [14 ]Centre for Disease Prevention and Control, LV-1005 Latvia, Riga; iveta.pudule@ 123456spkc.gov.lv
                [15 ]National Center of Public Health and Analyses, 1431 Sofia, Bulgaria; v.duleva@ 123456ncpha.government.bg
                [16 ]Turkish Ministry of Health, Public Health General Directorate, 34400 Istanbul, Turkey; nazan.yardim@ 123456saglik.gov.tr
                [17 ]Health Authority, Department of Health and Social Security, 47893 San Marino, San Marino; andrea.gualtieri.authority@ 123456pa.sm
                [18 ]National Nutrition Surveillance Centre, University College Dublin, Dublin, Ireland; mirjam.heinen@ 123456ucd.ie (M.H.); silvia.belserrat@ 123456ucd.ie (S.B.-S.)
                [19 ]Republican Center for Health Promotion and Mass Communication, 720040 Bishkek, Kyrgyzstan; jama.usupova@ 123456mail.ru
                [20 ]Institute of Paediatric Endocrinology, National Medical Research Centre for Endocrinology of the Ministry of Health of the Russian Federation, 117036 Moscow, Russian Federation; peterkovava@ 123456hotmail.com
                [21 ]National Center for Disease Control and Public Health of Georgia, 0198 Tbilisi, Georgia; l.shengelia@ 123456ncdc.ge
                [22 ]Institute of Public Health, 1007 Tirana, Albania; lhyska2002@ 123456yahoo.it
                [23 ]Internal Diseases Department of the Scientific Clinical Centre of Mother and Child Health, 744036 Ashgabat, Turkmenistan; ovezmyradovag@ 123456who.int
                [24 ]Department of Preventive Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; ausra.petrauskiene@ 123456lsmuni.lt
                [25 ]Department for Organization of Health Services to Children, Mothers, Adolescents and Family Planning, Ministry of Health and Social Protection of Population, 734025 Dushanbe, Tajikistan; sanavbar2010@ 123456list.ru
                [26 ]Institute of Public Health of Montenegro, 81 000 Podgorica, Montenegro; enisa.kujundzic@ 123456ijzcg.me
                [27 ]Applied Bioenergetics Lab, University of Novi Sad, 21000 Novi Sad, Serbia; sergej.ostojic@ 123456chess.edu.rs
                [28 ]Department of Pediatrics, Paracelsus Medical University, 5020 Salzburg, Austria; d.weghuber@ 123456salk.at
                [29 ]Arabkir Medical Centre-Institute of Child and Adolescent Health, 0014 Yerevan, Armenia; mmelkumova@ 123456mail.ru
                [30 ]Institute of Public Health, Faculty of Medicine, Ss. Cyril and Methodius University, 1000 Skopje, North Macedonia; i.spiroski@ 123456iph.mk
                [31 ]Faculty of Sport, University of Ljubljana, 1000 Ljubljana, Slovenia; gregor.starc@ 123456fsp.uni-lj.si
                [32 ]Department of Social and Policy Sciences, University of Bath, Bath BA2 7AY, UK; hr526@ 123456bath.ac.uk
                [33 ]WHO Country Office for Tajikistan, 734019 Dushanbe, Tajikistan; boymatovak@ 123456who.int
                [34 ]WHO Child and Adolescent Health and Development, WHO Regional Office for Europe, 2100 Copenhagen, Denmark; weberm@ 123456who.int
                Author notes
                [* ]Correspondence: williamsj@ 123456who.int
                Author information
                https://orcid.org/0000-0002-1238-0114
                https://orcid.org/0000-0002-4356-6202
                https://orcid.org/0000-0002-5737-026X
                https://orcid.org/0000-0002-2337-2582
                https://orcid.org/0000-0003-3504-0427
                https://orcid.org/0000-0003-3698-2619
                https://orcid.org/0000-0001-9116-0672
                https://orcid.org/0000-0002-7270-2541
                https://orcid.org/0000-0002-4389-0379
                https://orcid.org/0000-0002-9322-0656
                https://orcid.org/0000-0002-6815-5274
                https://orcid.org/0000-0002-8177-4926
                Article
                nutrients-12-02481
                10.3390/nu12082481
                7468747
                32824588
                63d2ca43-7535-4723-92ee-d50ba9b6e27e
                © 2020 by World Health Organization.

                Licensee MDPI, Basel, Switzerland. This is an open access article distributed under the terms of the Creative Commons Attribution IGO License ( http://creativecommons.org/licenses/by/3.0/igo/legalcode), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organisation or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL.

                History
                : 03 July 2020
                : 04 August 2020
                Categories
                Article

                Nutrition & Dietetics
                nutrition,child,obesity,surveillance,health,noncommunicable diseases,children,fruit,vegetables,soft drinks

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