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Bel-Serrat S¹, Ojeda-Rodríguez A^1,2, Heinen MM¹, Buoncristiano M³, Abdrakhmanova S⁴, Duleva V⁵, Sant’Angelo VF⁶, Fijałkowska A⁷, Hejgaard T⁸, Huidumac C⁹, Hyska J¹⁰, Kujundzic E¹¹, Milanović SM^12,13, Ovezmyradova G¹⁴, Pérez-Farinós N¹⁵, Petrauskiene A¹⁶, Rito AI¹⁷, Shengelia L¹⁸, Braunerová RT¹⁹, Rutter H²⁰, Murrin CM¹, Kelleher CC¹, Breda J³

¹National Nutrition Surveillance Centre, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland; ²Department of Nutrition, Food Science and Physiology, University of Navarra, Pamplona, Spain; ³Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO European Office for Prevention and Control of Noncommunicable Diseases, Moscow, Russia; ⁴National Center of Public Health, Ministry of Health of the Republic of Kazakhstan, Astana, Kazakhstan; ⁵National Center of Public Health and Analyses, Sofia, Bulgaria; ⁶Primary Health Care, Floriana, Malta; ⁷Department of Cardiology, Institute of Mother and Child, Warsaw, Poland; ⁸Danish Health Authority, København, Denmark; ⁹National Institute of Public Health, Bucharest, Romania; ¹⁰Institute of Public Health, Tirana, Albania; ¹¹Institute of Public Health of Montenegro, Podgorica, Montenegro; ¹²Croatian Institute of Public Health, Zagreb, Croatia; ¹³School of Medicine, School of Public Health Andrija Štampar, University of Zagreb, Zagreb, Croatia; ¹⁴WHO Country Office in Turkmenistan, Ashgabat, Turkmenistan; ¹⁵Spanish Agency for Food Safety and Nutrition (AESAN), Madrid, Spain; ¹⁶Department of Preventive Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania; ¹⁷National Institute of Health Doutor Ricardo Jorge, Lisbon, Portugal; ¹⁸National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia; ¹⁹Obesity Management Centre, Institute of Endocrinology, Prague, Czech Republic; ²⁰Department of Social and Policy Sciences, University of Bath, Claverton Down, Bath, UK

Nutrients 2019;11:511

Abstract: It is unclear how dietary, physical activity and sedentary behaviors co-occur in schoolaged children. We investigated the clustering of energy balance-related behaviors and whether the identified clusters were associated with weight status. Participants were 6- to 9-year-old children (n = 63,215, 49.9% girls) from 19 countries participating in the fourth round (2015/2017) of the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative. Energy balance-related behaviors were parentally reported. Weight and height were objectively measured. We performed cluster analysis separately per group of countries (North Europe, East Europe, South Europe/Mediterranean countries and West-Central Asia). Seven clusters were identified in each group. Healthier clusters were common across groups. The pattern of distribution of healthy and unhealthy behaviors within each cluster was group specific. Associations between the clustering of energy balance-related behaviors and weight status varied per group. In South Europe/Mediterranean countries and East Europe, all or most of the cluster solutions were associated with higher risk of overweight/obesity when compared with the cluster “Physically active and healthy diet.” Few or no associations were observed in North Europe and West-Central Asia, respectively. These findings support the hypothesis that unfavorable weight status is associated with a particular combination of energy balance-related behavior patterns, but only in some groups of countries.

Unmodified reproduction. This work is licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/deed.en)

Comments

Low fruits and vegetables intake, consumption of high energy-dense/low nutrientdense foods, low physical activity levels, and high sedentary time have been independently associated with obesity in children. However, the combined effect of these behaviors in relation with obesity development has been scarcely investigated.Healthy and unhealthy behaviors seem to co-exist in the same groups of children. The most adequate method to assess the combined effect of behaviors of different nature is cluster analysis. Previous studies have investigated the clustering of energy balance-related behaviors and its association with childhood obesity.However, studies assessing the association between behavior cluster patterns and obesity in children do not show consistent associations. One reason for this observation could be the different associations found in different geographic regions, as it is the case in different European regions in this study. In fact, in South Europe/Mediterranean countries and East Europe, most of the cluster solutions were associated with a higher risk of overweight/obesity when compared with the cluster “Physically active and healthy diet”; however, few associations were observed in North Europe and West-Central Asia. The applied methodology may also explain the lack of consistent results across the different regions. Behaviors were self-reported; for this reason, misclassification bias needs to be considered given that parentally reported measures are subject to possible misreporting of PA. Future studies should consider stronger methods to assess the target behaviors and longitudinal designs.Obesity prevention programs should consider different key behavior messages, and future public health initiatives should target an increase in fruits and vegetables consumption and the time devoted to moderate vigorous physical activity and also to reduce high energy-dense/low nutrient-dense foods and the time devoted to sedentary behaviors [18].

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