To explore perceived factors that impede or facilitate healthful eating within the home environment among overweight/obese adolescents.

In the present qualitative photovoice study, participants were instructed to take photographs of things that made it easier or harder to make healthful food choices at home. Digital photographs were reviewed and semi-structured interviews were conducted to promote discussion of the photographs. Data were analysed using constant comparative analysis.

Vancouver, Canada, in 2012–2013.

Twenty-two overweight/obese adolescents who completed a family-based lifestyle modification intervention.

The mean age of participants was 14 (sd 1·9) years, 77 % were female and their mean BMI Z-score was 2·4 (sd 0·6). Adolescents talked about six aspects of the home environment that influenced their eating habits (in order of frequency): home cooking, availability and accessibility of foods/beverages, parenting practices, family modelling, celebrations and screen use/studying. In general, homes with availability of less healthful foods, where family members also liked to eat less healthful foods and where healthier foods were less abundant or inaccessible were described as barriers to healthful eating. Special occasions and time spent studying or in front of the screen were also conducive to less healthful food choices. Home cooked meals supported adolescents in making healthier food choices, while specific parenting strategies such as encouragement and restriction were helpful for some adolescents.

Adolescents struggled to make healthful choices in their home environment, but highlighted parenting strategies that were supportive. Targeting the home food environment is important to enable healthier food choices among overweight/obese adolescents.

Fruit and vegetable claims on food packages are not regulated under Australian food standards. The present study aimed to: (i) investigate the number and healthiness of products carrying fruit and vegetable claims in Australia; and (ii) compare the nutrition composition of these products with fresh fruit and/or vegetables.

Content analysis of fruit and vegetable claims on food packages. The Australian food standards nutrient profiling model was used to determine the proportion of products not meeting nutrient profiling criteria. The nutrient composition of products carrying claims referencing the servings of fruit and vegetables in the product were compared with that of the dominant fruit and/or vegetables in each product.

The five largest supermarket chains in Australia.

All available products in the fruit snacks, soups and fruit and vegetable juices/fruit drinks categories (n 762) were surveyed. Nutrition composition, ingredients and claims were recorded for each product.

Of the products surveyed, 48 % (n 366) carried at least one claim, of which 34 % (n 124) did not meet nutrient profiling. Products carrying claims referencing the number of servings of fruit and vegetables had more energy, sodium, saturated fat and sugar, and less fibre, than fresh fruit and/or vegetables (all P<0·001).

Many products carried fruit and vegetable claims and were significantly higher in energy, saturated fat, sugars and sodium than fresh fruit and vegetables. Marketing these products as a way of meeting fruit and vegetable intake is inaccurate and potentially misleading. Fruit and vegetable claims should be regulated using nutrient profiling.

To examine tracking of body size among children participating in the Norwegian Mother and Child Cohort Study (MoBa) from birth to 7 years of age and additionally to explore child and parental characteristics associated with maintenance of a high body size in this period of life.

Anthropometric data at birth and at 1, 3 and 7 years of age were collected by questionnaires addressed to the mother.

Participants were recruited from all over Norway during the period 1999–2008.

A total of 3771 children had complete anthropometric data at birth and at 1, 3 and 7 years of age; the sample includes children born between 2002 and 2004.

Cohen’s weighted kappa pointed to fair (0·36) to moderate (0·43) tracking of body size from birth to 7 years of age. Generalized estimating equations further indicated that children in the highest tertile of ponderal index at birth had nearly one unit higher BMI (kg/m2) at the age of 7 years compared with children in other tertiles of ponderal index at birth. Having parents with high BMI (≥25·0 kg/m2) increased the odds of having a stable high body size from birth to 7 years of age; moreover, girls had significantly higher odds compared with boys.

The study indicates fair to moderate tracking of body size from birth to 7 years of age. From a public health perspective, early prevention of childhood overweight and obesity seems to be especially important among children of parents having a high BMI.

We aimed to identify barriers for meeting the fruit, vegetable and fish guidelines in older Dutch adults and to investigate socio-economic status (SES) differences in these barriers. Furthermore, we examined the mediating role of these barriers in the association between SES and adherence to these guidelines.

Cross-sectional.

Longitudinal Aging Study Amsterdam (LASA), the Netherlands.

We used data from 1057 community-dwelling adults, aged 55–85 years. SES was measured by level of education and household income. An FFQ was used to assess dietary intake and barriers were measured with a self-reported lifestyle questionnaire.

Overall, 48·9 % of the respondents perceived a barrier to adhere to the fruit guideline, 40·0 % for the vegetable and 51·1 % for the fish guideline. The most frequently perceived barriers to meet the guidelines were the high price of fruit and fish and a poor appetite for vegetables. Lower-SES groups met the guidelines less often and perceived more barriers. The association between income and adherence to the fruit guideline was mediated by ‘perceiving any barrier to meet the fruit guideline’ and the barrier ‘dislike fruit’. The association between income and adherence to the fish guideline was mediated by ‘perceiving any barrier to meet the fish guideline’ and the barrier ‘fish is expensive’.

Perceived barriers for meeting the dietary guidelines are common in older adults, especially in lower-SES groups. These barriers and in particular disliking and cost concerns explained the lower adherence to the guidelines for fruit and fish in lower-income groups in older adults.

To examine levels of exposure and content characteristics for recent televised obesity-prevention campaigns sponsored by state and community health departments, federal agencies, non-profit organizations and television stations in the USA.

Nielsen television ratings for obesity-prevention advertising were collected for the top seventy-five US media markets and were used to calculate household exposure levels for 2010 and 2011. Governmental advertisements were coded for content.

United States.

Average household exposure to obesity-prevention campaigns was 2·6 advertisements per month. Exposure increased by 31 % between 2010 and 2011, largely driven by increases in federal advertisements. In 2011, the federal government accounted for 62 % of obesity-prevention exposure, non-profit organizations for 9 %, community departments for 8 %, state departments for 3 %, and television station-sponsored public-service announcements for 17 %. The greatest percentage increase between 2010 and 2011 was in community advertising, reflecting efforts funded by the Communities Putting Prevention to Work (CPPW) programme. Among thirty-four state and community campaigns, the majority advocated both healthy eating and physical activity (53 %). Campaigns typically had positive or neutral emotional valence (94 %). Obesity or overweight was mentioned in 47 % of campaigns, but only 9 % specifically advocated weight loss.

Exposure to televised obesity-prevention advertising increased from 2010 to 2011 and was higher than previously found in 1999–2003, apart from in 2003 during the federal VERB campaign. Nevertheless, exposure remains low relative to advertising for unhealthy foods. New federal campaigns have increased exposure to obesity-prevention advertising nationally, while CPPW grants have increased exposure for targeted areas.

According to the Federal Trade Commission, in 2009, the top food category with teen-directed marketing expenditures was sugar-sweetened beverages (SSB). The present study reports on exposure to SSB advertisements using self-report data from adolescents.

Cross-sectional study design using descriptive statistics to assess self-reported frequency of exposure to SSB advertisements and multivariable logistic regression to examine associations between frequency of SSB advertising exposure and sociodemographic variables.

Online survey conducted at home.

US adolescents aged 12–17 years (n 847).

Among the surveyed adolescents, 42 % to 54 % reported seeing/hearing SSB advertisements ≥1 time/d. Those aged 14–15 years were more likely to report seeing/hearing soda, sports drink and energy drink advertisements ≥1 time/d than 16- to 17-year-olds. Males were more likely to report seeing/hearing sports drink advertising ≥1 time/d than females. Non-Hispanic black adolescents were more likely to report seeing/hearing fruit drink and sports drink advertisements ≥1 time/d than non-Hispanic white adolescents. Adolescents whose parents had high-school education or less were more likely to report seeing/hearing soda, fruit drink and energy drink advertisements ≥1 time/d than adolescents whose parents were college graduates.

Almost half of the adolescents sampled reported daily SSB advertising exposure, with higher exposure among African Americans and adolescents with less educated parents. These data can help inform potential actions that decision makers might take, such as education of adolescents and their caregivers on the potential impact of beverage advertising, especially among groups at higher risk for obesity.

To assess the reliability and validity of a semi-quantitative FFQ designed to evaluate the usual nutrient intake of adults in Quito, Ecuador.

Dietary data using 24 h recalls (24hR) were used to design a list of commonly consumed foods. The relative validity of a 111-item FFQ was evaluated by comparing nutrient intakes against three non-consecutive 24hR. All nutrients were energy-adjusted. Reliability was assessed using two FFQ (FFQ1 and FFQ2) and assessed by the intra-class correlation coefficient. The comparisons between the FFQ and the 24hR were assessed by the de-attenuated Pearson correlation coefficient, weighted kappa and by Bland–Altman plots.

Quito, Ecuador.

Overall, 345 adults were enrolled in the present study. Two hundred and fifty participated in FFQ development and ninety-five participated in the FFQ validity and reliability.

The FFQ produced higher energy and nutrient intakes. Reliability correlation coefficients after adjusting for energy ranged from 0·62 to 0·88 for protein and Ca, respectively. For the validity study, energy-adjusted and de-attenuated correlation coefficients between the questionnaire and the 24hR ranged from 0·21 for fat to 0·65 for Ca. Only 4 % of the participants were grossly misclassified and 46 % had weighted kappa higher than 0·42. The Bland–Altman plot showed a constant bias with a tendency to increase according to the intake level.

The FFQ showed reasonably good relative validity and reliable measurements, especially for nutrients considered protective and risk markers of non-communicable disease, and can be used to assess usual nutrient intake in this population.

(i) To examine associations between young adults’ meal routines and practices (e.g. food preparation, meal skipping, eating on the run) and key dietary indicators (fruit/vegetable, fast-food and sugar-sweetened beverage intakes) and (ii) to develop indices of protective and risky meal practices most strongly associated with diet.

Cross-sectional survey.

Minneapolis/St. Paul metropolitan area, Minnesota (USA).

A diverse sample of community college and public university students (n 1013).

Meal routines and practices most strongly associated with healthy dietary patterns were related to home food preparation (i.e. preparing meals at home, preparing meals with vegetables) and meal regularity (i.e. routine consumption of evening meals and breakfast). In contrast, factors most strongly associated with poor dietary patterns included eating on the run, using media while eating and purchasing foods/beverages on campus. A Protective Factors Index, summing selected protective meal routines and practices, was positively associated with fruit/vegetable consumption and negatively associated with fast-food and sugar-sweetened beverage consumption (P<0·001). A Risky Factors Index yielded significant, positive associations with fast-food and sugar-sweetened beverage consumption (P<0·001). The probability test for the association between the Risky Factors Index and fruit/vegetable intake was P=0·05.

Meal routines and practices were significantly associated with young adults’ dietary patterns, suggesting that ways in which individuals structure mealtimes and contextual characteristics of eating likely influence food choice. Thus, in addition to considering specific food choices, it also may be important to consider the context of mealtimes in developing dietary messaging and guidelines.

The development of food policy is strongly influenced by the understanding and position actors adopt in their ‘framing’ of sustainability. The Australian Government developed a National Food Plan (2010–2013). In public consultations on the National Food Plan Green Paper, the government sought stakeholders’ views on sustainability. The present study examined the way in which the food industry and civil society organizations framed sustainability in their submissions to the Green Paper.

Submissions by food industry actors and civil society organizations were analysed using a framing matrix that examined positioning, drivers, underlying principles and policy solutions related to sustainability. Submissions were open coded and subsequently organized based on themes within the framing matrix.

Australia.

One hundred and twenty-four written submissions (1420 pages).

While submissions from industry and civil society organizations often framed sustainability similarly, there were also major differences. Civil society organizations were more likely to make the link between the food supply and population health, while industry was more likely to focus on economic sustainability. Both viewed consumer demand as a driver of sustainability, welcomed the idea of a whole-of-government approach and stressed the need for investment in research and development to improve productivity and sustainable farming practices.

The meaning of sustainability shifted throughout the policy process. There are opportunities for creating shared value in food policy, where the health, environment and economic dimensions of sustainability can be compatible. However, despite pockets of optimism there is a need for a shared vision of sustainability if Australia is to have a food policy integrating these dimensions.

There is evidence that subclinical vitamin B12 (B12) deficiency is common in India. Vegetarianism is prevalent and therefore meat consumption is low. Our objective was to explore the contribution of B12-source foods and maternal B12 status during pregnancy to plasma B12 concentrations.

Maternal plasma B12 concentrations were measured during pregnancy. Children’s dietary intakes and plasma B12 concentrations were measured at age 9·5 years; B12 and total energy intakes were calculated using food composition databases. We used linear regression to examine associations between maternal B12 status and children’s intakes of B12 and B12-source foods, and children’s plasma B12 concentrations.

South Indian city of Mysore and surrounding rural areas.

Children from the Mysore Parthenon Birth Cohort (n 512, 47·1 % male).

Three per cent of children were B12 deficient (<150 pmol/l). A further 14 % had ‘marginal’ B12 concentrations (150–221 pmol/l). Children’s total daily B12 intake and consumption frequencies of meat and fish, and micronutrient-enriched beverages were positively associated with plasma B12 concentrations (P=0·006, P=0·01 and P=0·04, respectively, adjusted for socio-economic indicators and maternal B12 status). Maternal pregnancy plasma B12 was associated with children’s plasma B12 concentrations, independent of current B12 intakes (P<0·001). Milk and curd (yoghurt) intakes were unrelated to B12 status.

Meat and fish are important B12 sources in this population. Micronutrient-enriched beverages appear to be important sources in our cohort, but their high sugar content necessitates care in their recommendation. Improving maternal B12 status in pregnancy may improve Indian children’s status.

People eat more unhealthy foods when served more (portion size effect) and when the food is served in larger units (unit size effect). The present study aimed to examine whether these effects can be used for the good: to increase vegetable consumption among children.

A 2×2 between-subjects experiment was conducted at two schools. Pupils were presented in class with cucumber that varied both in unit size (one piece v. pre-sliced) and portion size (one-third v. two-thirds of a cucumber). Children ate ad libitum during the morning break and filled in a survey.

Primary schools in the centre of the Netherlands.

Primary-school pupils (n 255) aged 8–13 years.

Children ate 54 % more cucumber when served a large compared with a smaller portion (difference of 49 g; P<0·001). Large units did not impact consumption (P=0·58), but were considered as less convenient to eat than small units (P=0·001).

Findings suggest that children’s vegetable intake can be improved by serving larger portions in smaller-sized pieces.

We aimed to assess the relative validity and reproducibility of a semi-quantitative FFQ in Puerto Rican adults.

Participants completed an FFQ, followed by a 6 d food record and a second administration of the FFQ, 30 d later. All nutrients were log transformed and adjusted for energy intake. Statistical analyses included correlations, paired t tests, cross-classification and Bland–Altman plots.

Medical Sciences Campus, University of Puerto Rico.

Convenience sample of students, employees and faculty members (n 100, ≥21 years). Data were collected in 2010.

A total of ninety-two participants completed the study. Most were young overweight females. All nutrients were significantly correlated between the two FFQ, with an average correlation of 0·61 (range 0·43–0·73) and an average difference of 4·8 % between them. Most energy-adjusted nutrients showed significant correlations between the FFQ and food record, which improved with de-attenuation and averaged 0·38 (range 0·11–0·63). The lowest non-significant correlations (≤0·20) were for trans-fat, n 3 fatty acids, thiamin and vitamin E. Intakes assessed by the FFQ were higher than those from the food record by a mean of 19 % (range 4–44 %). Bland–Altman plots showed that there was a systematic trend towards higher estimates with the FFQ, particularly for energy, carbohydrate and Ca. Most participants were correctly classified into the same or adjacent quintile (average 66 %) by both methods with only 3 % gross misclassification.

This semi-quantitative FFQ is a tool that offers relatively valid and reproducible estimates of energy and certain nutrients in this group of mostly female Puerto Ricans.

Whether or not breast-feeding is protective against asthma among children is still controversial. Therefore, we examined the effects of breast-feeding on hospitalization for asthma in early childhood.

Secondary data analyses of a nationwide longitudinal survey of children in Japan ongoing since 2001, with results collected from 2001 to 2004. We used logistic regression models to evaluate the associations of breast-feeding with hospitalization for asthma in children between the ages of 6 and 42 months, adjusting for children’s factors (sex, day-care attendance and presence of older siblings) and maternal factors (educational attainment and smoking habit).

All over Japan.

Term singleton children with information on feeding practices during infancy (n 43367).

After adjusting for maternal factors and children’s factors, exclusive breast-feeding at 6–7 months of age was associated with decreased risk of hospitalization for asthma in children. The adjusted odds ratio was 0·77 (95 % CI 0·56, 1·06). One-month longer duration of breast-feeding was associated with a 4 % decreased risk of hospitalization for asthma (OR=0·96; 95 % CI 0·92, 0·99).

The protective effects of breast-feeding on hospitalization for asthma were observed in children between the ages of 6 and 42 months.

The present paper investigated the impact of the 2008 financial crisis on food security in Mexico and how it disproportionally affected vulnerable households.

A generalized ordered logistic regression was estimated to assess the impact of the crisis on households’ food security status. An ordinary least squares and a quantile regression were estimated to evaluate the effect of the financial crisis on a continuous proxy measure of food security defined as the share of a household’s current income devoted to food expenditures.

Both analyses were performed using pooled cross-sectional data from the Mexican National Household Income and Expenditure Survey 2008 and 2010.

The analytical sample included 29 468 households in 2008 and 27 654 in 2010.

The generalized ordered logistic model showed that the financial crisis significantly (P<0·05) decreased the probability of being food secure, mildly or moderately food insecure, compared with being severely food insecure (OR=0·74). A similar but smaller effect was found when comparing severely and moderately food-insecure households with mildly food-insecure and food-secure households (OR=0·81). The ordinary least squares model showed that the crisis significantly (P<0·05) increased the share of total income spent on food (β coefficient of 0·02). The quantile regression confirmed the findings suggested by the generalized ordered logistic model, showing that the effects of the crisis were more profound among poorer households.

The results suggest that households that were more vulnerable before the financial crisis saw a worsened effect in terms of food insecurity with the crisis. Findings were consistent with both measures of food security – one based on self-reported experience and the other based on food spending.

To estimate daily fruit and vegetable intakes and to investigate socio-economic and behavioural differences in fruit and vegetable consumption among urban Moroccan women.

A cross-sectional survey. Fruit and vegetable intake was measured with a single 24 h recall.

A representative population-based survey conducted in the area of Rabat-Salé.

Women (n 894) of child-bearing age (20–49 years).

Mean fruit and vegetable intake was 331 g/d (155 g/d for fruit and 176 g/d for vegetables). Only one-third (32·1 %) of women consumed ≥400 g/d and half the sample (50·6 %) were considered as low consumers, i.e. <280 g/d. Women of higher economic status ate significantly more fruit (P<0·05) and more fruit and vegetables combined (P<0·05). Women ate significantly less vegetables if they ate out of home more often or skipped at least one main meal (breakfast, lunch or dinner) or ate more processed foods (P<0·05, P<0·01 and P<0·001, respectively). Fruit and vegetable diversity was not associated with any of the factors investigated.

In this population, fruit and vegetable intakes are driven by different determinants. Indeed, while vegetable consumption was related only to behavioural determinants, fruit consumption was influenced only by economic status. Therefore, programmes promoting fruit and vegetable intake would be more effective if they account for these specific determinants in their design.

To assess the effectiveness of an intervention programme to improve kindergarten children's eating and leisure habits in Israel.

A cluster-randomised controlled trial.

Six full-day kindergartens in Israel were randomly divided into three groups. Group A received the full intervention programme, which included lessons on good eating habits and daily physical exercise. Group B received a partial intervention of lessons only. Group C, the reference group, did not receive any intervention.

Children aged 4–6 years (n 204) were recruited for the study.

Objective data for weight and height were collected to calculate BMI Z-scores. Activity, sedentary time, sleeping hours and daily energy intake were assessed via a parental questionnaire. Nutritional knowledge was assessed by a single dietitian using a questionnaire addressed to the children. Assessments were done at baseline and at the end of the intervention.

After adjustment for baseline levels we observed a significant reduction in daily energy intake for the full intervention group A (P = 0·03). A positive intervention effect was demonstrated on nutritional knowledge in the partial intervention group B (P = 0·03), although no significant change was demonstrated for BMI Z-score.

The study supports the incorporation of education on healthy lifestyle habits and physical activity into the curricula of kindergartens.

The current paper describes Diet In Nutrients Out (DINO), an integrated dietary assessment system incorporating dietary data entry and nutritional analysis within one platform for use in dietary assessment in small-scale intervention studies to national surveys.

DINO contains >6000 food items, mostly aggregated composites of branded foods, across thirty-one main food groups divided into 151 subsidiary groups for detailed reporting requirements, with fifty-three core nutrient fields.

MRC Human Nutrition Research (HNR), Cambridge, UK and MRC Keneba, Gambia.

DINO is used across dietary assessment projects at HNR and MRC Keneba.

DINO contains macro- and micronutrients as well as additional variables of current research and policy interest, such as caffeine, whole grains, vitamin K and added sugars. Disaggregated data are available for fruit, vegetables, meat, fish and cheese in composite foods, enabling greater accuracy when reporting food consumption or assessing adherence to dietary recommendations. Portion sizes are categorised in metric and imperial weights, with standardised portion sizes for each age group. Regular reviews are undertaken for portion sizes and food composition to ensure contemporary relevance. A training programme and a checking schedule are adhered to for quality assurance purposes, covering users and data. Eating context questions are integrated to record where and with whom the respondent is eating, allowing examination between these factors and the foods consumed.

An up-to-date quality-assured system for dietary assessment is crucial for nutritional surveillance and research, but needs to have the flexibility to be tailored to address specific research questions.

To understand factors which enhance or detract from farmers’ market shopper experiences to inform targeted interventions to increase farmers’ market utilization, community-building and social marketing strategies.

A consumer-intercept study using the Stanford Healthy Neighborhood Discovery Tool to capture real-time perceptions via photographs and audio narratives.

An urban farmers’ market in a large metropolitan US city.

Thirty-eight farmers’ market shoppers, who recorded 748 unique coded elements through community-based participatory research methods.

Shoppers were primarily women (65 %), 18–35 years of age (54 %), non-Hispanic (81 %) and white (73 %). Shoppers captured 291 photographs (7·9 (sd 6·3) per shopper), 171 audio narratives (5·3 (sd 4·7) per shopper), and ninety-one linked photograph + audio narrative pairs (3·8 (sd 2·8) per shopper). A systematic content analysis of the photographs and audio narratives was conducted by eight independent coders. In total, nine common elements emerged from the data that enhanced the farmers’ market experience (61·8 %), detracted from the experience (5·7 %) or were neutral (32·4 %). The most frequently noted elements were freshness/abundance of produce (23·3 %), product presentation (12·8 %), social interactions (12·4 %) and farmers’ market attractions (e.g. live entertainment, dining offerings; 10·3 %).

While produce quality (i.e. freshness/abundance) was of primary importance, other contextual factors also appeared important to the shoppers’ experiences. These results may inform social marketing strategies to increase farmers’ market utilization and community-building efforts that target market venues.

The present study aimed to examine the trends and differentials in key breast-feeding indicators in Nigeria for the period 1999–2013.

Longitudinal study of trends (1999–2013) in optimal feeding practices using a series of population-based Nigerian Demographic and Health Surveys. Trends in socio-economic, health service and individual characteristics associated with key breast-feeding indicators were examined using multilevel regression analyses.

Nigeria.

Children (n 88 152) aged under 24 months (n 8199 in 1999; n 7620 in 2003; n 33 385 in 2008; n 38 948 in 2013).

Among educated mothers, there was an increase in prevalence of exclusive breast-feeding (26 % in 1999 to 30 % in 2013) and predominant breast-feeding (27 % in 1999 to 39 % in 2013) compared with mothers with no schooling. A similar increasing trend was evident for mothers from wealthier households and mothers who had a higher frequency of health service access compared with mothers from poorer households and women who reported no health service access, respectively. Mothers with no schooling predominantly breast-fed, but the odds for bottle-feeding were higher among educated mothers and women from wealthier households. The odds for early initiation of breast-feeding were lower for mothers who reported no health service contacts and mothers of lower socio-economic status.

Significant increasing trends in key breast-feeding indicators were evident among mothers with higher socio-economic status and mothers who had more health service access in Nigeria. Broader national and sub-national policies that underpin nursing mothers in work environments and a comprehensive community-based approach are proposed to improve feeding practices in Nigeria.

To assess to what extent eight behavioural health risks related to breakfast and food consumption and five behavioural health risks related to physical activity, screen time and sleep duration are present among schoolchildren, and to examine whether health-risk behaviours are associated with obesity.

Cross-sectional design as part of the WHO European Childhood Obesity Surveillance Initiative (school year 2007/2008). Children’s behavioural data were reported by their parents and children’s weight and height measured by trained fieldworkers. Descriptive statistics and logistic regression analyses were performed.

Primary schools in Bulgaria, Lithuania, Portugal and Sweden; paediatric clinics in the Czech Republic.

Nationally representative samples of 6–9-year-olds (n 15 643).

All thirteen risk behaviours differed statistically significantly across countries. Highest prevalence estimates of risk behaviours were observed in Bulgaria and lowest in Sweden. Not having breakfast daily and spending screen time ≥2 h/d were clearly positively associated with obesity. The same was true for eating ‘foods like pizza, French fries, hamburgers, sausages or meat pies’ >3 d/week and playing outside <1 h/d. Surprisingly, other individual unhealthy eating or less favourable physical activity behaviours showed either no or significant negative associations with obesity. A combination of multiple less favourable physical activity behaviours showed positive associations with obesity, whereas multiple unhealthy eating behaviours combined did not lead to higher odds of obesity.

Despite a categorization based on international health recommendations, individual associations of the thirteen health-risk behaviours with obesity were not consistent, whereas presence of multiple physical activity-related risk behaviours was clearly associated with higher odds of obesity.