Clustering of Multiple Energy Balance-Related Behaviors in School Children and its Association with Overweight and Obesity—WHO European Childhood Obesity Surveillance Initiative (COSI 2015–2017)

Silvia Bel-Serrat, Ana Ojeda-Rodríguez, Mirjam M. Heinen, Marta Buoncristiano, Shynar Abdrakhmanova, Vesselka Duleva, Victoria Farrugia Sant’Angelo, Anna Fijałkowska, Tatjana Hejgaard, Constanta Huidumac, Jolanda Hyska, Enisa Kujundzic, Sanja Musić Milanović, Guljemal Ovezmyradova, Napoleón Pérez-Farinós, Ausra Petrauskiene, Ana Isabel Rito, Lela Shengelia, Radka Taxová Braunerová, Harry RutterCeline M. Murrin, Cecily C. Kelleher, João Breda

Research output: Contribution to journalArticle

6 Citations (Scopus)


It is unclear how dietary, physical activity and sedentary behaviors co-occur in school-aged 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.
Original languageEnglish
Article number511
Pages (from-to)1-20
Number of pages20
Issue number3
Publication statusPublished - 27 Feb 2019


  • Children
  • Cluster analysis
  • Dietary intake
  • Energy balance-related behaviors
  • Obesity
  • Overweight
  • Physical activity
  • Screen time
  • Sedentary behavior

ASJC Scopus subject areas

  • Food Science
  • Nutrition and Dietetics

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