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

Mirjam M. Heinen, Silvia Bel-Serrat, Cecily C. Kelleher, Marta Buoncristiano, Angela Spinelli, Paola Nardone, Sanja Musić Milanović, Ana Isabel Rito, A. Tülay Bağci Bosi, Enrique Gutiérrrez-González, Iveta Pudule, Shynar Abdrakhmanova, Zulfiya Abdurrahmonova, Lacramioara Aurelia Brinduse, Alexandra Cucu, Vesselka Duleva, Anna Fijałkowska, Andrea Gualtieri, Tatjana Hejgaard, Jolanda HyskaEnisa Kujundžić, Ausra Petrauskiene, Elena Sacchini, Lela Shengelia, Maya Tanrygulyyeva, Zhamilya Usupova, Ingunn Holden Bergh, Daniel Weghuber, Radka Taxová Braunerová, Marie Kunešová, Victoria Farrugia Sant'Angelo, Eha Nurk, Sergej M. Ostojic, Igor Spiroski, Ľubica Tichá, Harry Rutter, Julianne Williams, Khadichamo Boymatova, Ivo Rakovac, Martin W. Weber, João Breda

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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.

Original languageEnglish
Article numbere13207
JournalObesity Reviews
Issue numberS6
Early online date7 Jul 2021
Publication statusPublished - 30 Nov 2021

Bibliographical note

Funding Information:
We gratefully acknowledge all participating, children, their parents, and the schoolteachers and principals for kindly volunteering to participate in the study. We also thank the examiners and regional and local supervisors/coordinators who collected the data in each country. We also gratefully acknowledge support from Liza Villas and Gerben Rienk for making the WHO European Childhood Obesity Surveillance Initiative (COSI) project possible. Additionally, we acknowledge the leadership of the principal investigators from Kyrgyzstan (Gulmira Aitmurzaeva), Romania (Constanta Huidimac Petrescu), Norway (Else Karin Grøholt), Spain (Mª), and Turkey (Nazan Yardim). Ángeles Dal Re

Funding Information:
The authors gratefully acknowledge support from a grant from the Russian Government in the context of the WHO European Office for the Prevention and Control of NCDs.


  • children
  • fruit
  • rural
  • soft drinks
  • urban
  • vegetables

ASJC Scopus subject areas

  • Endocrinology, Diabetes and Metabolism
  • Public Health, Environmental and Occupational Health


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