Overweight and Obesity in Children under 5 Years: Surveillance Opportunities and Challenges for the WHO European Region
- 1Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, USA
- 2Department of Nutrition, Physical Activity, and Obesity, European Region of World Health Organization, Copenhagen, Denmark
- 3UCL Medical School, London, UK
- 4School of Public Health, University of Alberta, Edmonton, Canada
Background: Many children who have overweight or obesity before puberty can develop obesity in early adulthood, which is associated with increased morbidity and mortality. The preschool years (ages 0–5) represents a point of opportunity for children to be active, develop healthy eating habits, and maintain healthy growth. Surveillance of childhood overweight and obesity in this age group can help inform future policies and interventions.
Objective: To review and report available prevalence data in WHO European Region Member States and determine how many countries can accurately report on rates of overweight and obesity in children under 5 years.
Methods: We conducted a rapid review of studies reporting on overweight and obesity prevalence in children ages 0–5 in the WHO European region member states from 1998 to 2015.
Results: Currently, 35 of the 53 member states have data providing prevalence rates for overweight and obesity for children under 5 years. There was little consistency in study methods, impacting comparability across countries. The prevalence of overweight and obesity in children under 5 years ranges from 1 to 28.6% across member states.
Conclusion: Although measuring overweight and obesity in this age group may be challenging, there is an opportunity to leverage existing surveillance resources in the WHO European Region.
Childhood growth is an important factor that influences health outcomes across the lifecourse, including obesity (1). Emerging evidence indicates that a large proportion of children who have obesity before puberty can develop obesity in early adulthood, with early-life fat deposition associated with later risk of adult obesity (2–6). Although the relationship between childhood obesity and poor health outcomes is highly complex and there are individual variations influenced by genetic, maturational, and socioeconomic factors, it is a major public health priority. This is in part because physiological and psychological health consequences during childhood can continue into adolescence and adulthood to impact population health in the future (7, 8). Specifically, childhood obesity is associated with an increased risk of premature illness and mortality, although improving Body Mass Index (a tool used to measure obesity at the population level) in adulthood does appear to reduce the later risk of morbidity and mortality (9–13). For example, rapidly increasing weight trajectories across the life course have been shown to be a risk factor for the development of non-communicable diseases (NCDs), notably cardiovascular diseases, cancer, and diabetes, which collectively are estimated to cause 75% of deaths by 2020, and musculoskeletal and orthopedic complications (7, 12). Prevention and management of obesity in childhood is therefore likely to be an effective way to contribute to preventing chronic diseases in adults.
The prevalence of childhood obesity is increasing across European countries. A quarter of children aged 6–9 years in European Union countries who participated in the WHO Europe Childhood Obesity Surveillance Initiative (COSI) were classified as having overweight or obesity in 2008, increasing to a third in 2010, with estimates ranging from 18.4% (Belgian 6-year-old girls) to 49.0% (Italian 8-year-old boys) (14). This report was based on 12 countries; however, COSI has expanded to currently include the following countries: Albania, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Greece, Hungary, Ireland, Italy, Kazakhstan, Latvia, Lithuania, Malta, Norway, Poland, Portugal, Republic of Moldova, Romania, Slovenia, Spain, Sweden, the former Yugoslav of Macedonia, and Turkey. As a result, many governments and international organizations have recommended some form of policy action to prevent obesity, with a great focus on preventing obesity in children (12, 15, 16).
Identifying policy action to prevent childhood obesity requires a better understanding of potential modifiable factors that drive obesity in particular age groups. Some modifiable risk factors for obesity include dietary and physical activity behaviors, which to a large extent, are learned at an early age (17, 18). In this way, preschool years are increasingly part of the health promotion equation in the context of chronic disease prevention and a point of opportunity for children to be physically active, develop healthy eating habits, and maintain healthy growth trajectories (19–24).
However, in order to plan and evaluate policy interventions designed to change modifiable risk factors, such as social and physical environments in which children live and play, policy makers need good surveillance. While recent studies have shown that the development of obesity may well be initiated in infancy and early childhood (4, 5), in many countries, surveillance data on obesity are missing or not routinely collected at these younger ages. In this article, we review and report on the currently available prevalence data in WHO European Region Member States in order to determine how many countries can accurately estimate the prevalence of obesity in children under 5 years.
We undertook a rapid review to identify and synthesize current evidence regarding the prevalence of obesity in children under 5 years in the WHO European Region and to determine how many countries can accurately estimate on this issue.
Our specific review questions were
1 What is the current evidence regarding the prevalence of obesity in children under 5 years in the WHO European Region?
2 Can WHO European Region Member States accurately estimate the prevalence of obesity in children under 5 years?
These guiding questions helped us define the scope of the search strategy, as well as the inclusion and exclusion criteria, construct summary tables presenting key information and findings, and synthesize the evidence from the included studies.
We reviewed published and open access studies reporting on obesity prevalence in children aged 0–5 years (defined as data reporting body mass index; not including growth curves or aggregate data with children above these ages) in the WHO European Region Member States.
Our search strategy used structured relevant terms as follows:
• population: children, infants
• outcomes: body weight, growth, growth and development, body mass index, weight gain, prevalence, and incidence combined with overweight and obesity.
We searched four databases: PubMed, SCOPUS, Web of Science, and EMBASE. This search was conducted on November 16–20, 2015, and the searches were modified to suit the style of each database. We conducted a second search of the literature in 2016 and added a few more studies that were published in 2016. We employed keywords that would be aligned with the Medical Subject Headings used in the MEDLINE database. The following keywords were used: child, infant, ideal body weight, growth, growth and development, body mass index, body weight, weight gain, prevalence, and incidence combined with overweight and obesity. We also reviewed the references of electronically selected articles to see if any other relevant papers turned up. All data included are from studies whose participants signed a written informed consent form prior to inclusion and received approval from the appropriate ethics committee. We included articles that used various definitions of childhood obesity. For example, some articles used the WHO criterion (defined as the proportion of children with weight-for-height or BMI-for-age z-score values more than 2 SDs and more than 3 SDs, respectively, from the WHO growth standard median), while some used the International Obesity Task Force criterion. Other studies used country-specific criterion for obesity classification. We also included articles that used self-reported and/or measured data.
The inclusion criteria can be summarized as follows:
• population: child, infant
• outcomes: prevalence studies reporting obesity in children using various childhood obesity definitions (e.g., WHO and IOTF definitions) and using self-reported and/or measured data.
The electronic search yielded 5,595 results, with an additional three articles coming from other sources. We retrieved 3,134 from PubMed, 469 from Scopus, 989 from Web of Science, and 1,003 from EMBASE. We used RefWorks to organize and review all literature. After an initial deletion of exact or close duplicates, we were left with 3,357 articles. We then did two rounds of title screening, which left us with 298 articles for further screening. Our second round of screening involved abstract review for relevance. After full-text review, we were left with 66 records for analysis.
We extracted studies that were most relevant for the purpose of our review. We assessed relevance based on a number of factors, which included study type, the country in which the research was undertaken (i.e., WHO European Region), whether the research is single center or multi-center, and whether it included more than one measurement cycle. This process of quality and relevance assessment allowed us to determine the quantities of surveillance studies and their overall quality and direction. The studies included in the review were restricted to quantitative studies to ensure they addressed the key review questions and outcomes of interest (i.e., prevalence and reporting). We only included peer-reviewed studies that have been published and undergone methodological and expert scrutiny.
Flowchart of Study Inclusions
As an additional step and to form a cohesive perspective on the prevalence of overweight and obesity in the Region, we used data from existing nutrition surveillance studies. For example, the Demographic and Health Survey (DHS) and the Multiple Indicator Cluster Survey (MICS) monitor the prevalence of undernutrition in children under 5 in several European countries. We used data from the DHS and MICS surveys to calculate overweight and obesity prevalence in European countries that did not have specific overweight and obesity surveillance studies. Data available for Italy arises from WHO field-test data collected when trialing new WHO growth rate charts.
Sixty-one studies provided overweight and obesity prevalence data for children under 5 years in WHO European Region member states. These studies analyzed overweight and obesity outcomes in different age ranges. For example, 29 studies analyzed overweight and obesity outcomes in children who were between 0 and 4 years old. While other studies, evaluated overweight and obesity outcomes in one particular age group (e.g., 3 years). The majority (N = 38) of the studies used the WHO criteria for overweight obesity, while other studies (N = 20) used the IOTF cutoffs. Three studies used country-specific cutoff (25–27). Furthermore, these studies provided little consistency in terms of time points of measurements and national representativeness, impacting comparability across countries.
Despite these limitations, currently 38 of the 53 member states in the European Region of the WHO have data providing prevalence rates for overweight and obesity in children under 5 years. More data were available in eastern and northern Europe, with data for the eastern region provided primarily via the DHS and MICS.
Table 1 illustrates the variability in prevalence within the region and within countries, based on all resources for all available countries. In regards to DHS and MICS reports, the most recent report for each available country was used. Sixteen of the 53 Member States have available DHS or MICS reports. The proportion of the population classified as having overweight and obesity varied from 1 to 28.6% in these Member States.
Table 1. Prevalence of overweight and obesity for children under 5 years of age in the WHO European Region by country from published datasets and literature.
The lack of consistency in methods makes it difficult to assess overweight and obesity trends (both between and within countries at a given point and over time) in children under 5 years. DHS and MICS data also show that there is a large degree of variability in the prevalence of overweight between and even within countries across data collection time points (see Figure 1).
Currently, 35 of the 53 member states from the WHO European Region have prevalence data for overweight and obesity for children under the age of 5 years old. However, the current state of surveillance and monitoring in the European Region for children under the age of 5 years is discouraging with pervasive issues of inconsistency in both method of, and occurrence of, collection. For example, one MICS (which uses measured anthropometrics as opposed to self-reported data) for a Central Asian country from 2006 estimates prevalence of overweight and obesity to be 11.3% for children ages 0–4 using WHO cutoffs (82). The next MICS for the same country in 2010–2011 confusingly reports a prevalence of 0.6%, with the same age range and same cutoffs (83, 84). The next MICS for the same country in 2015 estimates prevalence to be 9.3% (56). This phenomenon holds true for multiple countries (29, 37, 85–88). Bosnia & Herzegovina and Armenia show a similar but less dramatic trend in vast differences between survey waves. Though difficult to provide a concrete explanation for these inconsistencies, it does perhaps highlight a general need for better training of interviewers in anthropometric measurements and/or careful attention to sampling techniques across survey years.
Furthermore, many of the estimates presented in this paper are outdated with some prevalence estimates reaching as far back as the early 1990s. Current data suggest that overweight and obesity may be increasing in the Central Asian part of the region whereas trends in other parts of the region are not immediately clear (89). Additional and more recent data points are needed to identify current trends and confirm current prevalence rates.
The variability in type of cutoffs used in these studies also reduces the Region’s capability of comparing between and within countries. In 2006, the WHO released growth standards based on the finding that well-nourished children of all populations follow similar growth patterns before puberty (82, 90). These can provide the basis and standardized cutoffs for countries to plot child growth and identify overweight and obesity.
Beyond measurement issues affecting the quality of data, there is a lack of data in general. Only 66% of Member States had published literature on prevalence of overweight and obesity in children under 5 years. Of those countries with data, 34% were from DHS or MICS surveys, which primarily focus on the prevalence of undernutrition in children under 5 years.
Considering that preventing childhood obesity and supporting health across the lifespan is an important priority for WHO European Member States, our review indicates that there is an opportunity to strengthen existing surveillance for children under the age of 5 years in order to provide timely, regular and quality data that can inform policy action. The development of surveillance systems is also vital for the successful monitoring and evaluation of population level interventions and policies and can help strengthening advocacy efforts for government action (12).
The European region has been a forerunner in regards to surveillance in other age groups, particularly with the implementation of COSI in nearly 30 countries. COSI routinely measures the prevalence of overweight and obesity in primary school-aged children (6–9 years) to monitor change in prevalence in this population group as well as to permit inter-country comparisons (91, 92). Furthermore, almost all European countries participate in the Health Behaviors in School-Aged Children survey (HBSC), which provides (self-reported) data on overweight and obesity in children and adolescents aged 11, 13, and 15 (91, 92). Both initiatives have been invaluable to countries in monitoring trends, documenting the prevalence of childhood obesity and helping to prioritize policy responses. Similar monitoring exercises for children under the age of 5 years could be used to detect relevant changes within and between countries over time and to support policy action in early-life years.
Increasing surveillance in this age group may have its challenges. Previous work in the region for older children [COSI (6–9 years) and HBSC (11–15 years)] has effectively used schools as the location for sampling (11, 91). For children under the age of 5 years old, new sampling approaches would be needed. For example, pediatric offices are potential sampling frames to consider, with many young children having repeat check-ups with health-care professionals. Surveillance among this age group may also bring up new challenges concerning measurement (including ensuring standardized approaches). Nevertheless, clear guidance exists for measuring young children’s growth for stunting/wasting, including checklists and step-by-step procedures, and there is no reason that these could not be adapted as a protocol for measurement of overweight/obesity (55).
The need to shift the focus to early-life obesity prevention was underscored by the 2016 “Ending Childhood Obesity Report” and Institute of Medicine’s report “Early Childhood Obesity Prevention Policies.” These called for further research into effective policy interventions to prevent obesity in early childhood (12, 18).
While it is generally recognized that childhood growth surveillance is crucial, despite many countries recommending growth monitoring in health care, routine and representative assessment of the prevalence of overweight and obesity are not common in the majority of the WHO European Member States. In order achieve the best outcomes from any future investment in obesity prevention in early life years, concerted efforts should be made to implement interventions and policies, which are specific and relevant to the target group and sub-groups. To best achieve this aim, there is a need for increased range of coverage and quality of data in surveillance on overweight and obesity in this age group that can be disaggregated according to socioeconomic variables.
More widespread and systematic direct measurement of childhood growth and weight trajectories at younger ages can also provide an improved understanding of how obesity develops in young children. At the European level, the Vienna Declaration committed countries in the European Region to addressing the root causes of obesity and diet-related NCDs and calls on WHO to support Member States monitor population trends. It is fully expected that surveillance programs focusing on younger age groups will complement the good existing work for school-aged children.
Consent for Publication
Not applicable. This was a review solely of previously published data, where the previous researchers had done all consenting and ethical proceedings in line with institutional review boards.
Data used in this paper is all currently publicly available online in journal articles and/or published results from surveys, and full references are provided.
RJ, together with JB, conceived the idea for this paper, conducted, supported, and interpreted results of literature reviews, and wrote original drafts of most of the text, including creating text. RS assisted in the literature reviews and wrote text. JJ and XRS assisted in the conception of the paper, assisted with the interpretation of the results, contributed to the discussion and all other aspects of the paper, and assisted with editing the paper. JB and JJ are staff members of the World Health Organization Regional Office for Europe. XRS is a technical consultant with the Department of Nutrition, Physical Activity, and Obesity, European Region of World Health Organization, Copenhagen, Denmark. The authors are responsible for the views expressed in this publication and they do not necessarily represent the decisions or stated policy of WHO.
Conflict of Interest Statement
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The handling Editor declared a shared affiliation, though no other collaboration, with several of the authors (RS and JB), and the handling Editor states that the process met the standards of a fair and objective review.
The authors would also like to acknowledge the support of the European Commission in facilitating this work.
NCDs, non-communicable diseases; WHO, World Health Organization; EU, European Union; COSI, WHO Europe Childhood Obesity Surveillance Initiative; DHS, Demographic and Health Survey; MICS, Multiple Indicator Cluster Survey; HBSC, Health Behaviors in School-Aged Children survey.
2. Sun SS, Liang R, Huang TT, Daniels SR, Arslanian S, Liu K, et al. Childhood obesity predicts adult metabolic syndrome: the Fels longitudinal study. J Pediatr (2008) 152(2):191–200. doi:10.1016/j.jpeds.2007.07.055
8. World Health Organization. Global Status Report on Non-Communicable Diseases. Geneva: World Health Orgaization (2014). Available from: http://apps.who.int/iris/bitstream/10665/148114/1/9789241564854_eng.pdf
9. O’Malley G, Santoro N, Northrup V, D’Adamo E, Shaw M, Eldrich S, et al. High normal fasting glucose level in obese youth: a marker for insulin resistance and beta cell dysregulation. Diabetologia (2010) 56(6):1199–209. doi:10.1007/s00125-010-1693-0
11. Wjnhoven TM, van Raaij JM, Sjöberg A, Eldin A, Yngve A, Kunešová M, et al. WHO European Childhood Obesity Surveillance Initiative: school nutrition environment and body mass index in primary schools. Int J Env Res Public Health (1956) 2014:11261.
12. World Health Organization. Report of the Commission on Ending Childhood Obesity. (2016). Available from: http://apps.who.int/iris/bitstream/10665/204176/1/9789241510066_eng.pdf
13. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Series: maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet (2013) 382:427–51. doi:10.1016/S0140-6736(13)60937-X
14. Wijnhoven TM, van Raaij JM, Spinelli A, Rito AI, Hovengen R, Kunesova M, et al. WHO European Childhood Obesity Surveillance Initiative 2008: weight, height and body mass index in 6-9-year-old children. Int J Pediatr Obes (2013) 8(2):79–97. doi:10.1111/j.2047-6310.2012.00090.x
15. Akdag R, Danzon M. WHO European Ministerial Conference on Countering Obesity: Diet and Physical Activity for Health. Copenhagen: WHO Regional Office for Europe (2006). Available from: http://www.euro.who.int/__data/assets/pdf_file/0006/96459/E90143.pdf
16. World Health Organization Regional Office of Europe. Vienna Declaration on Nutrition and Non-Communicable Diseases in the Context of Health 2020. Copenhagen: WHO Regional Office for Europe (2013). Available from: http://www.euro.who.int/__data/assets/pdf_file/0005/193253/CONSENSUS-Vienna-Declaration-5-July-2013.pdf
20. Ventura AK, Mennella JA, Ventura AK, Mennella JA. Innate and learned preferences for sweet taste during childhood. Curr Opi Clin Nutr Metab Care (2011) 14(4):379–84. doi:10.1097/MCO.0b013e328346df65
25. Hirani V, Stamatakis E. Chapter 1: Cardiovascular disease and associated risk factors. In: Bromley C, Sproston K, Shelton M, editors. The Scottish Health Survey 2003. Edinburgh, Scotland: Scottish Executive (2005). Available from: http://www.gov.scot/resource/doc/76169/0019727.pdf
27. Küpers LK, de Pijper JJ, Sauer PJJ, Stolk RP, Corpelejn E. Skipping breakfast and overweight in 2-and 5-year-old Dutch children – the GECKO Drenthe cohort. Int J Obes (2014) 38(4):569–71. doi:10.1038/ijo.2013.194
28. Albania Demographic and Health Survey 2008–2009, Institute of Statistics, Institute of Public Health, and I. Macro, editors. Tirana, Albania (2010). Available from: https://dhsprogram.com/pubs/pdf/FR230/FR230.pdf
29. Armenia Demographic and Health Survey 2010, National Statistic Service (Armenia), Ministry of Health (Armenia), and I. Macro, editors. Calverton, MD (2012). Available from: https://dhsprogram.com/pubs/pdf/FR252/FR252.pdf
30. Serbanescu F, Morris L, Rahimova S, Stupp P, editors. Adventists Development and Relief Agency, Azerbaijan Ministry of Health, State Committee of Statistics, Mercy Crops [Baku, Azerbaijan], DRH/CDC, USAID. UNFPA, UNHCR Reproductive health survey Azerbaijan 2001: Final Report. Atlanta, GA: US Department of Health and Human Services, CDC (2003).
31. Azerbaijan Demographic and Health Survey 2006, State Statistical Committee (Azerbaijan), Macro International. Calverton, MD (2008). Available from: https://dhsprogram.com/pubs/pdf/FR195/FR195.pdf
32. Ministry of Health of the Republic of Azerbaijan, the State Statistical Committee of Azerbaijan, and the Azerbaijan office of the United Nations Children’s Fund (UNICEF) Azerbaijan Nutrition Survey Report. Baku, Republic of Azerbaijan (2014).
33. Belarus Multiple Indicator Cluster Survey 2005, Final Report, Ministry of Statistics and Analysis of the Republic of Belarus. Minsk, Republic of Belarus (2007). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS3/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Belarus/2005/Final/Belarus%202005%20MICS_English.pdf
34. Bayingana K, Demarest S, Gisle L, Hesse E, Miermans P, Tafforeau J. Gezondheisenquete door middle van interview Belgie 2004 [Health Interview Survey Belgium 2004]. Brussels: Scientific Institute of Public Health (2006).
35. Massa G. Body mass index measurements and prevalence of overweight and obesity in school-children living in the province of Belgian Limburg. Eur J Pediatr (2002) 161(6):343–6. doi:10.1007/s00431-002-0932-x
36. Verbestel V, De Coen V, Van Winckel M, Huybrechts I, Maes L, De Bourdeaudhuij I. Prevention of overweight in children younger than 2 years old: a pilot cluster-randomized controlled trial. Public Health Nutr (2014) 17(06):1384–92. doi:10.1017/S1368980013001353
37. Multiple Indicator Cluster Survey (MICS) Bosnia and Herzegovina 2011–2012 Final Report, The Agency for Statistics Bosnia and Herzegovina, et al. Sarajevo (2013). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS4/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Bosnia%20and%20Herzegovina/2011-2012/Final/Bosnia%20and%20Herzegovina%202011-12%20MICS_English.pdf
38. Baykova D, Duleva V, Petrova S, Angelova K, Jordanov B, Vatralova K, et al. National Monitoring of Dietary Intake and Nutritional Status of Bulgarian Population 2004. Sofia: Department of Nutrition and Public Health (2008).
39. Savva SC, Tornaritis M, Chadjigeorgiou C, Kourides YA, Savva ME, Panagi A, et al. Prevalence and socio-demographic associations of undernutrition and obesity among preschool children in Cyprus. Eur J Clin Nutr (2005) 59(11):1259–65. doi:10.1038/sj.ejcn.1602237
40. Cattaneo A, Monasta L, Stamatakis E, Lioret S, Castetbon K, Frenken F, et al. Overweight and obesity in infants and pre-school children in the European Union: a review of existing data. Obes Rev (2010) 11(5):389–98. doi:10.1111/j.1467-789X.2009.00639.x
41. Vignerová J, Humeníkova L, Brabec M, Riedová J, Bláha P. Long-term changes in body weight, BMI, and adiposity rebound among children and adolescents in Czech Republic. Econ Hum Biol (2007) 5(3):409–25. doi:10.1016/j.ehb.2007.07.003
42. Larsen LM, Hertel NT, Mølgaard C, Christensen Rd, Husby S, Jarbøl DE. Prevalence of overweight and obesity in Danish preschool children over a 10-year period: a study of two birth cohorts in general practice. Acta Paediatr (2012) 101:201–7. doi:10.1111/j.1651-2227.2011.02551.x
43. Matthiessen J, Stockmarr A, Biltoft-Jensen A, Fagt S, Zhang H, Groth M. Trends in overweight and obesity in Danish children and adolescents: 2000-2008: exploring changes according to parental education. Scand J Public Health (2014) 42(4):385–92. doi:10.1177/1403494813520356
44. Morgen CS, Rokholm B, Brixval CS, Andersen CS, Andersen LG, Rasmussen M, et al. Trends in prevalence of overweight and obesity in Danish infants, children and adolescents are we still on a plateau. PLoS One (2013) 8(7):e69860. doi:10.1371/journal.pone.0069860
45. Chollet C, Ehlinger V, Dupuy M, Guitard C, Leautier D, Jouret B, et al. [Prevalence of overweight preschool-aged children: medical examination data of schoolchildren in southwestern France]. Arch Pediatr (2013) 20(11):1187–92. doi:10.1016/j.arcped.2013.08.010
46. Lioret S, Mariet B, Volatier JL, Charles MA. Child overweight in France and its relationship with physical activity, sedentary behavior and socioeconomic status. Eur J Clin Nutr (2007) 61:509–16. doi:10.1038/sj.ejcn.1602538
47. Lioret S, Touvier M, Dubuisson C. Trends in overweight rates and energy intake in France from 1999 to 2007: relationships with socioeconomic status. Obesity (2009) 17:1092–100. doi:10.1038/oby.2008.619
48. Unité de surveillance et d’épidémiologie nutritionnelle. Etude nationale nutrition santé (ENNS, 2006). Situation nutritionnelle en France en 2006 selon les indicateurs d’objectif et les repères du Programme National Nutrition Santé (PNNS). St Maurice: Institut de veille sanitaire Université de Paris 13, Conservatoire national des arts et métiers (2007).
49. Report of the Georgia National Nutrition Survey (GNNS) 2009. Tbilisi, Georgia: NCDC&PH and UNICEF (2010). Available from: http://unicef.ge/uploads/Report_of_the_Georgia_National_Nutrition_Survey_2009_-_eng.pdf
50. Multiple Indicator Cluster Survey: Georgia Final Report 2005, State Department of Statistics of Georgia. (2008). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS3/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Georgia/2005/Final/Georgia%202005%20MICS_English.pdf
51. Kurth BM, Schaffrath RA. Die Verbreitung von Übergewicht und Adipositas bei Kindern und Jugendlichen in Deutschland. Ergebnisse des bundesweiten Kinder- und Jugendgesundheitssurveys (KiGGS). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz (2010) 50:736–43. doi:10.1007/s00103-007-0235-5
52. Manios Y, Costarelli V, Kolotourou M, Kondakis K, Tzavara C, Moschonis G. Prevalence of obesity in preschool Greek children, in relation to parental characteristics and region of residence. BMC Public Health (2007) 7:178. doi:10.1186/1471-2458-7-178
53. McCarthy EK, ní Chaoimh C, Murray DM, Hourihane JB, Kenny LC, Kiely M. Eating behaviour and weight status at 2 years of age: data from the Cork BASELINE Birth Cohort Study. Eur J Clin Nutr (2015) 69:1356–9. doi:10.1038/ejcn.2015.130
54. Whelton H, Harrington J, Crowley E, Kelleher V, Cronin M, Perry IJ. Prevalence of overweight and obesity on the island of Ireland results from the North South Survey of children’s height, weight and body mass index. 2002. BMC Public Health (2007) 7:187. doi:10.1186/1471-2458-7-187
56. The Statistics Committee of the Ministry Economy of the Republic of Kazakhstan. 2015 Kazakhstan Multiple Indicator Cluster Survey, Key Findings. Astana, Kazakhstan: The Statistics Committee of the Ministry of National Economy of the Republic of Kazakhstan (2016). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS5/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Kazakhstan/2015/Key%20findings/Kazakhstan%202015%20MICS%20KFR_English.pdf
57. Kyrgyz Demographic and Health Survey: Key Findings, National Statistical Committee (Kyrgyz Republic) and Macro International. Bishek, Kyrgyz Republic; Calverton, MD (2013). Available from: https://dhsprogram.com/pubs/pdf/FR283/FR283.pdf
59. Statistical Office of Montenegro (MONSTAT) and Strategic Marketing Research Agency (SMMRI). Montenegro Multiple Indicator Cluster Survey 2005, Final Report. Podgorica (2006). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS3/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Montenegro/2005-2006/Final/Montenegro%202005-06%20MICS_English.pdf
60. van den Hurk K, van Dommelen P, van Buuren S, Verkerk PH, Hirasing RA. Prevalence of overweight and obesity in the Netherlands in 2003 compared to 1980 and 1997. Arch Dis Child (2007) 92(11):992–5. doi:10.1136/adc.2006.115402
61. Schönbeck Y, Talma H, van Dommelen P, Bakker B, Buitendijk SE, Hirasing RA, et al. Increase in prevalence of overweight in Dutch children and adolescents: a comparison of nationwide growth studies in 1980, 1997 and 2009. PLoS One (2011) 6(11):e27608. doi:10.1371/journal.pone.0027608
62. Juliusson PB. Overweight and Obesity in Norwegian Children: Trends, Current Prevalence, Effect of Socio-Demographic Factors and Parental Perception. Bergen: University of Bergen (2010). 100 p. 1333–7.
64. Rito AI. Estado nutricional de criancas e oferta alimentar do pre-escolar do municipio de Coimbra, Portugal, 2001. Rio de Janeiro: Escola Nacional De Saude Publica Sergio Arouca De Funcao Oswaldo Cruz and Saude (2004).
65. Bingham DD, Varela-Silva MI, Ferrão MM, Augusta G, Mourão MI, Nogueira H, et al. Socio-demographic and behavioral risk factors associated with the high prevalence of overweight and obesity in Portuguese Children. Am J Hum Biol (2013) 25:733–42. doi:10.1002/ajhb.22440
66. National Scientific and Applied Center for Preventive Medicine (NCPM) [Moldova] and ORC Macro. Moldova Demographic and Health Survey 2005. Calverton, MD: National Scientific and Applied Center for Preventive Medicine of the Ministry of Health and Social Protection and ORC Macro (2006). Available from: https://dhsprogram.com/pubs/pdf/FR178/FR178.pdf
68. Nazarova E, Kuzmichev Y. The height-, weight- and BMI-for-age of preschool children from Nzihny Novgorod city, Russia, relative to the international growth references. BMC Public Health (2016) 16:274. doi:10.1186/s12889-016-2946-8
69. Statistical Office of the Republic of Serbia and UNICEF 2014 Serbia Multiple Indicator Cluster Survey and 2014 Serbia Roma Settlements Multiple Indicator Cluster Survey (MICS). Key Findings. Belgrade, Serbia: Statistical Office of the Republic of Serbia and UNICEF (2014). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS5/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Serbia/2014/Final/Serbia%20%28National%20and%20Roma%20Settlements%29%202014%20MICS_English.pdf
71. Serra-Majem L, Aramcet-Batrina J, Perez-Rodrigo C, Ribas-Barba L, Delgado-Rubio A. Prevalence and determinants of obesity in Spanish children and young people. Br J Nutr (2006) 96(Suppl 1):S67–72. doi:10.1079/BJN20061703
72. Huus K, Kudvigsson JF, Enskär K, Ludvigsson J. Risk factors in childhood obesity-findings from the All Babies in Southwest Sweden (ABIS) cohort. Acta Paediatr (2007) 96(9):1321–5. doi:10.1111/j.1651-2227.2007.00408.x
73. Holmbäck U, Fridman J, Gustafsson J, Proos L, Sundelin C, Forslund A. Overweight more prevalent among children than among adolescents. Acta Paediatr (2007) 96(4):577–81. doi:10.1111/j.1651-2227.2006.00189.x
74. Enghardt BH, Pearson M, Becker W. Dietary Habits and Nutrient Intake in Swedish Children 4 Year Old and School Children in Grade 2 and 5 (Riksmaten-Barn 2003), Uppsala. Uppsala, Sweden: National Food Administration (Livsmedelsverket) (2006).
75. State Committee on Statistics [Republic of Tajikistan] and UNICEF Tajikistan Living Standards Measurement Survey (TLSS): Indicators at a Glance. (2007). Available from: http://www.stat.tj/en/img/e4f46968ef1143d0ddb14e16b8d9d6d9_1280833182.pdf
76. Hacettepe University Institute of Population Studies. Turkey Demographic and Health Survey. Ankara, Turkey: Hacettepe University (2013). Available from: https://dhsprogram.com/pubs/pdf/FR160/FR160.pdf
77. The State Committee of Statistics of Turkmenistan and UNICEF. 2015-2016 Turkmenistan Multiple Indicator Cluster Survey, Key Findings. Ashgabat, Turkmenistan: The State Committee of Statistics of Turkmenistan and UNICEF (2016). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS5/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Turkmenistan/2015-2016/Key%20findings/Turkmenistan%202015-16%20MICS%20KFR_English.pdf
78. Multiple Indicator Cluster Survey (MICS) Former Yugoslav Republic of Macedonia Final Report 2011, IPSOS Strategic Puls, et al. Former Yugoslav Republic of Macedonia. (2012). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS4/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Macedonia%2C%20The%20Former%20Yugoslav%20Republic%20of/2011/Final/Macedonia%20%28National%20and%20Roma%20Settlements%29%202011%20MICS_English.pdf
79. Stamatakis E. Anthropometric measurements, overweight and obesity. In: Sproston K, Primatesta P, editors. The Health for Children and Young People Health Survey for England 2002. London: Department of Health (2003).
80. Pearce A, Li L, Abbas J, Ferguson B, Graham H, Law C, et al. Is childcare associated with the risk of overweight and obesity in the early years? Findings from the UK Millennium Cohort Study. Int J Obes (2010) 34(7):1160–8. doi:10.1038/ijo.2010.15
81. UNICEF and State Statistical Committee of the Republic of Uzbekistan. Uzbekistan Multiple Indicator Cluster Survey 2006, Final Report. Tashkent, Uzbekistan: UNICEF (2007). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS3/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Uzbekistan/2006/Final/Uzbekistan%202006%20MICS_English.pdf
83. The Agency of Statistics (RK) and R.S.E.I.C. Centers. Multiple Indicator Cluster Survey (MICS) in the Republic of Kazakhstan, 2010-2011, Final Report. Astana, Kazakhstan (2012). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS4/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Kazakhstan/2010-2011/Final/Kazakhstan%202010-11%20MICS_English.pdf
84. Multiple Indicator Cluster Survey 2006, Kazakhstan, United Nations Children’s Fund (UNICEF). Bishkek, Kyrgyz Republic (2007). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS3/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Kazakhstan/2006/Final/Kazakhstan%202006%20MICS_English.pdf
85. National Statistical Service [Armenia], Ministry of Health [Armenia], and ORC Macro. Armenia Demographic and Health Survey 2000. Calverton, MD: National Statistical Service, Ministry of Health and ORC Macro (2001). Available from: https://dhsprogram.com/pubs/pdf/FR126/FR126.pdf
86. National Statistical Service [Armenia], Ministry of Health [Armenia], and ORC Macro. Armenia Demographic and Health Survey 2005. Calverton, MD: National Statistical Service, Ministry of Health, and ORC Macro (2006). Available from: https://dhsprogram.com/pubs/pdf/FR184/FR184.pdf
87. Directorate for Economic Planning, Ministry of Health and Social Welfare, Ministry of Health of the Federation of Bosnia and Herzegovina. Bosnia and Herzegovina Multiple Indicator Cluster Survey 2006, Final Report. Sarajevo, Bosnia and Herzegovina (2008). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS3/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Bosnia%20and%20Herzegovina/2006/Final/Bosnia%20and%20Herzegovina%202006%20MICS_English.pdf
88. Bosnia and Herzegovina Agency for Statistics. Bosnia and Herzegovina Multiple Indicator Cluster Survey 2000, Final Report. Sarajevo, Bosnia and Herzegovina (2002). Available from: http://mics.unicef.org/surveys
89. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet (2014) 384(9945):766–81. doi:10.1016/S0140-6736(14)60460-8
91. Wijnhoven TM, van Raaij JM, Spinelli A, Starc G, Hassapidou M, Spiroski I, et al. WHO European Childhood Obesity Surveillance Initiative: body mass index and level of overweight among 6-9-year-old children from school year 2007/2008 to school year 2009/2010. BMC Public Health (2014) 14:806. doi:10.1186/1471-2458-14-806
92. Roberts C, Freeman J, Samdal O, Schnohr CW, de Looze ME, Nic Gabhainn S, et al. The health behaviour in school-aged children (HBSC) study: methodological developments and current tensions. Int J Public Health (2009) 54(2):140. doi:10.1007/s00038-009-5405-9
94. Statistical Agency under the President of the Republic of Tajikistan (SA), Ministry of Health [Tajikistan], and ICF International. Tajikistan Demographic and Health Survey 2012. Dushanbe, Tajikistan, and Calverton, MD, USA: SA, MOH, and ICF International (2013). Available from: https://dhsprogram.com/pubs/pdf/FR279/FR279.pdf
95. National Centre of Public Health of the Ministry of Health of the Republic of Moldova, United Nations Children’s Fund (UNICEf). Republic of Moldova Multiple Indicator Cluster Survey 2012: Final Report (MICS4). Chisinau, Republic of Moldova (2014). Available from: https://www.unicef.org/moldova/2012_Moldova_MICS_FINAL_EN.1(1).pdf
96. Analytical and Information Center, Ministry of Health of the Republic of Uzbekistan, State Department of Statistics, Ministry of Macroeconomics and Statistics [Uzbekistan], and ORC Macro. Uzbekistan Health Examination Survey 2002. Demographic and Health Surveys. Calverton, MD, USA: Analytical and Information Center, State Department of Statistics, and ORC Macro (2004). Available from: https://dhsprogram.com/pubs/pdf/FR143/FR143.pdf
97. Albanian National Institute of Statistics. Albania Multiple Indicator Cluster Survey 2005, Final Report. Tirana, Albania: Albanian National Institute of Statistics (2007). Available from: http://mics.unicef.org/surveys
98. Albanian National Institute of Statistics. Albania Multiple Indicator Cluster Survey 2000, Final Report. Tirana, Albania: Albanian National Institute of Statistics (2002). Available from: http://mics.unicef.org/surveys
99. United Nations Children’s Fund (UNICEF). Azerbaijan Multiple Indicator Cluster Survey 2000 Final Report. Baku, Azerbaijan: UNICEF (2002). Available from: http://mics.unicef.org/surveys
100. Multiple Indicator Cluster Survey 2006, Kyrgyz Republic. Final Report. National Statistical Committee of the Kyrgyz Republic. United Nations Children’s Fund. (2007). Kyrgyzstan, Bishkek. Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS3/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Kyrgyzstan/2005-2006/Final/Kyrgyzstan%202005-06%20MICS_English.pdf
101. Statistical Office of Montenegro (MONSTAT) and UNICEF. 2013 Montenegro Multiple Indicator Cluster Survey and 2013 Montenegro Roma Settlements Multiple Indicator Cluster Survey, Final Report. Podgorica, Montenegro: Statistical Office of Montenegro (MONSTAT) and UNICEF (2014). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS5/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Montenegro/2013/Final/Montenegro%20%28National%20and%20Roma%20Settlements%29%202013%20MICS_English.pdf
102. Statistical Office of the Republic of Serbia and Strategic Marketing Research Agency. Republic of Serbia Multiple Indicator Cluster Survey 2005, Final Report. Belgrade, Republic of Serbia: Statistical Office of the Republic of Serbia (2006). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS3/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Serbia/2005-2006/Final/Serbia%202005-06%20MICS_English.pdf
103. Hacettepe University Institute of Population Studies, Turkey Demographic and Health Survey. Hacettepe University Institute of Population Studies, Ministry of Health General Directorate of Mother and Child Health and Family Planning, State Planning Organization and European Union. Ankara, Turkey (2003). Available from: https://dhsprogram.com/pubs/pdf/FR160/FR160.pdf
104. Statistical Office of the Republic of Macedonia. Republic of Macedonia Multiple Indicator Cluster Survey 2005-2006, Final Report. Skopje, Republic of Macedonia: Statistical Office of the Republic of Macedonia (2006). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS3/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Macedonia%2C%20The%20Former%20Yugoslav%20Republic%20of/2005-2006/Final/Macedonia%202005%20MICS_English.pdf
105. Statistical Office of the Republic of Serbia. Serbia Multiple Indicator Cluster Survey 2010. Belgrade, Republic of Serbia: Statistical Office of the Republic of Serbia (2011). Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS4/Central%20and%20Eastern%20Europe%20and%20the%20Commonwealth%20of%20Independent%20States/Serbia/2010/Final/Serbia%202010%20MICS_English.pdf
Keywords: surveillance, childhood obesity, European region, policy
Citation: Jones RE, Jewell J, Saksena R, Ramos Salas X and Breda J (2017) Overweight and Obesity in Children under 5 Years: Surveillance Opportunities and Challenges for the WHO European Region. Front. Public Health 5:58. doi: 10.3389/fpubh.2017.00058
Received: 02 November 2016; Accepted: 03 March 2017;
Published: 13 April 2017
Edited by:Clare Heidi Llewellyn, University College London, UK
Reviewed by:Melkam Alamerew Kebede, University of Sydney, Australia
Adela Hruby, Tufts University, USA
Copyright: © 2017 Jones, Jewell, Saksena, Ramos Salas and Breda. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Jo Jewell, firstname.lastname@example.org