title: WHO European Childhood Obesity Surveillance Initiative: School nutrition environment and body mass index in primary schools.
abstract: BACKGROUND
  Schools are important settings for the promotion of a healthy diet and sufficient physical activity and thus overweight prevention.
  
  
  OBJECTIVE
  To assess differences in school nutrition environment and body mass index (BMI) in primary schools between and within 12 European countries.
  
  
  METHODS
  Data from the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) were used (1831 and 2045 schools in 2007/2008 and 2009/2010, respectively). School personnel provided information on 18 school environmental characteristics on nutrition and physical activity. A school nutrition environment score was calculated using five nutrition-related characteristics whereby higher scores correspond to higher support for a healthy school nutrition environment. Trained field workers measured children's weight and height; BMI-for-age (BMI/A) Z-scores were computed using the 2007 WHO growth reference and, for each school, the mean of the children's BMI/A Z-scores was calculated.
  
  
  RESULTS
  Large between-country differences were found in the availability of food items on the premises (e.g., fresh fruit could be obtained in 12%-95% of schools) and school nutrition environment scores (range: 0.30-0.93). Low-score countries (Bulgaria, Czech Republic, Greece, Hungary, Latvia and Lithuania) graded less than three characteristics as supportive. High-score (≥0.70) countries were Ireland, Malta, Norway, Portugal, Slovenia and Sweden. The combined absence of cold drinks containing sugar, sweet snacks and salted snacks were more observed in high-score countries than in low-score countries. Largest within-country school nutrition environment scores were found in Bulgaria, Czech Republic, Greece, Hungary, Latvia and Lithuania. All country-level BMI/A Z-scores were positive (range: 0.20-1.02), indicating higher BMI values than the 2007 WHO growth reference. With the exception of Norway and Sweden, a country-specific association between the school nutrition environment score and the school BMI/A Z-score was not observed.
  
  
  CONCLUSIONS
  Some European countries have implemented more school policies that are supportive to a healthy nutrition environment than others. However, most countries with low school nutrition environment scores also host schools with supportive school environment policies, suggesting that a uniform school policy to tackle the "unhealthy" school nutrition environment has not been implemented at the same level throughout a country and may underline the need for harmonized school policies.
authors.affiliation: Division of Noncommunicable Diseases and Life-Course, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ø, Denmark. twi@euro.who.int.
authors.forename: Trudy M A
authors.initials: TM
authors.lastname: Wijnhoven
authors.affiliation: Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, P.O. Box 1, 3720 BA Bilthoven, The Netherlands. joop.vanraaij@wur.nl.
authors.forename: Joop M A
authors.initials: JM
authors.lastname: van Raaij
authors.affiliation: Department of Food and Nutrition and Sport Science, University of Gothenburg, P.O. Box 300, SE-405 30 Gothenburg, Sweden. agneta.sjoberg@gu.se.
authors.forename: Agneta
authors.initials: A
authors.lastname: Sjöberg
authors.affiliation: Health Promotion Department, Health Service Executive, Railway Street, Navan, County Meath, Ireland. nazih.eldin@hse.ie.
authors.forename: Nazih
authors.initials: N
authors.lastname: Eldin
authors.affiliation: School of Hospitality, Culinary Arts and Meal Science, Örebro University, Campus Grythyttan, P.O. Box 1, SE-712 60 Grythyttan, Sweden. agneta.yngve@oru.se.
authors.forename: Agneta
authors.initials: A
authors.lastname: Yngve
authors.affiliation: Obesity Management Centre, Institute of Endocrinology, Narodni 8, 11694 Prague 1, Czech Republic. mkunesova@endo.cz.
authors.forename: Marie
authors.initials: M
authors.lastname: Kunešová
authors.affiliation: Faculty of Sport, University of Ljubljana, Gortanova 22, 1000 Ljubljana, Slovenia. gregor.starc@guest.arnes.si.
authors.forename: Gregor
authors.initials: G
authors.lastname: Starc
authors.affiliation: Division of Noncommunicable Diseases and Life-Course, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ø, Denmark. jbr@euro.who.int.
authors.forename: Ana I
authors.initials: AI
authors.lastname: Rito
authors.affiliation: Division of Noncommunicable Diseases and Life-Course, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ø, Denmark. jbr@euro.who.int.
authors.forename: Vesselka
authors.initials: V
authors.lastname: Duleva
authors.affiliation: Division of Noncommunicable Diseases and Life-Course, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ø, Denmark. joop.van.raaij@rivm.nl.
authors.forename: Maria
authors.initials: M
authors.lastname: Hassapidou
authors.affiliation: Division of Noncommunicable Diseases and Life-Course, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ø, Denmark. joop.vanraaij@wur.nl.
authors.forename: Eva
authors.initials: E
authors.lastname: Martos
authors.affiliation: Division of Noncommunicable Diseases and Life-Course, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ø, Denmark. agneta.sjoberg@gu.se.
authors.forename: Iveta
authors.initials: I
authors.lastname: Pudule
authors.affiliation: Division of Noncommunicable Diseases and Life-Course, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ø, Denmark. nazih.eldin@hse.ie.
authors.forename: Ausra
authors.initials: A
authors.lastname: Petrauskiene
authors.affiliation: Division of Noncommunicable Diseases and Life-Course, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ø, Denmark. jbr@euro.who.int.
authors.forename: Victoria Farrugia
authors.initials: VF
authors.lastname: Sant'Angelo
authors.affiliation: Division of Noncommunicable Diseases and Life-Course, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ø, Denmark. agneta.yngve@oru.se.
authors.forename: Ragnhild
authors.initials: R
authors.lastname: Hovengen
authors.affiliation: Division of Noncommunicable Diseases and Life-Course, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ø, Denmark. jbr@euro.who.int.
authors.forename: João
authors.initials: J
authors.lastname: Breda
mesh_terms: D015992:Body Mass Index; D002648:Child; D005060:Europe; D005260:Female; D006801:Humans; D008297:Male; D009752:Nutritional Status; D063766:Pediatric Obesity / Q000453:epidemiology* / Q000209:etiology; D012574:Schools; D014944:World Health Organization