Differences in Energy Balance-Related Behaviours in European Preschool Children: The ToyBox-Study

March Differences in Energy Balance-Related Behaviours in European Preschool Children: The ToyBox-Study Marieke De Craemer 0 1 2 Mina Lateva 0 1 2 Violeta Iotova 0 1 2 Ellen De Decker 0 1 2 Mat Verloigne 0 1 2 Ilse De Bourdeaudhuij 0 1 2 Odysseas Androutsos 0 1 2 Piotr Socha 0 1 2 Zbigniew Kulaga 0 1 2 Luis Moreno 0 1 2 Berthold Koletzko 0 1 2 Yannis Manios 0 1 2 Greet Cardon 0 1 2 the ToyBox-study group 0 1 2 0 1 Ghent University , Ghent , Belgium , 2 Medical University Varna , Varna, Bulgaria, 3 Research Foundation Flanders, Brussels , Belgium , 4 Harokopio University , Athens , Greece , 5 Children's Memorial Health Institute , Warsaw , Poland , 6 University of Zaragoza , Zaragoza , Spain , 7 University of Munich Medical Centre , Munich , Germany 1 Academic Editor: Fiona Gillison, University of Bath, UNITED KINGDOM 2 Energy Balance-Related Behaviours in Preschoolers - Funding: The ToyBox-study is funded by the Seventh Framework Programme (CORDIS FP7) of the European Commission under grant agreement n 245200. The content of this article reflects only the authors views and the European Community is not liable for any use that may be made of the information contained therein. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The aim of the current study was to compare levels of energy balance-related behaviours (physical activity, sedentary behaviour, and dietary behaviours (more specifically water consumption, sugar-sweetened beverage consumption and unhealthy snacking)) in four- to six-year-old preschoolers from six European countries (Belgium, Bulgaria, Germany, Greece, Poland, and Spain) within the ToyBox cross-sectional study. A sample of 4,045 preschoolers (4.77 0.43 years; 52.2% boys) had valid physical activity data (steps per day), parents of 8,117 preschoolers (4.78 0.46 years; 53.0% boys) completed a parental questionnaire with questions on sedentary behaviours (television viewing, computer use, and quiet play), and parents of 7,244 preschoolers (4.77 0.44 years; 52.0% boys) completed a food frequency questionnaire with questions on water consumption, sugar-sweetened beverage consumption and unhealthy snacking. The highest levels of physical activity were found in Spain (12,669 steps/day on weekdays), while the lowest levels were found in Bulgaria and Greece (9,777 and 9,656 steps/day on weekdays, respectively). German preschoolers spent the least amount of time in television viewing (43.3 min/day on weekdays), while Greek preschoolers spent the most time in television viewing (88.5 min/day on weekdays). A considerable amount of time was spent in quiet play in all countries, with the highest levels in Poland (104.9 min/day on weekdays), and the lowest levels in Spain (60.4 min/day on weekdays). Belgian, German, and Polish Competing Interests: The authors have declared that no competing interests exist. preschoolers had the lowest intakes of water and the highest intakes of sugar-sweetened beverages. The intake of snacks was the highest in Belgian preschoolers (73.1 g/day) and the lowest in Greek preschoolers (53.3 g/day). Across six European countries, differences in preschoolers energy balance-related behaviours were found. Future interventions should target European preschoolers energy balance-related behaviours simultaneously, but should apply country-specific adaptations. The high prevalence of overweight and obesity is a worldwide health problem, and is already manifest in preschool children [1]. Childhood overweight is associated with serious health problems, the risk of premature illness and early death later in life [1]. In developed countries, the prevalence of overweight and obesity among children under the age of five years increased from 7.9% in 1990 to 11.7% in 2010 with an expected prevalence of 14.1% in 2020 [1]. In Europe, the prevalence of overweight in preschool boys ranges from 10% in Belgium and Germany to 30% in Spain. In preschool girls, it ranges from 8% in Germany to 30% in Spain [2]. Changes in lifestyle behaviour are likely to be the main cause of the increase in overweight and obesity, rather than changes in biologic or genetic factors [3]. Weight gain is determined by the cumulative effect of low levels of physical activity (PA), high levels of sedentary behaviour (SB), and unhealthy dietary behaviours, also referred to as energy balance-related behaviours (EBRBs) [4]. Focusing on several EBRBs could be more effective in overweight and obesity prevention in preschoolers, since focusing on one single EBRB as a universal causal factor of overweight and obesity is not ideal because it is the co-existence and interaction of these specific EBRBs that results in preschoolers weight gain [4, 5]. Furthermore, establishing healthy lifestyle behaviourssuch as more PA, less SB, and healthy dietary behavioursis already important at an early age, since these healthy EBRBs track into later life [69], and even into adulthood [10, 11]. For PA, SB and dietary behaviours, guidelines have been developed for children at preschool age. The most recent PA guidelines for preschool children suggest that preschoolers (one- to five-year-olds) should be physically active every day for at least three hours (180 minutes) at any intensity, spread throughout the day [1215]. This guideline corresponds to taking 11,500 steps/day [16].Next to the suggestion to limit prolonged periods of sitting [1719], SB guidelines also include specific recommendations for the amount of screen time per day, because screen time is the most common SB in preschool children, and is therefore frequently used as a proxy marker of overall SB in preschoolers [12, 20]. Recent guidelines recommend that preschool children (one- to five-year-olds) should limit watching television (TV) and the use of other electronic medialike computer, DVDs and other electronic gamesto less than one hour per day [17]. However, overall sedentary time is not made up of screen time alone, so it is important to measure preschoolers time spent in quiet play (e.g., drawing, tinkering, puzzling, looking into books) as well, since quiet play is categorized as productive SB [12]. Food-based dietary guidelines (FBDG) for preschool children only exist on a national basis. The FBDG used in the present study are based upon the nutrient recommendations of the Belgian Health Council and the World Health Organization, combined with data on habitual dietary intake in the Belgian population [21]. These FBDG are very similar to dietary guidelines in other countries, making these guidelines applicable for a European population of preschoolers [22]. The Belgian FBDG suggests limiting the consumption of sugar-sweetened beverages (SSBs) and unhealthy snacks, since these kinds of beverages and foods are strictly not necessary in a balanced diet (e.g., soft drinks, candy, potato chips). Furthermore, preschool children should consume 500 ml to 1,000 (...truncated)