European Childhood Obesity Surveillance Initiative Research Articles

Changes of anthropometric indicators of lithuanian first-graders in 2008–2019 according to International Obesity Task Force (IOTF) and World Health Organization (WHO) definitions

IntroductionThe monitoring of children’s growth plays a crucial role in assessing their growth patterns and indicating their weight status. Overweight and obesity, determined by cut-offs of body mass index (BMI), are most commonly associated with unhealthy nutrition, non-communicable diseases, and other health disorders. The World Health Organization (WHO) initiated the WHO European Childhood Obesity Surveillance Initiative (COSI) to measure routinely trends in children’s anthropometric changes, which allow intercountry comparisons within the European Region. Lithuania joined the COSI initiative. Our study aims to evaluate and compare underweight, normal and elevated weight (overweight and obesity) changes of Lithuanian first-graders during eleven years period.MethodsThis study was composed according to the COSI study protocol, and it compares the five rounds of anthropometric measurements of Lithuanian first-graders (7-8-year-old) from 2008 to 2019. The main analysed variables were weight and height; calculated BMI, weight-for-age (W/A), height-for-age (H/A) and body mass index-for-age (BMI/A) z-scores. Changes of the indicators were evaluated according to the International Obesity Task Force (IOTF) cut-offs and WHO child growth standards, grouped by 4 estimates: underweight (thinness), normal weight, overweight and obesity. All comparisons were performed between age groups, gender and COSI round year.ResultsThe mean values for weight, height, W/A and H/A Z-scores were significantly higher for both age and gender groups when comparing later COSI round years (2016 or 2019) to earlier years (2008–2013, in some cases 2016 is included in this range). Time trends of the WHO growth standards and IOTF cut-offs indicate significant decrease among 7-year-old overweight group for boys and girls. Also, a significant decrease was indicated among boys aged 8 years in the overweight group according to the WHO definitions. The only significant increase in trend were expressed in girl’s group with obesity aged 8 years according to IOTF cut-offs.ConclusionThe prevalence of overweight and obesity of first-grade children in Lithuania indicates positive changes, that is the proportion of children with elevated body weight decreased, during eleven-year period. However, it is important to continue the monitoring of children’s growth tendencies.

Type of delivery, birthweight, breastfeeding and overweight: the 2019 Italian results

Abstract Introduction According to recent studies, childhood obesity can be affected by type of delivery, birthweight and breastfeeding. The data from the surveillance system OKkio alla SALUTE, coordinated by the Italian National Institute of Health, have been used to investigate this association. OKkio alla SALUTE, promoted by the Italian Ministry of Health, is part of the WHO European Childhood Obesity Surveillance Initiative. Methods The study population are children aged 8 or 9 years in the third grade of all primary schools. A stratified cluster sample design, with class as the sampling unit, was used. Children were weighed and measured by trained local health staff and were classified as overweight or obese using the age and sex-specific International Obesity Task Force cut-offs. Parents of children completed a brief questionnaire to assess risk behavior, including information about the birth and the first few months of life of their child. Results In 2019, the sixth round of data collection involved 47,219 children and 50,370 parents with a response rate higher than 94%. 20.4% (95% CI 19.9-20.9) of 8-9 years old children were overweight and 9.4% (95% CI 9.0-9.7) were obese. The prevalence of obesity has decreased steadily since 2008 to 2019. The prevalence of overweight and obesity was higher for children born by caesarean section (33% vs 27% by vaginal childbirth), increased with birthweight (for birthweight >4,000 kg: 39.4% vs for birthweight<2,500 kg: 25.1%) and among children who had been breastfed never or less than 1 month (33.6% vs breastfeeding 6 months and above: 28.9%). Logistic regression analysis confirms the association between characteristics at birth/breastfeeding and overweight/ obesity. Conclusions Type of delivery, birth weight and breastfeeding seem to play a role in the prevalence of childhood overweight and obesity. Although these results may be affected by recall bias, this is unlikely to materially affect the results. Key messages • Type of delivery, birth weight and breastfeeding seem to play a role in the prevalence of childhood overweight and obesity. • Information on breastfeeding and other characteristics at birth that might be associated with overweight and obesity is essential for tracking progress in countries.

Does Physical Activity Moderate the Relationship between Myopia and Functional Status in Children 9-11 Years of Age?

Although previous studies have reported an association between physical activity (PA) and myopia in school-aged children, little is known about the link between myopia and children’s functional status. The purpose of this study was to investigate dynamic balance control in relation to the daily PA levels of myopic schoolchildren aged 9–11 years (n = 52) versus a non-myopic control group (n = 53). A single leg stance test performed on the instability platform of the Biodex Balance System was used to assess balance control. The overall stability index (OSI), anterior-posterior stability index (APSI) and medial-lateral stability index (MLSI) were analyzed. PA levels were calculated using the World Health Organization European Childhood Obesity Surveillance Initiative family record form. Myopes and non-myopes were separated into three subgroups based on PA level (low, moderate and high). Myopia significantly affected OSI (F = 40.46, p < 0.001), APSI (F = 33.93, p < 0.001) and MLSI (F = 49.51, p < 0.001). There were significant differences (p < 0.001) between myopic and non-myopic children with low and moderate levels of PA, whilst there were no differences between compared children with high levels of PA. High PA levels had a positive impact on balance control in myopes. Our results showed that PA levels moderate the relationship between myopia and children’s functional status.

S02 Physical activity surveillance across the life-course: from data to policy

As a major risk factor for non-communicable diseases (NCDs), physical inactivity is a prominent challenge for public health. The purpose of this symposium is to present an overview of physical inactivity prevalence in Europe using data collected through international surveillance initiatives, while highlighting successes and discussing future challenges for utilising data to promote physical activity across the life course.The World Health Organization (WHO) is involved in several physical activity surveillance systems on which discussions during this symposium will be based: 1. The WHO European Childhood Obesity Surveillance Initiative (COSI) is the largest survey of its kind in the world. An overview of results from the most recent round of COSI will be presented focusing on prevalence estimates for physical activity, screen time and sleep. Variations between countries of the socioeconomic determinants of physical inactivity, as well as the impact of the COVID-19 pandemic, will demonstrate the ongoing need for quality data to guide targeted policy actions in support of vulnerable groups throughout the life course.2. The WHO’s STEPwise approach to surveillance (STEPS) survey provides important national level prevalence data on the behavioural and metabolic risk factors for NCDs. For many countries, the STEPS survey has provided the first estimates of physical inactivity and sedentary behaviour in the population and has been essential in raising awareness of the need for national policy actions to increase population levels of physical activity.3. The European Commission, with the support of the WHO Regional Office for Europe, has established the European Union Physical Activity Focal Points Network to monitor implementation of the 23 indicators of the Health-Enhancing Physical Activity (HEPA) monitoring framework on physical activity policy development and implementation.4. Within the European Union Physical Activity Focal Points Network, and during the COVID-19 pandemic, some countries established a survey on physical activity and screen time in children and adolescents.

Clinical-social and psychological-pedagogical approaches in the prevention and treatment of obesity and metabolic syndrome in children

Childhood obesity is an acute problem in the European Region, including countries participating in the World Health Organization's European Childhood Obesity Surveillance Initiative. According to their data, the proportion of overweight children reaches 43%. Overweight and obesity, as well as related diseases, are largely preventable. For this reason, the prevention of childhood obesity should be given top priority. Adolescence obesity has reached epidemic proportions worldwide, with the prevalence of complicated obesity increasing at least fourfold over the past 35 years. Most obese adolescents also have excess body fat mass in adulthood, which increases the risk of obesity-related complications, such as type 2 diabetes and cardiovascular disease, and negatively affects social and psychological health. In modern conditions the prevention of the overweight and obesity formation among schoolchildren is not systemic: no attention is paid to the identification of possible risk factors, no unified approaches exist among specialists of various levels to the methodology for preventing the overweight and obesity formation, rational hygienic measures for preventing obesity are not always implemented, the causes of late diagnostics of overweight and obesity among schoolchildren by pediatricians are not fully analyzed, the motivation of children and parents to change their lifestyle in order to fight overweight are not sufficiently studied. The systemic implementation of such preventive measures could help to reduce the number of overweight schoolchildren and improve the health of the child population.

Prevalence of childhood obesity in Greece: Results from WHO Childhood Obesity Surveillance Initiative 2010-2020

1. Wijnhoven TMA, van Raaij JMA, Spinelli A, 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 CrossRef Google Scholar

Methodology and implementation of the WHO European Childhood Obesity Surveillance Initiative (COSI).

Establishment of the WHO European Childhood Obesity Surveillance Initiative (COSI) has resulted in a surveillance system which provides regular, reliable, timely, and accurate data on children's weight status-through standardized measurement of bodyweight and height-in the WHO European Region. Additional data on dietary intake, physical activity, sedentary behavior, family background, and school environments are collected in several countries. In total, 45 countries in the European Region have participated in COSI. The first five data collection rounds, between 2007 and 2021, yielded measured anthropometric data on over 1.3 million children. In COSI, data are collected according to a common protocol, using standardized instruments and procedures. The systematic collection and analysis of these data enables intercountry comparisons and reveals differences in the prevalence of childhood thinness, overweight, normal weight, and obesity between and within populations. Furthermore, it facilitates investigation of the relationship between overweight, obesity, and potential risk or protective factors and improves the understanding of the development of overweight and obesity in European primary-school children in order to support appropriate and effective policy responses.

Mobilizing governments and society to combat obesity: Reflections on how data from the WHO European Childhood Obesity Surveillance Initiative are helping to drive policy progress.

To meet the need for regular and reliable data on the prevalence of overweight and obesity among children in Europe, the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) was established in 2007. The resulting robust surveillance system has improved understanding of the public health challenge of childhood overweight and obesity in the WHO European Region. For the past decade, data from COSI have helped to inform and drive policy action on nutrition and physical activity in the region. This paper describes illustrative examples of how COSI data have fed into national and international policy, but the real scope of COSI's impact is likely to be much broader. In some countries, there are signs that policy responses to COSI data have helped halt the rise in childhood obesity. As the countries of the WHO European Region commit to pursuing United Action for Better Health in Europe in WHO's new European Programme of Work, COSI provides an excellent example of such united action in practice. Further collaborative action will be key to tackling this major public health challenge which affects children throughout the region.

Thinness, overweight, and obesity in 6- to 9-year-old children from 36 countries: The World Health Organization European Childhood Obesity Surveillance Initiative-COSI 2015-2017.

In 2015-2017, the fourth round of the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) was conducted in 36 countries. National representative samples of children aged 6-9 (203,323) were measured by trained staff, with similar equipment and using a standardized protocol. This paper assesses the children's body weight status and compares the burden of childhood overweight, obesity, and thinness in Northern, Eastern, and Southern Europe and Central Asia. The results show great geographic variability in height, weight, and body mass index. On average, the children of Northern Europe were the tallest, those of Southern Europe the heaviest, and the children living in Central Asia the lightest and the shortest. Overall, 28.7% of boys and 26.5% of girls were overweight (including obesity) and 2.5% and 1.9%, respectively, were thin according to the WHO definitions. The prevalence of obesity varied from 1.8% of boys and 1.1% of girls in Tajikistan to 21.5% and 19.2%, respectively, in Cyprus, and tended to be higher for boys than for girls. Levels of thinness, stunting, and underweight were relatively low, except in Eastern Europe (for thinness) and in Central Asia. Despite the efforts to halt it, unhealthy weight status is still an important problem in the WHO European Region.

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.

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 6-9years 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 >3days 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 >3days 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.

Socioeconomic differences in food habits among 6- to 9-year-old children from 23 countries-WHO European Childhood Obesity Surveillance Initiative (COSI 2015/2017).

Socioeconomic differences in children's food habits are a key public health concern. In order to inform policy makers, cross-country surveillance studies of dietary patterns across socioeconomic groups are required. The purpose of this study was to examine associations between socioeconomic status (SES) and children's food habits. The study was based on nationally representative data from children aged 6-9years (n=129,164) in 23 countries in the World Health Organization (WHO) European Region. Multivariate multilevel analyses were used to explore associations between children's food habits (consumption of fruit, vegetables, and sugar-containing soft drinks) and parental education, perceived family wealth and parental employment status. Overall, the present study suggests that unhealthy food habits are associated with lower SES, particularly as assessed by parental education and family perceived wealth, but not parental employment status. We found cross-national and regional variation in associations between SES and food habits and differences in the extent to which the respective indicators of SES were related to children's diet. Socioeconomic differences in children's food habits exist in the majority of European and Asian countries examined in this study. The results are of relevance when addressing strategies, policy actions, and interventions targeting social inequalities in children's diets.

Socioeconomic disparities in physical activity, sedentary behavior and sleep patterns among 6- to 9-year-old children from 24 countries in the WHO European region.

Physical activity, sedentary behavior, and sleep are important predictors of children's health. This paper aimed to investigate socioeconomic disparities in physical activity, sedentary behavior, and sleep across the WHO European region. This cross-sectional study used data on 124,700 children aged 6 to 9years from 24 countries participating in the WHO European Childhood Obesity Surveillance Initiative between 2015 and 2017. Socioeconomic status (SES) was measured through parental education, parental employment status, and family perceived wealth. Overall, results showed different patterns in socioeconomic disparities in children's movement behaviors across countries. In general, high SES children were more likely to use motorized transportation. Low SES children were less likely to participate in sports clubs and more likely to have more than 2h/day of screen time. Children with low parental education had a 2.24 [95% CI 1.94-2.58] times higher risk of practising sports for less than 2h/week. In the pooled analysis, SES was not significantly related to active play. The relationship between SES and sleep varied by the SES indicator used. Importantly, results showed that low SES is not always associated with a higher prevalence of "less healthy" behaviors. There is a great diversity in SES patterns across countries which supports the need for country-specific, targeted public health interventions.

Dietary Patterns and Weight Status of Primary School Children in Serbia.

The purpose of the present cross-sectional study was to examine dietary patterns and the prevalence of underweight, overweight, and obesity among Serbian children. Furthermore, the study analyzed the association between dietary patterns and weight status. A nationally representative sample of 6–9-year-old children (n = 3,067) was evaluated as part of the Fifth Round World Health Organization European Childhood Obesity Surveillance Initiative. The children's height and weight were measured by trained field examiners, while their parents or guardians filled paper versions of the food frequency questionnaire to collect information related to the child's breakfast habits and food and beverage intake. According to the International Obesity Task Force cut-off points, the overall prevalence of overweight (including obesity) and underweight were 28.9 and 8.1%, respectively. The majority of parents reported that their children (84.5%) had breakfast every day, while only 39.5 and 37% of children had daily fruit and vegetable consumption, respectively. The children who do not eat breakfast every day are more likely to be obese (OR = 1.50), while a higher intake frequency of nutrient-poor beverages such as soft drinks increases the risk of being not only overweight (OR = 1.32) but also underweight (OR = 1.39). Regular monitoring and understanding of dietary patterns and weight status is crucial to inform, design, and implement strategies to reduce national and global diet and obesity-related diseases. Urgent actions need to be taken from public policymakers to stop and reverse the increasing trend of overweight (including obesity) among Serbian children.

Childhood Obesity in Serbia on the Rise.

The aim of the study was to examine changes in obesity prevalence among primary school children in Serbia between 2015 and 2019 rounds of the national WHO European Childhood Obesity Surveillance Initiative (COSI-Serbia). Cross-sectional studies were conducted in 2015 and 2019. The nationally representative samples of primary school children were measured for body height and weight, following the COSI protocol. Body Mass Index was calculated, and the IOTF and WHO definitions were used to classify children as overweight or obese. Participants were children of both sexes aged 7.00–8.99 years (n = 6105). Significant differences in overweight (obesity included) prevalence between two COSI rounds were identified regardless of definitions applied. According to the WHO definitions, prevalence of overweight and obesity combined increased in 7–9-year-old children in Serbia from 30.7% in 2015 to 34.8% in 2019 (z = −3.309, p < 0.05), and according to the IOTF standards, the increase from 22.8% to 30% was registered (z = −6.08, p = 0.00). The childhood overweight/obesity rate is increasing in Serbia, which places monitoring and surveillance of children’s nutritional status high on the public health agenda.

Parental Perceptions of Children’s Weight Status in 22 Countries: The WHO European Childhood Obesity Surveillance Initiative: COSI 2015/2017

Introduction: Parents can act as important agents of change and support for healthy childhood growth and development. Studies have found that parents may not be able to accurately perceive their child’s weight status. The purpose of this study was to measure parental perceptions of their child’s weight status and to identify predictors of potential parental misperceptions. Methods: We used data from the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative and 22 countries. Parents were asked to identify their perceptions of their children’s weight status as “underweight,” “normal weight,” “a little overweight,” or “extremely overweight.” We categorized children’s (6–9 years; n = 124,296) body mass index (BMI) as BMI-for-age Z-scores based on the 2007 WHO-recommended growth references. For each country included in the analysis and pooled estimates (country level), we calculated the distribution of children according to the WHO weight status classification, distribution by parental perception of child’s weight status, percentages of accurate, overestimating, or underestimating perceptions, misclassification levels, and predictors of parental misperceptions using a multilevel logistic regression analysis that included only children with overweight (including obesity). Statistical analyses were performed using Stata version 15 1. Results: Overall, 64.1% of parents categorized their child’s weight status accurately relative to the WHO growth charts. However, parents were more likely to underestimate their child’s weight if the child had overweight (82.3%) or obesity (93.8%). Parents were more likely to underestimate their child’s weight if the child was male (adjusted OR [adjOR]: 1.41; 95% confidence intervals [CI]: 1.28–1.55); the parent had a lower educational level (adjOR: 1.41; 95% CI: 1.26–1.57); the father was asked rather than the mother (adjOR: 1.14; 95% CI: 0.98–1.33); and the family lived in a rural area (adjOR: 1.10; 95% CI: 0.99–1.24). Overall, parents’ BMI was not strongly associated with the underestimation of children’s weight status, but there was a stronger association in some countries. Discussion/Conclusion: Our study supplements the current literature on factors that influence parental perceptions of their child’s weight status. Public health interventions aimed at promoting healthy childhood growth and development should consider parents’ knowledge and perceptions, as well as the sociocultural contexts in which children and families live.

The overweight and obesity problem among 7-8 years old children in the Kyrgyz Republic: WHO European Childhood Obesity Surveillance Initiative - COSI -round 4

The overweight and obesity problem among 7-8 years old children in the Kyrgyz Republic: WHO European Childhood Obesity Surveillance Initiative - COSI -round 4

Biostatistical investigation of correlation between breastfeeding and obesity

Breastfeeding is a classic aspect of health, which has benefits for both children and mothers in the long and short terms. In Europe, the obesity epidemic for children becomes an urgent problem needed to be solved. Recent research indicates that prolonging breastfeeding time would reduce the proportion of obesity and overweight. Breastfeeding has been seen as a protective factor. In this article, we make a secondary analysis of the data from several European countries in the WHO European Childhood Obesity Surveillance Initiative (COSI) to study the correlation between breastfeeding and obesity. This survey is the fourth round. The result shows that there is a positive correlation between breastfeeding and obesity.

Physical Activity, Screen Time, and Sleep Duration of Children Aged 6–9 Years in 25 Countries: An Analysis within the WHO European Childhood Obesity Surveillance Initiative (COSI) 2015–2017

Background: Children are becoming less physically active as opportunities for safe active play, recreational activities, and active transport decrease. At the same time, sedentary screen-based activities both during school and leisure time are increasing. Objectives: This study aimed to evaluate physical activity (PA), screen time, and sleep duration of girls and boys aged 6–9 years in Europe using data from the WHO European Childhood Obesity Surveillance Initiative (COSI). Method: The fourth COSI data collection round was conducted in 2015–2017, using a standardized protocol that included a family form completed by parents with specific questions about their children’s PA, screen time, and sleep duration. Results: Nationally representative data from 25 countries was included and information on the PA behaviour, screen time, and sleep duration of 150,651 children was analysed. Pooled analysis showed that: 79.4% were actively playing for >1 h each day, 53.9% were not members of a sport or dancing club, 50.0% walked or cycled to school each day, 60.2% engaged in screen time for <2 h/day, and 84.9% slept for 9–11 h/night. Country-specific analyses of these behaviours showed pronounced differences, with national prevalences in the range of 61.7–98.3% actively playing for >1 h/day, 8.2–85.6% were not members of a sport or dancing club, 17.7–94.0% walked or cycled to school each day, 32.3–80.0% engaged in screen time for <2 h/day, and 50.0–95.8% slept for 9–11 h/night. Conclusions: The prevalence of engagement in PA and the achievement of healthy screen time and sleep duration are heterogenous across the region. Policymakers and other stakeholders, including school administrators and parents, should increase opportunities for young people to participate in daily PA as well as explore solutions to address excessive screen time and short sleep duration to improve the overall physical and mental health and well-being of children.

Nutrition and physical activity environments in primary schools in Poland - COSI study.

Schools are important settings for the promotion of healthy diet and sufficient physical activity to prevent civilisation diseases related to lifestyle. To describe school physical activity and nutrition environment in elementary schools in Poland, and to asses differences in school physical activity and nutrition environments, depending on school location and size. Data was used from the World Health Organisation European Childhood Obesity Surveillance Initiative (COSI) conducted in 2016 in 135 Polish schools. Logistic regression was used to asses association between the location and individual school environment indicator. On the basis of answers to 20 questions about school physical activity and nutrition environment, a positive school environmental assessment index was compiled. Large, urban schools were characterised by a significantly greater availability of sweet snacks, whereas flavoured milk with added sugar was more often available in small and rural schools. The univariate logistics analysis parameters showed that an urban-rural location had a significant association for the availability of an indoor gym and existence of a canteen and a shop. Analysing the positive schools environmental assessment index, there were no statistically significant differences in mean values due to location, but statistically significant differences were found depending on the school size, with the highest level in large schools and the lowest in small schools. The factor which adversely differentiates the school environment in terms of healthy nutrition and physical activity is primarily the school size, and then the school location. Systemic and social solutions should aim at reducing the small school "exclusion syndrome", both in rural and in urban areas, also with regard to infrastructure and availability of conditions conducive to healthy nutrition and physical activity.

The WHO Childhood Obesity Surveillance Initiative (COSI) and the CLICK framework

Abstract The WHO European Childhood Obesity Surveillance Initiative (COSI) is a well-established system that measures trends in overweight and obesity in over 300,000 primary school aged children from over 40 countries across the WHO European Region. The COSI collects important information related to child anthropometrics, school and family characteristics and child lifestyle behaviors. Major determinants covered by COSI include physical activity, dietary habits and school environments. COSI data has revealed substantial differences in physical activity estimates between countries. However, studies based on COSI data show that 40% of children spend at least two hours watching TV or using electronic devices per day. To prevent increased childhood obesity, policymakers should simultaneously increase opportunities for children to engage in physical activity and act to reduce the amount of time spent on sedentary activities. As children are increasingly online and connected to mobile devices, an emerging concern relates to digital marketing of unhealthy products, which can be effectively targeted at children using advanced persuasive techniques. The WHO CLICK report suggests the need to integrate information such as children's time spent online, device, app and social media usage with outcomes such as child obesity. One future possibility may be to integrate such questions into future COSI questionnaires, which would provide important information at minimal cost and could generate extensive, high quality data. The monitoring and surveillance advocated by the CLICK report is necessary to provide data on whether and how far WHO recommendations in online settings are adopted by governments and public health institutions. The WHO CLICK report acts on consultation with experts to provide a tool to support Member States in monitoring the digital marketing of unhealthy products to children and suggests policy options.