Opinion of the European Economic and Social Committee on ‘Measures to reduce child obesity’ (Exploratory opinion at the request of the Spanish Presidency)
Date: 2023-07-13
Institutions: European Economic and Social Committee
Subjects: child, eating habits, living conditions, nutrition, nutritional disease, public health








C_2023349EN.01010801.xml










29.9.2023   


EN


Official Journal of the European Union


C 349/108







Opinion of the European Economic and Social Committee on ‘Measures to reduce child obesity’
         
(Exploratory opinion at the request of the Spanish Presidency)
(2023/C 349/17)







Rapporteur:



Josep PUXEU ROCAMORA





Co-rapporteur:



Isabel CAÑO AGUILAR











Referral


Letter from the Spanish Presidency of the Council, 8.12.2022




Legal basis


Article 304 of the Treaty on the Functioning of the European Union




Section responsible


Agriculture, Rural Development and the Environment




Adopted in section


1.6.2023




Adopted at plenary


13.7.2023




Plenary session No


580




Outcome of vote
(for/against/abstentions)


197/0/0




1.   Conclusions and recommendations









1.1.


Health is a fundamental right. Moreover, for children, growing up happy and healthy, and being able to fulfil their full potential, is a right enshrined in the UN Convention on the Rights of the Child.












1.2.


Childhood overweight and obesity continue to be among the biggest public health challenges currently facing EU countries, bringing together environmental, social and economic factors. Childhood obesity is associated with physical, mental and social health problems in childhood and adulthood.












1.3.


The EESC highlights the need to reduce socioeconomic inequalities because they are directly linked to excess weight in children. In some cases, the percentage of children and adolescents with obesity doubles in lower-income households.












1.4.


The EESC notes that Member States have different approaches on how to address childhood obesity (in relation to various aspects, such as communication, nutrition labelling, promotion of physical exercise and sustainable diets, and newer aspects such as healthy use of screens and promotion of mental and emotional health). It urges the European Commission and the European Parliament to play a more proactive role in this area and to make progress towards more standardisation and a more effective framework.












1.5.


The EESC is concerned that most national restrictions on promoting and advertising food and non-alcoholic beverages to children are too weak and existing voluntary approaches are not enough to protect children and adolescents. It believes that the WHO’s nutrient profile could be used as a basis for limiting advertising of products high in sugar, fat and salt. It considers it important to learn from good measures and practices from countries that demonstrate the effectiveness of various policies, including regulations, to limit children’s exposure to audiovisual advertising for foods and drinks high in salt, sugars, fat, saturated fat or trans fatty acids. It is also essential to ensure that the rules surrounding children’s broadcasting hours are always respected and that all publicity complies with the principle of accurate advertising. It should be borne in mind that the WHO advocates restricting all relevant forms of food advertising aimed at children.












1.6.


Moreover, the EESC calls for the 2014–2020 EU Action Plan on Childhood Obesity to be renewed, taking into account the proposals set out in this opinion.












1.7.


To meet these objectives, the EESC believes that the institutions should boost consumption of those foods considered a key part of a healthy and sustainable diet (fresh, seasonal and locally produced fruits and vegetables, pulses, whole grains and animal proteins such as fish). This can be achieved, for example, by highlighting policies that promote EU agricultural produce, by developing public tenders that promote healthy and sustainable diets and by making use of tax incentives (such as VAT rebates) to support the purchase and consumption of those foods. Moreover, with inflation and prices on the rise, both measures could enable many more families, especially the most disadvantaged, to have easier access to nutritious and high-quality food. The EESC also believes that the process of reformulating and improving the composition of food and beverages on the European market should continue.












1.8.


The EESC calls for families to be provided with simple tools so that they have the knowledge to understand the many factors behind childhood obesity and its health impact in childhood and adulthood. Furthermore, the EESC believes that society as a whole should take steps to promote the healthy use of information and communication technologies (ICT) and take up existing recommendations in this regard. Excessive use of screens results in a sedentary lifestyle, greater exposure to advertising of foods and beverages high in sugars, fats and salt, and mental health risks for children and adolescents.












1.9.


The EESC calls for the educational environment to be a driving force behind physical activity, healthy diets, and mental and emotional health. Educational institutions are an ideal place to promote healthy lifestyles and to tackle childhood obesity in positive ways, without creating social stigma or rejecting certain body stereotypes. To this end, the Committee believes that current curricula should be overhauled, increasing the time set aside for physical activity, as well as investment in food and gastronomic education. School canteens are key to promoting healthy nutritional habits among children and adolescents, and the EESC therefore considers it hugely important to ensure that they are available at all stages of education and that the diet provided is healthy, balanced and of high quality. It also believes that the roll-out of the EU’s School Fruit, Vegetables and Milk Scheme could be stepped up, and lunch grants for disadvantaged children promoted.












1.10.


The EESC urges the Member States to expand and improve public spaces and infrastructure so as to encourage and facilitate active mobility, especially in areas surrounding educational institutions or the routes leading up to them. It also believes that urban spaces with sports areas, playgrounds and green spaces should be created that are accessible, safe and welcoming for children and adolescents.












1.11.


The EESC proposes using the digital environment to promote healthy lifestyles, relationships and behaviours. In this regard, the EESC once again calls for visual publicity campaigns inspired by positive social advertising aimed at children, in order to promote healthier foods and diets, an active lifestyle and healthy use of screens.












1.12.


The EESC highlights the recommendations made in its Evaluation of the EU school scheme (1), and its opinions on healthy and sustainable diets and the Farm to Fork Strategy and asks the Commission to include measures to combat childhood obesity in the next framework on sustainable food systems; for example, measures related to labelling and public procurement.












1.13.


Moreover, as stated in other opinions, the EESC firmly believes that democratic innovations such as food policy councils and the promotion of participatory approaches help to encourage quality and legitimacy in food policymaking. It advocates the establishment of an instrument at EU level such as a European Food Policy Council.












1.14.


In short, the EESC is committed to an overarching approach to obesity, looking into the healthy transformation of lifestyles, but also all the social determinants. It recommends public strategies guaranteeing universal access to healthy food, physical activity and sport, good rest, and mental and emotional well-being, without any discrimination.




2.   Health at the heart of all policies









2.1.


Health is a fundamental right (2) and a prerequisite for a functioning society and economy. Moreover, for children in particular, growing up happy and healthy, and being able to fulfil their full potential, is a right enshrined in the UN Convention on the Rights of the Child (3). The EESC supports the One Health concept promoted by the European Commission, as a comprehensive approach that strives to sustainably balance and optimise the health of humans.












2.2.


It is vital to address childhood obesity in order to achieve the Sustainable Development Goals (SDGs), especially SDG 3 (ensure healthy lives and promote well-being for all at all ages), and improve the health of all Europeans in the future. Science informs us that preventing obesity at key stages of life, such as early years and adolescence, is likely to have the greatest health benefits, reduces the associated costs and is the most promising way of breaking the intergenerational cycle of obesity and dietary inequality.












2.3.


The EESC therefore welcomes the request of the future Spanish Presidency for an exploratory EESC opinion on ways in which childhood obesity can be reduced. It chimes with the current trend among the EU institutions and governments to draw up and develop strategies to curb and prevent childhood obesity and overweight:






(i)


The EU Strategy on the Rights of the Child (4) recognises that healthy diets, together with physical activity, are key to children’s full physical and mental development.










(ii)


Under the European Child Guarantee initiative, which is intended to help put the rights of children and adolescents at the heart of EU policymaking, childhood obesity is one of the aspects that national plans should include.










(iii)


The opinion also follows on from the Strategy for Europe on Nutrition, Overweight and Obesity-related Health Issues (2007), the 2017 White Paper on obesity and the EU Action Plan on Childhood Obesity 2014–2020 (5) — initiatives which, like this opinion, were aimed at halting the rise in overweight and obesity in children and adolescents (aged 0–18). In this regard, the EESC calls for the 2014–2020 EU Action Plan on Childhood Obesity to be renewed.








3.   Childhood obesity in Europe: current state of play









3.1.


According to the World Health Organization (WHO) (6), obesity is a complex, non-communicable disease involving many factors, is defined by excessive weight and is harmful to health. Obesity is also a risk factor in the development of other non-communicable diseases (NCDs), such as cardiovascular, metabolic and osteoarticular diseases and cancer (7), mental health disorders and reduced quality of life, which lowers life expectancy and increases the risk of premature death. These consequences ultimately have an impact by considerably increasing countries’ health expenditure and other individual, social and economic expenses.












3.2.


Childhood overweight and obesity continue to be among the biggest public health challenges currently facing EU countries. In the fifth round of the WHO Childhood Obesity Surveillance Initiative (COSI), conducted between 2018 and 2020 (8), 29 % of children aged 7–9 in the 33 participating countries were found to have excess weight (9), and 12 % obesity. By gender, boys had slightly higher rates than girls (31 % compared to 28 % for overweight; and 14 % compared to 10 % for obesity).












3.3.


The EESC believes that the COVID-19 pandemic might have exacerbated the problem of childhood obesity. There are growing signs that the pandemic worsened childhood obesity figures, especially for those in the most vulnerable situations (10).












3.4.


The EESC notes that Member States have different approaches on how to address childhood obesity (in relation to various aspects, such as communication, nutrition labelling, promotion of physical exercise and sustainable diets, and newer aspects such as healthy use of screens and promotion of mental and emotional health). It urges the European Commission and the European Parliament to play a more proactive role in this area and to make progress towards more standardisation and a more effective framework.




4.   Determinants of childhood obesity

There is no single cause of obesity; rather, it results from the complex interaction of various factors (11). These include factors related to the individual (biological/genetic, physiological and lifestyle factors), environmental factors (the influence of the different environments in which the individual grows up: family, school, community), psychosocial factors (level of education and social class), and economic factors (household income level (12)).








4.1.


Psychosocial factors and economic resources mirror social patterns, can make low-income families more vulnerable to harmful environmental exposure at all stages of life and have a cumulative effect throughout people’s lifetimes.












4.2.


There is sufficient proof and evidence to show that exposure to unhealthy nutritional and body weight factors before conception and during pregnancy plays an important role in how body composition develops in the early years of life and how susceptible people are to obesity.












4.3.


Furthermore, socioeconomic inequalities in childhood, which have been exacerbated by the pandemic, rising inflation and the economic crisis, are directly related to excess weight in the child population. In some cases, the number of obese children is twice as high in low-income households, as they have different lifestyles to higher income households.












4.4.



Engaging in physical activity throughout one’s lifetime is a cornerstone of good health. It also plays an important role in preventing and treating childhood obesity and early metabolic risk factors (13), and is a key component in the development of basic cognitive, motor and social skills. However, 81 % of children aged 11–17 are not physically active enough (14). Before the pandemic, only one in seven 15-year-olds in the WHO European Region (14 %) reported doing at least one hour of moderate to vigorous physical activity every day (15). Similarly, only 25 % of 15-year-old boys and 15 % of girls of the same age achieved the recommended levels of physical activity in 2014 (16).












4.5.



Unbalanced diets, where there is a high consumption of foods and beverages high in fat, sugars and salt, are associated with higher levels of obesity as well as with poorer health overall. On the other hand, habits that tend towards models such as the Mediterranean, Atlantic or Nordic diets, or simply towards diets with a predominance of fresh and plant-based food, are associated with better health outcomes (17) (18). According to the latest round of the COSI study (19), less than half (43 %) of 6–9-year-olds in the European Region consume fresh fruit every day, and 7 % never eat any fruit or consume it less than once a week. When it comes to vegetables, only one third (34 %) of children aged 6–9 eat them every day.












4.6.


From an economic and social point of view, the EESC also notes that the global rise in food commodity prices is having an impact on consumer prices in the EU, affecting the purchasing and eating habits of European families, children and adolescents, especially the most vulnerable.












4.7.



Emotional well-being and obesity are closely interlinked. On the one hand, this is because such well-being is key to preventing obesity in children and, on the other, because childhood obesity increases the chances of discrimination, stigmatisation and bullying at school, and thus influences children’s emotional well-being.












4.8.



Excessive screen time has been shown to be one of the determining factors in the emergence of overweight/obesity, with the two phenomena being correlated (20) (21). Although international bodies and public agencies recommend limiting screen time to a maximum of 120 minutes a day, European children and adolescents seem to exceed this (22).




5.   Recommended action









5.1.


To tackle childhood obesity, a whole-of-life approach must be taken and, at the same time, the multiple causes of it must be addressed. The EESC proposes a holistic and participatory approach. Reducing obesity and overweight figures in European children and adolescents requires collaboration and commitment from all stakeholders (23): public administrations, private/business sector, the media, educational and health institutions and families. Moreover, this comprehensive response must be based on a positive and non-stigmatising approach.












5.2.


The EESC calls for the renewal of the 2014–2020 EU Action Plan on Childhood Obesity, which should aim to: promote adequate nutrition, encourage physical activity, foster healthy educational and social environments, guarantee healthcare, protect the most vulnerable groups, encourage and promote health-related social responsibility in business and advertising, and encourage the various public administrations to work in synergy. The Committee recommends implementing measures to make the environments in which children and adolescents live and grow up healthier in a comprehensive and cross-sectoral manner.












5.3.


The EESC highlights the recommendations made in its Evaluation of the EU school scheme (24), and its opinions on healthy and sustainable diets and the Farm to Fork Strategy and asks the Commission to include measures to combat childhood obesity in the next framework on sustainable food systems; for example, measures related to labelling and public procurement.












5.4.


Moreover, the EESC reiterates the importance of strengthening food democracy and, as stated in other opinions, firmly believes that democratic innovations such as food policy councils and the promotion of participatory approaches help to encourage quality and legitimacy in food policymaking. It advocates the establishment of an instrument at EU level such as a European Food Policy Council.




5.5.   Macro-social environment









5.5.1.


In this area, the EESC calls for all stakeholder actions to be aligned to create a social ecosystem that promotes cultural change helping to alleviate inequalities and makes lifestyles healthier.












5.5.2.


The EESC once again calls for measures to enhance the capacity of public systems to prevent and address particularly vulnerable situations that stop people from adopting healthy lifestyles.












5.5.3.


The EESC underlines the need to push ahead with social measures that facilitate work-life balance and shared family responsibility and that enable families to access and spend more time on healthy activities.












5.5.4.


The EESC recommends promoting public strategies that guarantee access to sports facilities without any discrimination, and making it easier to exercise properly. The EESC recommends closing the gender and social gap in the practice of physical activity and exercise, ensuring inclusive spaces and promoting diversity of supply.












5.5.5.


The EESC believes that public administrations should place greater emphasis on combating obesity when developing, implementing and monitoring regulations and policies in all policy areas, taking into account the key factors behind overweight and obesity.












5.5.6.


The EESC is concerned that most national restrictions on promoting and advertising food and non-alcoholic beverages to children are too weak and existing voluntary approaches are not enough to protect children and adolescents. It believes that the WHO’s nutrient profile could be used as a basis for limiting advertising of products high in sugar, fat and salt. It considers it important to learn from good measures and practices from countries that demonstrate the effectiveness of various policies, including regulations, to limit children’s exposure to audiovisual advertising for foods and drinks high in salt, sugars, fat, saturated fat or trans fatty acids. It is also essential to ensure that the rules surrounding children’s broadcasting hours are always respected and that all publicity complies with the principle of accurate advertising. It should be borne in mind that the WHO advocates restricting all relevant forms of food advertising aimed at children.












5.5.7.


The EESC believes that the institutions should boost consumption of those foods considered a key part of a healthy and sustainable diet (fresh, seasonal and locally produced fruits and vegetables, pulses, whole grains and animal proteins such as fish). This can be achieved, for example, by highlighting policies that promote EU agricultural produce, by developing public tenders that promote healthy and sustainable diets and by making use of tax incentives (such as VAT rebates) to support the purchase and consumption of those foods.












5.5.8.


The EESC also urges the Member States and food business operators to encourage improvements in the composition of products as a means of promoting healthier diets. If there is no voluntary reduction in certain critical nutrients, governments should consider additional incentives and measures, including progressive tax measures depending on the content of the nutrient in question.












5.5.9.


The EESC believes that public administrations, within their respective competences, should ensure the availability of free drinking water through properly indicated water sources in public spaces, educational establishments, places of relaxation and leisure, and sports and recreational areas.












5.5.10.


The EESC believes that research into the factors behind overweight and obesity, as well as the generation and dissemination of knowledge on it, should be promoted as a strategic element of coordinated action on health.












5.5.11.


On the demand side, the EESC once again emphasises that public policies must empower consumers to choose healthier diets, through training and information based on simple and direct awareness-raising campaigns or the dissemination of educational dietary guidelines.












5.5.12.


The EESC advocates a whole-of-society approach and therefore encourages the establishment of an instrument such as a European Food Policy Council, as suggested in several EESC opinions, and calls for this body to address childhood obesity.




5.6.   Family environment









5.6.1.


Aware that the family is a facilitator of knowledge and habits, as well as the first model through which daily reality is perceived and the first patterns of behaviour are developed (25), the EESC calls for the public to be provided with accurate and useful information on the importance of reducing digital sedentary behaviour, encouraging healthy sleep routines, highlighting the nutritional needs for each age and promoting physical activity.












5.6.2.


In particular, the EESC believes that programmes and actions should be put in place to increase skills and knowledge on managing excess weight among children, to avoid stigmatisation and to prevent negative dynamics surrounding the body. In the same way, it is vital to educate families on the healthy use of ICT (26), especially in terms of screen time and content.












5.6.3.


Similarly, it is important to encourage measures such as promoting breastfeeding, developing guidelines on complementary diets for breast-fed infants, improving parenting skills, and organising and making widely available classes on healthy and accessible cooking, especially for low-income families.




5.7.   The educational environment









5.7.1.


The educational environment is a place where children spend much of their time, not only in the purely educational context, but also in their leisure or after-school time.












5.7.2.


In this regard, it is essential that the issue of childhood obesity be approached in a positive way in the educational environment, without creating social stigma or rejecting the image that certain body stereotypes may represent. For the EESC, it is vital to promote a positive perception of the body, paying particular attention to any discriminatory conduct or any behaviour that might signal the onset of an eating disorder.












5.7.3.


The EESC also calls for the educational environment to be a promoter of physical activity and healthy diets. To this end, it considers one key measure to be the transformation of the current curricula, with a need for more time to be spent on physical activity, a wide range of sporting activities, and investment in nutrition, food and gastronomic education.












5.7.4.


The EESC believes that school canteens are key to promoting healthy nutritional habits among children and adolescents, and the EESC therefore considers it hugely important to ensure that they are available at all stages of education and that the diet provided is healthy, balanced and of high quality.




5.8.   Leisure spaces. Designing healthy urban environments









5.8.1.


For the EESC, the design and use of the physical environment (including schools, transport systems, neighbourhoods and sports centres) should provide adequate and safe opportunities for recreation and active play, as well as for physical exercise (27).












5.8.2.


In view of the above, the EESC urges the Member States to expand and improve public spaces and infrastructure so as to encourage and facilitate active mobility, with more pedestrian areas and making bicycles easier to use, especially in areas surrounding educational institutions and the routes leading up to them. It also believes that urban spaces with sports areas, playgrounds and green spaces should be created that are accessible, safe and welcoming for children and adolescents.












5.8.3.


The EESC believes that green areas, parks and recreational areas for physical activity should be extended and the use of stairs promoted as an alternative to lifts or escalators in leisure spaces, while also facilitating free access to drinking water.




5.9.   Digital and audiovisual environment









5.9.1.


The EESC stresses the importance of properly transposing the EU Audiovisual Media Services Directive and proposes making use of the digital environment, moving from radio and television broadcasts to newer forms of media such as social networks, Instagram and TikTok as facilitators of lifestyles, relationships and healthy behaviour. In this regard, the EESC once again calls, as it has done on previous occasions (28), for visual publicity campaigns inspired by advertising for healthy food and diets, an active lifestyle and healthy use of screens.




5.10.   Health environment









5.10.1.


For the EESC, it is essential for health administrations to maintain up-to-date recommendations based on scientific evidence covering activities and interventions that have proven effective in preventing, tackling and monitoring overweight and obesity.












5.10.2.


What is more, as part of universal health coverage, people who are overweight and obese or at risk of being so should have equal access to comprehensive health services, and to systematic and tailor-made advice by health personnel in order to promote physical activity and balanced diets. In this regard, children’s health status should be monitored from birth to adolescence, including checking for overweight and obesity, promoting health education, and raising awareness of healthy lifestyles among children and adolescents and their families.












5.10.3.


It is vital to provide socioeconomically vulnerable families with specific support from health professionals that is culturally appropriate, practical and empowering, and that promotes positive parenting in terms of obesity and overweight and the associated lifestyles.












5.10.4.


Furthermore, drawing on existing literature, the EESC considers it necessary to actively engage with women and couples considering having a child and to provide timely and culturally sensitive support to promote healthy lifestyles during pregnancy and while breastfeeding — coupled with public messaging to promote better nutrition and physical activity before conception — and to coordinate facilities and support for breastfeeding.






Brussels, 13 July 2023.


The President of the European Economic and Social Committee

Oliver RÖPKE
            





(1)  EESC evaluation report: Evaluation of the EU school scheme.

(2)  The right to health was first laid down in the Constitution of the World Health Organization (1946), which states that ‘The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being …’. The constitution’s preamble defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. The 1948 Universal Declaration of Human Rights mentioned health as part of the right to an adequate standard of living (Article 25). It was again recognised as a human right in 1966 in Article 12 of the International Covenant on Economic, Social and Cultural Rights.

(3)  United Nations Convention on the Rights of the Child, 1989.

(4)  European Commission, 2021, EU strategy on the rights of the child. COM(2021) 142 Final: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:52021DC0142.

(5)  https://health.ec.europa.eu/system/files/2016-11/childhoodobesity_actionplan_2014_2020_en_0.pdf.

(6)  
            Draft recommendations for the prevention and management of obesity over the life course, including potential targets, WHO Discussion Paper, 2021. Available at: https://cdn.who.int/media/docs/default-source/obesity/who-discussion-paper-on-obesity---final190821.pdf?sfvrsn=4cd6710a_24&download=true.

(7)  Weihrauch-Blüher, S., Wiegand, S., ‘Risk Factors and Implications of Childhood Obesity’, Curr Obes Rep, 2018 Dec; 7(4):254–59.

(8)  
            Report on the fifth round of data collection, 2018–2020: WHO European Childhood Obesity Surveillance Initiative (COSI), Copenhagen, WHO Regional Office for Europe, 2022.

(9)  Excess weight = overweight + obesity.

(10)  WHO European Regional Obesity Report 2022 and https://www.who.int/europe/news/item/11-05-2021-high-rates-of-childhood-obesity-alarming-given-anticipated-impact-of-covid-19-pandemic.

(11)  World Health Organization (2012), Population-based approaches to childhood obesity prevention, Geneva, WHO.

(12)  Kansra, A.R., Lakkunarajah, S., Jay, M.S., Childhood and Adolescent Obesity: A Review, 2021; 8:581461.

(13)  Whiting, S., et. al., ‘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’, Obes Facts, 2021; 14(1):32–44.

(14)  Guthold R., Stevens G.A., Riley L.M., Bull F.C., ‘Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1· 6 million participants’, Lancet Child Adolesc Heal, 2020; 4(1):23–35.

(15)  OECD/European Union (2022), Health at a Glance: Europe 2022: State of Health in the EU Cycle, OECD Publishing, Paris.

(16)  
            Adolescent obesity and related behaviours: trends and inequalities in the WHO European Region, 2002–2014, Copenhagen, WHO Regional Office for Europe, 2017.

(17)  Willett, W. et al., ‘Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems’, 2019, The Lancet, Vol. 393, pp. 447–492.

(18)  Afshin, Ashkan et al., ‘Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017’, The Lancet, Volume 393, Issue 10184, 1958–1972.

(19)  
            Report on the fifth round of data collection, 2018–2020: WHO European Childhood Obesity Surveillance Initiative (COSI), Copenhagen, WHO Regional Office for Europe, 2022.

(20)  Fang, K., Mu, M., Liu, K., He, Y., ‘Screen time and childhood overweight/obesity: A systematic review and meta-analysis’, Child Care Health Dev, 2019 Sep; 45(5):744–753.

(21)  Haghjoo, P., Siri, G., Soleimani, E., Farhangi, M.A., Alesaeidi, S., ‘Screen time increases overweight and obesity risk among adolescents: a systematic review and dose-response meta-analysis’, BMC Primary Care, 2022; 23(1):161.

(22)  
            Report on the fifth round of data collection, 2018–2020: WHO European Childhood Obesity Surveillance Initiative (COSI), Copenhagen, WHO Regional Office for Europe, 2022.

(23)  Dobbs, R., Sawers, C., Thompson, F., Manyika, J., Woetzel, J.R., Child, P. et al., Overcoming obesity: An initial economic analysis, McKinsey Global Institute, 2014.

(24)  EESC evaluation report: Evaluation of the EU school scheme.

(25)  Hebestreit, A., Intemann, T., Siani, A., et al., ‘Dietary Patterns of European Children and Their Parents in Association with Family Food Environment: Results from the I.Family Study’, Nutrients, 2017; 9(2):126.

(26)  Information and communication technologies.

(27)  Tackling obesity by creating healthy residential environments, WHO, 2007.

(28)  Opinion of the European Economic and Social Committee on ‘Promoting healthy and sustainable diets in the EU’ (own-initiative opinion) (OJ C 190, 5.6.2019, p. 9).