It is unclear how dietary, physical activity and sedentary behaviors co-occur in school-aged children. We investigated the clustering of energy balance-related behaviors and whether the identified clusters were associated with weight status. Participants were 6- to 9-year-old children (n = 63,215, 49.9% girls) from 19 countries participating in the fourth round (2015/2017) of the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative. Energy balance-related behaviors were parentally reported. Weight and height were objectively measured. We performed cluster analysis separately per group of countries (North Europe, East Europe, South Europe/Mediterranean countries and West-Central Asia). Seven clusters were identified in each group. Healthier clusters were common across groups. The pattern of distribution of healthy and unhealthy behaviors within each cluster was group specific. Associations between the clustering of energy balance-related behaviors and weight status varied per group. In South Europe/Mediterranean countries and East Europe, all or most of the cluster solutions were associated with higher risk of overweight/obesity when compared with the cluster 'Physically active and healthy diet'. Few or no associations were observed in North Europe and West-Central Asia, respectively. These findings support the hypothesis that unfavorable weight status is associated with a particular combination of energy balance-related behavior patterns, but only in some groups of countries.

Croatian Institute of Public Health 10000 Zagreb Croatia

Danish Health Authority 2300 København Denmark

Department of Cardiology Institute of Mother and Child 01 211 Warsaw Poland

Department of Nutrition Food Science and Physiology University of Navarra 31008 Pamplona Spain

Department of Preventive Medicine Lithuanian University of Health Sciences 44307 Kaunas Lithuania

Department of Social and Policy Sciences University of Bath Claverton Down BA2 7AYBath UK

Division of Noncommunicable Diseases and Promoting Health through the Life course WHO European Office for Prevention and Control of Noncommunicable Diseases 125009 Moscow Russia

Institute of Public Health 1001 Tirana Albania

Institute of Public Health of Montenegro 8100 Podgorica Montenegro

National Center for Disease Control and Public Health of Georgia 0186 Tbilisi Georgia

National Center of Public Health and Analyses 1431 Sofia Bulgaria

National Center of Public Health Ministry of Health of the Republic of Kazakhstan 50010 Almaty Kazakhstan

National Institute of Health Doutor Ricardo Jorge 1 P 1649 016 Lisbon Portugal

National Institute of Public Health 050463 Bucharest Romania

National Nutrition Surveillance Centre School of Public Health Physiotherapy and Sports Science University College Dublin D4 Dublin Ireland

Obesity Management Centre Institute of Endocrinology 113 94 Prague Czech Republic

Primary Health Care 1940 Floriana Malta

School of Medicine School of Public Health Andrija Štampar University of Zagreb 10000 Zagreb Croatia

Spanish Agency for Food Safety and Nutrition 28071 Madrid Spain

WHO Country Office in Turkmenistan 744000 Ashgabat Turkmenistan

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