Consuming a healthy diet in childhood helps to protect against malnutrition and noncommunicable diseases (NCDs). This cross-sectional study described the diets of 132,489 children aged six to nine years from 23 countries participating in round four (2015-2017) of the WHO European Childhood Obesity Surveillance Initiative (COSI). Children's parents or caregivers were asked to complete a questionnaire that contained indicators of energy-balance-related behaviors (including diet). For each country, we calculated the percentage of children who consumed breakfast, fruit, vegetables, sweet snacks or soft drinks "every day", "most days (four to six days per week)", "some days (one to three days per week)", or "never or less than once a week". We reported these results stratified by country, sex, and region. On a daily basis, most children (78.5%) consumed breakfast, fewer than half (42.5%) consumed fruit, fewer than a quarter (22.6%) consumed fresh vegetables, and around one in ten consumed sweet snacks or soft drinks (10.3% and 9.4%, respectively); however, there were large between-country differences. This paper highlights an urgent need to create healthier food and drink environments, reinforce health systems to promote healthy diets, and continue to support child nutrition and obesity surveillance.

Applied Bioenergetics Lab University of Novi Sad 21000 Novi Sad Serbia

Arabkir Medical Centre Institute of Child and Adolescent Health 0014 Yerevan Armenia

Centre for Disease Prevention and Control LV 1005 Latvia Riga

Croatian Institute of Public Health University of Zagreb School of Medicine 10000 Zagreb Croatia

Danish Health Authority 2300 Copenhagen S Denmark

Department for Organization of Health Services to Children Mothers Adolescents and Family Planning Ministry of Health and Social Protection of Population 734025 Dushanbe Tajikistan

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

Department of Nutrition Research National Institute for Health Development 11619 Tallinn Estonia

Department of Pediatrics Paracelsus Medical University 5020 Salzburg Austria

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

Department of Public Health and Management University of Medicine and Pharmacy Carol Davila 030167 Bucharest Romania

Department of Social and Policy Sciences University of Bath Bath BA2 7AY UK

Faculty of Sport University of Ljubljana 1000 Ljubljana Slovenia

Health Authority Department of Health and Social Security 47893 San Marino San Marino

Institute of Endocrinology Obesity Unit 116 94 Prague Czechia

Institute of Paediatric Endocrinology National Medical Research Centre for Endocrinology of the Ministry of Health of the Russian Federation 117036 Moscow Russian Federation

Institute of Public Health 1007 Tirana Albania

Institute of Public Health Faculty of Medicine Ss Cyril and Methodius University 1000 Skopje North Macedonia

Institute of Public Health of Montenegro 81 000 Podgorica Montenegro

Internal Diseases Department of the Scientific Clinical Centre of Mother and Child Health 744036 Ashgabat Turkmenistan

Italian National Institute of Health 00161 Rome Italy

National Center for Disease Control and Public Health of Georgia 0198 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 010000 Nur Sultan City Kazakhstan

National Institute of Health Dr Ricardo Jorge 1600 560 Lisbon Portugal

National Institute of Public Health University of Southern Denmark 1455 Copenhagen K Denmark

National Nutrition Surveillance Centre University College Dublin Dublin Ireland

Primary Health Care Ministry for Health 1940 Floriana Malta

Republican Center for Health Promotion and Mass Communication 720040 Bishkek Kyrgyzstan

Spanish Agency for Food Safety and Nutrition 28014 Madrid Spain

Turkish Ministry of Health Public Health General Directorate 34400 Istanbul Turkey

WHO Child and Adolescent Health and Development WHO Regional Office for Europe 2100 Copenhagen Denmark

WHO Country Office for Tajikistan 734019 Dushanbe Tajikistan

WHO European Office for the Prevention and Control of Noncommunicable Diseases 125009 Moscow Russian Federation

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