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 6-9 years 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 >3 days 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 >3 days 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.

Biomedical Sciences Department Faculty of Sport and Physical Education University of Novi Sad Novi Sad Serbia

Center for Health Ecology Institute of Public Health Podgorica Montenegro

Children's Hospital National Institute of Children's Diseases Medical Faculty Comenius University Bratislava Slovakia

College of Health and Agricultural Sciences University College Dublin Dublin Ireland

Croatian Institute of Public Health Zagreb Croatia

Department Food and Nutrition National Centre of Public Health and Analyses Sofia Bulgaria

Department of Cardiology Institute of Mother and Child Warsaw Poland

Department of Health and Inequality Division of Mental and Physical Health Norwegian Institute of Public Health Oslo Norway

Department of Nutrition Research National Institute for Health Development Tallinn Estonia

Department of Pediatrics Paracelsus Medical University Salzburg Austria

Department of Preventive Medicine Lithuanian University of Health Sciences Kaunas Lithuania

Department of Research and Health Statistics Centre for Disease and Prevention Control Riga Latvia

Department of Science and Professional Development National Center of Public Health of the Ministry of Health of the Republic of Kazakhstan Almaty Kazakhstan

Department of Social and Policy Sciences University of Bath Bath UK

Division of Noncommunicable Diseases and Promoting Health Through the Life Course WHO Country Office for Tajikistan Dushanbe Tajikistan

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

Faculty of Medicine SS Cyril and Methodius University Skopje North Macedonia

Faculty of Midwifery and Nursing Discipline of Public Health and Health Management University of Medicine and Pharmacy Carol Davila Bucharest Bucharest Romania

Health Authority Ministry of Health San Marino San Marino

Health Promotion and Inequality Danish Health Authority Copenhagen Denmark

Institute of Public Health Skopje North Macedonia

Kazakhstan School of Public Health Kazakhstan's Medical University Almaty Kazakhstan

Maternal Child and Reproductive Health National Center for Disease Control and Public Health of Georgia Tbilisi Georgia

Medical Faculty Department of Public Health Hacettepe University Ankara Turkey

National Centre for Disease Prevention and Health Promotion Italian National Institute of Health Rome Italy

National Centre of Health Promotion and Health Evaluation National Institute of Public Health Bucharest Romania

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

Nutrition and Food Safety Sector Institute of Public Health Tirana Albania

Obesity Management Centre Institute of Endocrinology Prague Czech Republic

Primary Child Health Unit Primary Health Care Floriana Malta

Republican Center for Health Promotion and Mass Communication Ministry of Health of the Kyrgyz Republic Bishkek Kyrgyzstan

Republican Centre for Nutrition Ministry of Health and Social Protection of Population Duschanbe Tajikistan

School of Medicine University of Zagreb Zagreb Croatia

Scientific Research Institute of Maternal and Child Health Ashgabat Turkmenistan

Spanish Agency for Food Safety and Nutrition Ministry of Consumer Affairs Madrid Spain

WHO Europe Collaborating Center for Nutrition and Childhood Obesity Food and Nutrition Department National Institute of Health Dr Ricardo Jorge Lisbon Portugal

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

World Health Organization European Office for the Prevention and Control of Noncommunicable Diseases Division of Country Health Programmes WHO Regional Office for Europe Moscow Russian Federation

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