Inventory of surveillance systems assessing dietary, physical activity and sedentary behaviours in Europe: a DEDIPAC study

Abstract

Background

There is a need for harmonized public health surveillance systems to monitor regional variations and temporal trends of health behaviours and health outcomes and to align policies, action plans and recommendations in terms of healthy diet and physical (in)activity within Europe. We provide an inventory of currently existing surveillance systems assessing diet, physical activity, and sedentary behaviours in Europe as a tool to assist in the identification of gaps and needs and to contribute to the roadmap for an integrated pan-European surveillance system.

Methods

An inventory questionnaire was completed by representatives of eleven European countries. Eligible surveillance systems were required to meet specific inclusion criteria. First, pre-screening of available surveillance systems in each country was conducted. Second, an in-depth appraisal of the retained surveillance systems complying with the pre-defined requirements was performed.

Results

Fifty surveillance systems met the inclusion criteria: six multinational European surveys and forty-four national surveys. Dietary intake and physical activity are the domains predominantly assessed and adults are the most frequently studied age group.

Conclusions

Many on-going activities were identified at the national level focussing on adults, but fewer surveillance systems involving vulnerable groups such as infants and pre-school children. Assessment of sedentary and dietary behaviours should be more frequently considered. There is a need for harmonization of surveillance methodologies, indicators and target populations for between-country and over time comparisons. This inventory will serve to feed future discussions within the DEDIPAC-JPI major framework on how to optimize design and identify priorities within surveillance.

Introduction

The Vienna Declaration on Nutrition and Non-communicable Diseases (NCDs)¹ acknowledged the disease burden caused by unhealthy dietary and lifestyle patterns, i.e. growing sedentary activities and lower physical activity (PA) levels, and its major health, societal and economic impacts in Europe. In order to address these challenges, a series of actions were adopted and ministers from Member States of the European WHO region committed to support nutrition and health surveillance systems, as a means to monitor the effectiveness of their action plans. There is a need for harmonised public health surveillance systems of the European population as a means to obtain more comparable data across countries and align their policies, action plans and recommendations to combat unhealthy diets, physical inactivity and overweight/obesity more easily within the European Region.²

Within the first pillar of the ‘Joint Programming Initiative’ (JPI) ‘Healthy Diet for Healthy Life’ (HDHL), the Determinants of Diet and Physical Activity (DEDIPAC) Knowledge Hub (KH)³ aims to develop a roadmap of European monitoring systems of dietary intake, dietary behaviour, PA and sedentary behaviours and their key determinants. The ultimate goal is to provide a framework for an integrated (future) pan-European surveillance system for studying population trends and regional variations. This is needed for the evaluation of (systematic) policy interventions at the population level. Therefore, this paper summarizes and discusses the main outcomes of an inventory compiled to investigate existing international (involving several countries within the WHO-European region), regional (involving several countries from a specific WHO-European region) and national surveillance systems on diet, physical activity and sedentary behaviours in Europe. The inventory will contribute to the identification of needs and gaps in this area to guide the development of a roadmap for a future pan-European surveillance system.

Methods

An inventory questionnaire was developed to gather information on existing surveillance systems and their supporting research infrastructures (RI) in eleven European countries participating in DEDIPAC (Austria, Belgium, France, Germany, Ireland, Italy, Netherlands, Norway, Poland, Spain and UK). Eligible surveillance systems were required to meet the following criteria to be included in the inventory: (i) international, European regional and national initiatives collecting data on dietary, PA and/or sedentary behaviours and/or their determinants in these countries; and (ii) surveillance systems currently on-going, or with at least one recently completed data collection wave that are carried out on a periodic basis, i.e. as repeated cross-sectional studies. Single cross-sectional studies, cohort and intervention studies were not eligible. Any population group was eligible to be included within the inventory.

The inventory was compiled into a two-step procedure. The first step included a pre-screening of available surveillance systems in each DEDIPAC country. For that purpose, a first-step questionnaire was developed to ask about general characteristics and domains covered by the identified systems in order to retain surveillance systems complying with the pre-defined inclusion criteria. In the second step, detailed information was retrieved on each eligible system, using the second-step questionnaire with pre-entered data information gathered with the first-step questionnaire (step 1 of the inventory).

The main contents of the second-step questionnaire included questions regarding main characteristics of the surveillance systems; methodological aspects like the target population, study design or sample size; existence of any supporting RI available; measurements taken and assessment methods applied; and data accessibility and ethical issues. All these aspects were asked by means of a combination of open and closed questions.

Representatives from each DEDIPAC participating country were identified, based on their expertise in the field of monitoring surveys, as DEDIPAC contact persons (DCPs) (see Annex 1—Supplemental material). The DCPs were responsible for (i) completing the first-step questionnaire and (ii) approaching any national experts, internal or external to the DEDIPAC consortium, to help getting the second-step questionnaire completed. Additionally, international contact persons i.e. WHO-Europe, European Food Safety Authority and Eurostat, were also approached to gather information about the main existing international and regional surveillance systems in Europe.

The two inventory questionnaires were developed using Excel and circulated to all DCPs by email. When completed, both the first-step and second-step questionnaires were sent back to the contact person at IARC. Data were merged and checked for completeness and fulfilment of the inclusion criteria. Before wider circulation of the second-step questionnaire, first-step questionnaire was evaluated during an e-workshop where all DCPs, together with other experts in the field, were invited to attend. The final second-step questionnaire version was distributed for completion including data about the surveillance systems previously entered into the first-step questionnaire. Data compiled through the second-step questionnaire was summarized in tables that were sent back to all DCPs to check their completeness and accuracy and to provide missing information.

Results

A total of 50 surveillance systems at both the international and national level are currently on-going (or were recently conducted) within the DEDIPAC countries. Forty-four were exclusively national. The domains covered by the surveillances systems are shown in tables 1 and 2. Additional information in terms of main characteristics and methodologies applied within each system can be found online at the DEDIPAC website (www.dedipac.eu). Surveillance systems are grouped according to geographical level. Multinational surveys (including both international and pan-European regional initiatives) are reported separately from national surveillance systems. A summary of the identified surveys in terms of targeted age groups, domains covered and methodology applied is provided below.

Table 1

Domains covered by the multinational European surveillance systems

Survey name	Countries	Dietary intake			Dietary behaviours			Physical activity			Sedentary behaviours			Alcohol			Tobacco			Anthropometry			Socio-demographic variables			Health status			Biomarkers
		Mand- atory	Opti- onal	Standar- dizationa	Manda- tory	Opti- onal	Standar- dization	Manda- tory	Opti- onal	Standar- dization	Manda- tory	Optio- nal	Standar- dization	Manda- tory	Optio- nal	Standar- dization	Manda- tory	Optio- nal	Standar- dization	Manda- tory	Optio- nal	Standar- dization	Manda- tory	Opti- onal	Standar- dization	Manda- tory	Optio- nal	Standar- dization	Manda- tory	Optio- nal	Standar- dization
Nordic monitoring of food, physical activity and overweight	DNK, SWE, NOR, IS, FIN	X		Y		–		X		Y	X		Y	X		Y	X		Y	X		Y	X		Y		–			–
HBSC	ALB, RUS, GRC, NLD, BEL, BGR, FRA, ESP, HUN, ITA, ROU, CHE, AUT, GRB, DNK, SWE, NOR, POL, DEU, TUR, GRL, PRT, LUX, IRL, ISL, MLT, FIN, LTU, LVA, EST, MKD, MDA, ARM, UKR, HRV, SVN, CZE, SVK, ISR	X		Y	X		Y	X		Y	X		Y	X		Y	X		Y	X		Y	X		Y	X		Y		–
WHO-COSI	GRC, BEL, ESP, ITA, ROU, NOR, TUR, PRT, IRL, ALB, MLT, BGR, LTU, LVA, MKD, SVN, MDA, CZE		X	Y		X	Y		X	Y		X	Y		–			–		X	X	Y		X	Y		X	Y		–
EHIS	GRC, BEL, FRA, ESP, HUN, ROU, CHE, AUT, NOR, POL, DEU, IS, MLT, CYP, BGR, LVA, EST, SVN, CZE, SVK	X		Y		–		X		Y		–		X		Y	X		Y	X		Y	X		Y	X		Y		–
EU Menu	GRC, NLD, BEL, FRA, ESP, ROU, PRT, CYP, LVA, EST	X		N		X	N	X		N		–		X		N		–		X		N	X		Y		–			–
GloboDiet- Europe consortium	NLD, BEL, FRA, CHE, AUT, DEU, MLT	X		Y	X		Y		X	N		X	N	X		Y		X	N	X		Y	X		Y		X	N		X	N

DI, dietary intake; DB, dietary behaviours; PA, physical activity; SB, sedentary behaviours; AL, alcohol consumption; TB, tobacco consumption; AN, anthropometry; SD, sociodemographic data; HS, health status; BIO, biomarkers; Y, yes; N, no.

Country code: Albania= ALB; Armenia= ARM; Austria= AUT; Belgium= BEL; Bulgaria= BGR; Canada= CAN; Croatia= HRV; Cyprus= CYP; Czech Republic= CZE; Denmark= DNK; Estonia= EST; Finland= FIN, France= FRA; Germany= DEU; Greece= GRC; Greenland= GRL; Hungary= HUN; Iceland= IS; Ireland= IRL; Israel= ISR; Italy= ITA; Latvia= LVA; Lithuania= LTU; Luxembourg= LUX, Macedonia (Former Yugoslav Republic of)= MKD; Malta= MLT; Moldova (Republic of)= MDA; Netherlands= NLD; Norway= NOR; Poland= POL; Portugal= PRT; Romania= ROU; Russia= RUS; Slovakia= SVK; Slovenia= SVN; Spain= ESP; Sweden= SWE; Switzerland= CHE; Turkey= TUR; Ukraine= UKR; United Kingdom= GRB; United States of America= USA.

a

Standardization within surveillance systems refers to the implementation of technical standards, i.e. common methodology, guidelines, rules, etc., to maximize the comparability of the data collected.

Table 2

Domains covered by each national surveillance system

Survey name	Dietary intake		Dietary behaviours		Physical activity		Sedentary behaviours		Alcohol		Tobacco		Anthropometry		Socio-demographic variables		Health status		Biomarkers
	Mand- atory	Optional	Manda- tory	Optional	Manda- tory	Optional	Manda- tory	Optional	Manda- tory	Optional	Manda- tory	Optional	Manda- tory	Optional	Manda- tory	Optional	Manda- tory	Optional	Manda- tory	Optional
Austria
HBSC-Austria	X		X		X		X		X		X		X		X		X		–	–
EHIS-Austria (ATHIS)	X		–	–	X		X		X		X		X		X		X		–	–
Austrian Nutrition Reporta	X		X		X		X		X		X		X		X		–	–	X
Belgium
HBSC-Belgium	X		X		X		X		X		X		X		X		X		–	–
WHO-COSI-Belgium	–	–		X		X		X	–	–	–	–	X			X		X	–	–
EHIS-Belgium (BHIS)	X		–	–	X		–	–	X		X		–	–	X		X		–	–
Belgian National Food Consumption Surveya	X		X		X		X		X		X		X		X		X		X
France
HBSC-France	X		X		X		X		X		X		X		X		X		–	–
EHIS-France (ESPS)	X		–	–	X		–	–	X		X		X		X		X		–	–
Enquêtes nationales de santé en milieu scolaire (National Health Surveys in Schools)	X		X		X		X		–	–	–	–	X		X		X		–	–
Corpulence CE1-CE2: prévalences du surpoids et de l'obésité chez les enfants de 7 à 9 ans	–	–	–	–	X		X		–	–	–	–	X		X		–	–	–	–
ABENA	X		X	–	–	–	–	–	–	–	–	–	X		X			X		X
KANNARI/ESCAL-CALBAS	X		X		X		X		X		–	–	X		X			X		X
Baromètre santé	–	–	–	–	X		X		X		X		X		X		X		–	–
INCAa	X		X		X		X		X		X		X		X		X		–	–
Baromètre santé nutrition	X		X		X		X		X		X		X		X		X		–	–
ENNS/ESTEBAN	X		X		X		X		X		X		X		X		X		X
Germany
HBSC-Germany	X			X		X	X		X		X		X		X		X		–	–
EHIS II-Germany(integrated in GEDA 14/15)	X		–	–	X		–	–	X		X		–	–	X		X		–	–
DEGS	X		X		X		–	–	X		X		X		X		X			X
KiGGS	X		X		X		X		X		X		X		X		X			X
NVS IIa	X		X		X		–	–	X			X	X		X			X	–	–
Ireland
HBSC—Ireland	X		X		X		X		X		X		–	–	X		X		–	–
WHO-COSI-Ireland		X	X		X		X		–	–	–	–	X		X		–	–	–	–
National Perinatal Reporting System	–	–	X		–	–	–	–	–	–	–	–	X		X		X		–	–
SLÁN	X		X		X		X		X		X		X		X		X		X
Italy
HBSC-Italy	X		X		X		X		X		X		X		X		X		–	–
WHO-COSI—Italy(OKkio Alla SALUTE)	X		X		X		X		–	–	–	–	X		X		X		–	–
Italian Behavioral Risk Factor Surveillance System—PASSI	X		–	–	X		–	–	X		X		X		X		X		–	–
PASSI d’Argento	X		–	–	X		–	–	X		X		X		X		X		–	–
Indagini Multiscopo sulle famiglie	X		X		X		X		X		X		X		X		X		–	–
IPSAD	X		X		X		X		X		X		X		X		X		–	–
ESPAD	X		X		X		X		X		X		X		X		X		–	–
Netherlands
HBSC-Netherlands	X		X		X		X		X		X		X		X		X		–	–
Dutch national food consumption surveysa	X		X		X		X		X		X		X		X		–	–	–	–
Public Health Monitor	–	–	–	–	X		–	–	X		X		X		X		X		–	–
Lifestyle Monitor	X		–	–	X		X		X		X		X		X		X		–	–
Norway
HBSC-Norway	X		X		X		X		X		X		X		X		X		–	–
WHO-COSI-Norway(The Child Growth Study)	–	–	X		X		X		–	–	–	–	X		X		X		–	–
EHIS-Norway	X		–	–	X		–	–	X		X		X		X		X		–	–
CONOR	X		–	–	X		–	–	X		X		X		X		X		X
Spedkost	X		–	–	–	–	–	–	–	–	X		X		X		–	–	–	–
Småbarnskost	X		–	–	–	–	–	–	–	–	X		X		X		–	–	–	–
Ungkost	X		X		X		X		X		X		X		X		–	–	–	–
Norkost	X		X		X		X		X		X		X		X		–	–	–	–
KAN1 og KAN 2	X		–	–	X		X		X		X		X		X		X		–	–
UNGKAN1 og UNGKAN2	X		–	–	X		X		–	–	–	–	X		X		X		X
IPAQ-Norway	–	–	–	–	X		X		–	–	–	–	–	–	X		–	–	–	–
Poland
HBSC-Poland	X		X		X		X		X		X		X		X		X		–	–
EHIS-Poland	X		–	–	X		X		X		X		X		X		X		–	–
Spain
HBSC-Spain	X		X		X		X		X		X		X		X		X		–	–
WHO-COSI-Spain(Estudio ALADINO)	X		X		X		X		–	–	–	–	X		X		X		–	–
EHIS-Spain(National Health Survey)	X		X		X		X		X		X		X		X		X		–	–
Health Survey of Valencian region	X		–	–	X		–	–	X		X		X		X		X		–	–
Health Survey of Basque country	X		X		X		–	–	X		X		X		X		X		–	–
Health Survey of Andalusia	X		X		X		–	–	X		X		X		X		X		–	–
Health Survey of Asturias	X		X		X		–	–	X		X		X		X		X		–	–
Health Survey of Canarias islands	X		X		X		X		X		X		X		X		X		–	–
United Kingdom																			–	–
HBSC-England	X		X		X		X		X		X		X		X		X		–	–
HBSC-Scotland	X		X		X		X		X		X		X		X		X		–	–
HBSC-Wales	X		X		X		X		X		X		X		X		X		–	–
HSE	X		–	–	X		X		X		X		X		X		X		X
Scottish Health Survey	X		–	–	X		X		X		X		X		X		X		X
Welsh Health Survey	X		–	–	X		–	–	X		X		X		X		X		–	–
Health Survey Northern Ireland	X		X		X		–	–	X		X		X		X		X		–	–
NDNS	X		X		X		X		X		X		X		X		X		X
Active People Survey	–	–	–	–	X		–	–	–	–	–	–	X		X				–	–
HIS—includes LCF and LFS—latter forms part of the APS	–	–	–	–	–	–	–	–	–	–	X		–	–	X		X		–	–
National Study of Health and Wellbeing (formerly Adult Psychiatric Morbidity Survey)	–	–	–	–	–	–	–	–	–	–	–	–	X		X		X		–	–

HBSC, Healthy Behaviour in School Children, ATHIS, Austrian Health Interview Survey; BHIS, Belgian Health Interview Survey; ESPS, Enquête sur la santé et la protection sociale; ENNS, Étude nationale nutrition santé; ABENA, Alimentation et état nutritionnel des bénéficiaires de l'aide alimentaire; INCA, étude Individuelle Nationale sur les Consommations Alimentaires; ESTEBAN, Étude de santé sur l’environnement, la biosurveillance, l’activité physique et la nutrition; DEGS, German Health Interview and Examinations Survey for Adults; KiGGS, German Health Interview and Examination Survey for Children and Adolescents; GEDA, German Health Update; NVS II, German National Nutrition Survey II; SLÁN, Survey of Lifestyle and Attitude to Nutrition; PASSI, Progress by Local Health Units Towards a Healthier Italy; ESPAD, the European School Survey Project on Alcohol and Other Drugs; IPSAD, Italian Population Survey on Alcohol and other Drugs; CONOR, Regional health surveys from Oslo, Hedmark/Oppland, Bergen and Tromsø; KAN1 og KAN 2, Physical activity among Norwegian Adults and older people; UNGKAN1 og UNGKAN2, Physical activity among Norwegian children and adolescents; IPAQ, International Physical Activity Questionnaire Norway; HSE, Health Survey for England; NDNS, National Diet and Nutrition Survey; HIS, Integrated Household Survey; LCF, Living Costs & Food Survey; LFS, the Labor Force Survey.

a

National dietary surveillance system contributing to EU-Menu and/or GloboDiet.

Multinational surveillance systems

Six international initiatives were identified, five European wide—Healthy Behaviour in School Children (HBSC), WHO-Childhood Obesity Surveillance Initiative (WHO-COSI), European Health Interview Survey (EHIS), EU Menu, and the GloboDiet-Europe consortium—and one regional—Nordic monitoring of food, physical activity and overweight. Children (1–12 years), particularly school-aged children (> 6 years), adolescents (13–17 years) and adults (18–65 years) were the most common target populations, followed by elderly people (> 65 years) and infants (0–12 months).

Dietary intake was assessed in the six multinational surveillance systems. Food frequency questionnaires (FFQ) and (standardized) 24-h dietary recall (24-HDR) were the two main methods applied. The amount of dietary information collected also varied according to the main scope of the survey, i.e. health or dietary survey. Dietary behaviours, which could be defined as the thoughts, actions, and intents that a person enacts in order to ingest solids or liquids,⁴ were mandatory measurements in two international initiatives (HBSC, GloboDiet-Europe consortium). Information on breakfast consumption, breastfeeding, special diet, places of consumption and food consumption occasions was collected through self-completed paper-based questionnaires or as part of the 24-HDRs.

Most of the multinational initiatives evaluated PA performance in at least one domain i.e. at work/school PA or during leisure time. The frequency and duration of different types of PA was mainly asked, except WHO-COSI which focused on sport membership or dancing club and the frequency of free time playing outside. Data were mostly based on self-reports, sometimes applying existing questionnaires such as the International Physical Activity Questionnaire (IPAQ), amongst others. Data on sedentary behaviours were collected in three multinational surveillance systems within two major domains i.e. total sitting time and screen time. The level of detail of the information collected varied across studies. As sedentary behaviours and PA were often assessed together, applied methodology (self-reported vs. objective measurements, type of questionnaire, administration method) was also same.

All the international studies collected information on anthropometric variables, mainly self-reported weight and height. Although health status data were gathered in four European initiatives, the type and level of details of the information collected varied largely across initiatives. General health status, family health history and chronic diseases were those more frequently asked for. Neither of the multinational surveillance systems collected biological samples; therefore, no biomarkers were analysed.

National surveillance systems

A total of 44 surveillance systems were identified at the country level, including within-country regional initiatives. The main target population group was adults, followed by elderly, adolescents, children and infants.

Dietary intake was assessed in 36 of 44 national surveillance systems regardless of their scope. Although various dietary assessment methods were available, FFQs (25 studies) followed by 24-HDRs (nine surveillance systems) were most used. 24-HDRs were combined with food records and/or food propensity questionnaires (FPQ) in seven surveillance systems. Only one study used FFQs and 24-HDRs simultaneously. Many studies assessed the whole diet or collected information on many food items to get a picture of the overall diet of the individuals. Twenty-five out of the 44 national surveillance systems assessed, at least, one type of dietary behaviour, although the information collected was diverse. Those behaviours most often evaluated were breakfast consumption, breastfeeding, meal location, meal frequency, snacking habits and dieting habits, and were usually asked in conjunction with questions on dietary intake.

PA was assessed in 38 of 44 national surveillance systems. Total and leisure time PA were the domains mostly assessed, followed by work-related PA. Data were self-reported in all the surveys, although in seven initiatives questionnaires were combined with accelerometers. Five already existing PA questionnaires i.e. IPAQ,^5–7 Recent Physical Activity Questionnaire (RPAQ),⁸ Short Questionnaire to Assess Health Enhancing Physical Activity (SQUASH),⁹ Global Physical Activity Questionnaire (GPAQ)¹⁰ and HBSC questionnaire⁷ (only for adolescents), were used in 15 surveillance systems. Twenty-seven out of 44 surveillance systems gathered information on sedentary behaviours, specifically within two main domains: total sitting time and screen time. Screen time, watching television and playing computer games were the behaviours most frequently assessed using practically identical methodologies to that used for PA.

Weight and height were collected in all the national surveys. Waist and hip circumferences were only taken in six initiatives and two surveillance systems assessed body fat with skinfolds thicknesses. Data were mostly self-reported, with only 13 initiatives exclusively taking direct anthropometric measurements. Very diverse information was collected regarding health status in 37 national monitoring surveys including general health status, chronic diseases, family disease history, allergies and mental health. Biomarkers such as serum lipids, blood glucose and vitamins were analysed in 12 out of the 45 national surveys. Blood samples followed by urine samples were those most frequently taken.

Discussion

We compiled an inventory of current European surveillance systems assessing dietary intake/behaviour, PA and sedentary behaviours and related determinants in the DEDIPAC participating countries (national level), but also at the international and European regional level. We identified many different surveillance systems, particularly at the national level, with a high variation in the number of existing initiatives available across countries. Overall, dietary intake and PA are the behaviours most frequently assessed and adults emerge as the population group evaluated most often at the national level. Vulnerable groups such as infants and pre-school children are frequently omitted, particularly with regard to sedentary behaviour. While international surveillance systems tended to use harmonized methodologies, there was a large heterogeneity of procedures and methods used across surveys conducted at the national level.

Policy development and evaluation and monitoring of trends in diseases require a surveillance framework with a minimum set of indicators covering both exposures and outcomes.¹¹ Lack of relevant information in terms of exposure data may lead to inconclusive results. The need for regular data collection on dietary and PA behaviours as part of wider lifestyle behaviours has recently been acknowledged.¹² In this regard, dietary exposure and PA behaviours emerged as the domains most frequently assessed among current surveillance systems which might suggest an ever-increasing awareness among European Member States about their key role in the prevention of NCDs. Sedentary behaviour has recently been identified as another important risk factor for NCDs development, that might be the reason why it is still insufficiently assessed in European surveillance systems. Another reason could be the fact that, unlike PA, the measurement of sedentary behaviours remains under-developed.¹³ Nevertheless, dietary intake, dietary behaviours, PA and sedentary behaviours should be considered as a cluster of indicators that must be systematically addressed in surveillance as relevant health indicators of chronic disease. The type of information collected and the methodology will need to be specified by the survey itself. Equally important is the measurement of determinants. Although self-reported weight and height are routinely assessed in monitoring surveys, it is recommended to take more objective measures together with other measurements such as body circumferences and/or skinfolds thicknesses to obtain more reliable information on body composition. Also, more regular collection of samples to analyse specific biomarkers could provide reliable data on the population health status; however, it cannot be precluded the challenge and burden that it represents for both researchers and participants.

Conducting regular and continuous surveillance will have the potential to support both policies and action plans to better monitor and address the global disease burden in Europe as well as to evaluate the effectiveness of health-related policy interventions. The inventory showed high variability in terms of periodicity among initiatives, and seems to be an intrinsic feature of each survey; while some surveys are being conducted every 7 or 8 years, others are rolling programmes continuously run. The periodicity to conduct surveillance will be determined by the need to monitor the population health status and/or to evaluate the effectiveness of health policies. Besides, the inventory highlighted the need to address vulnerable population groups such as infants and pre-school children. It might result quite challenging to run regular surveys on young populations given the potential difficulties to recruit participants, obtain parental consent and perform measurements, among others. However, these challenges must be overcome and more efforts are needed to equally monitor health-related indicators along the life cycle, helping researchers and policy makers to address current and future societal challenges with a more population targeted approach.

Common indicators were measured across multinational surveillance systems, with diet and physical activity being systematically assessed, and only half of the initiatives collecting sedentary behaviours data. Whether evaluation of these indicators was mandatory or not is another issue. However, there was no harmonization among initiatives in terms of methodologies and type of information collected. Overall, there was no interaction between either international-national or national-national surveillance systems, which turned out in an overlap of several indicators and age groups addressed, while others not being addressed. More interaction among initiatives should be pursued at three levels, i.e. international-international, international-national and national-national, to avoid duplication of work and misuse of resources.

Although international initiatives supported internal data harmonization, the degree of harmonization achieved is yet insufficient. Indeed, lack of data comparability between countries still remains a problem in Europe¹² and beyond, as revealed by an inventory conducted in Africa.¹⁴ Differences in the prevalence of indicators of interest between countries can often be attributed to the use of different assessment methodologies, different reference populations and different cut-offs.¹⁵ Furthermore, the existing international surveillance systems do not cover all European countries.

Few harmonization processes were observed within national existing initiatives and the methodologies applied varied substantially across surveys. In view of the large number of national initiatives available in several countries generating lots of data, data comparability should be enhanced across national surveillance systems. Ideally, countries should aim to conduct regular national surveys in the same age groups and with the same methods, including both objective measures and/or questionnaires, to avoid the need for a posteriori adjustments.¹¹

Overall, there is a need for harmonized public health surveillance systems to obtain more comparable data across European countries. Reliable methodologies that have already been proven to apply standardized procedures and provide comparable trans-national data collection, i.e. GloboDiet software¹⁶ for dietary assessment, need to be identified and their use enhanced among surveillance systems in order to improve harmonization processes. Recommendations on the best standardized method(s) and tool(s) for each specific indicator and/or determinant need to be made to assist researchers in the selection and application of common methodologies. Moreover, definition of a set of basic data to be collected for each indicator will allow obtaining similar information across surveys and a posteriori comparisons. International agreement in terms of age groups it is also essential to ease data comparability.

To the best of our knowledge, this is the first inventory of surveillance systems conducted in the area of diet and physical activity research in Europe. It is also a strength that the inventory data were retrieved by experts from 11 European countries representing the four European regions, i.e. Northern (Ireland, Norway, UK), Western (Austria, Belgium, France, Germany, Netherlands), Eastern (Poland) and Southern (Italy and Spain). Furthermore, key people at the international level were actively involved in the inventory compilation to obtain accurate data about the eligible surveillance systems.

The inventory has also some limitations. Inclusion of more Member States would have been desirable to get better insights into the surveillance systems available in other European countries. The inventory is by no means fully exhaustive, but provides an overall overview and broad evaluation of the current picture in terms of existing surveillance systems in Europe. The information retrieved through this inventory will be used as a tool to assist in the identification of gaps and needs within the field of surveillance in Europe that will feed the development of a roadmap for an integrated pan-European surveillance system with improved methodologies and better design, as the ultimate DEDIPAC goal.

In conclusion, the European picture regarding surveillance systems is quite promising as there are a lot of on-going activities, mainly at the national level, but more harmonization of methodologies, indicators and age groups is still needed. There is a lack of surveillance systems addressing vulnerable population groups, such as infants and pre-school children, hampering the ability of Member States to monitor the impact and progress of NCDs and their related risk factors in these population groups. Surveillance systems should be carefully planned and designed to ensure that measures on potentially relevant risk factors and indicators are not omitted, i.e. sedentary and dietary behaviours, and to develop more targeted public health strategies. There is also a need for the assessment of determinants of these behaviours in surveillance. Action is needed to address the current lack of harmonized measurements and methodologies at both the international and national levels. Data comparability across countries and over time is crucial to draw more solid, reliable and concerted conclusions that will be translated into more effective policies and targeted interventions at the European level. This still remains a challenge. Therefore, additional emphasis should be given to the promotion and implementation of harmonized pan-European surveillance systems as essential tools for better information on diet, physical activity and sedentary behaviours.

Acknowledgements

We thank Dr João Breda (WHO-Europe), Dr Trudy Winjhoven (WHO-Europe), Dr Liisa Valsta (EFSA) and Jakub Hrkal (Eurostat) as well as the national experts external to DEDIPAC for their input to complete this inventory.

Funding

The present study was financially supported by the IARC and the Joint Programming Initiative ‘Healthy Diet for a Healthy Life’. The funding agencies supporting this initiative are (in alphabetical order of participating Member States): Austria: Federal Ministry of Science, Research and Economy; Belgium: Research Foundation—Flanders; Germany: Federal Ministry of Education and Research; Italy: Ministry of Education, University and Research/Ministry of Agriculture Food and Forestry Policies; Ireland: The Health Research Board (HRB); The Netherlands: The Netherlands Organization for Health Research and Development (ZonMw); Norway: The Research Council of Norway, Division for Society and Health; Poland: The National Centre for Research and Development; Spain: Carlos III Institute of Health (ISCIII); The United Kingdom: The Medical Research Council (MRC).

Conflicts of interest: None declared.

Key points

• This inventory provides for the first time an overview of surveillance systems assessing diet, physical activity and sedentary behaviours in Europe.

• Many existing surveillance systems were identified, particularly at the national level, with a high variation across countries.

• Dietary intake and physical activity were the behaviours most frequently assessed and adults emerged as the population group most often evaluated.

• There was a large heterogeneity of procedures and methods used across surveys, mainly at the national level.

• The critical appraisal of existing surveillance systems will support policies and action plans to better monitor and address the global disease burden in Europe and to evaluate the effectiveness of health-related policy interventions.