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The prevalence of healthy habits gradually decreased from childhood to adolescence in school-age children

Konstantinos D Tambalis1*, Giannis Arnaoutis2, Dimitrios Vlachopoulos3, Demosthenes B Panagiotakos2, Labros S Sidossis4

¹Department of Physical Education and Sport Science, National and Kapodistrian University of Athens, Greece.
²Department of Nutrition and Dietetics, School of Health Science & Education, Harokopio University, Athens, Greece.
³Children’s Health and Exercise Research Centre, University of Exeter, Exeter, United Kingdom.
⁴Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ 08901, USA.

*Corresponding author

*Konstantinos D. Tambalis, ID: (http://orcid.org/0000-0002-5817-9395), Assistant Professor, Department of Physical Education and Sport Science, National and Kapodistrian University of Athens, 41Ethnikis Antistasis Str., 17237, Dafni Athens, Greece, Tel: +302105811857, E-mail: ktambal@phed.uoa.gr.

Abstract

This study aimed to explore the secular trend of healthy habits from childhood to adolescence and to assess associations withobesity and physical fitness (PF).Healthy habits such as physical activity (PA), screen time, and sleep and dietary habits were assessed through a self-completed questionnaire in a sample of 177,091 children and adolescents. Sufficient sleep time, adequate PA, allowable screen time, and sufficient dietary habits were gradually decreased from childhood to adolescence, among both genders.Resultsshoweda decrease in the cluster of healthy habits from 21.4±0.1% in 13-y-old to 2.1±0.1% in 18-y-old boys, (p<0.001), and a corresponding decreasefrom 15.3±0.2% in 13-y-old to 1.1±0.1% in 18-y-old girls, (p<0.001). Participants having a cluster of healthy habits decreased the odds of being obese and having low PF by almost 12% and 38%, respectively, than those who did not. Conclusively, healthy habits decrease from childhood to adolescence and are associated with less obesity and better PF.

Keywords: Dietaryhabits; screen time;physical fitness;sleep; obesity; children.

Introduction

Numerous scientific datapropose that childhood is a critical period of life during which long-term healthylifestyle factors are formed and established that are regularly tracked later in life(Dalal et al., 2022). In adolescence, healthy behaviors such as adequate physical activity (PA) and sleep, healthy dietary habits, maintenanceof optimal body weight, and abstinence from alcohol drinking and smoking promote well-being and health and are associated with increased levels of healthy behaviors during adulthood (Frech, 2012). According to the CDC guide to promoting health for children and adolescents, establishing healthy lifestyle habits to prevent chronic disease is easier and more efficient during childhood and adolescence than trying to alter unhealthy habits in adulthood (CDC, 2021). Healthy lifestyle habits and PA are powerfully interconnected(Tremblay et al., 2011), while a sedentary lifestyle is now intensely presented in childhood and adolescence (Booth et al., 2012). Children with inadequate PA are more likely to develop risk factors for cardiometabolic disease such as higher blood pressure(Booth et al., 2012), decreased level of HDL-C, higher seruminsulin levels(Andersen et al., 2003), and obesity(Boreham & Riddoch, 2001). The World Health Organization (WHO) speculated that regular moderate-to-vigorous physical activity (MVPA) in children and adolescents promotes physical fitness, lifelong health, and quality of life (Chaput et al., 2020). Healthy dietary habits in childhood and adolescence are a critical behavioral path that might reduce the risk of cardiovascular disease(WHO, 2003). They may help prevent the development of chronic diseases such as excess body fat, type 2 diabetes mellitus(Schröder, 2007), and sub-optimal immunity, in adulthood (Post et al., 2001). Also, dietary habits change significantly from childhood to adulthood (Post et al., 2001).It is considered that sufficient sleephas an important contribution to the regulation of metabolic and hormonal functions in children and adolescents(Miller et al., 2015), whileinsufficient sleep time is associated with unfavorable outcomes in adolescents’ health issues (Owens et al., 2014)such asmental and physical health and academic achievement(Shochat et al., 2014). Moreover, insufficient sleep time is related to cardiometabolic risk factors,for instance, higher blood pressure(Guo et al., 2011), disruption of glucose homeostasis(Azadbakht et al., 2013), and worsening of lipidemic profile, in children and adolescents(Klingenberg et al., 2013).Healthy habitsmayhave an effect togetherin a synergistic or antagonistic way to manipulateobesity status or physical fitness (PF)(Grigorakis et al., 2016), so it is essential to explore the potential association of obesity and PF with probably modifiable health habits such as PA(Tambalis et al., 2019b),dietary habits, sleep, and sedentary activities, considered simultaneously(Tambalis et al., 2019a).To the best of our knowledge the changes in the adoption of healthy habits in the longitudinal development between childhood and adolescence, and the potential associations of health habits with metabolic (e.g. obesity, PF) indices have not been fully explored in large, representative, country-wide studies in children and adolescents.

Thus, the current study aimed: (a) to investigate the secular trend ofhealthy habits such as sleep, screen time, PA, anddietary habits from early childhood to adolescence and (b) to assess potential associations between the cluster of the abovementioned health habits and obesity andPFparameters taking into consideration several potential confounders, in abroad, nationally representative sample of schoolchildren 7- to 18-years old.

Materials and methods

Study population: The data was derived from a population-representative, nationwide, school-based health survey in Greece, under the auspices of the Ministry of Education. We collected nutritional, anthropometric, PA, screen, sleep time, and PF data along with information on age and sex. Children and adolescents (n=177,091, aged 7- to 18 years old) from public and private schools participated in the study (the participation rate was almost 40% of the total student population of Greece). Parents were informed in writing for this school health survey and gave their written consent.

Assessment of demographic and anthropometric data: Demographic information of students (e.g., school, class, sex, and date of birth) was obtained from the school records. Children’s body weight, height, and waist circumference were measured in the morning, using a standardized procedure. Specifically, body weight was measured in the standing upright position with electronic scales with a precision of 100 g (children wear little clothing). Standing height was determined to the nearest .5 cm with the child's weight being equally distributed on the two feet, head back, and buttocks on the vertical land of the height gauge. Body Mass Index (BMI) was calculated as the ratio of body weight to the square of height (kg/m2). Waist circumference was measured at the midpoint between the lower margin of the least palpable rib and the top of the iliac crest, using a flexible measure to the nearest 0.1 cm. BMI status (e.g., normal-weight, overweight, obese) was classified using the International Obesity Task Force age- and sex-specific BMI cut-off criteria(Cole et al., 2000). Central obesity was defined as a waist circumference-to-height ratio≥0.5(Browning et al., 2010). Physical Education (PE) professionals performed all anthropometric measurements. Since the collected data were part of the obligatory school curriculum, students' verbal informed consent was considered sufficient.

Assessment of physical fitness levels: The Euro-fit PF test battery was used to evaluate children's PF levels(Eurofit test handbook, 1993). Given that PF constitutes a significant factor in a healthier life, the Euro-fit tests form a complete fitness package that evaluates strength, speed, muscle endurance, flexibility, and cardiorespiratory endurance (23). The battery consists of 5 tests: i.e. (a) a multi-stage 20 m shuttle run test, to estimate aerobic performance; (b) a maximum 10×5 m shuttle run test to evaluate speed and agility; (c) a sit-ups test in 30 s, to measure the endurance of the abdominal and hip-flexor muscles; (d) a standing long jump, to evaluate lower body explosive power; and (e) a sit and reach test to measure flexibility. All fitness tests were administered during the PE class by PE professionals, who were instructed through a detailed manual of operations and followed a standardized procedure of measurements to minimize the inter-rate variability among schools. Moreover, participants’ performance in PF tests was evaluated based on PF normative age- and sex-specific values for 6-18-year-old Greek boys and girls(Tambalis et al., 2016). Specifically, for each of the five PF tests applied, a performance≤25th percentile was considered as low, between the 25th and 75th as average, and ≥75th as high(Tambalis et al., 2016).

Assessment of dietary habits: Children's dietary, PA and sedentary habits were recorded via the use of an electronic questionnaire that was completed at school with the assistance of the teachers and/or Information Technology professors. Students' dietary habits were assessed using the KIDMED (Mediterranean Diet Quality Index for Children and Adolescents)(Serra-Majem et al., 2004). This index contains 16 YES or NO questions, including dietary habits that are under the principles of the Mediterranean diet (MD) dietary pattern and the general dietary guidelines for youth, and habits that undermine them. Questions denoting a negative connotation concerning a high-quality diet are assigned a value of −1, while those with a positive aspect are assigned a value of +1. Thus, the total KIDMED score ranges from 0 to 12 and is classified into 3 levels: ≥8, suggesting an optimal adherence to the MD (sufficient dietary habits); 4–7, suggesting an average adherence to the MD and an improvement needed to adjust dietary intake to guidelines (relatively sufficient dietary habits); and ≤3, suggesting a low adherence to the MD and generally a low diet quality (insufficient dietary habits).

Assessment of self-reported physical activity and sedentary time: Patterns of PA were also self-reported. The questionnaire used had been previously validatedand included simple closed-type questions regarding children's frequency, time, and intensity of participation in (a) school-related PA (including activity during PE classes; (b) organized sports activities; and (c) PA during leisure time(Grigorakis et al., 2016). Children who participated in moderate to vigorous PA (MVPA) for at least 60 min per day were considered as meeting the recommendations for PA.Weekly time spent in sedentary activities (e.g.,TV viewing, playing with the computer or/and console games, use of the Internet for non-study reasons) was also calculated for each student (via multiplying the weekly frequency of participation with the duration per bout of participation in sedentary activities). In the current study, screen-viewing was used as a proxy for sedentary behaviors. Using the threshold of two hours per day, as per current guidelines, students were classified as sedentary or not, i.e., exceeding (>2 h/d) or not (≤2 h/d)(Colley et al., 2012).

Sleep time was self-reported. Children who were sleeping at least 9 hours daily and adolescents who were sleeping at least 8 hours daily were classified as meeting the recommendations for sufficient sleep. Children and adolescents sleeping less than the recommended hours were classified as having insufficient sleep(Paruthi et al., 2016).

Ethical approval: Ethical approval for the health survey was granted by the Ethical Review Board of the Ministry of Education and the Ethical Review Committee of Harokopio University.

Statistical analyses: Descriptive statistics were expressed as mean ± standard deviation or frequency (percentages). The chi-square test evaluated associations between the categorical variables. TheStudent’s t-test was applied to assess differences in mean values of normally distributed variables (The effect size for the t-test for independent samples was calculated using Cohen's d). For the current study, a new variable was created, namely healthy life habits, which included the participants met the criteria for sufficient sleep time plus adequate PA plus allowable screen time plus sufficient dietary habits; all the other participants did not meet even one of the abovementioned criteria were classified as non-healthy life habits.Tests for sex-specific trends in the prevalence rates of the cluster of healthy habits were performed using linear regression analysis (with lag 0). Serial dependency was evaluated using the partial autocorrelation function; no autocorrelation was observed for various lags tested. Results are presented as b-coefficient ± SE. Aiming to assess the potential effect of several metabolic indices (e.g.,total, and central obesity, PF measurements) on the category (NO or YES) of healthy life habits, hierarchical binary logistic regression analysis with Enter as the selected Method was implemented, and OR with the corresponding 95% CI were calculated to obtain adjusted association of covariates while controlling for confounding. The distribution of the independent variables in the Models was done with scientific criteria.The Hosmer and Lemeshow's goodness-of-fit test was calculated to evaluate the model's goodness-of-fit and residual analysis was implicated using the dbeta, the leverage, and Cook's distance D statistics to identify outliers and influential observations. All statistical analyses were performed using the SPSS version 23.0 software for Windows (SPSS Inc. Chicago, II, USA). The statistical significance level from two-sided hypotheses was set at p-value<.05.

Results

Descriptive statistics of the participants in the study are presented in Table 1. Overall, 177,091 children and adolescents aged 7- to 18-y-old participated in the study. Significant differences between boys and girls were incorporated in PF measurements, anthropometric variables, PA, dietary habits, and screen time (all p-values<0.001). Figure 1 presents the percentages of boys and girls with sufficient sleep time (Fig. 1a), adequate PA (Fig. 1b), allowable screen time (Fig. 1c), and sufficient dietary habits (Fig. 1d), from childhood to adolescence.Specifically, it seems that the proportion of participants who met all the above-mentioned healthy habits gradually decreased from childhood to adolescence, among both genders.Figure 2 presents the proportions of boys and girls who fulfill the total of healthy life habits, from childhood to adolescence, while an open bell-shaped recording exists in both genders. Thus, further analysis was performed, splitting the time series into two periods (childhood and adolescence). Data analysis revealed an increase in the cluster of healthy habits from 10.8±0.1% in 7-y-old to 20.2±0.2% in 12-y-old (p<0.001)boys, with an annual trend equal to 1.61±0.01% (p<0.001), and from 11.2±0.2% in 7-y-old to 17.6±0.2% in 12-y-old girls (p<0.001) with an annual trend equal to 1.07±0.05% (p<0.001). On the opposite, the analysis showed a decrease in the cluster of healthy habits from 21.4±0.1% in 13-y-old to 2.1±0.1% in 18-y-old boys (p<0.001), with an annual trend equal to -3.21±0.01% (p<0.001), and a corresponding decreasefrom 15.3±0.2% in 13-y-old to 1.1±0.1% in 18-y-old girls, (p<0.001), with an annual trend equal to ­2.35±0.05% (p<0.001).

Participants from both genders who belonged to the healthy life habits group (Table 2) had better anthropometric and PF measurementscompared to those who did not belong, to the same gender (all p-values<0.001). Considering that healthy life habits participantpresented a better metabolic profile in comparison with the participants who did not meet the abovementioned health lifestyle criteria, hierarchical binarylogistic regression analyses (2 Models) were applied to search the probable associations of included factors on a cluster of healthy life habits(NO vs. YES), in children and adolescents from both genders. The initial analysis (Table 3, Model 1) showed that having a cluster of healthy life habits decreased the odds of being overweight/obese or centrally obese by almost 13% and 11% in boys and girls, respectively, adjusted for age. When PF measurements (Table 3, Model 2), were included in the analysis, it was shown that children and adolescentswith healthy life habits had decreased odds of low PF performancesthan those who did not meet the criteria for belonging to the healthy life habits group, in both genders. For example, boys and girls with healthy life habits were 40% (95% CI:0.52-0.68) and 39% (95% CI:0.53-0.66) less likely to have low performances in CRF tests.

Discussion

The most importantresults of this study are: (a) the percentages of boys and girls with sufficient sleep time, adequate PA, acceptable screen time, and sufficient dietary habits were gradually decreased from childhood to adolescence; (b) the proportion of participants who met the cluster of healthy habits (e.g. sleep time and PA and screen time, and dietary habits)raised in childhood, and fell significantly in the period of adolescence, among both sexes; (c) participants from both sexes who belonged to healthy life habits group had better anthropometric and PF measurements compared to those who did not belong, and (d) healthy habits were associated withlower odds ofobesity andlow PF performances compared tothose who did not meet the criteria for belonging in the healthy life habits group, in both genders.

Table 1: Baseline characteristics (means, SD) of participants in the study aged 7- to 18 years.

†KIDMED score (≤3: insufficient dietary habits, 4-7: relatively sufficient dietary habits, ≥8: sufficient dietary habits. *P-values for differences between boys and girls.

Table 2: Anthropometric and physical fitness characteristics (mean ± SD) according to the cluster of healthy habits (e.g., sleep time and physical activity and screen time and dietary habits) in Greek boys.

*P<0.05 for differences between participants who met the cluster of healthy habits or those not from the same gender

Table 3: Results (OR, 95%CI) from logistic regression models that were used to evaluate the association of participant’s (7 to 18 y-old) anthropometric and physical fitness characteristics with health behavior (no vs. yes)

Healthy habits are routines that support emotional, mental, and physical well-being. Examples include eating a balanced diet, getting adequate sleep, and exercising frequently(Frech, 2012). Healthy lifestyles have a complicated and reciprocal relationship in children and adolescents(Booth et al., 2012). Our results show that sufficient dietary habits reached their highest rate at age 12 years old (44.7% for boys and 47% for girls) and then showed a rapid decline during adolescence, in both sexes (20.3% for boys and 17.3% for girls, at age 18 years old). A study among 2913 Poland participants between 6 and 17 years concluded that adolescents made more unhealthy choices than younger children(Basiak-Rasała et al., 2022).Also, an analysis of healthy eating habits in the U.S.A. (NHANES 2015-2016) showed that from childhood to adolescence, the Healthy Eating Index score drops by 10 points, while,compared to younger children, adolescents have lower intakes of vegetables, fruits, and dairy, and higher intake of added sugars(NHANES, 2021).Scientific evidence proposes that because adolescents are becoming more independent in their food choices as compared to children, it is less likely to pick healthy foods(Seymour et al., 1997).

Insufficient sleep in childhood and adolescence may cause, among other, long-term health problems such as obesity, diabetes, and cardiovascular risk(Shochat et al., 2014).A review study among children and adolescents proposes that over the last 100 years, there have been constant declines in sleep duration (Matricciani et al., 2012).In the current study, we found that boys and girls by the age of 14 years reportedsufficient sleep at a rate of about 70% to 75%, while this rate then drops to about 20% by the age of 18 years, in both sexes. Our results are in line with those of the Longitudinal Study of Australian Children which stated that as young people got older their sleep timedecreased, while almost 25% of 12 to 13-year-olds and 50% of 16 to 17-year-olds did not sleep the minimum of eight hours of sleep(Evans-Whipp& Gasser, 2019).Also, in a study among 24896 Canadian schoolchildren aged 10 to 17 years, it is stated that almost one-third of participants sleep less than the recommended amount(Chaput& Janssen, 2016). Finally, a review study stated that as students get older, sleep durations decrease in many countries (Owens et al., 2014). Specifically, in the U.S.A. the National Sleep Foundation Sleep stated that by the 12th grade, 75% of students self-reported sleep durations of less than 8 hours per night compared with 16% of sixth graders(Owens et al., 2014).

PA and healthy habits are distinctly connected, whereaschildren who do not achieve recommended PA levels are more likely to develop risk factors for cardiometabolic disease (Boreham & Riddoch, 2001). The present results incorporated a steady increase of adequate PA from 7 to 12-year-old boys and girlswhich was followed by a rapid declineuntil the age of 18 years, in both sexes. Moreover, girls presented lower levels of PA in all age groups. A statement from the European Union (Health at a Glance:Europe 2020: State of Health in the EU Cycle) revealed that average across EU countries, only one in four 11-year-olds and only one in seven 15-year-olds met the recommended PA levels (MVPA at least one hour per day) in 2018; in all countries, girls are to a lesser extent physically active than boys, and PAdecrease sharply between ages 11 to 15 in most EU countries for both genders(European Union, 2020). Furthermore, a recent review study examining the global prevalence of PAin children and adolescents revealed inadequate levels of PA among children and adolescents across the world; lower levels of PA among girls as compared to boys with same age, and the reduction of PA levels with age(Aubert et al., 2021).

The American Academy of Child and Adolescent Psychiatry proposed for ages 6 and older to encourage healthy habits and limit activities that include screens(Aubert et al., 2021).Excessive screen time (>2/d) is associated with childhood obesity, physical inactivity, unfavorable dietary habits, and disrupted sleep(McGough, 2022).Screen time has also been demonstrated to enhance between childhood and adolescence, particularly among boys(Jones et al., 2021).The current results showed that the acceptable screen time (≤2 h/d) decreased from 88% at 7 years old to 59% at 18 years old schoolchildren, in both sexes. Our results followed a recent review of 53 articles which stated thatthe average screen time of schoolchildren aged 6 to 14 years was 2.7 h/d, and 46.4% of them incorporated an average screen time ≥2 h per day(Qi et al., 2023).Similarly, in another review, it was reported that only about 50% of schoolchildren in North America met guidelines of <2 h/d of recreational screen time(Saunders & Vallance, 2017). Also, the report from the Health Behavior in School-Age Children conducted on adolescents from 41 countries in Europe and North America, revealed that almost 60% of them spent >2 h/d watching television(Currie et al., 2012).

Our data analysis showed an increase in the cluster of healthy habits (adequate PA and sleep levels sufficient dietary habits and acceptable screen time) from almost 11% in 7-y-old to19% in 12-y-old boys and girls, while, in adolescence, the results revealed an extensive decline to those who met all the healthy habits criteria(2.1% and 1.1% for 18-y-old boys and girls, respectively). Similarly, a systematic review and meta-analysis aiming to investigate the overall (non)adherence to the 24-Hour Movement Guidelines (MVPA>1h/d and screen time<2h/d and sleep duration>8-9h/d) among children and adolescents, worldwide, reported that overall, only 7.1% of participants met all three 24-Hour Movement Guidelines, while adherence to all recommendations was significantly lesser in girls and adolescents (Tapia-Serrano et al., 2022). A review study indicated that the achievement of high levels of PA (≥60 min of MVPA), low levels (≤2 h) of screen time, and sufficient sleep (8-11h/d), for youth (5-17 years old) each dayhas important implications for health (including adiposity) in children and adolescents (Rollo et al., 2020).

One of the main causes of obesity is poor health habits, such as overeating junk food, drinking sugary beverages, skipping breakfast, having poor sleep increasing screen time, and not getting enough PA(Fruh et al., 2021). Moreover, these habits can also affect the metabolism, hormones, and appetite regulation of the body, making it harder to lose weight or maintain a healthy weight(Fruh et al., 2021).Our findings propose that participants with healthy life habits hadlower odds of being overweight/obese or centrally obese by almost 12%, adjusted for age.A review study aiming to present a practical approach to childhood obesity prevention concluded that establishing healthy habits early in life can protect against the development of overweight/obesity(Fruh et al., 2021).In another review study, it is considered that all children with unhealthy diets, inadequate PA, and spending a lot of time in sedentary activities, in the future, will be possible to grow into overweight/obese adults(Nittari et al., 2019). Moreover, a review study that explored barriers to and enablers of healthy lifestyle behaviors in obese adolescentshighlighted the significance of multilevel interventions to empower healthy lifestyle behaviors for weight management(Kebbe et al., 2017).Finally, it is considered that clinic-based interventions against obesity that couldpresent favorable effects include dietary or other lifestyle changes like increasing PA and exercise(Kelishadi& Azizi-Soleiman, 2014). Therefore, schoolchildren need to adopt healthy habits from an early age to prevent or treat obesity limiting screen time and sedentary activities, engaging in at least 60 min/d of MVPA, getting enough sleep every night, and adopting healthy dietary habits.

Indicators of health and well-being in children and adolescents, such as PF, are crucial. PF measures one's capacity for carrying out different PA and tasks and is influenced by a few variables, including heredity, environment, diet, and behavior(Ortega et al., 2008). Although PF is the result of a multifactorial behavior, it is well documented that high levels are related to favorable body composition, improved skeletal health, protection against cardiometabolic risk factors, as well as improved mood, psychological health, academic performance, and wellness in general(Ortega et al., 2008).In the current study, we found that boys and girls with healthy life habits were almost 40% less likely to have low performances in CRF tests.Our findings agree with the results of similar investigations. More precisely, a systematic review by Saunders and his colleagues,found that thecombination of high PA, low sedentary behavior, andhigh sleep duration was associated with the most desirablephysical health outcomesin a sample of children and adolescents aged from 5 to 17 years old(Saunders et al., 2016).Moreover, the results from the present study follow those deriving from a recent systemic review assessing more than 140 studies, which indicated that high physical activity sedentary behavior sleep levels were the "best" combination to achieve significant health outcomes in children and adolescents(Wilhite et al., 2023).Finally, the results from a study conducted by our laboratory, consisting of 335,810 schoolchildren, indicated that low PF was positively associated with the presence of overweight/obesity, increased time spent in sedentary activities/screen time, and low adherence to healthy dietary patterns like the Mediterranean Diet(Arnaoutis et al., 2018).Healthy behaviors can influence PF by supplying vital fuel, nutrients, rest, and recuperation for the body's growth and performance(Wilhite et al., 2023).Therefore, the adoption of healthy lifestyle habits and the maintenance of a high PF level should be priorities for health promotion throughout childhood, adolescence, and consequently adulthood.

This study was conducted in an extensive range of ages (7 to 18 years old), explored a vast part of the schoolchildren population, and includedseveral covariates. Although PA, dietary habits, and sleep were self-reported, the questionnaires used had been validated in research among schoolchildren(Serra-Majem et al., 2001). Specifically, concerning the KIDMED questionnaire,in a new study among children and adolescents, the results showed that thisindex had acceptable validity and reproducibility(Rei et al., 2021).

Limitations of the current study include the issue that probable confounding factors, such as maturation status, energy intake, and socio-economic level have not been assessed. Furthermore, because of the huge sample size, statistical significance can without difficulty be achieved. Consequently, the current findings could be interpreted with concern for their public or practical health importance. This is an observational, cross-sectional study so causality cannot be assigned. PA, sedentary time, sleep time, and dietary habits were self-reported, consequentlysubject to desirable reporting bias. However, schoolchildren's responses were anonymous; accordingly, they had no reason to misreport.

Conclusions

The results of this nationwide, representative health researchin schoolchildren showed that the prevalence ofhealthy habits decreased from childhood to adolescence. Also, healthy habits were associated with decreased odds of obesity and low PF measurements. This knowledge could be helpful in recommendations to make certain healthy habits in children and adolescents.

Acknowledgments: All authors contributed to the study's conception and design. Material preparation, data collection, and analysis were performed by KDT, DBP,DV, GA,and LSS. The first draft of the manuscript was written by KDT, DV, and GA, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

All authors agree with the manuscript and declare that the content has not been published elsewhere.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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