Preventive Medicine 131 (2020) 105955

Contents lists available at ScienceDirect

Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed

Clustering of lifestyle risk factors for non-communicable diseases in 304,779 T

adolescents from 89 countries: A global perspective
⁎
Riaz Uddina,b, Eun-Young Leec, Shanchita R. Khand, Mark S. Tremblaye, Asaduzzaman Khana,b,
a
School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD 4072, Australia
b
Active Healthy Kids Bangladesh (AHKBD), Dhaka, Bangladesh
c
School of Kinesiology and Health Studies, Queen's University, Kingston, ON, Canada
d
School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia
e
Healthy Active Living and Obesity Research Group, CHEO Research Institute, Ottawa, ON, Canada

A R T I C LE I N FO A B S T R A C T

Keywords: The precursors of non-communicable diseases (NCDs) are often manifested during childhood and adolescence
Adolescent health with little knowledge about co-occurrence of their related lifestyle risk factors. To address this deficit, we es-
Chronic disease timated the prevalence and clustering of six major NCD-risk factors in adolescents around the world. Data from
Cluster analysis the Global School-based Student Health Survey, collected between 2007 and 2016, were analysed in 304,779
Health promotion
adolescents aged 11–17 years (52.2% females) from 89 countries. We compared the observed (O) to expected (E)
Public health
prevalence ratios of 64 possible combinations of six risk factors to determine their clustering patterns. Overall,
82.4% (95% CI 82.1–82.7) of adolescents had ≥2 risk factors, while 34.9% (34.6–35.3) had ≥3. Adolescents
aged 16–17 years, compared to those aged 11–13 years, had higher odds (OR 1.33; 95% CI 1.31–1.36) of
reporting ≥3 risk factors. Risk factors clustered in multiple combinations and differed by sex. The clustering of
physical inactivity and low fruit and vegetable intake was evident in both males (O/E 1.10; 95% CI 1.07–1.12)
and females (1.08; 1.06–1.10). The co-occurrence of cigarette smoking, alcohol drinking, physical inactivity, and
low fruit and vegetable intake was 165% greater in females (2.65; 2.28–3.07) and 110% greater in males (2.10;
1.90–2.32) than expected. Globally, adolescents exhibit multiple modifiable risk factors for future development
of NCDs. Early gender-specific prevention strategies targeting clusters of lifestyle risk factors should be priori-
tised to help mitigate future burden of NCDs globally. Periodical collection of behavioural risk factor data should
be encouraged to facilitate a sustainable global surveillance.

1. Introduction
Non-communicable diseases (NCDs) including cardiovascular dis-
eases, type 2 diabetes, cancers, and chronic respiratory diseases are the
leading causes of poor health and premature mortality worldwide,
collectively accounting for seven out of 10 global deaths annually
(Bennett et al., 2018). Most NCDs share predisposing risk factors such
as obesity and unhealthy lifestyle behaviours including prolonged time
spent in sedentary pursuits, insufficient physical activity, poor dietary
habits, cigarette smoking, and alcohol consumption (Arena et al., 2015;
Bennett et al., 2018). These risk factors are unlikely to occur in isola-
tion, but, instead, can cluster and interact to exponentially elevate the
risks of NCDs (Arena et al., 2015). While co-occurrence of these risk
factors can adversely influence morbidity and mortality, adhering to
healthy lifestyle behaviours can proportionately decrease the risks (Loef
and Walach, 2012). Understanding the clustering of NCD risk factors
can help inform strategies to better prevent, manage, and mitigate NCD-
related poor health and premature death (Loef and Walach, 2012;
Meader et al., 2016).
Adolescence is a period vulnerable to adopting unhealthy lifestyle
behaviours (Aguilar-Farias et al., 2018; Caleyachetty et al., 2015;
Darfour-Oduro et al., 2018; Xi et al., 2016). Several key health-related
behaviours, including insufficient physical activity, prolonged seden-
tary behaviour, poor diet, obesity, and alcohol and tobacco abuse often
emerge or intensify during adolescence, and carry risks for concurrent
and future NCD burden (Patton et al., 2012; Patton et al., 2016). For
example, globally, approximately 90% of smokers initiate tobacco use
before the age of 18 years, with about 100,000 children and adolescents
first starting to smoke every day (Xi et al., 2016). While fruit-vegetable
consumption in developed countries has increased among adolescents
between 2002 and 2010 (Vereecken et al., 2015), the consumption
remains low in many developing countries (Darfour-Oduro et al.,

⁎
Corresponding author at: School of Health and Rehabilitation Sciences, The University of Queensland, Therapies Annex, St Lucia, Brisbane, QLD 4072, Australia.
E-mail address: a.khan2@uq.edu.au (A. Khan).

https://doi.org/10.1016/j.ypmed.2019.105955
Received 25 July 2019; Received in revised form 4 December 2019; Accepted 16 December 2019
Available online 17 December 2019
0091-7435/ © 2019 Elsevier Inc. All rights reserved.
R. Uddin, et al.
2018). These risk behaviours contribute significantly to the global
burden of youth morbidity and mortality (Mokdad et al., 2016; Xi et al.,
2016). Hence, a comprehensive understanding of adolescent-onset risk
behaviours is essential to improve adolescent health and reduce sub-
sequent disease burden in adulthood (Patton et al., 2012).
Available evidence suggests that behavioural risk factors are highly
prevalent among adolescents (Aguilar-Farias et al., 2018; Darfour-
Oduro et al., 2018; Xi et al., 2016) and exposure to multiple risk factors
increases the likelihood of poor health (Catalano et al., 2012). How-
ever, little is known about the prevalence and distribution of co-oc-
currence of these factors in this population (Caleyachetty et al., 2015).
Given the between- and within-region variability in adolescent health
(Patton et al., 2012), it is important to understand regional differences
in these risk behaviours that can facilitate local context-specific pre-
vention priorities across the region. In this study, we aimed to estimate
the prevalence of six lifestyle risk factors of NCDs (i.e., sedentary pur-
suits, physical inactivity, low fruit and vegetable intake, cigarette
smoking, alcohol consumption, and overweight/obesity) and their
clustering patterns among adolescents aged 11–17 years from 89
countries across the world. The information generated could help
forecast the future burden of NCDs, and identify potential target groups
for early prevention programs (Alamian and Paradis, 2009), which in
turn, can minimise the associated health care costs and loss of future
productivity (United Nations, 2018).
2. Methods
2.1. Data sources and participants
We used secondary data from the Global School-based Student
Health Survey (GSHS), which is a WHO initiative designed to assess
health behaviours of adolescents through cross-sectional school-based
surveys. The GSHS used the same standardised methodology in all
participating countries to generate comparable data. In each country,
the GSHS used a standardised two-stage probability sampling design.
First, schools were selected with probability proportional to size sam-
pling and then classrooms were selected randomly from each selected
school. All students in the selected classrooms were eligible to partici-
pate [details (World Health Organization, n.d.-b)]. The present study
used nationally representative data for all countries except Colombia
and Ecuador.
Of the 320,728 students who participated in the GSHS between
2007 and 2016 from 89 countries, 11,111 students aged 18 years were
excluded to restrict the sample to adolescents aged 11–17 years. An
additional 4838 were excluded due to missing information on sex and/
or age. The analytical sample consisted of 304,779 adolescents from 89
countries with 11 from Africa (representing 9.7% of total sample), 29
from the Americas (30.7%), 19 from the Eastern Mediterranean
(21.5%), 1 from Europe (0.7%), 9 from Southeast Asia (14.8%), and 20
from the Western Pacific region (22.5%) (Appendix Table e1). Europe,
with only one country, was excluded from any regional level analyses.
2.2. Measures
2.2.1. Outcome variables
Participants were asked the following questions: “During the past 30
days, on how many days did you smoke cigarettes?” and “During the
past 30 days, on how many days did you have at least one drink con-
taining alcohol?” Current cigarette smoking was defined as smoking on
one or more of the past 30 days (Xi et al., 2016), and current alcohol use
as having at least one drink containing alcohol in the past 30 days
(Dumith et al., 2012). Fruit-vegetable consumption was assessed with
the questions: “During the past 30 days, how many times per day did
you usually eat fruits?” and “During the past 30 days, how many times
per day did you usually eat vegetables?” Low or inadequate fruit and
vegetable intake was defined as having fruit and vegetables less than
2
Preventive Medicine 131 (2020) 105955
two and three times per day during the past 30 days, respectively
(Darfour-Oduro et al., 2018). Insufficient physical activity was defined
as not doing at least 60 min of activity on all seven days of the week
(Aguilar-Farias et al., 2018). Sitting time was measured by asking about
total time spent watching television, playing computer games, talking
with friends, or doing other sitting activities during a typical day. High
sedentary behaviour was defined as ≥3 h/day of leisure-time sitting
outside of school (Khan et al., 2019). Trained survey staff measured
participants' height and weight (Ashdown-Franks et al., 2019). Body
mass index (BMI) was categorised as underweight (BMI < −2SD),
overweight (BMI > +1SD), and obese (BMI > +2SD), relative to
median BMI, by age and sex based on the WHO Child Growth Standards
(World Health Organization, n.d.-a).
2.2.2. Independent variables
The independent variables included age, sex, hunger status, survey
year, and WHO region. The participants were asked: “During the past
30 days, how often did you go hungry because there was not enough
food in your home?” Hunger status was used as a proxy measure of
socioeconomic status (Ashdown-Franks et al., 2019; Uddin and Khan,
2019) as the GSHS did not include any direct measure of socioeconomic
status.
2.3. Statistical analyses
Each of the six risk behaviours was coded as 1 (“Yes”) and 0 (“No”)
before summing them to generate a risk factor index, ranging from 0
(“none”) to 6 (“all”). The proportions of adolescents in each of the
single and multiple risk factors and their 95% confidence intervals (CI)
were estimated by taking into account the GSHS weighting factor to
adjust for non-response and the varying probability of selection. The
analyses were performed separately for male adolescents (hereafter
“males”) and female adolescents (hereafter “females”). Additionally,
WHO regional estimates were derived by sex and age group. Given the
complexity of GSHS design, a Stata command svyset was used to obtain
the prevalence estimates.
Clustering of lifestyle risk factors was studied by examining ratios of
observed (O) and expected (E) prevalence of one or more simulta-
neously occurring risk behaviours for males and females separately. The
observed proportions of 64 different combinations of the risk factors
were estimated using the GSHS weighting. The expected proportion was
calculated by multiplying the individual probabilities of each risk factor
based on their occurrence in the study sample. A ratio (O/E) greater
than one suggests the presence of clustering (Galán et al., 2005).
Considering the nested structure of the data, multilevel Poisson
regression modeling was conducted to examine the associations, using
MLwiN V3.04 software where country was considered as level 3, school
as level 2, and student as level 1 factor. Prevalence odds ratios (OR)
along with their 95% CI were estimated to examine the associations
between pairs of risk behaviours, adjusted for age, hunger status, survey
year, and region for males and females separately. If the 95% CI of the
OR does not include one, it suggests a clustering between the two risk
factors. In addition, multilevel Poisson regression was used to examine
the relationships of age and sex with the presence of ≥3 risk factors
(Caleyachetty et al., 2015; Dumith et al., 2012), adjusted for hunger
status, survey year, and region. Separate regression models were con-
structed for WHO regions to estimate the associations.
3. Results
The mean age of participants was 14.4 (SD 1.38) years, and 52.2%
were females (Appendix Table e1). The most common single lifestyle
risk factor for NCDs was low fruit-vegetable intake with a prevalence of
85.9% (95% CI 85.6–86.1) with no apparent sex differences (Fig. 1).
Males were more likely to report alcohol drinking and cigarette
smoking compared to females. There was no obvious trend in physical
R. Uddin, et al. Preventive Medicine 131 (2020) 105955

100

90 88 88
86 86 86 86 86
85 85
84 84
81
80

70

60
% of adolescents

50

40 39

30 29 30
30 29

24 24

19
20
17
15 14 15 14
14 13 13 13
12 11
9 9
10 8
6
4

0
Overall Males Females 11–13 years 14–15 years 16–17 years
Low fruit-vegetable Physical inactivity High sedentary behaviour Overweight/obesity Currently drink alcohol Currently smoke

Fig. 1. Prevalence of single lifestyle risk factors in adolescents aged 11–17 years, by sex and age-group, Global School-based Student Health Survey, 2007–2016
(n = 304,779).
Note: Error bars represent 95% confidence intervals.

inactivity across age groups; however, the prevalence of overweight/
obesity decreased with increasing of age from 19.3% (18.7–19.9) in
adolescents aged 11–13 years to 11.3% (10.8–11.9) in adolescents aged
16–17 years. The remaining four risk behaviours demonstrated no-
ticeable trends with the prevalence becoming higher monotonically
with increasing age.
Table 1 presents the distribution of total number of lifestyle risk
factors. One in three adolescents (34.9% [33.2–36.7]) reported ≥3 risk
factors with males (36.3% [34.3–38.4]) reporting more than females
(33.5% [31.7–35.3]). The prevalence of having ≥3 risk factors in-
creased monotonically with age with 29.4% (27.8–31.0) for
11–13 years old and 46.4% (43.7–49.2) for 16–17 years old (Fig. 2).
In regional analyses (Table 1), adolescents of the Americas reported
the highest prevalence of ≥3 risk factors (56.2% [54.2–58.2]), fol-
lowed by adolescents of Western Pacific region (44.5% [42.1–47.1]).
Three in 10 adolescents in Eastern Mediterranean and Southeast Asia
reported having had ≥3 risk factors. Males were more likely to report
≥3 risk factors in Western Pacific and Southeast Asia regions. With
older age, the prevalence of ≥3 risk factors became higher in all re-
gions.
Multilevel Poisson regression analyses showed no overall gender
differences in reporting ≥3 risk factors (Appendix Table e2). However,
males had higher odds of reporting ≥3 risk factors in Southeast Asia
region (OR 1.34; 95% CI 1.29–1.39). The odds of having ≥3 risk factors
were higher with older age globally and across all regions.
Clustering patterns of the 64 combinations of the six risk beha-
viours, stratified by sex, are presented in Table 2. Lifestyle risk factors
clustered in multiple combinations with an evidence of sex differences
in the clustering. The simultaneous occurrence of all six risk factors was
significantly higher than expected in both males and females. The
clustering of cigarette smoking, alcohol drinking, physical inactivity,
low fruit-vegetable intake, and overweight/obese was evident in both
males and females. The co-occurrence of cigarette smoking, alcohol
drinking, physical inactivity, and low fruit-vegetable intake was 110%
greater in males (O/E ratio 2.10; 95% CI 1.90–2.32) and 165% greater
in females (2.65; 2.28–3.07) than expected. The analyses demonstrated
clustering of physical inactivity, high sedentary behaviour, and low
fruit-vegetable intake among females. The combination of physical in-
activity and fruit-vegetable intake was common in both males and fe-
males.
Table 3 presents the clustering for pairs of lifestyle risk factors,
stratified by sex. Cigarette smoking and alcohol intake showed the
strongest association among the pairwise clusters for both males and
females. Of the 15 possible pairs, ten were significantly (six positive and
four negative) associated with one another in males, and nine were
significantly (seven positive and two negative) associated with one
another in females. The odds of cigarette smoking and alcohol intake
were considerably higher among adolescents who reported high se-
dentary behaviour. Physical inactivity was positively associated with
low fruit-vegetable intake in both sexes.
In all regions, cigarette smoking was positively associated with al-
cohol consumption for males and females (Appendix Table e3).
Cigarette smoking was also positively associated with high sedentary
behaviour in all regions. High sedentary behaviour was positively as-
sociated with alcohol consumption in both sexes in all regions.
Inactivity and low fruit-vegetable intake were positively associated for
males in all regions.
4. Discussion
This study was the first to investigate clustering patterns of six
major NCD-related lifestyle risk factors among adolescents on a global
scale. To our knowledge, this is the largest study to provide prevalence
estimates of six lifestyle risk factors and their clustering patterns among
adolescents aged 11–17 years, with data from 89 countries around the
globe. The two most prominent lifestyle risk factors for NCDs were low

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Table 1
Prevalence of total number of lifestyle risk factors in adolescents aged 11–17 years, by sex and age-group, Global School-based Student Health Survey, 2007–2016
(n = 304,779).
Risk factors Overall, % (95% CI) Sex, % (95% CI) Age group (years), % (95% CI)

Males Females 11–13 14–15 16–17

Global
0 1.9 (1.6–2.2) 1.9 (1.7–2.3) 1.7 (1.4–2.2) 2.2 (1.8–2.7) 2.0 (1.7–2.4) 1.0 (0.8–1.3)
1 15.8 (14.9–16.7) 16.4 (15.4–17.6) 15.0 (14.2–15.9) 17.7 (16.8–18.7) 16.5 (15.4–17.6) 11.3 (10.3–12.5)
2 47.4 (46.3–48.5) 45.2 (43.9–46.5) 49.7 (48.5–50.9) 50.6 (49.4–51.8) 48.1 (47.0–49.3) 41.2 (39.3–43.1)
3+ 34.9 (33.2–36.7) 36.3 (34.3–38.4) 33.5 (31.7–35.3) 29.4 (27.8–31.0) 33.4 (31.5–35.2) 46.4 (43.7–49.2)

WHO region – Africa

0 3.6 (2.9–4.4) 4.0 (3.2–4.9) 3.2 (2.5–4.9) 4.2 (3.2–5.4) 3.9 (3.0–5.0) 2.1 (1.7–2.7)
1 23.9 (21.4–26.6) 24.3 (21.5–27.3) 23.6 (21.1–26.3) 25.8 (23.2–28.6) 25.9 (22.0–30.2) 17.9 (16.4–19.4)
2 49.2 (46.6–51.8) 47.7 (44.8–50.6) 50.7 (48.2–53.3) 49.3 (46.3–52.4) 47.3 (43.6–51.0) 52.5 (50.2–54.7)
3+ 23.3 (21.0–25.6) 24.0 (21.6–26.6) 22.5 (20.1–25.0) 20.6 (18.2–23.2) 22.9 (20.1–26.0) 27.5 (25.2–30.0)

WHO region – The Americas

0 1.0 (0.8–1.1) 1.1 (0.9–1.4) 0.8 (0.7–1.0) 1.4 (1.1–1.8) 0.8 (0.7–1.0) 0.7 (0.5–1.1)
1 9.4 (8.7–10.1) 10.1 (9.3–11.1) 8.7 (7.9–9.5) 11.3 (10.4–12.2) 9.2 (8.4–10.1) 7.3 (6.2–8.5)
2 33.4 (31.9–34.9) 33.5 (32.0–35.1) 33.3 (31.5–35.1) 38.7 (37.1–40.4) 33.4 (31.7–35.1) 26.3 (24.1–28.6)
3+ 56.2 (54.2–58.2) 55.1 (53.0–57.3) 57.2 (54.9–59.6) 48.6 (46.5–50.6) 56.5 (54.2–58.7) 65.7 (62.5–68.8)

WHO region – Eastern Mediterranean

0 1.2 (1.0–1.4) 1.5 (1.2–1.8) 0.9 (0.7–1.2) 1.3 (1.0–1.6) 1.1 (0.9–1.4) 1.3 (0.9–1.8)
1 14.7 (13.6–15.9) 16.0 (14.6–17.5) 13.2 (11.7–14.8) 15.0 (13.3–16.8) 14.8 (13.5–16.2) 13.5 (12.2–14.9)
2 53.4 (51.5–55.3) 51.4 (49.1–53.8) 55.7 (53.3–58.1) 52.7 (50.3–55.1) 54.5 (52.1–56.8) 51.2 (49.1–53.4)
3+ 30.6 (28.8–32.6) 31.1 (28.8–33.5) 30.1 (27.8–32.7) 31.0 (28.5–33.6) 29.6 (27.4–31.9) 33.9 (31.6–36.3)

WHO region – Southeast Asia

0 2.6 (2.0–3.3) 2.4 (1.9–3.1) 2.7 (1.8–4.0) 2.6 (1.9–3.7) 3.0 (2.2–4.1) 1.0 (0.7–1.4)
1 18.7 (17.1–20.4) 19.1 (17.0–21.4) 18.2 (16.7–19.9) 19.4 (18.0–21.0) 20.0 (18.0–22.3) 12.7 (10.1–15.9)
2 49.5 (47.5–51.6) 46.7 (44.2–49.2) 52.7 (50.5–54.8) 52.3 (50.1–54.6) 49.6 (47.2–52.0) 42.5 (39.2–45.8)
3+ 29.2 (26.0–32.6) 31.8 (28.2–35.6) 26.4 (23.1–29.9) 25.6 (22.8–28.6) 27.3 (24.0–31.0) 43.8 (38.6–49.1)

WHO region – Western Pacific

0 0.9 (0.7–1.1) 1.1 (0.8–1.5) 0.7 (0.5–1.0) 1.1 (0.8–1.5) 1.0 (0.7–1.3) 0.7 (0.4–1.1)
1 10.8 (10.0–11.7) 11.1 (10.2–12.0) 10.5 (9.4–11.6) 13.3 (11.8–14.9) 11.7 (10.7–12.8) 8.5 (7.4–9.8)
2 43.8 (41.9–45.7) 40.3 (38.1–42.6) 47.0 (45.0–49.1) 50.2 (47.7–52.7) 47.0 (45.1–49.0) 36.9 (34.8–39.2)
3+ 44.5 (42.1–47.1) 47.5 (44.8–50.3) 41.8 (39.0–44.6) 35.4 (32.3–38.7) 40.3 (37.8–42.8) 53.8 (51.1–56.6)

Abbreviations: CI = confidence interval; WHO = World Health Organization.

fruit-vegetable intake and physical inactivity (86% and 85%, respec-
tively), similar to what has been reported elsewhere (Caleyachetty
et al., 2015). Prevalence of ≥3 lifestyle risk factors was more common
in males than females. The strongest clustering of pairwise risk factors
was cigarette smoking and alcohol consumption in both sexes. When
multiple risk factors were considered simultaneously, different patterns
of clusters were observed. Globally, physical inactivity and low fruit-
vegetable consumption were clustered together as the most common
risk factors in both sexes. In addition, clustering of all six risk factors
were more than expected in both males and females, indicating the
need to develop global strategies for primary prevention of multiple risk
factors. Our findings of clustering patterns of NCD risk factors can in-
form the development of effective and scalable early preventive stra-
tegies for the improvement of global adolescent health, which in turn
can minimise future burden of NCDs (Catalano et al., 2012; Patton
et al., 2012; Patton et al., 2016).
Globally, approximately 82% of adolescents had ≥2 risk factors for
NCDs, and the rates were different across different WHO regions with
lowest in Africa (73%) and highest in the Americas (89%), suggesting
that the co-occurrence of lifestyle risk factors is a universal phenom-
enon. The prevalence of multiple risk factors increased with the in-
crease of age globally and across all regions. Although males had a
higher tendency of reporting multiple risk factors than their female
counterparts in adult population (Meader et al., 2016), this was not
supported by our study findings with adolescent population. However,
sex disparities in the clustering of risk factors were observed in some
WHO regions. Reporting ≥3 risk factors was more common among
males than females in Western Pacific and Southeast Asian regions, and
these regions, therefore, should have specific focus on reducing sex
disparities.
The most prominent clustering of pairwise lifestyle risk factors was
cigarette smoking and alcohol consumption for both sexes globally as
well as at the regional level. Similar findings have been reported with
the adult population (Meader et al., 2016). Given that both tobacco
smoking (Kelder et al., 1994) and alcohol consumption (Andersen et al.,
2003) during adolescence track into adulthood, prevention and early
intervention for these behaviours may be of importance for healthy
adulthood in the global population. The danger of early tobacco and
alcohol consumption includes the potential to develop nicotine and
alcohol dependency in these early years of life (Xi et al., 2016). Thus,
health-promoting interventions for this age group should specifically
target discouraging the engagement of these two addictive behaviours
simultaneously.
Adolescents who smoked cigarettes or consumed alcohol were more
likely to be sedentary than their non-smoking or non-drinking coun-
terparts, regardless of sex. This is consistent with a previous study that
reported the clustering of television viewing and computer use with
alcohol consumption and tobacco smoking among German adolescents
(Landsberg et al., 2010). Our study also showed that physical inactivity
was associated with low fruit-vegetable consumption in both males and
females. A recent systematic review reported that clustering of obeso-
genic behaviours among adolescents is complex, and sedentary beha-
viour, diet, and physical inactivity cluster differently according to sex
(Loef and Walach, 2012). Prolonged sedentary behaviour can be asso-
ciated with increased snacking while watching television or using a
computer, which may disrupt energy balance by displacing time for
recreational physical activity that in turn can promote adiposity (Uddin
and Khan, 2019). Sedentary behaviour has been found to be negatively
associated with health and well-being among children and adolescents
and has been recognised as an important lifestyle risk behaviour

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R. Uddin, et al. Preventive Medicine 131 (2020) 105955

Females

Males

Overall

Value

60

40

20

(caption on next page)

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R. Uddin, et al. Preventive Medicine 131 (2020) 105955

Fig. 2. Prevalence of three or more lifestyle risk factors in adolescents aged 11–17 years, by sex, Global School-based Student Health Survey, 2007–2016
(n = 304,779).

Table 2
Clustering patterns of lifestyle risk factors in adolescents aged 11–17 years, by sex, Global School-based Student Health Survey, 2007–2016.
# risks SMK ALC iPA SB iF-V Ov-Ob Males Females

O% E% O/E ratio (95% CI) O% E% O/E ratio (95% CI)

0 − − − − − − 1.43 1.15 1.25 (1.06–1.47) 1.49 0.87 1.71 (1.53–1.91)

1 − − − − − + 0.22 0.20 1.08 (0.72–1.60) 0.19 0.14 1.30 (0.94–1.79)
1 − − − − + − 7.04 7.04 1.00 (0.93–1.08) 5.77 5.23 1.10 (1.04–1.17)
1 − − − + − − 0.53 0.47 1.11 (0.87–1.43) 0.46 0.37 1.24 (1.00–1.55)
1 − − + − − − 4.87 4.94 0.99 (0.92–1.06) 6.07 6.35 0.96 (0.90–1.01)
1 − + − − − − 0.15 0.23 0.66 (0.46–0.94) 0.08 0.12 0.72 (0.33–1.57)
1 + − − − − − 0.63 0.18 3.47 (2.91–4.14) 0.03 0.04 0.85 (0.49–1.47)
2 − − − − + + 1.09 1.24 0.88 (0.74–1.04) 0.73 0.86 0.85 (0.72–0.99)
2 − − − + − + 0.13 0.08 1.61 (1.09–2.37) 0.10 0.06 1.64 (1.06–2.52)
2 − − − + + − 2.81 2.89 0.97 (0.88–1.08) 2.10 2.23 0.94 (0.85–1.04)
2 − − + − − + 0.84 0.87 0.97 (0.81–1.14) 1.00 1.05 0.95 (0.83–1.09)
2 − − + − + − 33.25 30.28 1.10 (1.07–1.12) 41.26 38.23 1.08 (1.06–1.10)
2 − − + + − − 1.84 2.03 0.91 (0.81–1.02) 2.48 2.70 0.92 (0.84–1.00)
2 − + − − − + 0.02 0.04 0.61 (0.27–1.37) 0.01 0.02 0.41 (0.11–1.44)
2 − + − − + − 0.74 1.41 0.52 (0.44–0.62) 0.31 0.71 0.44 (0.34–0.57)
2 − + − + − − 0.13 0.09 1.39 (0.83–2.32) 0.08 0.05 1.56 (0.86–2.80)
2 − + + − − − 0.43 0.99 0.44 (0.35–0.54) 0.43 0.86 0.50 (0.40–0.62)
2 + − − − − + 0.05 0.03 1.66 (0.59–4.69) 0.00 0.01 0.40 (0.10–1.62)
2 + − − − + − 0.57 1.10 0.52 (0.39–0.68) 0.08 0.24 0.31 (0.19–0.52)
2 + − − + − − 0.09 0.07 1.26 (0.66–2.39) 0.00 0.02 0.22 (0.07–0.68)
2 + − + − − − 0.55 0.77 0.71 (0.58–0.87) 0.08 0.29 0.26 (0.16–0.42)
2 + + − − − − 0.05 0.04 1.40 (0.80–2.43) 0.00 0.01 0.89 (0.51–1.56)
3 − − − + + + 0.61 0.51 1.20 (0.95–1.53) 0.28 0.37 0.76 (0.61–0.95)
3 − − + − + + 5.12 5.32 0.96 (0.90–1.03) 4.84 6.30 0.77 (0.72–0.81)
3 − − + + − + 0.44 0.36 1.22 (1.00–1.49) 0.56 0.45 1.25 (1.04–1.49)
3 − − + + + − 11.71 12.44 0.94 (0.90–0.98) 17.73 16.27 1.09 (1.06–1.12)
3 − + − − + + 0.15 0.25 0.60 (0.40–0.90) 0.05 0.12 0.41 (0.24–0.70)
3 − + − + − + 0.02 0.02 0.98 (0.40–2.37) 0.01 0.01 0.81 (0.40–1.62)
3 − + − + + − 0.74 0.58 1.27 (1.03–1.56) 0.23 0.30 0.77 (0.54–1.09)
3 − + + − − + 0.08 0.17 0.45 (0.26–0.75) 0.06 0.14 0.41 (0.27–0.61)
3 − + + − + − 3.68 6.07 0.61 (0.56–0.66) 2.72 5.18 0.53 (0.48–0.57)
3 − + + + − − 0.41 0.41 1.01 (0.80–1.28) 0.42 0.37 1.14 (0.91–1.44)
3 + − − − + + 0.09 0.19 0.44 (0.27–0.73) 0.00 0.04 0.10 (0.03–0.36)
3 + − − + − + 0.02 0.01 1.34 (0.39–4.58) 0.00 0.00 0.19 (0.05–0.72)
3 + − − + + − 0.41 0.45 0.90 (0.69–1.17) 0.04 0.10 0.42 (0.26–0.68)
3 + − + − − + 0.11 0.14 0.84 (0.54–1.32) 0.01 0.05 0.27 (0.14–0.54)
3 + − + − + − 3.71 4.75 0.78 (0.71–0.85) 0.44 1.77 0.25 (0.21–0.30)
3 + − + + − − 0.24 0.32 0.77 (0.57–1.03) 0.04 0.13 0.34 (0.18–0.65)
3 + + − − − + 0.04 0.01 6.67 (1.35–32.91) 0.01 0.00 13.65 (4.41–42.22)
3 + + − − + − 0.32 0.22 1.43 (1.10–1.85) 0.07 0.03 2.02 (1.35–3.02)
3 + + − + − − 0.12 0.01 8.31 (5.35–12.91) 0.02 0.00 6.58 (3.32–13.04)
3 + + + − − − 0.28 0.16 1.80 (1.39–2.33) 0.09 0.04 2.38 (1.65–3.41)
4 − − + + + + 2.77 2.18 1.27 (1.16–1.39) 2.70 2.68 1.01 (0.93–1.09)
4 − + − + + + 0.11 0.10 1.06 (0.70–1.62) 0.04 0.05 0.87 (0.57–1.33)
4 − + + − + + 0.54 1.07 0.51 (0.42–0.61) 0.40 0.85 0.47 (0.39–0.57)
4 − + + + − + 0.06 0.07 0.90 (0.47–1.73) 0.09 0.06 1.47 (0.91–2.38)
4 − + + + + − 2.56 2.50 1.03 (0.92–1.14) 2.89 2.20 1.31 (1.20–1.43)
4 + − − + + + 0.05 0.08 0.66 (0.41–1.04) 0.02 0.02 1.07 (0.38–2.98)
4 + − + − + + 0.55 0.83 0.66 (0.54–0.79) 0.14 0.29 0.48 (0.35–0.67)
4 + − + + − + 0.05 0.06 0.83 (0.48–1.43) 0.02 0.02 1.15 (0.44–3.02)
4 + − + + + − 1.51 1.95 0.77 (0.69–0.87) 0.44 0.75 0.59 (0.48–0.71)
4 + + − − + + 0.04 0.04 0.91 (0.62–1.33) 0.03 0.01 5.37 (2.75–10.48)
4 + + − + − + 0.01 0.00 3.62 (1.71–7.66) 0.00 0.00 9.37 (3.00–29.28)
4 + + − + + − 0.32 0.09 3.51 (2.74–4.49) 0.11 0.01 7.81 (5.64–10.83)
4 + + + − − + 0.05 0.03 1.86 (0.97–3.57) 0.03 0.01 4.38 (2.24–8.59)
4 + + + − + − 2.00 0.95 2.10 (1.90–2.32) 0.64 0.24 2.65 (2.28–3.07)
4 + + + + − − 0.29 0.06 4.57 (3.49–5.97) 0.12 0.02 7.14 (5.19–9.81)
5 − + + + + + 0.54 0.44 1.23 (1.01–1.49) 0.39 0.36 1.08 (0.90–1.30)
5 + − + + + + 0.27 0.34 0.78 (0.60–1.01) 0.09 0.12 0.76 (0.53–1.07)
5 + + − + + + 0.05 0.02 3.35 (2.05–5.48) 0.03 0.00 12.29 (7.43–20.34)
5 + + + − + + 0.31 0.17 1.86 (1.51–2.29) 0.19 0.04 4.70 (3.65–6.05)
5 + + + + − + 0.06 0.01 5.12 (2.85–9.20) 0.02 0.00 7.26 (4.01–13.17)
5 + + + + + − 1.76 0.39 4.51 (3.99–5.08) 0.88 0.10 8.62 (7.60–9.77)
6 + + + + + + 0.34 0.07 5.01 (3.94–6.38) 0.33 0.02 19.84 (15.75–24.98)

Abbreviations: SMK = cigarette smoking; ALC = alcohol consumption; iPA = physical inactivity; SB = sedentary behaviour; iF-V = insufficient fruit and vege-
tables; Ov-Ob = overweight and obesity; O = observed; E = expected; (+) positive sign = presence of the risk factor; (−) negative sign = absence of the risk factor.

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R. Uddin, et al. Preventive Medicine 131 (2020) 105955

Table 3
Associationsa between pairs of lifestyle risk factors among adolescents aged 11–17 years, by sex, Global School-based Student Health Survey, 2007–2016.
Risk factor combinations Males Females

Prev (%) OR (95% CI) Prev (%) OR (95% CI)

Smoking and alcohol 6.24 4.11 (3.95–4.26) 3.12 6.81 (6.36–7.29)

Smoking and physical inactivity 11.07 1.01 (0.98–1.05) 3.94 0.93 (0.88–0.99)
Smoking and sedentary behaviour 5.13 1.33 (1.29–1.37) 2.10 1.52 (1.47–1.58)
Smoking and low fruit-vegetable 11.35 0.95 (0.92–0.99) 3.85 1.04 (0.99–1.10)
Smoking and overweight/obese 2.07 0.95 (0.91–0.98) 0.88 1.13 (1.07–1.18)
Alcohol and physical inactivity 13.85 0.96 (0.93–0.98) 10.80 0.94 (0.90–0.97)
Alcohol and sedentary behaviour 7.53 1.35 (1.32–1.38) 6.02 1.42 (1.39–1.46)
Alcohol and low fruit-vegetable 14.51 1.02 (0.98–1.06) 10.41 1.03 (0.99–1.07)
Alcohol and overweight/obese 2.56 1.02 (0.98–1.05) 1.79 1.03 (0.99–1.07)
Physical inactivity and sedentary behaviour 23.07 0.97 (0.96–0.98) 26.46 0.99 (0.98–1.00)
Physical inactivity and low fruit-vegetable 70.68 1.09 (1.07–1.11) 76.05 1.06 (1.05–1.08)
Physical inactivity and overweight/obese 12.31 1.03 (1.01–1.05) 12.53 1.01 (0.99–1.02)
Sedentary behaviour and low fruit-vegetable 24.8 1.01 (0.98–1.03) 25.64 1.04 (1.01–1.06)
Sedentary behaviour and overweight/obese 5.42 1.04 (1.01–1.06) 4.79 1.04 (1.01–1.06)
Low fruit-vegetable and overweight/obese 12.76 1.00 (0.98–1.01) 11.80 0.99 (0.97–1.00)

Abbreviations: CI = confidence interval; OR = odds ratio; prev = prevalence.

a
Adjusted for age, hunger status, survey year, and WHO region.

(Carson et al., 2016). Therefore, by including a broader spectrum of Nations, 2018).

human movement spanning from sedentary behaviour to physical ac-
tivity, this study supports the need to include sedentary behaviour
when examining risk factor clustering for health promotion among
young people. Future interventions should consider how discouraging
sedentary behaviour could be incorporated into effective behavioural
change strategies, especially those linked with other adverse beha-
viours.
In addition to the addictive behaviours (smoking and drinking), two
health-promoting behaviours (physical activity and fruit-vegetable
consumption) demonstrated pairwise clustering in both sexes.
Targeting addictive behaviours, along with health-promoting beha-
viours, has the potential for effective behavioural changes (de Vries
et al., 2008). However, the effectiveness of interventions targeting both
physical activity and healthy diet among young people has been equi-
vocal (De Bourdeaudhuij et al., 2011; Leech et al., 2014). More research
is needed to better understand how these behaviours cluster and in-
teract together, and eventually impact health and wellbeing. In a recent
review examining the clustering of diet, physical activity, and sedentary
behaviour among young people also suggested that cluster membership
varied by socioeconomic status (Leech et al., 2014). Therefore, future
analysis should include more intrapersonal variables to identify at-risk
population to better allocate resources.
Low fruit-vegetable intake and physical inactivity have been iden-
tified as the most prevalent and clustered NCD risk factors among those
examined in this study, underscoring the need for targeting these risk
behaviours with priority, globally. However, the effectiveness of in-
tervening on these behaviours along with other risk behaviours is yet to
be determined (Caleyachetty et al., 2015). Given the context, global
strategies to promote adolescent health and health behaviours were
developed and implemented with the leadership of WHO and United
Nations (United Nations, 2018; World Health Organization, 2018). The
WHO Global Action Plan for Control and Prevention of Non-commu-
nicable Diseases 2018–2030 has offered pragmatic policy options to
address behavioural risk factors to reduce the burden of NCDs (World
Health Organization, 2018). Taking into account the diversity across
regions, culturally and locally appropriate and feasible interventions
should be designed to target clusters of modifiable risk factors at na-
tional and regional levels through national and international colla-
boration and capacity building. Informed by our study, these global
initiatives can be effectively used to promote healthy behaviours of
adolescents, which can help to promote healthy lifestyles and wellbeing
(Sustainable Development Goals: SDG-3) as well as to achieve sex
equality in health-related behaviours early in life (SDG-5) (United
The GSHS is the first survey that allows a global evaluation of be-
havioural risk and protective factors among adolescents; however,
many countries did not participate in this initiative. Having additional
surveillance to triangulate the GSHS data would be beneficial, espe-
cially in the low- and middle-income countries (LMICs) where risk
factor-related data are scarce. This is particularly relevant given that
internationally collaborative research initiatives such as the Active
Healthy Kids Global Alliance's Global Matrices for children and youth
have identified lack of relevant data in LMICs as one of the major
challenges in the current literature (Aubert et al., 2018; Manyanga
et al., 2018). Thus, additional resources should be committed to collect
robust behavioural risk factor data at the regional and country levels,
especially in LMICs, in order to facilitate a sustainable global surveil-
lance and monitoring of trends. At the very least, periodic participation
in the GSHS by all countries across regions should be encouraged.
The strength of this study is the analysis of a very large, mostly
nationally representative, sample of adolescents from 89 countries from
diverse socio-economic and cultural backgrounds. The other strengths
include examination of six behavioural risk factors including sedentary
behaviours and objective measures of height and weight. Use of the
same standardised methods including data collection procedures and
survey items across countries facilitated valid assessment of regional
differences in the risk factors. However, the regional estimates may not
be representative of their respective regions as not all countries across
the regions participated in the GSHS. All lifestyle risk factors, except
overweight/obesity, were self-reported. Although binge or high-in-
tensity drinking is more universally an indicator of health-risk beha-
viour, the current analysis used the prevalence of at least one drink
containing alcohol in the past 30 days, which may not well represent
the level of alcohol exposure among adolescents in many countries. As
the results are based on cross-sectional data, longitudinal studies are
recommended to detect possible changes in the characteristics of clus-
tering of lifestyle risk factors in adolescents.
In conclusion, our findings show that major lifestyle risk factors for
NCDs cluster more frequently than expected among adolescents glob-
ally and differed by sex. This is of a particular concern, as many of these
behaviours acquired during adolescence tend to remain in adulthood,
and each additional risk factor increases future health risk. Our study,
therefore, underscores the need for early prevention programmes tar-
geting common clusters of modifiable risk factors among adolescents
with special emphasis on males and older adolescents. Further in-
vestigation is required at national and regional levels to identify the
best strategies and tools to monitor the lifestyle risk factors starting

7
R. Uddin, et al.
from the early years of life to help inform early and upstream inter-
vention opportunities. Such surveillance can be valuable in under-
standing how the clusters of lifestyle risk factors track from childhood
to adolescence and into adulthood, which in turn can help to mitigate
future burden of NCDs globally.
Authors' contribution
RU and AK were involved in the conception and design of the study,
and extraction and collation of data from the Global School-based
Student Health Survey database. RU and AK analysed the data. RU, E-
YL, SRK, MST, and AK interpreted the data. RU, E-YL, and AK drafted
the article. SRK and MST revised the article critically for important
intellectual content. All authors contributed to, reviewed, and approved
this manuscript.
Acknowledgements
The authors would like to thank the US Centers for Disease Control
and Prevention and the World Health Organization for making the
Global School-based Student Health Survey (GSHS) data publicly
available for analysis. The authors thank the GSHS country co-
ordinators and other staff members.
Declaration of competing interest
The authors declare that they have no conflicts of interest con-
cerning this article.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Ethical approval
In each of the participating countries, the GSHS received ethics
approval from the Ministry of Education or a relevant Institutional
Ethics Review Committee, or both. Only adolescents who provided
written or verbal consent, as well as written consent from their parents,
participated. As the current study used retrospective publicly available
data, we did not seek ethics approval from any Institutional Ethics
Review Committee.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.ypmed.2019.105955.
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