primary schools, children, childhood obesity, nutrition environment, school food environment


Introduction: Childhood obesity remains a global public health challenge. 

Aim: Using WHO COSI-6th round data, the aim of this study was to depict availability of select foods, dairy and beverages in a nationally representative sample of primary schools across North Macedonia.

Material and methods: Data were drawn from the WHO COSI-6th round conducted in North Macedonia in 2022. A designated official (n=111) at the respective primary school reported availability of the following: (1) food (fruits, vegetables, ice cream, sweet snacks, and savory snacks), (2) dairy (milk, yogurt, and/or ayran), (3) beverages without added sugar (water, tea, and fruit juices), and (4) beverages with added sugar (non-carbonated fruit juices, carbonated drinks, hot drinks [e.g., cocoa], and flavored milk).  Additionally, the designated school official reported whether their primary school had a canteen and/or shop/cafeteria where foods or beverages could be purchased.

Results: Across primary schools in North Macedonia, availability of healthy options (i.e., fruits and vegetables) was lower as compared to energy-dense selections (i.e., sweet and savory snacks). Overall, 18.3% of schools offered dairy products (including milk, yogurt, and ayran).  Water was the most commonly available (69.0%) beverage.  No significant differences emerged in availability of food, dairy, beverages without added sugar or beverages with added sugar across primary school enrollment (small versus large).  Less than one-fifth of primary schools had a canteen (17.4%) and/or shop/cafeteria (14.4%) where foods or beverages could be purchased.

Conclusion: In conclusion, access to food, dairy, and beverages for primary school children in North Macedonia was limited. 


Gurnani M, Birken C, Hamilton. J. Childhood obesity: causes, consequences, and management. Pediatr Clin North Am 2015; 62(4): 821-840. doi: 10.1016/j.pcl.2015.04.001.

Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS. Childhood obesity: causes and consequences. J Family Med Prim Care 2015; 4(2): 187-192. doi: 10.4103/2249-4863.154628.

Brown CL, Halvorson EE, Cohen GM, Lazorick S, Skelton JA. Addressing childhood obesity: opportunities for prevention. Pediatr Clin North Am 2015; 62(5): 1241-1261. doi: 10.1016/j.pcl.2015.05.013.

World Health Organization. WHO European regional obesity report 2022. World Health Organization. Regional Office for Europe. Available at:

UNICEF. The state of the world’s children 2019. Children, Food and Nutrition: Growing Well in a Changing World. UNICEF, New York.

Grigsby-Duffy L, Brooks R, Boelsen-Robinson T, Blake MR, Backholer K, Palermo C, et al. The impact of primary school nutrition policy on the school food environment: a systematic review. Health Promot Int 2022; 37(5): daac084. doi: 10.1093/heapro/daac084.

World Health Organization (WHO). WHO European Childhood Obesity Surveillance Initiative—Implementation of round 1 (2007/2208) and round 2 (2009/2010). Available at:

Breda J, McColl K, Buoncristiano M, Williams J, Abdrakhmanova S, Abdurrahmonova Z, et al. Methodology and implementation of the WHO European Childhood Obesity Surveillance Initiative (COSI). Obesity Rev 2021; 22(S6): e13215. doi:10.1111/obr.13215.

Korzycka M, Jodkowska M, Oblacińska A, Fijałkowska A. Nutrition and physical activity environments in primary schools in Poland - COSI study. Ann Agric Environ Med 2020; 27(4): 605-612. doi: 10.26444/aaem/114223.






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