In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Heal hy Li es yle in Child en and Adolescen s and I s
Associa ion wi h Subjec i e Heal h Complain s:
Findings om 37 Coun ies and Regions om he
HBSC S udy
Adilson Ma ques 1,2,* , Yolanda Deme iou 3, Riki Tesle 4,Él io R. Gou eia 5,6,
Miguel Pe al a 1,2 and Ma ga ida Gaspa de Ma os 2,7
1Cen o In e disciplina do Es udo da Pe o mance Humana, Faculdade de Mo icidade Humana,
Uni e sidade de Lisboa, 1499-002 Lisboa, Po ugal
2Ins i u o de Saúde Ambien al, Faculdade de Medicina, Uni e sidade de Lisboa, 1649-028 Lisboa, Po ugal
3Depa men o Spo s and Heal h Sciences, Technical Uni e si y o Munich, 80333 Munich, Ge many
4
Depa men o Heal h Sys ems Managemen , Facul y o Heal h Sciences, A iel Uni e si y, A iel 40700, Is ael
5Depa men o Physical Educa ion and Spo , Uni e si y o Madei a, 9000-082 Funchal, Po ugal
6Madei a In e ac i e Technologies Ins i u e, 9020-105 Funchal, Po ugal
7Faculdade de Mo icidade Humana, Uni e sidade de Lisboa, 1499-002 Lisboa, Po ugal
*Co espondence: [email p o ec ed]; Tel.: (+351)-214-149-100
Recei ed: 16 Augus 2019; Accep ed: 4 Sep embe 2019; Published: 7 Sep embe 2019
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Abs ac :
Backg ound: I is impo an o clea ly unde s and he ac o s associa ed wi h subjec i e
heal h complain s. The s udy aimed o in es iga e he ela ionship be ween subjec i e heal h
complain s, se e al heal h beha io s, and a composi e measu e o heal hy li es yle. Me hods: Da a
we e om he Heal h Beha iou in School-aged Child en (HBSC) 2014 in e na ional da abase.
Pa icipan s we e 167,021 child en and adolescen s, aged 10–16 yea s, om 37 coun ies and egions.
A composi e sco e o heal hy li es yle was c ea ed using a combina ion o daily physical ac i i y, daily
consump ion o ui and ege ables, <2 hou s spen daily in sc een-based beha io s, no d inking,
and no smoking. The subjec i e heal h complain s assessed we e headaches, s omach aches, backache,
dizziness, eeling low, i i abili y, ne ousness, and sleep di icul ies. Resul s: Those who engage
in physical ac i i y e e y day, spend less han wo hou s a day in sc een-based beha io s, do no
d ink alcohol, and do no smoke obacco p esen ed a highe likelihood o no ha ing subjec i e heal h
complain s. A heal hy li es yle was signi ican ly ela ed o ha ing less o all he subjec i e heal h
complain s. Those wi h a heal hy li es yle we e 50% (OR =0.5, 95% CI: 0.5–0.6, p <0.001) less likely
o ha e mul iple heal h complain s. Conclusions: Heal hy beha io s and heal hy li es yles a e ela ed
wi h less subjec i e heal h complain s and less mul iple heal h complain s.
Keywo ds: school-aged child en; heal h; beha io s; li es yle; HBSC
1. In oduc ion
Du ing childhood and adolescence, subjec i e soma ic and psychological complain s such as
headaches, s omach aches, backaches, eeling dizzy, eeling low, being i i a ed, eeling ne ous o
ha ing di icul ies in sleeping a e common [
1
]. Subjec i e heal h complain s inc ease wi h ising age,
mainly among gi ls and you h om lowe socioeconomic s a us [2–5].
Subjec i e heal h complain s can be de ined as symp oms expe ienced wi h o wi hou a medical
diagnosis, and his ep esen s a shi in he c i e ia used o e alua e people’s heal h ou comes.
The adi ional endpoin s used by physicians, such as clinical obse a ion, unc ion es o labo a o y
In . J. En i on. Res. Public Heal h 2019,16, 3292; doi:10.3390/ije ph16183292 www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2019,16, 3292 2 o 14
alues, ha e also been complemen ed, o subs i u ed in some cases by people-o ien ed ou comes [
6
–
8
].
Repo ed subjec i e heal h complain s cons i u e a public heal h conce n because subjec i e heal h
eelings a e linked o heal h ou comes [
6
–
8
]. Among adolescen s, subjec i e heal h complain s a e also
ela ed o d opping-ou o school [
9
] and consequen ly o lowe le els o educa ion in adul hood [
10
],
ep esen ing a unc ional signi icance. In addi ion, subjec i e heal h complain s a e associa ed wi h
physical wellbeing, a e an indica o o men al ill heal h, and may become ch onic pain symp oms and
psychological diso de s in adul hood [5].
As a public heal h conce n, i is impo an o ha e a be e unde s anding o he ac o s associa ed
wi h subjec i e heal h complain s in o de o de elop s a egies o dec ease hei p e alence in
childhood and adolescence, once he e is a connec ion wi h hei heal h s a us. Mo eo e , in his age
g oup, beha io s a e main de e minan s o heal h [
11
]. The mos impo an beha io s associa ed
wi h child en’s and adolescen s’ heal h s a us a e in daily physical ac i i y, spending less han wo
hou s in sc een-based seden a y ime, ha ing a heal hy die , and abs aining om alcohol and obacco
consump ion [
12
,
13
]. Li e a u e has shown ha engaging in physical ac i i y and spending less ime
in sc een-based seden a y beha io s a e ela ed o ewe heal h complain s [
14
–
16
]. Simila ly, smoking
and alcohol consump ion a e subs an ially associa ed wi h he adolescen s’ subjec i e heal h and could
a ec he quali y o li e and lead o a g ea e bu den o ch onic diseases in he u u e [
5
,
17
]. Howe e ,
hus a , a measu e has no been c ea ed ha exp esses a heal hy li es yle and es ablishes a ela ionship
wi h adolescen s’ subjec i e heal h complain s, using a combina ion o se e al heal h beha io s.
Acco ding o he sel -de e mina ion heo y (SDT), mo i a ion adop ed o di e en ac i i ies (e.g.,
pa aking in physical ac i i y o main aining a heal hy die ) depends on he en i onmen al suppo o
indi iduals’ h ee psychological needs: au onomy, compe ence, and ela edness [
18
]. Sa is ac ion om
hese needs depends on en i onmen al suppo [
19
–
21
]. SDT conside s ha mo i a ion is dependen
on con ex , while emphasizing he ole o he en i onmen in mo i a ional change [
22
]. The e o e,
acco ding o SDT, signi ican indi iduals (e.g., eache s o pa en s) ake on a p ima y ole in suppo ing
child en’s and adolescen s’ psychological needs, con ibu ing o hei mo i a ion o a ious ac i i ies.
Beha io s suppo ing au onomy include showing an unde s anding o ano he pe son’s
pe spec i e and o e ing choices. Beha io s suppo ing compe ence include se ing challenging
goals and p o iding in o ma i e eedback. Beha io s suppo ing ela edness include empa hy and
accep ance, in addi ion o minimizing compe i ion [
23
]. Acco ding o SDT, when hese beha io s
a e conduc ed by pa en s in he con ex o hei adolescen ’s physical ac i i y o die ing beha io ,
i impac s hei child en’s mo i a ion o be in ol ed in he physical ac i i y o die p ocess, and plays a
ole in he success o pa aking in physical ac i i ies and die habi s.
Findings om s udies ha e shown ha when engaging in ac i i ies o au onomous easons (i.e.,
enjoying i o iew as impo an ), indi iduals achie e be e esul s and mani es highe wellbeing.
When asks a e aken on o less au onomous easons (e.g., o please o he s o a oid punishmen ),
hey ha e been shown o p oduce lowe achie emen and wellbeing [24].
Joining a ious heal h beha io s o de e mine a heal hy li es yle measu e is an asse ha may
imp o e public heal h guidelines. I could also ep esen a pa adigm shi in he way people hink
abou li es yle as a combina ion o se e al heal hy beha io s. The e o e, he p esen s udy aimed o
in es iga e he ela ionship be ween child en’s and adolescen s’ subjec i e heal h complain s, se e al
heal h beha io s, and a composi e measu e o heal hy li es yle. Fo his s udy, we used a ep esen a i e
wide sample o adolescen s om 37 coun ies and egions in Eu ope, Is ael, and No h Ame ica
(Canada). To he bes o ou knowledge, his is he i s s udy examining he ela ionship be ween
subjec i e heal h complain s and a heal hy li es yle.
In . J. En i on. Res. Public Heal h 2019,16, 3292 3 o 14
2. Ma e ials and Me hods
2.1. Pa icipan s and P ocedu es
Da a was e ie ed om he Heal h Beha io in School-aged Child en (HBSC) 2014 in e na ional
da abase. The me hods and design o he HBSC a e desc ibed elsewhe e [
25
,
26
]. B ie ly, he HBSC is a
Wo ld Heal h O ganiza ion collabo a i e s udy ha is conduc ed e e y 4 yea s in se e al Eu opean
and No he n Ame ican coun ies. The HBSC popula ion a ge a e child en and adolescen s aged
11, 13 and 15, who a end egula schools. The s udy examines heal h beha io s and li es yle o
young people, aiming o gain an unde s anding o hei heal h s a us and well-being. The su ey
is conduc ed in acco dance wi h he e hical guidelines om e hical commi ees om each coun y.
School adminis a o s in each coun y gi e hei consen , and legal gua dians gi e w i en in o med
consen . Pa icipa ion is anonymous and he adminis a ion o he su eys is conduc ed acco ding o
he HBSC s anda d su ey p o ocol [
25
]. The HBSC 2014 su ey sample consis ed o 214,080 pupils
(105,414 boys and 108666 gi ls) a ending g ades 6, 8 and 10. Fo he p esen s udy, eligible pupils we e
hose who epo ed subjec i e heal h complain s (n =198,386) and he ollowing beha io s: physical
ac i i y le els (n =207,980), sc een-based seden a y beha io s (n =188,491), ea ing ui and ege ables
(n =207,966), and alcohol (n =203,383) and obacco consump ion (n =210,395). The esul was a
inal sample size o 167,021 pupils (80,558 boys and 86,463 gi ls) who epo ed bo h subjec i e heal h
complain s and all hea h beha io s, aged 10–16 (mean =13.6
±
1.6), om 37 coun ies and egions
(Albania, Aus ia, Flemish Belgium, F ench Belgium, Bulga ia, Canada, C oa ia, Czech Republic,
Denma k, England, Es onia, F ance, Ge many, G eece, Hunga y, Iceland, I eland, Is ael, I aly, La ia,
Luxembou g, Macedonia, Mal a, Moldo a, he Ne he lands, No way, Poland, Po ugal, Romania,
Russia, Sco land, Slo akia, Slo enia, Spain, Sweden, Swi ze land, and Wales). E hical app o al was
sough om he uni e si ies, e hics boa ds, and o he au ho i ies associa ed wi h he esea ch eam in
each coun y.
2.2. Measu es
2.2.1. Socio-Demog aphic Cha ac e is ics
Pupils epo ed hei gende , age, and school g ade. In o de o assess socioeconomic s a us,
he amily a luence scale was used, which consis s o asking pupils abou amily ca owne ship,
bed oom o hemsel es, holidays, and he numbe o compu e s a home. A e wa ds, a composi e
sco e was calcula ed based on esponses o hese ou i ems, and a h ee-poin o dinal scale was
ob ained: low (0 o 2), middle (3 o 5), and high (6 o 9). The amily a luence scale is a alid measu e
o adolescen s’ weal h, and a p oxy o socioeconomic s a us [27].
2.2.2. Heal hy Li es yle Beha io s and Heal hy Li es yle Composi e Sco e
To assess physical ac i i y, pupils we e eques ed o a e he numbe o days o e he pas week
du ing which hey we e physically ac i e o a o al o a leas 60 minu es pe day. Answe s we e
gi en on an 8-poin scale (0 =none o 7 =daily). Responses we e dicho omized in o
≥
6 imes pe
week and daily, acco ding o he physical ac i i y guidelines [
28
]. Pupils we e asked o indica e he
cus oma y ime (hou s pe day) ha hey spend wa ching ele ision, playing ideogames, and using
he compu e . To al sc een-based beha io was calcula ed by he sum o hese beha io s. The sum o
sc een-based seden a y beha io s was dicho omized in o
≥
2 hou s and <2 hou s daily [
29
]. Boys and
gi ls we e asked o epo he equency wi h which hey ea ui and ege ables. The op ions we e
“ne e ”, “less han once a week”, “once a week”, “2–4 days a week”, “5–6 days a week”, “once e e y
day” and “se e al imes e e y day”. The wo i ems we e dicho omised in o daily and less han
daily because ui and ege able a e ecommend o be ea en e e y day [
30
,
31
]. Pupils we e asked
how o en hey d ank alcohol d inks, such as bee , wine, and liquo /spi i s. Fo each alcoholic d ink,
esponse op ions we e “ne e ,” “ a ely,” “e e y mon h,” “e e y week,” and “e e y day.” Because
In . J. En i on. Res. Public Heal h 2019,16, 3292 4 o 14
alcohol consump ion is ha m ul o adolescen s’ heal h [
32
], esponses we e dicho omised in o d inking
( ega dless o equency) and ne e d inking. Tobacco consump ion was assessed acco ding o ques ion
“how o en do you smoke obacco a p esen ?”. Responses op ions we e “e e y day”, “a leas once a
week, bu no e e y day”, “less han once a week” o “ne e ”. Because he e is no h eshold o sa e y
o smoking, esponses we e ecoded in o cu en smoke ( egula ly o some imes), and non-smoke .
The heal hy li es yle composi e sco e was c ea ed by combining all hese heal hy beha io s. Pupils
sco ed one poin o achie ing each o he ollowing heal hy li es yle ca ego ies: a) daily physical
ac i i y b) daily consump ion o ui and ege ables c) spen <2 daily hou s in sc een-based seden a y
beha io s, d) ne e d inking, and e) ne e smoking. Thus, he heal hy li es yle sco e anged om 0 o
5, wi h only a sco e o 5 ep esen ing a heal hy li es yle.
2.2.3. Subjec i e Heal h Complain s
The subjec i e heal h complain s assessed we e headaches, s omach aches, backache, dizziness,
eeling low, i i abili y, ne ousness, and sleep di icul ies. Child en and adolescen s we e asked o
epo he equency o subjec i e heal h complain s du ing he las six mon hs on a i e-poin scale
anging om 1 =” a ely o ne e ” o 5 =”abou e e y day”.
2.3. Da a Analysis
Subjec i e heal h complain s can be di ided as soma ic complain s (headache, s omach ache,
backache, dizziness) and psychological complain s ( eeling low, i i abili y, ne ousness, sleep
di icul ies) [
33
,
34
], and used oge he o measu e a one-dimensional la en ai o psychosoma ic
complain s [
35
]. An explo a o y ac o analysis and he C onbach’s Alpha, pe o med o in es iga e
he unde lying s uc u e o subjec i e heal h complain s [
33
–
35
], showed ha he solu ion e lec ed
soma ic heal h complain s (
α
=0.705), psychological heal h complain s (
α
=0.722), and psychosoma ic
heal h complain s (
α
=0.811). The e o e, h ee new a iables we e compu ed o calcula e he symp oms’
sco es. Highe alues indica ed highe subjec i e heal h complain s, bu he scales we e e e sed.
In o de o acili a e he in e p e a ion o hese a iables, he ollowing ans o ma ion me ic was
applied:
i
=(z
i×
5) +10. This maps he z-sco es o each a iable on o ‘10’ as he mean alue and ‘5’
as he s anda d de ia ion. Also, a mul iple heal h complain s a iable was c ea ed, ep esen ing hose
who epo ed wo o mo e symp oms mo e han once a week in he pas six mon hs [2,36].
Desc ip i e s a is ics we e calcula ed (means, s anda d de ia ion, and pe cen ages) o all a iables.
Independen Chi-Squa e es and ANOVA we e used o analyze he ela ionship be ween subjec i e
heal h complain s, heal hy beha io s, heal hy li es yle sco e and he pupils’ age g oups. Two models
o logis ic bina y eg ession we e conduc ed o analyze he e ec o he heal hy li es yle sco e on
adolescen s’ heal h complain s, and mul iple heal h complain s. Model 1 was unadjus ed, and model 2
was adjus ed o amily a luence scale and sel - a ed heal h. Finally, a linea eg ession was conduc ed
o analyze he ela ionship be ween heal hy li es yle sco e wi h soma ic symp oms, psychological
symp oms, and psychosoma ic symp oms. A signi ican in e ac ions e ec was obse ed o sex, age,
and heal hy li es yle. Thus, he analysis was s a i ied acco ding o sex and age g oups. S a is ical
analysis was pe o med using SPSS 25 (IBM, Chicago, IL, USA). The signi icance le el was se a
p<0.05.
3. Resul s
Table 1p esen s he cha ac e is ics o he s udy sample. The p e alence o subjec i e heal h
complain s anged om 10.4% (95% CI: 10.3, 10.6) o dizziness o 22.8% (95% CI: 22.6, 23.0) o
i i abili y, and 33.4% (95% CI: 33.2, 33.6) p esen ed mul iple heal h complain s. Abou 20% (19.6%,
95% CI: 19.4, 19.8) o adolescen s engage in physical ac i i y e e y day, 26.3% (95% CI: 26.1, 26.5) spend
less han wo hou s a day in sc een-based beha io s, and 23.4% (95% CI: 23.2, 23.6) had daily ui and
ege ables consump ion. On he o he hand, 61.1% (95% CI: 60.8, 61.3) do no d ink alcohol and 92.1%
In . J. En i on. Res. Public Heal h 2019,16, 3292 5 o 14
(95% CI: 92.0, 92.3) do no smoke obacco. Only 1.9% (95% CI: 1.8, 1.9) o he adolescen s p esen ed a
heal hy li es yle, by adop ing all o hese heal h- ela ed beha io s.
Table 1. Pa icipan s’ cha ac e is ics (n =167,021 adolescen s).
To al % o M (95% CI)
Sex
Boys 48.2 (48.0, 48.5)
Gi ls 51.8 (51.5, 52.0)
Age (yea s) 13.6 (13.6, 13.6)
Age
10–12 yea s 32.3 (32.1, 32.6)
13–14 yea s 35.3 (35.1, 35.5)
15–16 yea s 32.4 (32.2, 32.6)
FAS index 14.0 (14.0, 14.0)
Heal h symp oms (mo e han once a week)
Headache 17.6 (17.5, 17.8)
S omach ache 11.0 (10.8, 11.1)
Backache 13.3 (13.1, 13.4)
Dizziness 10.4 (10.3, 10.6)
Feeling low 17.7 (17.5, 17.9)
I i abili y 22.8 (22.6, 23.0)
Ne ousness 22.2 (22.0, 22.4)
Di icul ies sleeping 21.7 (21.5, 21.9)
Mul iple heal h complain s (mo e han once a week)
Less han 1 complain 66.6 (66.4, 66.8)
≥2 complain s 33.4 (33.2, 33.6)
Physical ac i i y
≤6 days/week 80.4 (80.2, 80.6)
Daily 19.6 (19.4, 19.8)
Sc een-based beha io s
≥2 hou s/day 73.7 (73.5, 73.9)
<2 hou s/day 26.3 (26.1, 26.5)
F ui and ege ables
No daily 76.6 (76.4, 76.8)
Daily 23.4 (23.2, 23.6)
D ink alcohol
D ink 38.9 (38.7, 39.2)
Do no d ink 61.1 (60.8, 61.3)
Smoking
Smoke 7.9 (7.7, 8.0)
Do no smoke 92.1 (92.0, 92.3)
Heal hy li es yle sco e
≤4 heal hy beha io s 98.1 (98.1, 98.2)
5 heal hy beha io s 1.9 (1.8, 1.9)
%, pe cen age; M, mean; CI, con idence in e al; FAS, amily a luence scale.
The ela ionship be ween subjec i e heal h complain s, heal hy beha io s, heal hy li es yle and
age g oups a e p esen ed in Table 2. In gene al, as age inc eases, he e a e mo e heal h complain s
among bo h boys and gi ls. Fu he mo e, o boys, mul iple complain s inc ease signi ican ly om
23.5% (95% CI: 22.4, 24.5) by he age o 10-12 o 27.3% (95% CI: 26.3, 28.4) a he age o 15–16. Among
gi ls, he inc ease is mo e p onounced, om 30.8% (95% CI: 29.8, 31.7) by he age o 10–12 o 50.2% (95%
CI: 49.3, 51.0) a he age o 15–16. Simila ly, he e is also a signi ican inc ease in he le el o soma ic,
psychological, and psychosoma ic symp oms. On he o he hand, as age inc eases, he numbe o
child en and adolescen s who engage in heal hy beha io s dec ease. The a e age o heal hy beha io s
dec ease om 2.6 (95% CI: 2.6, 2.6) o 1.8 (95% CI: 1.7, 1.8) o he boys and om 2.8 (95% CI: 2.8, 2.8) o
1.8 (95% CI: 1.8, 1.8) o he gi ls.

In . J. En i on. Res. Public Heal h 2019,16, 3292 6 o 14
Table 2. Rela ionship be ween subjec i e heal h complain s, heal hy beha io s, and heal hy li es yle compu ed a iable and adolescen s age g oups.
Boys (n =805,58) Gi ls (n =864,63)
10–12 yea s
(260,52)
13–14 yea s
(285,65)
15–16 yea s
(259,41) p10–12 yea s
(279,43)
13–14 yea s
(281,55)
15-16 yea s
(864,63) p
Heal h symp oms 1, a
Headache 11.9 (10.8, 13.0) 12.1 (11.0, 13.2) 12.1 (11.0, 13.3) 0.719 16.5 (15.4, 17.6) 22.5 (21.5, 23.5) 29.5 (28.6, 30.5) <0.001
S omach ache 8.3 (7.1, 9.5) 7.3 (6.2, 8.5) 6.5 (5.3, 7.7) <0.001 13.3 (12.2, 14.3) 14.1 (13.0, 15.1) 15.5 (14.4, 16.6) <0.001
Backache 8.5 (7.3, 9.7) 10.8 (9.7, 11.9) 12.9 (11.7, 14.0) <0.001 10.6 (9.5, 11.7) 15.7 (14.7, 16.7) 20.7 (20.0, 22.1) <0.001
Dizziness 7.2 (6.0, 8.4) 7.7 (6.6, 8.8) 8.2 (7.0, 9.3) <0.001 9.2 (8.0, 10.3) 13.7 (12.6, 14.7) 16.2 (15.1, 17.3) <0.001
Feeling low 10.9 (9.8, 12.1) 11.0 (9.9, 12.1) 13.4 (12.3, 14.5) <0.001 15.2 (8.0, 10.3) 24.1 (12.6, 14.7) 30.1 (15.1, 17.3) <0.001
I i abili y 15.6 (–1.2, 1.2) 17.8 (16.8, 18.9) 19.8 (18.7, 20.9) <0.001 18.6 (17.6, 19.7) 28.6 (27.7, 29.6) 35.2 (34.3, 36.2) <0.001
Ne ousness 15.2 (14.1, 16.3) 17.0 (15.9, 18.0) 18.9 (17.8, 20.0) <0.001 18.3 (17.3, 19.4) 28.3 (27.4, 29.3) 34.2 (33.2, 35.1) <0.001
Di icul ies sleeping 18.4 (17.3, 19.5) 17.6 (16.6, 18.7) 18.2 (17.1, 19.3) 0.056 21.0 (19.9, 22.0) 25.5 (24.6, 26.5) 28.6 (27.6, 29.6) <0.001
Mul iple complain s 1, a <0.001 <0.001
Less han 1 complain 76.5 (75.9, 77.1) 75.0 (74.4, 75.6) 72.7 (72.0, 73.3) 69.2 (68.6, 69.9) 58.0 (57.3, 58.8) 49.8 (49.0, 50.7)
≥2 complain s 23.5 (22.4, 24.5) 25.0 (24.0, 26.0) 27.3 (26.3, 28.4) 30.8 (29.8, 31.7) 42.0 (41.1, 42.8) 50.2 (49.3, 51.0)
Soma ic symp oms b8.7 (8.6, 8.7) 9.1 (9.0, 9.1) 9.4 (9.3, 9.4) <0.001 9.5 (9.5, 9.6) 10.9 (10.9, 11.0) 12.1 (12.1, 12.2) <0.001
Psychological symp oms b8.7 (8.6, 8.8) 9.1 (9.0, 9.1) 9.4 (9.3, 9.4) <0.001 9.3 (9.3, 9.4) 11.1 (11.0, 11.1) 12.3 (12.2, 13.3) <0.001
Psychosoma ic symp oms b8.5 (8.5, 8.6) 9.0 (8.9, 9.0) 9.4 (9.4, 9.5) <0.001 9.3 (9.3, 9.4) 11.1 (11.1, 11.2) 12.4 (12.4, 12.5) <0.001
Physical ac i i y (daily) b29.2 (28.1, 30.2) 24.0 (23.0, 25.0) 20.4 (19.3, 21.4) <0.001 20.0 (18.9, 21.0) 14.6 (13.6, 15.7) 10.6 (9.5, 11.7) <0.001
Sc een-based beha io s (≤2 hou s/day)a33.0 (32.0, 34.0) 20.3 (19.3, 21.3) 15.9 (14.8, 17.0) <0.001 44.2 (43.3, 45.0) 24.9 (23.9, 25.8) 19.4 (18.3, 20.4) <0.001
F ui and ege ables (daily) a23.9 (22.8, 25.0) 19.6 (18.6, 20.7) 18.3 (17.2, 19.4) <0.001 29.1 (28.1, 30.1) 24.8 (23.8, 25.8) 24.5 (23.5, 25.5) <0.001
D ink alcohol (do no d ink) a74.5 (73.8, 75.1) 60.5 (59.8, 61.3) 37.2 (36.2, 38.1) <0.001 84.9 (84.4, 85.3) 67.2 (66.5, 67.8) 41.0 (40.1, 41.9) <0.001
Smoking (do no smoke) a98.0 (97.9, 98.2) 94.2 (93.9, 94.5) 84.0 (83.5, 84.5) <0.001 98.9 (98.8, 99.0) 94.0 (93.7, 94.3) 83.5 (83.0, 83.9) <0.001
Heal hy li es yle (5 heal hy beha io s) a3.2 (2.0, 4.4) 1.3 (0.2, 2.5) 0.7 (–0.5, 2.0) <0.001 3.8 (2.6, 4.9) 1.5 (0.4, 2.6) 0.7 (–0.5, 1.8) <0.001
Heal h li es yle sco e b2.6 (2.6, 2.6) 2.2 (2.2, 2.2) 1.8 (1.7, 1.8) <0.001 2.8 (2.8, 2.8) 2.3 (2.2, 2.3) 1.8 (1.8, 1.8) <0.001
Abb e ia ion: M, mean; SD, s anda d de ia ion; FAS, amily a luence scale.
1
Heal h symp oms and mul iple heal h complain s we e mo e han once a week. Di e ences we e es ed by
Qui-squa e and ANOVA. a% (95% CI). bMean (95% CI).
In . J. En i on. Res. Public Heal h 2019,16, 3292 7 o 14
Table 3p esen s he associa ion be ween he heal hy li es yle sco e and pupils’ heal h complain s.
Fo boys and gi ls, in all age g oups, i is obse ed ha a highe heal hy li es yle sco e dec eases he
likelihood o child en and adolescen s ha ing heal h complain s mo e han once a week. This was
obse ed in he c ude model, and e en when he analysis was adjus ed o he amily a luence scale
and sel - a ed heal h, he esul s emained simila .
Resul s o he ela ionship be ween heal hy li es yle sco e and psychosoma ic symp oms a e
p esen ed in Table 4. A highe heal hy li es yle sco e is nega i ely co ela ed wi h soma ic, psychological,
and psychosoma ic symp oms, among boys and gi ls, in each age g oup. The obse ed co ela ion
emained signi ican , e en a e adjus ing he model o amily a luence scale and sel - a ed heal h.
The ela ionship be ween psychosoma ic symp oms and a heal hy li es yle sco e, by sex and
coun y, is shown in Figu e 1. Rega dless o sex and coun y, a highe heal hy li es yle sco e is
signi ican ly and nega i ely co ela ed wi h psychosoma ic symp oms. Among boys, a highe dec ease
in symp oms when leading a heal hy li es yle was especially obse ed in G eece (
β
=–0.91, 95% CI:
–1.10, –0.73), I eland (
β
=–0.92, 95% CI: –1.13, –0.71), and Is ael (
β
=–0.99, 95% CI: –1.29, –0.69).
Among gi ls, he heal hy li es yle sco e had a highe impac on child en and adolescen s om Sco land
(
β=–1.23
, 95% CI: –1.43, –1.04), Swi ze land (
β
=–1.23, 95% CI: –1.44, –1.02), and I aly (
β
=–1.29, 95%
CI: –1.49, –1.10).
In . J. En i on. Res. Public Heal h 2019, 16, x 10 o 15
The ela ionship be ween psychosoma ic symp oms and a heal hy li es yle sco e, by sex and 11
coun y, is shown in Figu e 1. Rega dless o sex and coun y, a highe heal hy li es yle sco e is 12
signi ican ly and nega i ely co ela ed wi h psychosoma ic symp oms. Among boys, a highe 13
dec ease in symp oms when leading a heal hy li es yle was especially obse ed in G eece (β = –0.91, 14
95% CI: –1.10, –0.73), I eland (β = –0.92, 95% CI: –1.13, –0.71), and Is ael (β = –0.99, 95% CI: –1.29, –15
0.69). Among gi ls, he heal hy li es yle sco e had a highe impac on child en and adolescen s om 16
Sco land (β = –1.23, 95% CI: –1.43, –1.04), Swi ze land (β = –1.23, 95% CI: –1.44, –1.02), and I aly (β = 17
–1.29, 95% CI: –1.49, –1.10). 18
19
20
Figu e 1. Rela ionship be ween psychosoma ic symp oms and a heal hy li es yle sco e, by sex and 21
coun y. 22
4. Discussion 23
This s udy esul s showed ha subjec i e heal h complain s a e equen du ing adolescence, 24
wi h almos one- hi d epo ing mul iple heal h complain s. I i abili y is he mos common 25
complain . On he o he hand, only 1.9% o he adolescen s p esen ed a heal hy li es yle (i.e. hose 26
who achie ed all i e heal hy beha io s). This s udy adds no el in o ma ion o he li e a u e, 27
showing ha bo h indi idual heal hy beha io s and a heal hy li es yle (a combina ion o indi idual 28
heal h beha io s) beha io we e ela ed wi h ewe subjec i e heal h complain s and ewe mul iple 29
heal h complain s. 30
Bo h he bene i s o physical ac i i y and he ha m ul e ec o sc een-based seden a y beha io s 31
on heal h a e well documen ed [37,38]. Physical ac i i y is ela ed wi h less heal h complain s, such 32
as i i abili y, ne ousness, and musculoskele al complain s [14,39]. On he o he hand, he e is a 33
posi i e associa ion be ween sc een-based beha io s, musculoskele al pain, backache, dep ession, 34
Figu e 1.
Rela ionship be ween psychosoma ic symp oms and a heal hy li es yle sco e, by sex
and coun y.
In . J. En i on. Res. Public Heal h 2019,16, 3292 8 o 14
Table 3. Associa ion be ween heal hy li es yle sco e and adolescen s’ heal h complain s.
Heal h Complain s Mo e han
Once a Week
Heal hy Li es yle Sco e OR (95% CI)
Model 1 Model 2
Boys 10–12 yea s 13–14 yea s 15–16 yea s 10–12 yea s 13–14 yea s 15–16 yea s
Headache 0.82 (0.78, 0.85) 0.81 (0.78, 0.84) 0.82 (0.79, 0.85) 0.88 (0.84, 0.92) 0.87 (0.84, 0.91) 0.88 (0.84, 0.92)
S omach ache 0.80 (0.77, 0.84) 0.81 (0.77, 0.85) 0.81 (0.77, 0.86) 0.87 (0.83, 0.91) 0.88 (0.83, 0.92) 0.88 (0.83, 0.93)
Backache 0.81 (0.77, 0.85) 0.83 (0.80, 0.86) 0.86 (0.82, 0.89) 0.87 (0.83, 0.91) 0.88 (0.84, 0.92) 0.91 (0.88, 0.95)
Dizziness 0.79 (0.75, 0.83) 0.83 (0.79, 0.87) 0.82 (0.78, 0.86) 0.86 (0.81, 0.91) 0.90 (0.86, 0.94) 0.89 (0.85, 0.93)
Feeling low 0.79 (0.76, 0.82) 0.77 (0.74, 0.81) 0.81 (0.78, 0.85) 0.86 (0.83, 0.90) 0.84 (0.81, 0.88) 0.89 (0.86, 0.93)
I i abili y 0.75 (0.73, 0.78) 0.75 (0.73, 0.78) 0.79 (0.77, 0.82) 0.81 (0.78, 0.84) 0.80 (0.78, 0.83) 0.85 (0.82, 0.88)
Ne ousness 0.79 (0.77, 0.82) 0.80 (0.78, 0.83) 0.81 (0.78, 0.83) 0.84 (0.81, 0.87) 0.85 (0.82, 0.88) 0.85 (0.83, 0.88)
Di icul ies sleeping 0.83 (0.80, 0.85) 0.84 (0.81, 0.86) 0.86 (0.83, 0.88) 0.88 (0.85, 0.91) 0.89 (0.86, 0.92) 0.92 (0.89, 0.95)
Mul iple heal h complain s 0.76 (0.73, 0.78) 0.78 (0.75, 0.80) 0.79 (0.77, 0.81) 0.82 (0.79, 0.85) 0.84 (0.81, 0.86) 0.85 (0.83, 0.88)
Gi ls 10–12 yea s 13–14 yea s 15–16 yea s 10–12 yea s 13–14 yea s 15–16 yea s
Headache 0.82 (0.80, 0.85) 0.75 (0.73, 0.78) 0.80 (0.78, 0.82) 0.90 (0.87, 0.94) 0.83 (0.81, 0.86) 0.86 (0.84, 0.89)
S omach ache 0.85 (0.82, 0.88) 0.74 (0.72, 0.77) 0.76 (0.74, 0.79) 0.88 (0.88, 0.96) 0.81 (0.79, 0.84) 0.83 (0.80, 0.86)
Backache 0.83 (0.80, 0.87) 0.80 (0.77, 0.83) 0.85 (0.83, 0.88) 0.91 (0.87, 0.95) 0.87 (0.84, 0.89) 0.92 (0.89, 0.95)
Dizziness 0.82 (0.78, 0.86) 0.74 (0.71, 0.76) 0.82 (0.79, 0.84) 0.92 (0.87, 0.96) 0.82 (0.79, 0.85) 0.90 (0.87, 0.93)
Feeling low 0.77 (0.74, 0.79) 0.66 (0.64, 0.68) 0.74 (0.72, 0.76) 0.85 (0.82, 0.87) 0.73 (0.71, 0.76) 0.81 (0.79, 0.83)
I i abili y 0.75 (0.72, 0.77) 0.66 (0.64, 0.68) 0.73 (0.71, 0.74) 0.81 (0.78, 0.84) 0.73 (0.69, 0.73) 0.78 (0.76, 0.80)
Ne ousness 0.78 (0.75, 0.80) 0.73 (0.71, 0.75) 0.80 (0.78, 0.82) 0.83 (0.80, 0.86) 0.78 (0.76, 0.81) 0.86 (0.84, 0.88)
Di icul ies sleeping 0.84 (0.81, 0.86) 0.77 (0.75, 0.79) 0.82 (0.79, 0.84) 0.90 (0.87, 0.93) 0.83 (0.80, 0.85) 0.87 (0.85, 0.86)
Mul iple heal h complain s 0.76 (0.74, 0.78) 0.68 (0.66, 0.70) 0.75 (0.73, 0.76) 0.84 (0.81, 0.86) 0.74 (0.72, 0.76) 0.81 (0.79, 0.83)
Abb e ia ion: OR, odds a io; CI, con idence in e al. Less han once a week is he e e ence ca ego y o all adolescen s’ heal h complain s and mul iple heal h complain s. Model 1:
unadjus ed. Model 2: analysis we e adjus ed o amily a luence scale and sel - a ed heal h.
In . J. En i on. Res. Public Heal h 2019,16, 3292 9 o 14
Table 4. Rela ionship be ween heal hy li es yle sco e and psychosoma ic symp oms.
Heal hy Li es yle Sco e β(95% CI)
Model 1 Model 2
Boys 10–12 yea s 13–14 yea s 15–16 yea s 10–12 yea s 13–14 yea s 15–16 yea s
Soma ic symp oms –0.54 (–0.60, –0.49) –0.94 (–1.00, –0.88) –0.81 (–0.87, –0.75) –0.37 (–0.43, –0.32) –0.38 (–0.43, –0.32) –0.33 (–0.38, –0.27)
Psychological symp oms –0.64 (–0.70, –0.58) –0.69 (–0.75, –0.64) –0.66 (–0.71, –0.60) –0.46 (–0.52. –0.40) –0.51 (–0.56, –0.46) –0.45 (–0.51, –0.40)
Psychosoma ic symp oms –0.66 (–0.72, –0.61) –0.70 (–0.75, –0.65) –0.66 (–0.72, –0.61) –0.47 (–0.52, –0.41) –0.50 (–0.55, –0.45) –0.44 (–0.49, –0.39)
Gi ls 10–12 yea s 13–14 yea s 15–16 yea s 10–12 yea s 13–14 yea s 15–16 yea s
Soma ic symp oms –0.60 (–0.66, –0.54) –0.54 (–0.61, –0.50) –0.52 (–0.57, –0.46) –0.35 (–0.41, –0.29) –0.64 (–0.70, –0.58) –0.50 (–0.56, –0.45)
Psychological symp oms –0.79 (–0.85, –0.73) –1.19 (–1.25, –1.23) –0.94 (–0.99, –0.88) –0.55 (–0.61, –0.49) –0.89 (–0.95, –0.83) –0.66 (–0.72, –0.60)
Psychosoma ic symp oms –0.78 (–0.84, –0.72) –1.20 (–1.25, –1.39) –0.97 (–1.03, –0.92) –0.51 (–0.57, –0.45) –0.86 (–0.92, –0.81) –0.66 (–0.71, –0.60)
Abb e ia ion: CI, con idence in e al. Model 1: unadjus ed. Model 2: analysis was adjus ed o amily a luence scale and sel - a ed heal h.