Patterns of alcohol consumption and risk of falls in older adults: a prospective cohort study.

Falls are a major health problem in older adults, but their relationship with alcohol consumption in this population remains unclear. In a cohort with 2170 older adults followed up for 3.3 years, both moderate drinking and the Mediterranean drinking pattern were associated with a lower risk of falls and injurious falls. INTRODUCTION: This study aims to examine the association between certain patterns of alcohol consumption, including the Mediterranean drinking pattern (MDP), and the risk of falls in older adults. METHODS: A prospective cohort with 2170 community-dwelling individuals aged ≥60 years was recruited in Spain in 2008-2010 and followed up through 2012. At baseline, participants reported alcohol consumption and, at the end of follow-up, their falls during the previous year. The MDP was defined as moderate alcohol consumption (threshold between moderate and heavy intake was 40 g/day for men and 24 g/day for women) with preference for wine and drinking only with meals. Analyses were conducted with negative binomial or logistic regression, as appropriate, and adjusted for the main confounders. RESULTS: Compared with never drinkers, the number of falls was lower in moderate drinkers (incidence rate ratio (95% confidence interval), 0.79 (0.63-0.99)) and drinkers with MDP (0.73 (0.56-0.96)). Also, moderate drinkers and those with MDP showed a lower risk of ≥2 falls (odds ratio (95% confidence interval), 0.58 (0.38-0.88) and 0.56 (0.34-0.93), respectively) and of falls requiring medical care (0.67 (0.46-0.96) and 0.61 (0.39-0.96), respectively). CONCLUSION: Both moderate drinking and the MDP were associated with a lower risk of falls and injurious falls in older adults. However, sound advice on alcohol consumption should balance risks and benefits.

Association of the duration of residence with obesity-related eating habits and dietary patterns among Latin-American immigrants in Spain.

The dietary patterns of immigrants usually change with the duration of residence and progressively resemble those of the host country. However, very few studies have investigated individuals migrating to countries with a high-quality diet, such as the Mediterranean diet (MD), and none has yet focused on Latin-American immigrants. The present study examined the association of the duration of residence with obesity-related eating habits and dietary patterns among Latin-American immigrants residing in Spain. A cross-sectional study was conducted in 2008-10 in a representative sample of the adult population residing in Spain. Adherence to the MD was defined as a MD Adherence Screener score ≥ 9. Analyses were conducted by including 419 individuals aged 18-64 years born in Latin-American countries. Compared with immigrants residing in Spain for < 5 years, those residing for ≥ 10 years accounted for a lower percentage of individuals who habitually ate at fast-food restaurants and never trimmed visible fat from meat. Moreover, these immigrants were found to have a lower intake of sugary beverages and a higher intake of Na, saturated fat, fibre, olive oil, vegetables and fish and to more frequently strictly adhere to the MD. A longer duration of residence in Spain was found to be associated with both healthy and unhealthy changes in some eating habits and dietary patterns among Latin-American immigrants. Some of the healthy changes observed contrasted the 'Westernisation' of the diet reported in studies conducted in other Western countries. The results of the present study support the role of the food environment of the host country in the modification of the dietary patterns of immigrants.

Physical Activity, Sitting Time and Mortality in Older Adults with Diabetes.

The purpose of this study was to examine the independent and combined association of physical activity (PA) and sitting time (ST) with all-cause mortality in older adults with diabetes. A total of 611 individuals representative of the Spanish diabetic population aged ≥ 60 years. Participants were selected in 2000/2001 and were prospectively followed-up through 2011. PA and ST were self-reported at baseline. Study associations were summarized as hazard ratios (HR) and their 95% confidence interval (CI). During a mean follow-up of 8.3 years, 282 deaths occurred. The HR (95% CI) of mortality for very/moderately active individuals compared to those who were inactive/less active was 0.59 (0.45, 0.78). The association between ST and mortality was non-linear (P<0.001 in spline analysis), and mortality was increased only among individuals who reported a ST>8 h/day (HR=1.77, 95% CI 1.25, 2.52). The HR (95% CI) of mortality was 0.50 (0.32, 0.77) in participants who either were very/moderately active or had ST≤8 h/day, and 0.32 (0.20, 0.50) in those with both health behaviors, compared to those with none of these behaviors. In conclusion, among older adults with diabetes, high PA and less ST are independently and jointly associated with lower risk of all-cause mortality.

Alcohol drinking patterns and biomarkers of coronary risk in the Spanish population.

BACKGROUND AND AIMS: To estimate the association between patterns of alcohol consumption and biomarkers of coronary heart disease (CHD) risk. METHODS AND RESULTS: Cross-sectional study among 10,793 individuals representative of the Spanish population aged ≥ 18 years. The threshold between moderate and heavy drinking was 40 g of alcohol/day in men and 24 g/day in women. Binge drinking was defined as intake of ≥ 80 g of alcohol in men and ≥ 60 g in women at any drinking occasion in the preceding 30 days. Analyses were performed with generalized linear models with adjustment for the main confounders, and results were expressed as the percentage change in the geometric mean (PCGM). Compared to non-drinkers, moderate and heavy drinkers had progressively higher serum HDL-cholesterol, with a PCGM ranging from 4.8% (95% CI: 3.7-6.0%) in moderate drinkers without binge drinking (MNB) to 9.6% (5.1-14.2%) in heavy drinkers with binge drinking (HB). Fibrinogen decreased progressively with alcohol intake, from -2.2% (-3.1 to -1.3%) in MNB to -5.8% (-9.4 to -2.0%) in HB. Leptin, glycated hemoglobin and the HOMA-index also decreased with increasing alcohol intake, and particularly with binge drinking. CONCLUSIONS: Moderate alcohol intake is associated with improved HDL-cholesterol, fibrinogen and markers of glucose metabolism, which is consistent with the reduced CHD risk of moderate drinkers in many studies. Heavy and binge drinking were also associated with favorable levels of CHD biomarkers; since these drinking patterns produce substantial health harms, our results should not be used to promote alcohol consumption.

Is a specific drinking pattern a consistent feature of the Mediterranean diet in Spain in the XXI century?

BACKGROUND AND AIM: Over the last 50 years, people in Spain have increasingly been eating their main meal away from home and are shifting from the typical Mediterranean diet (MD). In addition, wine consumption has decreased whereas beer intake has risen. Consequently, it is uncertain if the Mediterranean drinking pattern (MDP; moderate alcohol intake mainly from wine and during meals) is a habitual feature of the MD today. METHODS AND RESULTS: Cross-sectional study conducted from 2008 to 2010 among 8894 individuals representative of the Spanish population aged 18-64 years. Consumption of alcoholic beverages and food was collected with a validated diet history. Accordance with the MD was defined as a score ≥8 on the Mediterranean Diet Adherence Screener (MEDAS) or ≥5 in the Trichopoulou index (after excluding alcohol intake from both indices). Among individuals with MEDAS-based MD accordance, only 17.1% had a MDP. After adjustment for potential confounders, this drinking pattern showed a weak association with higher MD accordance (odds ratio (OR) 1.32; 95% confidence interval (CI) 1.12-1.57). Only 14.7% of those with Trichopoulou-based MD accordance had a MDP; this pattern showed an even weaker association with higher MD accordance (OR 1.17; 95% CI 1.01-1.36). Similar results were obtained when this drinking pattern was redefined to include persons who drank wine with or outside of meals, as well as those who were primarily beer drinkers. CONCLUSIONS: The MDP is not a habitual feature of the MD in the early XXI century in Spain.

Consumption of fried foods and weight gain in a Mediterranean cohort: the SUN project.

BACKGROUND AND AIMS: The consumption of fried foods is believed to be linked with obesity and higher weight gain, however, the evidence from long-term randomized trials or prospective epidemiological studies is scarce. Therefore, the aim of our study was to prospectively evaluate the association between the consumption of fried foods and weight change and the incidence of overweight/obesity in a Mediterranean cohort. METHODS AND RESULTS: Prospective cohort study of 9850 men and women with a mean age of 38.1 years (SD 11.4) were followed-up for a median of 6.1 years to assess average yearly change in body weight, and incidence of overweight/obesity. The consumption of fried foods was associated with higher weight gain, but the differences were of small magnitude and statistically non-significant. The incidence of overweight/obesity during follow-up was also assessed in the subset of 6821 participants with initial body mass index <25 kg/m(2) (initially free of overweight/obesity), after adjusting for potential confounders, the odds ratio for developing overweight/obesity among participants who consumed fried foods >4 times/week was 1.37 (95% confidence interval: 1.08 to 1.73) in comparison with those who consumed fried foods <2 times/week (p for trend = 0.02). CONCLUSION: In this Mediterranean prospective cohort, a more frequent consumption of fried foods at baseline was associated with a higher risk of subsequently developing overweight/obesity during follow-up.

Major dietary patterns and risk of coronary heart disease in middle-aged persons from a Mediterranean country: the EPIC-Spain cohort study.

BACKGROUND AND AIM: No previous study has assessed the association between major dietary patterns and the risk of coronary heart disease (CHD) in a large cohort from a Mediterranean country. METHODS AND RESULTS: We studied prospectively 40,757 persons, aged 29-69 years, participating in the Spanish cohort of the EPIC study. Food consumption was collected between 1992 and 1996 with a validated history method. Individuals were followed-up until 2004 through record linkage with hospital discharge registers, population-based registers of myocardial infarction, and mortality registers to ascertain CHD events (fatal and non-fatal acute myocardial infarction or angina requiring revascularization). Two major dietary patterns were identified from factor analysis. The first pattern was labeled as Westernized, because of the frequent consumption of refined cereals and red meat; the second was called the evolved Mediterranean pattern, because of the frequent intake of plant-based foods and olive oil. During a median follow-up of 11 years, 606 CHD events were ascertained. No association was found between the Westernized pattern and CHD risk. In contrast, the score for the evolved Mediterranean pattern was inversely associated with CHD risk (p for trend = 0.0013); when compared with the lowest quintile of the evolved Mediterranean pattern score, the multivariable hazard ratios for CHD were 0.77 (95% confidence interval 0.61-0.98) for the second quintile, 0.64 (95% CI 0.50-0.83) for the third quintile, 0.56 (95% CI 0.43-0.73) for the fourth quintile, and 0.73 (95% CI 0.57-0.94) for the fifth quintile. CONCLUSION: A Mediterranean diet, as consumed in this study population, was associated with a lower risk of CHD.

High-quality intake of carbohydrates is associated with lower prevalence of subclinical atherosclerosis in femoral arteries: The AWHS study.

BACKGROUND AND AIMS: High-quality of the carbohydrates consumed, apart from their total amount, appear to protect from cardiovascular disease (CVD). However, the relationship between the quality of carbohydrates and the early appearance of atherosclerosis has not yet been described. Our objective was to estimate the association between the quality of dietary carbohydrates and subclinical atherosclerosis in femoral and carotid arteries. METHODS: Cross-sectional study of femoral and carotid atherosclerosis assessed using ultrasounds of 2074 middle-aged males, 50.9 (SD 3.9) years old, with no previous CVD, and pertaining to the Aragon Workers' Health Study (AWHS) cohort. Food frequency questionnaires were used to calculate a carbohydrate quality index (CQI) defined as: consumption of dietary fiber, a lower glycemic index, the ratio of whole grains/total grains, and the ratio of solid carbohydrates/total carbohydrates. The presence of plaques across four CQI intervals was studied using adjusted logistic regression models. RESULTS: The CQI showed a direct inverse association with subclinical atherosclerosis in femoral territories. Participants with a higher consumption of high-quality carbohydrates (13-15 points) were less likely to have femoral plaques when compared with participants in the lowest index interval (4-6 points) (OR = 0.59; 95% CI = 0.39, 0.89; p = 0.005). No association was found between the CQI and the presence of subclinical atherosclerosis in carotid territories. A lower consumption of high-quality carbohydrates tended to be associated with a greater atherosclerosis extension, considered as the odds for having more affected territories (p = 0.011). CONCLUSIONS: Among middle-aged males, a high-quality intake of carbohydrates is associated with a lower prevalence of femoral artery subclinical atherosclerosis when compared with a lower consumption. Thus, indicating an early relationship between the quality of carbohydrates and the development of CVD.

Trends in overweight and misperceived overweight in Spain from 1987 to 2007.

OBJECTIVE: To examine trends in overweight and misperceived overweight in adults (≥ 20 years) and children (5-15 years) of Spain from 1987 to 2007. METHODS: Data were obtained from five cross-sectional studies, representative of the population of Spain in 1987, 1995, 1997, 2001 and 2006/2007. Self-reported weight and height were used to obtain the body mass index (BMI). Overweight was defined in adults as BMI of ≥ 25 kg m⁻², and in children using age- and sex-specific BMI cutoffs proposed by the International Obesity Task Force. People with overweight were considered to have misperceived overweight when adults considered their weight or their child's weight to be normal or less than normal. RESULTS: From 1987 to 2006/2007, the prevalence of overweight increased in absolute terms by 14.1% in men and 10.3% in women. Concurrently, the frequency of misperceived overweight remained relatively stable, approximately 35% in men, but rose from 16.5 to 20.8% in women. From 1995/1997 to 2006/2007, the prevalence of overweight increased in absolute terms by 3.2% in boys and 4.6% in girls. Over the same period, there was an absolute 8% increase in misperception of overweight among children of both sexes. As a result, during 2006/2007, approximately 60% of parents did not correctly perceive the weight status of their overweight children. Moreover, misperceived overweight was highest for younger children, and for those whose parents had a higher education. CONCLUSIONS: The obesity epidemic in Spain has been accompanied by an increased misperception of overweight in women and children of both sexes. Our results warn of the low family's readiness to modify the environment and lifestyle needed to control overweight.

Eating behaviours and obesity in the adult population of Spain.

To examine the association between several eating behaviours and obesity, data were taken from a cross-sectional study conducted with 34,974 individuals aged 25-64 years, representative of the non-institutionalised Spanish population. Obesity was defined as BMI >or= 30 kg/m2. Study associations were summarised with OR obtained from logistic regression, with adjustment for socio-demographic and lifestyle factors. The results showed that those skipping breakfast were more likely to be obese, both in men (OR 1.58; 95 % CI 1.29, 1.93) and women (OR 1.53; 95 % CI 1.15, 2.03). Moreover, obesity was more prevalent in those having only two meals per day than in those having three or four meals in men (OR 1.63; 95 % CI 1.37, 1.95) and women (OR 1.30; 95 % CI 1.05, 1.62). Also, snacking was associated with obesity in women (OR 1.51; 95 % CI 1.17, 1.95). However, no association was observed between obesity and having one or more of the main meals away from home, in either sex. In conclusion, skipping breakfast and eating frequency were associated with obesity. The lack of association between eating away from home and obesity is in contrast to most previous research conducted in Anglo-Saxon countries. Differences in the type of establishment frequented when eating out or in the characteristics of restaurant customers in a Mediterranean population might explain these conflicting results.

Metabolically healthy obesity and health-related quality of life: A prospective cohort study.

BACKGROUND: Metabolically healthy obesity (MHO) has been associated with lower risk of diabetes than obesity with cardiometabolic abnormalities (CA). However, the effect of MHO on other health outcomes is unknown. OBJECTIVE: To examine the association of metabolic status across categories of body mass index (BMI) with health-related quality of life (HRQL). METHODS: Prospective cohort with 4397 individuals aged ≥18 years, recruited in 2008-2010 and followed-up to 2012 in Spain. Normal weight was defined as BMI <25, overweight as BMI 25-29.9, and obesity as BMI ≥30 kg/m2. Two metabolic statuses were defined: healthy (0-1 CA) and unhealthy (≥2 CA). HRQL was measured with the physical component summary (PCS) and the mental component summary (MCS) of the SF-12 questionnaire. The association of joint categories of BMI and metabolic status at baseline with HRQL at 2012 was examined using linear regression, and adjusted for the main confounders. RESULTS: Compared to healthy normal-weight subjects, the unhealthy normal-weight and the healthy overweight individuals had a similar PCS score; however, the PCS was lower (worse) among those with unhealthy overweight (-1.79; 95% confidence interval [CI]: -2.66 to -0.94), with MHO (-1.45; 95% CI: -2.67 to -0.24) and unhealthy obesity (-1.97; 95% CI: -2.88 to -1.05). Being overweight or obese was not associated with the MCS score regardless of metabolic status. CONCLUSION: Metabolically unhealthy overweight, as well as obesity regardless of metabolic status, showed a worse physical HRQL. These results suggest that both obesity and CA should be addressed to improve HRQL.

Blood pressure in Spain: distribution, awareness, control, and benefits of a reduction in average pressure.

Distribution of blood pressure (as per US Joint National Committee VI classification and staging criteria) plus awareness, treatment, and control of hypertension were studied in a representative Spanish population sample of 2021 persons (age range, 35 to 64 years). Pressure was determined in accordance with World Health Organization guidelines. A total of 45.1% of subjects were hypertensive (>/=140/>/=90 mm Hg or undergoing drug therapy); 12% had isolated systolic hypertension, and 8.7% had isolated diastolic hypertension. Pulse pressure was 48.7 mm Hg. Heart rate was 81.4 bpm in untreated hypertensives and 78.9 bpm in normotensives (P<0.05). A substantial proportion of the community burden of blood pressure was attributable to stage 1 (28.3% of subjects), the most frequent category of hypertension, and to the high-normal blood pressure group (17% of subjects). A percentage breakdown showed that among hypertensives, 44.5% were aware of their condition; of these, 71.9% were undergoing drug therapy, and of those being treated, only 15.5% were controlled (5% of hypertensives). Not only are these figures consistent with the fact that Spain has a higher cerebrovascular mortality than other countries such as the United States, but they represent a great potential for improvement, particularly among those groups registering relatively worse data (younger men, rural residents, and unskilled professionals). A decrease of only 1 to 4 mm Hg in average blood pressure could reduce the prevalence of hypertension in Spain by 12.4% to 15.4%.

Frequency and determinants of white coat hypertension in mild to moderate hypertension: a primary care-based study. Monitorización Ambulatoria de la Presión Arterial (MAPA)-Area 5 Working Group.

Most of the previous studies on white coat hypertension were performed in hypertension clinics or academic settings and included relatively small series of patients. Consequently, the prevalence of white coat hypertension in primary care settings and the clinical and epidemiologic characteristics of this subgroup of patients are not well known. We performed this study to estimate the frequency of white coat hypertension in a population of mildly to moderately hypertensive subjects attended in a primary care setting and to examine possible epidemiologic and clinical factors that may identify these patients. Patients included in the study underwent clinical interview, measurement of clinic blood pressure (BP) on three visits, determination of serum lipids, glucose, uric acid, and urinary albumin excretion, 24-h ambulatory BP monitoring, and M-mode and Doppler echocardiography. Patients were classified as white coat hypertensives if their daytime ambulatory BP were < 135/85 mm Hg. We studied 345 patients, 136 (39%) of whom were diagnosed with white coat hypertension. The frequency of white coat hypertension was inversely proportional to the severity of clinic BP values. The diagnosis of white coat hypertension was independently associated with female gender and low educational level. Left ventricular mass index and urinary albumin excretion were lower in the white-coat hypertensive group compared with the group with sustained hypertension. Our results show that a high proportion of patients with mild to moderate hypertension attended in a primary care setting have white coat hypertension. Some clinical characteristics may be helpful in the identification of this group of subjects. White coat hypertensives show less target-organ damage than sustained hypertensive patients.

Alzheimer's risk associated with human apolipoprotein E, alpha-2 macroglobulin and lipoprotein receptor related protein polymorphisms: absence of genetic interactions, and modulation by gender.

Apolipoprotein E (apoE), the lipoprotein receptor related protein (LRP) and alpha-2 macroglobulin (alpha2M) have been proposed as a functional complex involved in amyloid clearance, a crucial event for Alzheimer's disease development. In this work, we present an epidemiological approach aimed to study the interactions among these genes, age and gender. This approach did not reveal significant associations between the genes; however, the present study indicated that the risk associated with APOE promoter and LRP gene polymorphisms is modulated by gender.

Consumption of alcoholic beverages and subjective health in Spain.

STUDY OBJECTIVE: To examine the relation between alcohol and main alcoholic beverage consumption and subjective health in Spain. DESIGN: Logistic regression analysis using a cross sectional survey based on self reported data on alcohol and alcoholic beverage consumption, subjective health and the principal confounding factors (age, sex, civil status, educational level, job status, social support, region of residence, size of town or city, tobacco consumption, physical activity during leisure time and work hours, and chronic disease). SETTING: The 1993 Spanish National Health Survey. PARTICIPANTS: A 19 573 person sample, representative of the non-institutionalised Spanish population aged 16 years and over. MAIN RESULTS: Among Spaniards, 31.4% reported their health as suboptimal (fair, poor or very poor) and 56.9% consumed alcohol regularly, with the majority having a preference for wine. Light (1-2 drinks per day) or moderate consumption (3-4 drinks per day) was the most frequent pattern. After adjusting for confounding factors, a negative dose-response relation was observed between consumption of total alcohol, wine and beer, and prevalence of suboptimal health (linear trend: p<0.001 for total alcohol, p=0.023 for wine, and p=0.030 for beer). In contrast, for consumption of spirits the prevalence of ill health in moderate drinkers was lower than in non-drinkers, with no clear relation at higher consumption. While persons reporting a preference for wine had a lower frequency of suboptimal health than did abstainers, they showed no difference in frequency of subjective ill health with respect to persons with preference for other types of drink or no preference whatsoever. CONCLUSIONS: The higher the consumption of total alcohol, wine and beer, the lower the prevalence of suboptimal health. These results differ from those obtained in several Nordic countries, where a "J shaped" relation has been observed for total alcohol and wine, and suggest that the relation between alcohol consumption and subjective health may be different in Mediterranean countries.

Systolic vs diastolic blood pressure: community burden and impact on blood pressure staging.

Systolic blood pressure (SBP) is a more frequent cardiovascular risk factor than diastolic blood pressure (DBP), and has a greater impact on blood pressure staging, though this can vary with age, sex and country. Therefore this paper compares SBP and DBP in terms of community burden and impact on blood pressure staging, among Spain's middle-aged population. Data were drawn from a cross-sectional study on a representative sample of the Spanish population aged 35-64 years. Blood pressure was determined under standardised conditions, and was classified as per WHO-ISH and JNC-VI criteria. Prevalence of SBP > or =140 mm Hg was 34.1%, and that of DBP > or =90 mm Hg, 30.9%. A total of 12% of subjects had isolated systolic hypertension (ISH) and 8.7% had isolated diastolic hypertension (IDH). Of treated hypertensives, 31% had their SBP controlled and 34% their DBP controlled. Of subjects not undergoing antihypertensive drug therapy, 60.8% had congruent SBP and DBP levels, 22.5% were up-staged on the basis of their SBP, and 16.7% were up-staged on the basis of their DBP. SBP alone thus correctly classified JNC-VI staging in 83.3% of subjects vs 77.5% for DBP alone. It was solely among the population >50 years of age, in both sexes, that systolic proved more frequent than diastolic hypertension, ISH greater than IDH prevalence, SBP worse than DBP control, and the percentage of SBP higher than that of DBP up-staged subjects. SBP constitutes a greater community burden than does DBP, and has a greater impact on blood pressure staging in Spain's middle-aged population. However, the differential impact of SBP and DBP upon blood pressure burden and staging is favourable to SBP only among subjects >50 years old. These findings are in accordance with recent guidelines on hypertension management.

Cost-benefit analysis of Haemophilus influenzae type b vaccination in children in Spain.

OBJECTIVE: Invasive disease caused by Haemophilus influenzae type b (Hib), including meningitis, pneumonia, sepsis and epiglottitis, is associated with high mortality and serious neurological sequelae in children under 5 years of age. The availability of an efficacious vaccine suggests the need to perform an economic evaluation of its use. The objective of this study was to evaluate the costs and benefits of introducing a universal vaccination programme for children under 1 year of age in Spain. DESIGN & SETTING: A cost-benefit analysis (CBA) was conducted over a 5-year period from the societal perspective in the Spanish healthcare setting. Both direct and indirect costs were included in the analysis [using 1996 Spanish pesetas (Pta); Pta126.5 = $US1 in April 1996]. PATIENTS AND PARTICIPANTS: The target population used for cost and benefit estimation was the 384,883 Spaniards aged 1 year or less in the last Spanish Population and Housing Census of 1991. MAIN OUTCOME MEASURES AND RESULTS: The introduction of the universal Hib vaccination programme would imply vaccinating 346,395 children under 1 year of age, with a global expense of Pta2,444,855,910. For an average incidence of 15 cases of invasive disease per 100,000 children per year nationwide, the programme would prevent 219 cases of invasive disease and 8 deaths over a 5-year period, with a benefit of Pta2,182,868,907, a net benefit (i.e. benefit minus cost) of -Pta261,987,003, a benefit/cost ratio of 0.89 and a benefit per case prevented of -Pta1,196,288. Benefit/cost ratios above 1 would be obtained in the regions of highest incidence of invasive disease. CONCLUSION: The decision to implement a universal vaccination programme should not be based only on economic factors, but our results suggest that the economic returns of the programme for children under 1 year of age in Spain would be at least of a similar magnitude as its expenses.

A simple estimate of mortality attributable to excess weight in the European Union.

OBJECTIVE: To estimate the current burden of mortality attributable to excess weight in the European Union (EU). METHODS: Prevalence of overweight (body mass index, BMI 25-29.9 kg/m(2)) and obesity (BMI >or=30 kg/m(2)) were based on self-reported data from a survey with samples representative of the 15 EU Member States in 1997. Primary source of relative risk (RR) of death by BMI was the first American Cancer Prevention Study (CPS I). Additional calculations were performed to account for effect of smoking (using CPS I data for non- or never-smokers), for pre-existing illness (using the second CPS, CPS II, data for healthy never-smokers) and using RRs derived from European rather than US data (using data from a meta-analysis of prospective studies). Mortality attributable to excess weight was calculated by combining the prevalences of overweight and obesity, the RRs, and the number of deaths in the EU countries. RESULTS: Annual deaths attributable to overweight and obesity totalled approximately 279 000 when RRs for all subjects were used. When RRs for nonsmokers only were applied to the entire population, about 304 000 deaths were attributable to excess weight. In analyses using RRs which controlled for both smoking and history of disease, the number of deaths attributable to excess weight was estimated at about 337 000 based on European data and at about 401 000 based on US data. In the EU, therefore, a minimum of 279 000 deaths were attributable to excess weight (7.7% of all deaths, varying from 5.8% for France through 8.7% for the UK). More attributable deaths occurred among the obese (175 000) than among the overweight (104 000). Around 70% were cardiovascular disease deaths (195 000) and 20% cancer deaths (53 000). CONCLUSION: Mortality attributable to excess weight is a major public health problem in the EU. At least one in 13 annual deaths in the EU are likely to be related to excess weight.

Self-perception of being overweight in Spanish adults.

OBJECTIVE: To describe the frequency, distribution and trend in misperceived overweight and obesity. DESIGN: Three independent cross-sectional studies carried out in 1987, 1995 and 1997 over representative samples of Spanish adult population. SETTING: Spanish adult population aged 20 y and over. SUBJECTS AND INTERVENTIONS: A total of 11 496 men and women aged 20 y and over with a body mass index (BMI) >or=25 kg/m(2). MAIN OUTCOME MEASURES: Prevalence and time trend of misperceived overweight and obesity based on self-perceived weight and height. RESULTS: Some 28.4% of the population did not perceive themselves to be overweight or obese in 1987 (26.9% in 1995/97). Overweight was more frequently misperceived among men, persons over 64 y of age, those residing in rural areas and those with an elementary educational level. The largest percentages of misperceived overweight were in the more moderate levels of BMI: 50% of men and 30% of women with a BMI of 25-26.9 kg/m(2) in 1995/1997 did not perceive themselves to be overweight. CONCLUSIONS: Misperceived overweight and obesity is frequent in the adult population in Spain. Some social and cultural factors may explain its higher frequency in men, older individuals and those with elementary level of education. The fact that most of those who do not perceive themselves to be overweight are in the moderate levels of overweight should be taken into account when designing strategies for the prevention and control of overweight and obesity in the general population.

[Geographic variation in hospitalizations and mortality related to congestive heart failure in Spain, 1980-1993]. / Variación geográfica en las hospitalizaciones y en la mortalidad por insuficiencia cardíaca congestiva en España, 1980-1993.

BACKGROUND AND OBJECTIVES: Geographical differences in hospitalizations and mortality for heart failure serve to estimate the potential for reducing the associated hospital and demographic burden on the population. Accordingly, the objective of this paper is to analyze the geographic variation in heart failure hospitalizations and mortality in Spain during the period of 1980-1993, and to examine their potential determinants. METHODS: Data on the primary diagnosis of heart failure were taken from the National Hospital Morbidity Survey and National Vital Statistics. Information on determinants of heart failure were obtained from large-scale nationally representative surveys conducted by the National Statistics Office. RESULTS: The period of 1980-1993 witnessed a decrease in geographical differences in heart failure hospitalizations and mortality. Theoretically, however, heart failure hospitalizations and mortality among persons aged > or = 45 years could still be further reduced by 60% and 30% respectively. In the period of 1989-1993 heart failure hospitalizations were correlated (p < 0.05) with ischaemic heart disease hospitalizations and the number of beds/1,000 inhabitants. Heart failure mortality showed a statistically significant correlation (p < 0.05) with ischaemic heart disease mortality, illiteracy and unemployed status. CONCLUSIONS: There is a great potential for a reduction in the hospital and demographic burden of heart failure in Spain. Control of ischaemic heart disease and a reduction in the geographical differences in socio-economic status would probably contribute to lessening the healthcare burden of heart failure in Spain.