Assessment of exposure to secondhand tobacco smoke in Spain: A scoping review.

INTRODUCTION: There is no consensus on the questions that should be included in questionnaires to properly ascertain exposure to secondhand tobacco smoke (SHS). The objective of this study is to analyze the questions included in studies which have assessed SHS exposure in Spain. METHODS: A scoping review was performed, using PubMed, Embase and Web of Science databases, selecting original articles published in English and Spanish, across the period 2012-2021. We extracted data from each study regarding its design, target population, sample size or geographical scope; we also collected data regarding how studies dealt with exposure to SHS including assessment and intensity of SHS, exposure setting, geographical scope, and the verbatim questions used. RESULTS: Finally, 75 studies were identified. In the 23 studies carried out in children, verbatim questions were included in 8 studies, and the setting most studied was the home. SHS exposure was assessed during pregnancy and postnatally by 8 studies, the verbatim questions used were described in 2 studies, being exposure ascertained at home and workplace. In the adult population, 14 of 44 studies described the verbatim questions; the setting most studied was the home. Verbatim questions varied among studies. CONCLUSIONS: Questionnaire-based assessment of SHS exposure is highly heterogeneous, hindering comparability between studies. Therefore, it is necessary to set a standard questionnaire to assess exposure to SHS.

Alcohol Consumption Patterns and Mortality Among Older Adults With Health-Related or Socioeconomic Risk Factors.

Importance: Alcohol consumption is a leading cause of morbidity and mortality that may be more important in older adults with socioeconomic or health-related risk factors. Objective: To examine the association of alcohol consumption patterns with 12-year mortality and its modification by health-related or socioeconomic risk factors. Design, Setting, and Participants: This prospective cohort study used data from the UK Biobank, a population-based cohort. Participants were current drinkers aged 60 years or older. Data were analyzed from September 2023 to May 2024. Exposure: According to their mean alcohol intake in grams per day, participants' drinking patterns were classified as occasional: ≤2.86 g/d), low risk (men: >2.86-20.00 g/d; women: >2.86-10.00 g/d), moderate risk (men: >20.00-40.00 g/d; women: >10.00-20.00 g/d) and high risk (men: >40.00 g/d; women: >20.00 g/d). Main Outcomes and Measures: Health-related risk factors were assessed with the frailty index, and socioeconomic risk factors were assessed with the Townsend deprivation index. All-cause and cause-specific mortality were obtained from death certificates held by the national registries. Analyses excluded deaths in the first 2 years of follow-up and adjusted for potential confounders, including drinking patterns and preferences. Results: A total of 135 103 participants (median [IQR] age, 64.0 [62.0-67.0] years; 67 693 [50.1%] women) were included. In the total analytical sample, compared with occasional drinking, high-risk drinking was associated with higher all-cause (hazard ratio [HR], 1.33; 95% CI, 1.24-1.42), cancer (HR, 1.39; 95% CI, 1.26-1.53), and cardiovascular (HR, 1.21; 95% CI, 1.04-1.41) mortality; moderate-risk drinking was associated with higher all-cause (HR, 1.10; 95% CI, 1.03-1.18) and cancer (HR, 1.15; 95% CI, 1.05-1.27) mortality, and low-risk drinking was associated with higher cancer mortality (HR, 1.11; 95% CI, 1.01-1.22). While no associations were found for low- or moderate-risk drinking patterns vs occasional drinking among individuals without socioeconomic or health-related risk factors, low-risk drinking was associated with higher cancer mortality (HR, 1.15; 95% CI, 1.01-1.30) and moderate-risk drinking with higher all-cause (HR, 1.10; 95% CI, 1.01-1.19) and cancer (HR, 1.19; 95% CI, 1.05-1.35) mortality among those with health-related risk factors; low-risk and moderate-risk drinking patterns were associated with higher mortality from all causes (low risk: HR, 1.14; 95% CI, 1.01-1.28; moderate risk: HR, 1.17; 95% CI, 1.03-1.32) and cancer (low risk: HR, 1.25; 95% CI, 1.04-1.50; moderate risk: HR, 1.36; 95% CI, 1.13-1.63) among those with socioeconomic risk factors. Wine preference (>80% of alcohol from wine) and drinking with meals showed small protective associations with mortality, especially from cancer, but only in drinkers with socioeconomic or health-related risk factors and was associated with attenuating the excess mortality associated with high-, moderate- and even low-risk drinking. Conclusions and Relevance: In this cohort study of older drinkers from the UK, even low-risk drinking was associated with higher mortality among older adults with health-related or socioeconomic risk factors. The attenuation of mortality observed for wine preference and drinking only during meals requires further investigation, as it may mostly reflect the effect of healthier lifestyles, slower alcohol absorption, or nonalcoholic components of beverages.

Additive interaction of disability with chronic conditions on mortality risk in middle-aged and older adults in Spain.

BACKGROUND: Disability and chronic diseases are prevalent conditions associated with mortality, but little information is available on their potential synergistic effects. OBJECTIVE: This study aimed to describe additive interactions between disability and chronic diseases on mortality risk in middle-aged and older adults. METHODS: A representative cohort of 22,800 community-dwelling Spanish people aged 50 years or older were interviewed for disability with the Global Activity Limitation Indicator and specific chronic diseases in the 2011-12 and 2014 National Health Surveys and subsequently followed up for mortality. Five-year all-cause mortality risks were standardized in each disability-by-comorbidity category through inverse probability weighting. We computed interaction contrasts as the departure of the standardized risk difference for people with both conditions from the sum of the standardized risk differences for those with any single condition. RESULTS: The baseline prevalence of disability was 35.1 % (95 % confidence interval [CI] 34.4 %, 35.9 %). There was compelling evidence of synergistic effects of disability with chronic liver disease, heart diseases other than myocardial infarction, cancer, and cerebrovascular disease, with large positive interaction contrasts (95 % CIs) of 106.7 (-16.4, 229.9), 45.7 (6.9, 84.5), 45.1 (-15.0, 105.2), and 42.9 (-41.0, 126.9) excess deaths per 1000 persons. Less clear synergistic responses were observed for other comorbidities. We found some evidence of antagonism for osteoporosis, with a negative interaction contrast of -18.0 (95 % CI -82.2, 46.2) deaths per 1000 persons. CONCLUSION: Given the high mortality risk in people with disability, the study of its synergistic effects with target comorbidities can provide relevant information regarding preventive measures.

Volume of alcohol intake, heavy episodic drinking, and all-cause mortality in Spain: A longitudinal population-based study.

INTRODUCTION: The impact of alcohol consumption on health, particularly in low quantities, remains controversial. Our objective was to assess the association between alcohol volume and heavy episodic drinking (HED) with all-cause mortality, while minimizing many of the known methodological issues. METHODOLOGY: This longitudinal study used data from the 2011-2012 National Health Survey and the 2014 European Health Survey in Spain. Data from 43,071 participants aged ≥ 15 years were linked to mortality records as of December 2021. Alcohol consumption categories were defined based on intake volume and frequency: never-drinkers, former drinkers, infrequent occasional drinkers (≤once/month), frequent occasional drinkers ( once /month). Regular drinkers (≥once/week) were further classified by volume: >0-10 g/day, >10-20 g/day, >20-40 g/day, and > 40 g/day. Heavy Episodic Drinking (HED) was defined as ≥ 6 and ≥ 5 standard drinks (10 g) within 4-6 h for men and women, respectively. Hazard ratios (HR) were calculated using Cox regression, adjusting for sociodemographic variables, lifestyle factors, health status, and alcohol volume or HED. RESULTS: Compared to infrequent occasional drinkers, HRs for never-drinkers and former drinkers were 1.30 (95 %CI:1.14-1.47) and 1.32 (95 %CI:1.15-1.50), respectively. No differences in mortality risk were observed for intakes up to 20 g/day, but it increased for consumptions > 20-40 g/day and > 40 g/day (HR = 1.29; 95 %CI:1.05-1.58 and HR = 1.57; 95 %CI:1.14-2.17, respectively). The HR of weekly HED vs. never was 1.31 (95 %CI:0.98-1.75). CONCLUSIONS: Compared to infrequent occasional drinking, consuming low amounts of alcohol had no impact on mortality risk. However, never-drinkers, former drinkers, individuals with regular consumption > 20 g/day, and those engaging in weekly HED, experienced higher mortality risk.

Towards stronger tobacco control policies to curb the smoking epidemic in Spain.

Smoking and exposure to secondhand smoke pose a significant risk to the health of populations. Although this evidence is not new, the commitment of countries to implement laws aimed at controlling consumption and eliminating exposure to secondhand smoke is uneven. Thus, in North America or in Europe, locations like California or Ireland, are pioneers in establishing policies aimed at protecting the population against smoking and secondhand smoke. Identifying measures that have worked would help control this important Public Health problem in other countries that are further behind in tobacco control policies. In Spain, there has been almost 15 years of little political action in legislation oriented to control the tobacco epidemic. If we want to achieve the tobacco endgame, new legislative measures must be implemented. In this paper, we have elucidated tobacco control policies that could be implemented and show how different countries have done so.

Alcohol consumption patterns and adherence to the Mediterranean diet in the adult population of Spain.

PURPOSE: The objective is to evaluate the association between various indicators of alcohol consumption and the degree of adherence to the Mediterranean diet among the Spanish adult population. METHODS: A cross-sectional study including 44,834 participants ≥ 15 years of age from the 2017 National Health Survey and the 2020 European Health Survey in Spain. Alcohol patterns were defined based on (1) average intake: individuals were classified as low risk (1-20 g/day in men and 1-10 g/day in women) and high risk (> 20 g/day in men or > 10 g/day in women), (2) binge drinking, and (3) alcoholic beverage preference. Non-adherence to the Mediterranean diet was defined as scoring < 7 points on an adapted Mediterranean Diet Adherence Screener index (range 0-10). Odds ratios (OR) were estimated using logistic regression models adjusted for relevant covariates. RESULTS: Compared to non-drinkers, low and high-risk drinkers were more likely to report non-adherence to the Mediterranean diet: ORs 1.35 (95% CI 1.23; 1.49) and 1.54 (95% CI 1.34; 1.76), respectively. Similarly, reports of binge drinking less than once a month was associated with higher likelihood of non-adherence (OR 1.17; 95% CI 1.04; 1.31). Individuals reporting no preference for a specific beverage and those with a preference for beer or for spirits had lower adherence: ORs 1.18 (95% CI 1.05; 1.33), 1.31 (95% CI 1.17; 1.46), and 1.72 (95% CI 1.17; 2.54), respectively, while a preference for wine showed no association (OR 1.01; 95% CI 0.90; 1.13). CONCLUSION: Alcohol consumption, even in low amounts, is associated with lower adherence to the Mediterranean diet. Therefore, alcoholic beverages should not be included in measures that define the Mediterranean diet.

Impact of psychological distress on mortality in Spain. The importance of early detection and treatment of mental disorders.

BACKGROUND: Mental health problems account for 14% of mortality worldwide. The aim of this study was to evaluate the association between psychological distress and mortality in the Spanish adult population. METHODS: Data came from a longitudinal study in population ≥15 years of age (n=21,005) who participated in the 2011-12 Spanish National Health Survey, which was linked to mortality records as of December 2020. Mental health was assessed with the GHQ-12, defining psychological distress as a dichotomous variable using a GHQ-12 score ≥3 as the cutoff point. Using Poisson regression, standardized mortality rate ratios (SRR) were estimated for all-cause, cardiovascular disease, and tumor-related mortality, adjusting for sociodemographic variables, lifestyles, and comorbidities. RESULTS: The standardized overall mortality rate in individuals with and without psychological distress was 14.58 and 10.90 per 1000 person-years, respectively, estimating an SRR of 1.34 (95%CI: 1.19-1.50). The SRR for tumor-related mortality was 1.17 (95%CI: 0.90-1.53), and cardiovascular-related mortality was related to higher distress (GHQ-12 ≥ 4): SRR of 1.22 (95%CI: 0.98-1.51). Among psychological distressed individuals, the overall mortality SRR for those with a previous mental disorder diagnosis was 1.18 (95%CI: 0.91-1.53) versus 1.34 (95%CI: 1.18-1.54) for those without such diagnosis (p for interaction=0.067). Similarly, distressed participants taking prescription drugs for mental disorders had a lower mortality risk than those not taking them (p for interaction=0.016). CONCLUSIONS: Individuals with psychological distress had a higher risk of overall-, cardiovascular disease- and tumor-related mortality. This association was higher among participants not previously diagnosed with a mental disorder and those not taking medication for mental issues.

Association between biomarkers of iron status and cardiometabolic risk in Spanish children aged 9-10 years. The ELOIN study.

The relationship between iron metabolism and cardiometabolic risk factors has been scarcely studied in children, and the results are controversial. The objective of this study was to evaluate the association between iron parameters and lipid, glycemic and blood pressure alterations in the pediatric population. This was a cross-sectional study of 1954 children between 9 and 10 years of age in Madrid (Spain), participants in a longitudinal study of childhood obesity. Iron metabolism parameters, i.e., serum iron (Is), ferritin (Fs), transferrin (Tf) and transferrin saturation (STf) and lipid, glycemic and blood pressure profiles were evaluated. Odds ratios (ORs) were estimated using logistic regression models adjusted for sociodemographic characteristics, diet, physical activity, C-reactive protein and body mass index. Compared with the participants in the low Is and STf tertiles, those in the upper tertiles had a lower risk of low HDL-Chol (OR: 0.34; 95%CI: 0.17; 0.67) and OR: 0.44 (95%CI: 0.23; 0.84), respectively, and children in the upper Fs tertile had an OR of 2.07 (95%CI: 1.16; 3.68) for low HDL-Chol. Children in the highest Is and STf tertiles had a lower risk of prediabetes [OR: 0.63 (95%CI: 0.41; 0.97) and OR: 0.53 (95%CI: 0.34; 0.82)] and insulin resistance (IR) (OR: 0.37; 95%CI: 0.22; 0.64), and those in the upper Tf tertile had a higher risk of IR (OR: 1.90; 95%CI: 1.16; 3.12). An increased risk of hypertension was found only in children in the upper Fs tertile (OR: 1.46; 95%CI: 1.01; 2.13). CONCLUSIONS: Biomarkers of iron metabolism are associated with cardiometabolic alterations in the pediatric population, with a variable direction and magnitude depending on the indicators used. WHAT IS KNOWN: • Iron metabolism is related to important cardiometabolic alterations such as metabolic syndrome and its components. • Association between biomarkers of iron status and cardiometabolic risk have been less explored in children. WHAT IS NEW: • Biomarkers of iron metabolism are associated with cardiometabolic alterations in the pediatric population. • Iron parameters in the pediatric population could be of great help to detect and prevent cardiometabolic abnormalities early.

Small-area models to assess the geographical distribution of tobacco consumption by sex and age in Spain.

INTRODUCTION: Complete and accurate data on smoking prevalence at a local level would enable health authorities to plan context-dependent smoking interventions. However, national health surveys do not generally provide direct estimates of smoking prevalence by sex and age groups at the subnational level. This study uses a small-area model-based methodology to obtain precise estimations of smoking prevalence by sex, age group and region, from a population-based survey. METHODS: The areas targeted for analysis consisted of 180 groups based on a combination of sex, age group (15-34, 35-54, 55-64, 65-74, and ≥75 years), and Autonomous Region. Data on tobacco use came from the 2017 Spanish National Health Survey (2017 SNHS). In each of the 180 groups, we estimated the prevalence of smokers (S), ex-smokers (ExS) and never smokers (NS), as well as their coefficients of variation (CV), using a weighted ratio estimator (direct estimator) and a multinomial logistic model with random area effects. RESULTS: When smoking prevalence was estimated using the small-area model, the precision of direct estimates improved; the CV of S and ExS decreased on average by 26%, and those of NS by 25%. The range of S prevalence was 11-46% in men and 4-37% in women, excluding the group aged ≥75 years. CONCLUSIONS: This study proposes a methodology for obtaining reliable estimates of smoking prevalence in groups or areas not covered in the survey design. The model applied is a good alternative for enhancing the precision of estimates at a detailed level, at a much lower cost than that involved in conducting large-scale surveys. This method could be easily integrated into routine data processing of population health surveys. Having such estimates directly after completing a health survey would help characterize the tobacco epidemic and/or any other risk factor more precisely.

Estimations of smoking-attributable mortality in Spain at a regional level: comparison of two methods.

PURPOSE: To estimate and discuss smoking-attributable mortality (SAM) for the 17 regions in Spain among the population aged ≥35 years in 2017, using two methods. METHODS: A descriptive analysis of SAM was conducted using two methods, the prevalence-independent method (PIM) and the prevalence-dependent method (PDM). Observed mortality was obtained from the National Institute of Statistics; smoking prevalence from three National Health Surveys; lung cancer mortality rates from the Cancer Prevention Study-II; and relative risks from five US cohorts. SAM and percentages of change were estimated for each region overall, by sex, age and cause of death. RESULTS: In 2017, tobacco caused 56,203 deaths in Spain applying the PIM. Using the PDM the number of deaths was 4.4% (95% CI: 3.4-5.5) lower (53,825 deaths). Except in four regions, the PIM estimated a higher overall SAM and the maximum percentage of change was 18.6%. Overall percentages of change were higher for women (15.7% 95% CI: 12.6-19.0) and for cardiovascular diseases-diabetes mellitus (13.8%; 95% CI: 11.5-16.2). CONCLUSIONS: At the national level, both methods estimate similar figures for SAM. However, the difference in estimates appears at the subnational level. Differences were higher in subgroups with lower smoking prevalence and for causes of death with periods of induction shorter than those for lung cancer.

Changes in general and abdominal obesity in children at 4, 6 and 9 years of age and their association with other cardiometabolic risk factors.

Temporary changes in childhood obesity and their association with cardiometabolic risk factors have been receiving increased attention. The objective of this study was to evaluate changes in general (GO) and abdominal (AO) obesity in children from 4 to 9 years of age and their associations with cardiometabolic risk factors at 9 years of age. This study includes 1344 children from the Longitudinal Childhood Obesity Study (ELOIN). Physical examinations performed at 4, 6 and 9 years of age and a blood sample was only taken at 9 years of age. Changes in obesity from 4 to 9 years of age were estimated using Body Mass Index and waist circumference. Participants were classified into four groups according to GO and AO: (1) stable without obesity (no obesity at all three measurements); (2) remitting obesity at 9 years (obesity at 4 and/or 6 years but not at 9 years); (3) incident or recurrent obesity at 9 years (obesity only at 9 years, at 4 and 9 years or at 6 and 9 years); and (4) stable or persistent with obesity (obesity at 4, 6 and 9 years). Dyslipidemia and dysglycemia were defined by the presence of at least one altered parameter of the lipid or glycemic profile. Odds ratios (OR) were estimated using logistic regression. Compared with children without GO at all ages, those with persistent GO had an OR of 3.66 (95% CI: 2.06-6.51) for dyslipidemia, 10.61 (95% CI: 5.69-19.79) for dysglycemia and 8.35 (95% CI: 4.55-15.30) for high blood pressure. The associations were fairly similar in the case of AO, with ORs of 3.52 (95% CI: 1.96-6.34), 17.15 (95% CI: 9.09-32.34) and 8.22 (95% CI: 4.46-15.15), respectively, when comparing persistent versus stable without AO. Children with incident obesity at 9 years presented a moderate cardiometabolic risk that was nevertheless higher compared to those stable without obesity, whereas those with remitting obesity did not show any significant associations. CONCLUSION: Incident, and especially, persistent obesity, is associated with an increased cardiometabolic risk. The very early prevention of obesity, with a focus on nutrition, physical activity and sedentary behaviour, as well as tracking growth from birth to age 5, should be a priority to prevent the burden of cardiometabolic disease with consequences for adulthood. WHAT IS KNOWN: • General and abdominal obesity has been shown to be associated with other cardiometabolic risk factors such as dyslipidemia, insulin resistance and hypertension. • Temporary changes in obesity and their associations with cardiometabolic risk factors have not been sufficiently explored in childhood. WHAT IS NEW: • Children with incident, and especially persistent, general and/or abdominal obesity, had an increased risk of dyslipidemia, dysglycemia and high blood pressure. •Remitting obesity was not associated with an increased cardiometabolic risk.

Light cigarette smoking and all-cause mortality in Spain. A national population-based cohort study.

PURPOSE: Regular light cigarette consumption (light smoking) is increasing in many countries; however, few studies have assessed its impact on mortality. The main aim of this study is to estimate the association between the number of cigarettes consumed and all-cause mortality in Spain while focusing on light smoking. METHODS: Longitudinal study based on data from 42,902 individuals aged ≥15 years included in the 2011-2012 (Spanish) National Health Survey or the 2014 European Health Survey for Spain. Data were linked with the mortality registry up to December 2020. Multivariate Cox regression models were used to estimate hazard ratios (HR) adjusted for sociodemographic variables, lifestyle factors, and health status indicators. RESULTS: Compared to never smokers, the mortality HR for nondaily smokers was 1.30 (95% CI: 0.81-2.09), increasing to 2.23 (95% CI: 1.25-3.96) among those smoking 1-2 cigarettes/d, and to 1.54 (95%CI: 1.14-2.07) for consumers of 3-5 cigarettes/day. When individuals who reported trying to quit during the previous year were excluded, resulting HRs were 1.31 (95% CI: 0.81-2.10), 1.48 (95% CI: 0.69-3.19) and 1.64 (95% CI: 1.16-2.34), respectively. CONCLUSIONS: Compared to never smokers, consumers of small quantities of tobacco, that is, light smoking, had an increased mortality risk. In view of these results, we suggest the need for awareness-raising campaigns regarding how smoking even a small number of cigarettes a day causes serious harm to one´s health.

Trends in smoking-attributable mortality in Spain: 1990-2018.

BACKGROUND: This study sought to analyse the trend in smoking-attributable mortality (SAM) in Spain among the population aged ≥35 years across the period 1990-2018. METHODS: SAM was estimated by applying a prevalence-independent method, which uses lung cancer (LC) mortality as a proxy of tobacco consumption. We sourced observed mortality from the National Institute of Statistics (Spain), LC mortality rates in smokers and never smokers from the Cancer Prevention Study I-II, and relative risks from 5 US cohorts. Estimates of annual SAM by cause of death, sex and age are shown, along with crude and annual standardised SAM rates. The trend in standardised all-cause and LC rates was analysed using a joinpoint regression model. RESULTS: Tobacco caused 1 717 150 deaths in Spain in the period 1990-2018. Among men, cancers replaced cardiovascular diseases-diabetes mellitus (CVD-DM) as the leading group of tobacco-related cause of death in 1994. Among women, CVD-DM remained the leading cause of death throughout the period. Trend analysis of standardised SAM rates due to all causes and LC showed a decrease in men and an increase in women. CONCLUSIONS: The tobacco epidemic in Spain across the period 1990-2018 has had an important impact on mortality and has evolved differently in both genders. SAM is expected to increase dramatically in women in the coming years. SAM data highlight the importance of including a gender perspective in SAM analyses, in designing more effective and comprehensive public health interventions and in developing gender-specific tobacco control policies to curb tobacco consumption.

Rural-urban gradients and all-cause, cardiovascular and cancer mortality in Spain using individual data.

•The literature reporting on rural-urban health status disparities remains inconclusive.•We analyzed data from a longitudinal population-based study using individual observations.•Our results show that the risks of all-cause and cancer mortality are greater in large cities than in other municipalities, with no clear urban-rural gradient.•Not differences were found among territories in cardiovascular mortality.

Changes in obesity and iron deficiency between 4 and 9 years of age. Longitudinal study of childhood obesity (ELOIN).

BACKGROUND: Recent studies revealed that children who are overweight have a higher risk of iron deficiency, although the etiology of this relationship remains unclear. The aim of the study was to evaluate the association between changes in obesity status between 4 and 9 years of age and iron deficiency. SUBJECTS: This population-based cohort study included 1347 children from the ELOIN study, conducted in Madrid, Spain. Follow-up with physical examinations and a computer-assisted telephone interview were carried out at 4, 6 and 9 years of age, and a blood test was performed at 9 years. METHODS: Changes in obesity were estimated based on body mass index and waist circumference, according to the persistence or variation in obesity rates at 4, 6 and 9 years and were classified as follows: (1) Stable without obesity; (2) Remitting obesity at 9 years; (3) Incident obesity or relapse at 9 years; and (4) Stable with obesity. Iron deficiency was defined as transferrin saturation value below 16%. Odds ratios (ORs) for iron deficiency were estimated according to obesity status using logistic regression and adjusted for confounding variables, including C-reactive protein (CRP). RESULTS: The prevalence of iron deficiency in the stable general obesity (GO) and abdominal obesity (AO) groups was 38.2% and 41.2%, versus 23.6% and 23.4% in the stable without obesity groups, respectively. The ORs for iron deficiency were 1.85 (95% CI: 1.03-3.32) in the stable GO group and 2.34 (95% CI: 1.29-4.24) in the stable AO group. This association disappeared when CRP was included in the analysis. CONCLUSIONS: An extended state of obesity during the first stages of life is associated with iron deficiency, and this association may be mediated by CRP. Prevention and early detection of obesity in children should be a priority to avoid a double burden of malnutrition.

Predictive capacity of self-rated health on all-cause mortality in Spain: differences across sex, age and educational level.

BACKGROUND: Published evidence on self-rated health's capacity to predict mortality and its variability across subpopulations lacks consistency. Our objective is to evaluate this predictive association and whether/how it varies by sex, age and educational attainment at the population level in Spain. METHODS: Data came from a prospective longitudinal study based on 42 645 individuals aged ≥15 years who participated in the 2011-2012 and 2014 Spanish Health Surveys. Median follow-up time for mortality was 5.4 years. Cox proportional hazards models adjusted for sociodemographic, lifestyle and chronic disease variables were used to estimate the predictive capacity of self-rated health on mortality. RESULTS: Self-rated health was associated with mortality with a dose-response effect (p value for linear trend <0.001). Compared with respondents who rated their health as very good, those rating it as very poor presented an HR of 3.33 (95% CI 2.50 to 4.44). Suboptimal self-rated health was a stronger predictor of mortality among 15-44 year-olds (HR 2.87; 95% CI 1.59 to 5.18), compared with the estimate for 45-64 year-olds (HR 1.86; 95% CI 1.45 to 2.39) (p value for interaction=0.001) and for those 65 and older (HR 1.51; 95% CI 1.36 to 1.68) (p value for interaction <0.001). Regarding educational attainment, the association was stronger for individuals with university studies (HR 2.51; 95% CI 1.67 to 3.76) than for those with only primary or no studies (HR 1.31; 95% CI 1.17 to 1.48) (p value for interaction=0.010). No statistically significant differences were observed between men and women. CONCLUSIONS: Self-rated health may be considered a good predictor of all-cause mortality in the population of Spain, although the magnitude of this predictive association varies by age and educational level.

Physical and social environmental factors related to co-occurrence of unhealthy lifestyle behaviors.

Previous work identifying determinants of co-occurrence of behavioral risk factors have focused on their association with individuals' characteristics with scant attention paid to their relationship to contextual factors. Data came from 21,007 individuals ≥15 years of age who participated in the cross-sectional 2011-2012 Spanish National Health Survey. Two indicators were defined by tobacco consumption, alcohol intake, diet, physical activity, and body mass index. The first indicator, based on dichotomized measures, ranges from 0 to 5. The second one (unhealthy lifestyle index), ranges from 0 to 15, with 0 denoting the healthiest score. Among the determinants, we examined social support, five perceived characteristics of the neighborhood, and the socioeconomic deprivation index of the census tract of residence. Data were analyzed using multilevel linear and logistic regression models adjusted for the main sociodemographic characteristics. Using the dichotomized indicator, the probability of having 3-5 risk factors versus <3 factors was associated with low social support (Odds Ratio [OR] 1.50; 95% Confidence Interval [CI]: 1.25-1.80). Issues surrounding neighborhood cleanliness (OR = 1.18; 95%CI: 1.04-1.33), air pollution (OR = 1.38; 95%CI: 1.16-1.64), and street crime (OR = 1.21; 95%CI: 1.03-1.42) were associated with determinants of co-occurrence. Risk factors co-occurrence increased as deprivation level increased: the OR for the highest deprivation quintile versus the lowest was 1.30 (95%CI: 1.14-1.48). Similar results were observed when using the unhealthy lifestyle index. Poorer physical and social environments are related to greater co-occurrence of risk factors for chronic diseases. Health promotion interventions targeting the prevention of risk factors should consider the contextual characteristics of the neighborhood environment.

Tracking and risk of abdominal and general obesity in children between 4 and 9 years of age. The Longitudinal Childhood Obesity Study (ELOIN).

BACKGROUND: Studies have shown that overweight and obesity conditions tend to be stable from childhood and adolescence to adulthood. Unfortunately, little is known about the evolution of abdominal obesity during childhood. The aim of this study was to evaluate the temporal variations and risk of general and abdominal obesity between 4, 6, and 9 years of age. METHODS: Measurements of children in the ELOIN study taken at the three follow-ups of 4, 6, and 9 years of age were included (N = 1,902). Body mass index and waist circumference were recorded via physical examination. General obesity was determined according to the criteria of the World Health Organization (WHO) and abdominal obesity according to the cut-off points proposed by the International Diabetes Federation (IDF). Prevalence ratios (PRs) were estimated by sex and family affluence using generalized estimating equation models and relative risks (RRs) of obesity were obtained via Poisson regression. RESULTS: The prevalence of general obesity was 5.1%, 9.1%, and 15.6% at 4, 6, and 9 years, respectively, yielding a PR of 3.05 (95%CI: 2.55-3.60) (9 years old relative to 4 years). The prevalence of abdominal obesity was 6.8%, 8.4%, 14.5% at 4, 6, and 9 years, respectively, and the PR was 2.14 (95%CI: 1.82-2.51) (9 years old relative to 4 years). An inverse correlation was observed between both general and abdominal obesity and socioeconomic status. Among participants with general or abdominal obesity at 4 years of age, 77.3% and 63.6% remained in their obesity classification at 9 years, respectively, and 3.4% and 3.5% presented general or abdominal obesity also at 6 and 9 years of age, respectively. The RRs of general and abdominal obesity at 9 years were 4.61 (95%CI: 2.76-7.72) and 4.14 (95%CI: 2.65-6.48) for children classified with obesity at 4 years of age, increased to 9.36 (95%CI: 7.72-11.35) and 9.56 (95%CI: 7.79-11.74) for children who had obesity at 6 years, and up to 10.27 (95%CI: 8.52-12.37) and 9.88 (95%CI: 8.07-12.11) for children with obesity at both 4 and 6 years, respectively. CONCLUSIONS: General and abdominal obesity begin at an early age and increase over time, showing an inverse correlation with socioeconomic status. In addition, general and abdominal obesity at 9 years are strongly associated with being classified with obesity at 4 and 6 years, so preventive interventions should be established at very early ages.

Methodological guidelines for the estimation of attributable mortality using a prevalence-based method: the STREAMS-P tool.

BACKGROUND: There is evidence of strong links between exposure to different risk factors and life-threatening diseases. Assessing the burden of a risk factor on the population's mortality due to a given disease provides a clear picture of these links. The estimation of attributable mortality to a risk factor is the most widely used procedure for doing this. Although different methods are available to estimate attributable mortality, the prevalence-based methodology is the most frequent. The main objective of this study is to develop guidelines and checklists to STrengthen the design and REporting of Attributable Mortality Studies using a Prevalence-based method (STREAMS-P) and also to assess the quality of an already published study which uses this methodology. METHODS: The design of the guideline and checklists has been done in two phases. A development phase, where we set recommendations based on the review of the literature, and a validation phase, where we validated our recommendations against other published studies that have estimated attributable mortality using a prevalence-based method. RESULTS: We have developed and tested a guideline that includes the information required to perform a prevalence-based attributable mortality study to a given risk factor; a checklist of aspects that should be present when a report or a paper on attributable mortality is written or interpreted and a checklist of quality control criteria for reports or papers estimating attributable mortality. CONCLUSION: To our knowledge, the STREAMS-P is the first set of criteria specifically created to assess the quality of such studies and it could be valuable for authors and readers interested in performing attributable mortality studies or interpreting their reliability.

Childhood obesity and risk of SARS-CoV-2 infection.

OBJECTIVE: To estimate the association between childhood obesity and the risk of SARS-CoV-2 infection in a cohort followed from 4 to 12 years of age. METHODS: The data were obtained from two independent sources: the Longitudinal Childhood Obesity Study (ELOIN) and the epidemiological surveillance system data from the Community of Madrid (Spain), which served to identify the population within the cohort with confirmed SARS-CoV-2 infection. The SARS-CoV-2 registry was cross-checked with the cohort population at 11-12 years of age. A total of 2018 eligible participants were identified in the cohort, who underwent physical examinations at 4, 6, and 9 years of age during which weight, height, and waist circumference were recorded. General obesity (GO) was determined according to the WHO-2007 criteria whereas abdominal obesity (AO) was defined based on the International Diabetes Federation (IDF) criteria. The relative risks (RRs) of infection were estimated using a Poisson regression model and adjusted by sociodemographic variables, physical activity, and perceived health reported by the parents. RESULTS: The accumulated incidence of SARS-CoV-2 infection was 8.6% (95% CI: 7.3-9.8). The estimated RR of SARS-CoV-2 infection was 2.53 (95% CI: 1.56-4.10) and 2.56 (95% CI: 1.55-4.21) for children 4-9 years old with stable GO and AO, respectively, compared with those who did not present GO. CONCLUSIONS: Childhood obesity is an independent risk factor for SARS-CoV-2 infection. This study provides new evidence that indicates that obesity increases the vulnerability of the paediatric population to infectious diseases.