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Beltrán-Garrayo L, Solar M, Blanco M, Graell M, Sepúlveda AR. Examining associations between obesity and mental health disorders from childhood to adolescence: A case-control prospective study. Psychiatry Res 2023; 326:115296. [PMID: 37331070 DOI: 10.1016/j.psychres.2023.115296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 06/20/2023]
Abstract
Childhood obesity and mental disorders often co-exist. To date, most of the studies are cross-sectional, involve the assessment of a specific disorder, and rely on self-report questionnaires. This study aimed to provide a comprehensive psychological assessment to examine the concurrent and prospective association between childhood obesity and mental health problems. We compared 34 children with obesity with 37 children with normal weight at baseline, and at a five-year follow-up, to examine the development of mental health disorders from childhood (8-12 years) to adolescence (13-18 years). Both assessments included a clinical interview and self-reported measures of psychosocial and family markers. Findings showed that the obesity group had a higher prevalence of mental disorders, and psychological comorbidity increased in five years. Prospectively, childhood obesity was associated with a psychological diagnosis in adolescence. Moreover, the obesity group displayed higher severity of symptoms at both times. Finally, body esteem contributed to predicting mental health disorders in adolescence regardless of weight status, while eating symptomatology was a specific marker for the obesity group. Therefore, in the management of childhood obesity is suggested to address also psychosocial variables such as weight-related teasing and body esteem, to prevent the onset or development of mental health problems.
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Affiliation(s)
- Lucia Beltrán-Garrayo
- Department of Biological and Health Psychology, Faculty of Psychology, Autonomous University of Madrid, Madrid, Spain.
| | - María Solar
- Research & Development Department, Hogrefe TEA Ediciones, Madrid, Spain
| | - Miriam Blanco
- Department of Biological and Health Psychology, Faculty of Psychology, Autonomous University of Madrid, Madrid, Spain
| | - Montserrat Graell
- Department of Child and Adolescent Psychiatry and Psychology, University Hospital Niño Jesús, Madrid, Spain
| | - Ana Rosa Sepúlveda
- Department of Biological and Health Psychology, Faculty of Psychology, Autonomous University of Madrid, Madrid, Spain
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2
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Ortiz-Marrón H, Cabañas Pujadas G, Ortiz-Pinto MA, Martín García A, Matesanz Martínez C, Antonaya Martín MDC, Cortés Rico O, Galán I. Changes in general and abdominal obesity in children at 4, 6 and 9 years of age and their association with other cardiometabolic risk factors. Eur J Pediatr 2023; 182:1329-1340. [PMID: 36639534 PMCID: PMC10023764 DOI: 10.1007/s00431-022-04802-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/22/2022] [Accepted: 12/29/2022] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Honorato Ortiz-Marrón
- Department of Epidemiology, General Directorate of Public Health, Ministry of Health, C/López de Hoyos, n° 35, 1st Floor, Community of Madrid, 28006, Madrid, Spain.
| | - Gloria Cabañas Pujadas
- Department of Epidemiology, General Directorate of Public Health, Ministry of Health, C/López de Hoyos, n° 35, 1st Floor, Community of Madrid, 28006, Madrid, Spain
| | | | - Aránzazu Martín García
- Clinical Analysis and Biochemistry Service, Puerta de Hierro University Hospital, Majadahonda, Community of Madrid, Spain
| | | | | | - Olga Cortés Rico
- Canillejas Health Center, Northern Area of Primary Care of Madrid, Community of Madrid, Madrid, Spain
| | - Iñaki Galán
- National Center for Epidemiology, Institute of Health Carlos III, Madrid, Spain
- Department of Preventive Medicine and Public Health, Autonomous University of Madrid/IdiPAZ, Madrid, Spain
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Cerrillo I, Saralegui-Díez P, Morilla-Romero-de-la-Osa R, González de Molina M, Guzmán GI. Nutritional Analysis of the Spanish Population: A New Approach Using Public Data on Consumption. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1642. [PMID: 36674397 PMCID: PMC9867222 DOI: 10.3390/ijerph20021642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/04/2023] [Accepted: 01/11/2023] [Indexed: 06/17/2023]
Abstract
Official population consumption data are frequently used to characterize the diet of countries; however, this information may not always be representative of reality. This study analyses the food consumption of the Spanish population by reconstructing the whole food chain. The results have been compared with the data provided by the National Consumption Panel to which the food losses/waste reported in the literature along the distribution chain have been added. The difference between them allowed a new calculation of the estimated food consumption that was subjected to a dietary-nutritional analysis. Most of the foods were consumed more than those officially reported (range of 5-50%). The unhealthy ratios of consumed foods and recommended servings were: meat products (Rcr = 3.6), fruits and legumes (Rcr = 0.5), and nuts (Rcr = 0.14). Caloric intake surpasses needs. The results were consistent with the data on the prevalence of overweight and obesity in Spain, as well as with the prevalence of associated diseases. To make a judgment about the quality of a country's diet, it is necessary to have reliable data on food consumption, as well as energy and nutrient intake. This study encourages other authors to implement this method to verify and quantify the possible difference between official and real consumption data.
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Affiliation(s)
- Isabel Cerrillo
- Department of Molecular Biology and Biochemistry Engineering, Area of Nutrition and Food Sciences, Pablo de Olavide University, Carretera de Utrera Km 1, 41013 Seville, Spain
- Alimentta, Think Tank para la Transición Alimentaria, 18320 Santa Fe, Spain
| | - Pablo Saralegui-Díez
- Alimentta, Think Tank para la Transición Alimentaria, 18320 Santa Fe, Spain
- Laboratory of the History of Agroecosystems, Pablo de Olavide University, Carretera de Utrera Km 1, 41013 Seville, Spain
| | - Rubén Morilla-Romero-de-la-Osa
- Alimentta, Think Tank para la Transición Alimentaria, 18320 Santa Fe, Spain
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podiatry, Universidad de Sevilla, 41015 Seville, Spain
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, Spanish National Research Council (CSIC), Universidad de Sevilla, 41015 Seville, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Hospital Universitario Virgen del Rocío, 41015 Seville, Spain
| | - Manuel González de Molina
- Alimentta, Think Tank para la Transición Alimentaria, 18320 Santa Fe, Spain
- Laboratory of the History of Agroecosystems, Pablo de Olavide University, Carretera de Utrera Km 1, 41013 Seville, Spain
| | - Gloria I. Guzmán
- Alimentta, Think Tank para la Transición Alimentaria, 18320 Santa Fe, Spain
- Laboratory of the History of Agroecosystems, Pablo de Olavide University, Carretera de Utrera Km 1, 41013 Seville, Spain
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Aragón-Vela J, Alcalá-Bejarano Carrillo J, Moreno-Racero A, Plaza-Diaz J. The Role of Molecular and Hormonal Factors in Obesity and the Effects of Physical Activity in Children. Int J Mol Sci 2022; 23:15413. [PMID: 36499740 PMCID: PMC9737554 DOI: 10.3390/ijms232315413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/27/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Obesity and overweight are defined as abnormal fat accumulations. Adipose tissue consists of more than merely adipocytes; each adipocyte is closely coupled with the extracellular matrix. Adipose tissue stores excess energy through expansion. Obesity is caused by the abnormal expansion of adipose tissue as a result of adipocyte hypertrophy and hyperplasia. The process of obesity is controlled by several molecules, such as integrins, kindlins, or matrix metalloproteinases. In children with obesity, metabolomics studies have provided insight into the existence of unique metabolic profiles. As a result of low-grade inflammation in the system, abnormalities were observed in several metabolites associated with lipid, carbohydrate, and amino acid pathways. In addition, obesity and related hormones, such as leptin, play an instrumental role in regulating food intake and contributing to childhood obesity. The World Health Organization states that physical activity benefits the heart, the body, and the mind. Several noncommunicable diseases, such as cardiovascular disease, cancer, and diabetes, can be prevented and managed through physical activity. In this work, we reviewed pediatric studies that examined the molecular and hormonal control of obesity and the influence of physical activity on children with obesity or overweight. The purpose of this review was to examine some orchestrators involved in this disease and how they are related to pediatric populations. A larger number of randomized clinical trials with larger sample sizes and long-term studies could lead to the discovery of new key molecules as well as the detection of significant factors in the coming years. In order to improve the health of the pediatric population, omics analyses and machine learning techniques can be combined in order to improve treatment decisions.
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Affiliation(s)
- Jerónimo Aragón-Vela
- Department of Health Sciences, Area of Physiology, Building B3, Campus s/n “Las Lagunillas”, University of Jaén, 23071 Jaén, Spain
| | - Jesús Alcalá-Bejarano Carrillo
- Department of Health, University of the Valley of Mexico, Robles 600, Tecnologico I, San Luis Potosí 78220, Mexico
- Research and Advances in Molecular and Cellular Immunology, Center of Biomedical Research, University of Granada, Avda, del Conocimiento s/n, 18016 Armilla, Spain
| | - Aurora Moreno-Racero
- Research and Advances in Molecular and Cellular Immunology, Center of Biomedical Research, University of Granada, Avda, del Conocimiento s/n, 18016 Armilla, Spain
| | - Julio Plaza-Diaz
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, University of Granada, 18071 Granada, Spain
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
- Instituto de Investigación Biosanitaria IBS, Granada, Complejo Hospitalario Universitario de Granada, 18014 Granada, Spain
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Bravo-Saquicela DM, Sabag A, Rezende LFM, Rey-Lopez JP. Has the Prevalence of Childhood Obesity in Spain Plateaued? A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5240. [PMID: 35564634 PMCID: PMC9105543 DOI: 10.3390/ijerph19095240] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/17/2022] [Accepted: 04/23/2022] [Indexed: 02/07/2023]
Abstract
The prevalence of excess body weight (overweight plus obesity) in children has risen during the last decades in many countries, but it is unclear whether it has reached a plateau in Spanish children. We performed an updated systematic review and meta-analysis for the prevalence of excess body weight in children from Spain, comparing the trends between 1999 and 2010 and 2011 and 2021. Data were reported in a prior meta-analysis, plus an updated search using the Web of Science, MEDLINE (via PubMed) and EMBASE databases for data from January 2018 until December 2021. Thirteen representative studies were identified (34,813 children aged 2 to 13 years), with sample sizes averaging 2678 (range: 396-16,665). The prevalence of excess body weight in Spanish children aged 2 to 6 years increased from 23.3% (95% CI, 18.5% to 25.5%) during the period 1999-2010 to 39.9% (95% CI, 35.4% to 44.7%) during 2011-2021. In children aged 7 to 13 years, the prevalence of excess body weight increased from 32.3% (95% CI, 29.1-35.6%) during the period 1999-2010 to 35.3% (95% CI, 32.9-37.7%) during 2011-2021. The prevalence of childhood overweight and obesity in Spain has substantially increased in the last decade. New food policies to address the childhood obesity epidemic are urgently required to reverse current trends.
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Affiliation(s)
- Diana M. Bravo-Saquicela
- Faculty of Medical Sciences, University Laica Eloy Alfaro de Manabí (ULEAM), Manta 130217, Ecuador;
- Faculty of Health Sciences, Valencian International University (VIU), 46002 Valencia, Spain
| | - Angelo Sabag
- NICM Health Research Institute, Western Sydney University, Westmead, NSW 2145, Australia;
| | - Leandro F. M. Rezende
- Department of Preventive Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo 04023-900, Brazil;
| | - Juan Pablo Rey-Lopez
- Faculty of Health Sciences, Valencian International University (VIU), 46002 Valencia, Spain
- Faculty of Sport, Catholic University San Antonio of Murcia (UCAM), 30107 Murcia, Spain
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Ortiz-Marrón H, Ortiz-Pinto MA, Cabañas Pujadas G, Martínez Mosquera JG, Lorente Miñarro M, Menchero Pinos F, Ordobás Gavín M, Galán I. Tracking and risk of abdominal and general obesity in children between 4 and 9 years of age. The Longitudinal Childhood Obesity Study (ELOIN). BMC Pediatr 2022; 22:198. [PMID: 35413845 PMCID: PMC9004048 DOI: 10.1186/s12887-022-03266-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/04/2022] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Honorato Ortiz-Marrón
- Epidemiology Service, Directorate-General of Public Health, Ministry of Health, Community of Madrid, Madrid, Spain.
| | - Maira Alejandra Ortiz-Pinto
- Epidemiology Service, Directorate-General of Public Health, Ministry of Health, Community of Madrid, Madrid, Spain
| | - Gloria Cabañas Pujadas
- Epidemiology Service, Directorate-General of Public Health, Ministry of Health, Community of Madrid, Madrid, Spain
| | | | | | | | - María Ordobás Gavín
- Epidemiology Service, Directorate-General of Public Health, Ministry of Health, Community of Madrid, Madrid, Spain
| | - Iñaki Galán
- National Centre for Epidemiology, Institute of Health Carlos III, Madrid, Spain.,Department of Preventive Medicine and Public Health, Faculty of Medicine, Autonomous University of Madrid (IdiPaz), Madrid, Spain
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Rojo-Marticella M, Arija V, Alda JÁ, Morales-Hidalgo P, Esteban-Figuerola P, Canals J. Do Children with Attention-Deficit/Hyperactivity Disorder Follow a Different Dietary Pattern than That of Their Control Peers? Nutrients 2022; 14:1131. [PMID: 35334788 PMCID: PMC8949924 DOI: 10.3390/nu14061131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 12/15/2022] Open
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children and adolescents. A current area of interest is the association between ADHD and food consumption. The aim of this study was to determine the food consumption and dietary patterns of children with and without ADHD in relation to their age and ADHD presentation. The study involved 259 preschoolers aged 3 to 6 years old (57 with ADHD and 202 controls) and 475 elementary-school-age children, aged 10 to 12 years old (213 with ADHD and 262 controls) from Spain. ADHD was diagnosed in accordance with the Diagnostic and Statistical Manual of Mental Disorders (5th edition) from Schedule for Affective Disorders and Schizophrenia for School-Age Children interviews. Eating data were collected using a food consumption frequency questionnaire, and principal component analysis was carried out to analyze dietary patterns. Western-like, sweet, and healthy patterns were identified. The ADHD group was negatively associated with the healthy pattern (p < 0.001) and positively associated with the Western-like diet (p = 0.004). Children with inattentive presentation showed lower adherence (12.2%) to a healthy pattern than that of the control group (39.9%) (p < 0.001). There is an association between ADHD and dietary habits; children with inattentive presentation may particularly be at risk of unhealthy eating habits.
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Affiliation(s)
- Meritxell Rojo-Marticella
- Nutrition and Mental Health Research Group (NUTRISAM), Rovira i Virgili University (URV), 43201 Reus, Spain; (M.R.-M.); (V.A.); (P.M.-H.); (P.E.-F.)
- Research Centre for Behavioral Assessment (CRAMC), Department of Psychology, Rovira i Virgili University (URV), 43007 Tarragona, Spain
| | - Victoria Arija
- Nutrition and Mental Health Research Group (NUTRISAM), Rovira i Virgili University (URV), 43201 Reus, Spain; (M.R.-M.); (V.A.); (P.M.-H.); (P.E.-F.)
- Institut d’Investigació Sanitaria Pere Virgili (IISPV), Rovira i Virgili University (URV), 43204 Reus, Spain
| | - José Ángel Alda
- Attention Deficit Hyperactivity Disorder Unit, Sant Joan de Déu Hospital, 08950 Barcelona, Spain;
- Children and Adolescent Mental Health Research Group, Institut de Recerca Sant Joan de Déu, 08950 Barcelona, Spain
| | - Paula Morales-Hidalgo
- Nutrition and Mental Health Research Group (NUTRISAM), Rovira i Virgili University (URV), 43201 Reus, Spain; (M.R.-M.); (V.A.); (P.M.-H.); (P.E.-F.)
- Research Centre for Behavioral Assessment (CRAMC), Department of Psychology, Rovira i Virgili University (URV), 43007 Tarragona, Spain
- Institut d’Investigació Sanitaria Pere Virgili (IISPV), Rovira i Virgili University (URV), 43204 Reus, Spain
| | - Patricia Esteban-Figuerola
- Nutrition and Mental Health Research Group (NUTRISAM), Rovira i Virgili University (URV), 43201 Reus, Spain; (M.R.-M.); (V.A.); (P.M.-H.); (P.E.-F.)
- Research Centre for Behavioral Assessment (CRAMC), Department of Psychology, Rovira i Virgili University (URV), 43007 Tarragona, Spain
- Institut d’Investigació Sanitaria Pere Virgili (IISPV), Rovira i Virgili University (URV), 43204 Reus, Spain
| | - Josefa Canals
- Nutrition and Mental Health Research Group (NUTRISAM), Rovira i Virgili University (URV), 43201 Reus, Spain; (M.R.-M.); (V.A.); (P.M.-H.); (P.E.-F.)
- Research Centre for Behavioral Assessment (CRAMC), Department of Psychology, Rovira i Virgili University (URV), 43007 Tarragona, Spain
- Institut d’Investigació Sanitaria Pere Virgili (IISPV), Rovira i Virgili University (URV), 43204 Reus, Spain
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