Relation between body weight and health-related quality of life among the elderly in Spain

OBJECTIVE

This study examines the relation between body weight and the physical and mental components of health-related quality of life (HRQL) in the population aged 60 y and over in Spain.

RESEARCH METHODS AND PROCEDURES

Cross-sectional study covering 3605 subjects, representative of the noninstitutionalised Spanish population aged 60 y and over. Information was collected through home-based personal interview and measurement of blood pressure and anthropometric variables. Logistic regression was used to examine the relation of suboptimal HRQL (score<100) on each SF-36 questionnaire scale with body mass index (BMI) and waist circumference. Separate regression models were constructed for each sex and adjusted for sociodemographic variables, tobacco and alcohol consumption, physical activity, arterial hypertension and diagnosed chronic disease.

RESULTS

Mean age of the study population was 70.9 y for men and 72.2 y for women. The percentage of overweight subjects was 48.5% in men and 39.8% in women, and of obese subjects, 31.9 and 41.1% respectively. Men registered a better HRQL than women on most of the SF-36 scales. Compared to normal-weight subjects (BMI: 18.5-24.9 kg/m(2)), frequency of suboptimal physical functioning was higher among obese subjects (BMI>or=30 kg/m(2)), both male (OR: 1.91; 95% CI: 1.22-3.00) and female (OR: 2.58; 95% CI: 1.59-4.19). The aspects of physical functioning most affected were bending, kneeling or stooping, climbing stairs and strenuous effort. Male, though not female, obesity was nonetheless associated with a better HRQL on the SF-36 mental scales. Frequencies of suboptimal scores for overweight persons (BMI: 25-29.9 kg/m(2)) were similar to those for normal-weight subjects on most of the SF-36 scales. Results proved similar for subjects in both the 60-74 and 75-and-over age groups, and also when waist circumference was used as the measure of obesity (>102 cm in men and >88 cm in women).

CONCLUSIONS

Obese men and women showed worse physical functioning than normal-weight persons. This occurred irrespective of whether subjects were over or under 74 y of age, or whether obesity was measured by BMI or waist circumference, and was not explained by unhealthy lifestyles or obesity-related chronic disease.

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.

The size of obesity differences associated with educational level in Spain, 1987 and 1995/97

OBJECTIVE

To determine the size of obesity differences associated with educational level in the adult population in Spain.

DESIGN

Three cross sectional studies representative of the adult population in Spain were carried out in 1987, 1995, and 1997.

SETTING

The general population in Spain.

PARTICIPANTS

11 461 men and 10 219 women aged 25 to 64 years.

MAIN RESULTS

For both men and women the obesity prevalence was highest in those with elementary education. In 1987 the obesity prevalence proportion associated with less than third level education (PA) was 24.5% (95% CI 6.0 to 42.8) and 47.9% (15.7 to 71.8) in men and women, respectively. The PAs in 1995/97 were 19.8% (0.2 to 40.2) and 55.1% (21.3 to 72.8).

CONCLUSIONS

In 1995/97 the burden of obesity associated with less than third level education was 20% in men and 55% in women aged 25 to 64 years. Between 1987 and 1997 the obesity prevalence proportion associated with less than third level education increased in women and decreased in men.

The relationship of overweight and obesity with subjective health and use of health-care services among Spanish women

OBJECTIVE

To examine the relationship of overweight and obesity with subjective health and use of health-care services among women in Spain.

METHODS

Data were drawn from the 1993 Spanish National Health Survey, covering a 13 244-woman sample representative of the non-institutionalised Spanish population aged 16 y and over. Information was collected through home-based interviews. Multiple logistic regression models were used to calculate odds ratios for suboptimal health (fair, poor or very poor) and utilisation of health-care services by women with normal weight (BMI 18.5-24.9 kg/m(2)), overweight (BMI 25.0-29.9 kg/m(2)) and obesity (BMI>or=30 kg/m(2)). Analyses were adjusted for age, education level, occupation, civil status, social support, tobacco use, alcohol consumption, physical activity at work and during leisure time, job status and town of residence.

RESULTS

Frequency of suboptimal health was higher in women with overweight (OR 1.7; 95% CI 1.5-1.9) and obesity (OR 2.1; 95% CI 1.8-2.5) than in those with normal weight. Overweight and obese women visited the physician, used hospital emergency services and took medication with greater frequency than did women of normal weight. There was a positive dose-response relationship (P<0.05) of BMI>or=18.5 kg/m(2) with suboptimal health and utilisation of health-care services. These associations were not wholly explained by BMI-related risk factors and chronic diseases, since their statistical significance remained unchanged and their magnitude was only slightly reduced after adjustment for those factors. The association of overweight and obesity with the use of health-care services did not vary with age, educational level or presence of chronic disease.

CONCLUSION

Overweight and obese women have worse subjective health and make greater use of health-care services. This finding is an additional argument for implementing weight-control programmes in Spain.

[The transition from acute to chronic ischemic heart disease in Spain, 1980-1994]

BACKGROUND AND OBJECTIVES

The remarkable increase in hospital admissions from heart failure in Spain in the last few years may result paradoxical because it coincides with a decrease in ischemic heart disease mortality, the leading cause of heart failure. A plausible explanation is the increase in ischemic heart disease survival, derived from the recent therapeutic advances, which will translate into an increase in the chronic forms of disease. Thus, an analysis was made of mortality and hospital admission trends due to acute and chronic ischemic heart diseases in the 1980-1994 period in Spain.

METHODS

Population-based study of temporal trends with data of primary diagnosis of acute (CIE-9: 410-411) and chronic (CIE-9: 412-414) ischemic heart disease obtained from the National Vital Statistics and the National Survey of Hospital Morbidity.

RESULTS

The number of deaths due to acute ischemic heart disease has increased by 8.3%, from 18,559 in 1980 to 20,101 in 1994. Deaths due to chronic ischemic heart disease increased by 49.3%, from 4,703 in 1980 to 7,020 in 1994. As a result, chronic forms accounted for 20.2% of all deaths attributable to ischemic heart disease in 1980 and 25.8% in 1994. The age-adjusted acute ischemic heart disease mortality rates decreased by 20.1%, whereas those due to chronic increased by 14.6%. The number and rate of age-adjusted hospital admissions increased remarkably for both acute and chronic ischemic heart disease. Nevertheless, the increase observed with chronic form was higher, from 39.4% of all hospital admissions due to ischemic heart disease in 1980 to 58.4% in 1994. This classification of ischemic heart disease was more notorious among males and younger patients.

CONCLUSION

Currently, we are witnessing a transition from acute to chronic ischemic heart disease. That partly explains the increase in hospital care for heart diseases, particularly ischemic heart disease and heart failure.

[Smoking-attributable deaths in Spain in 1998]

BACKGROUND

Between 1993 and 1997, smoking prevalence remained stable in Spain yet age-adjusted death rates by smoking-related diseases decreased. Our study aimed to estimate the burden of smoking-attributable mortality in Spain in 1998.

POPULATION AND METHOD

Spain's smoking prevalence, mortality and relative risks for death from the Cancer Prevention Study II were used to estimate smoking-attributable mortality in the population aged 35 years and over.

RESULTS

In 1998, 55,613 deaths were attributable to smoking. One out of 4 deaths in males and one out of 40 deaths in females were attributable to tobacco. Two thirds of the attributable mortality corresponded to deaths due to lung cancer, chronic obstructive pulmonary disease, ischemic heart disease and stroke.

CONCLUSIONS

Smoking actually represents a remarkable burden of avoidable deaths in Spain. Smoking-attributable mortality appears to continue increasing in the last years.

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.

Increasing prevalence of overweight and obesity among Spanish adults, 1987-1997

OBJECTIVE

To study the trend in the prevalence of obesity and overweight in Spanish men and women 25-64 y of age between 1987 and 1997.

DESIGN

Cross-sectional surveys of representative samples of the non-institutionalized population in Spain in 1987, 1995 and 1997.

SUBJECTS

14,676 and 7004 adults aged 25-64 who were representative of the Spanish population in 1987 and 1995/1997.

MEASURES

Body mass index (BMI) calculated from self-reported weight and height. Overweight is defined as BMI = 27-29.9 kg/m2 and obesity as BMI > or = 30 kg/m2.

RESULTS

Between 1987 and 1995/97, the prevalence of overweight in the Spanish population aged 25-64 increased by 2.2% (P < 0.01); the increase was greater in men (3.8%; P < 0.01) than in women (0.6%; P > 0.05). The largest increases in the prevalence of overweight were seen in men (5.2%; P < 0.01) and women (2.3%; P < 0.05) aged 25-34. During the same period, the prevalence of obesity increased by 3.9% (P < 0.01), 4.6% in men (P < 0.01) and 3.2% in women (P < 0.01). The largest increases were seen in men aged 45-54 (6.5%, P < 0.01) and in women aged 25-34 (2.2%, P < 0.05). By educational level, the prevalence of overweight increased significantly in men with fewer than 12 y of education (4.7%, P < 0.01). Obesity increased by 4.6% (P < 0.01) and by 4.9% (P < 0.01) in men and women with fewer than 12 y of education, respectively.

CONCLUSIONS

The prevalence of overweight and obesity is increasing in Spain, the same as it is in other developed countries. The increase, which is found in most age and sex groups in the population, especially affects middle-aged men, young women and persons with lower educational level. The causes of the increase in the prevalence of overweight and obesity are likely to be multifactorial.

The association between mortality from ischaemic heart disease and mortality from leading chronic diseases

AIMS

Coronary risk factors raise the risk of other chronic disorders. We therefore tested the hypothesis that the geographic distribution of ischaemic heart disease mortality is associated with that of other chronic diseases with which it shares risk factors.

METHODS AND RESULTS

For the 50 provinces of Spain, we collected mortality data for the period 1980-1995 from the national vital statistics. We calculated age-adjusted mortality rates for the leading causes of death in quintiles of provincial distribution of ischaemic heart disease mortality, and correlation coefficients with respect to provincial ischaemic heart disease mortality. As expected, because they share risk factors with ischaemic heart disease, mortality from cerebrovascular disease, malignant tumours, lung cancer, respiratory diseases, chronic obstructive pulmonary disease, diseases of the digestive system, cirrhosis of the liver and all causes, increase with the rise from lower to higher quintiles of ischaemic heart disease mortality. Ischaemic heart disease mortality registered correlations over 0.5 (P<0.001) with mortality from many of the above diseases in the periods 1980-1984 and 1991-1995. Expectations were similarly borne out for disorders not sharing risk factors with ischaemic heart disease, in that mortality from prostate and breast cancer, injury and poisoning, traffic accidents and ill-defined causes in most cases did not show a provincial association with ischaemic heart disease mortality. In general, these results were observed for both sexes and across all age groups.

CONCLUSION

Ischaemic heart disease mortality is associated with mortality from chronic diseases which share coronary risk factors, across provinces of Spain over the period 1980-1995. This suggests that the geographic variation in such chronic diseases is due to common factors, potentially susceptible to similar preventive interventions.

[Cholesterolemia control in Spain, 2000: a tool for cardiovascular disease prevention]

The document "Cholesterolemia control in Spain, 2000: a tool for cardiovascular disease prevention" reviews the current evidence on cardiovascular disease prevention and the therapeutic advances achieved in recent years, in order to aid risk-based clinical decision-making. Cardiovascular diseases rank as the first cause of death in Spain. Their demographic, health and social impact is increasing and it is likely to continue to do so in the next decades. Appropriate treatment for high blood cholesterol and other major risk factors is crucial in cardiovascular disease prevention. Individual risk stratification is essential to determine follow-up periodicity and treatment. Priorities for the control of cholesterolemia and the consequent cardiovascular risk are based on risk stratification. In primary prevention, the therapeutic objective in high risk patients has been established as LDL-cholesterol < 130 mg/dl. In secondary prevention, drug treatment is indicated when LDL-cholesterol > or = 130 mg/dl and the therapeutic objective is LDL-cholesterol < 100 mg/dl. Statins are first line drugs for treatment of high blood cholesterol. In moderate-severe hypertriglyceridemia or low HDL-cholesterol, fibrates are preferred. In acute coronary syndrome, hypolipemiant treatment, should be started as soon as possible, when indicated. Secondary prevention programmes that continually provide good clinical and risk factor control should be provided to coronary heart disease patients.

[Recommendations for the control of cholesterolemia in Spain]

A number of recommendations are provided regarding the detection, assessment and management in primary and secondary prevention, approaching hypercholesterolaemia from a multifactorial standpoint based on cardiovascular risk. Cardiovascular diseases are the leading cause of death in Spain. The major risks involved are coronary heart disease and cerebrovascular disease. The demographic, health-related and social impact thereof will be increasing over the coming decades. Controlling hypercholesterolaemia, in conjunction with eradicating the smoking habit and controlling hypertension, diabetes, obesity and physical inactivity comprise one of the main strategies for preventing cardiovascular diseases. Breaking down the risk of individuals based on the major cardiovascular risk factors is essential, given that these factors condition the frequency with which these individuals must be monitored and the type and degree of treatment entailed. Based on this breakdown, the priorities have been set for taking steps to prevent cardiovascular disease. In primary prevention, the therapeutic objective in high-risk persons (20% risk or higher or those persons involving two or more risk factors) has been established as LDL-cholesterol < 130 mg/dl. In secondary prevention, drug treatment is indicated when LDL-cholesterol (130 mg/dl and the therapeutic objective is LDL-cholesterol < 100 mg/dl. Those patients having coronary heart disease must be included in secondary prevention programs that will ensure good, constant clinical and risk factor-related control.

[Geographic variation in hospitalizations and mortality related to congestive heart failure in Spain, 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.

[Control of cholesterolemia in Spain, 2000. A tool for cardiovascular prevention]

The document "Cholesterolemia Control in Spain, 2000: A Tool for Cardiovascular Disease Prevention" reviews the current evidence on cardiovascular disease prevention and the therapeutic advances achieved in recent years, in order to aid risk-based clinical decision-making. Cardiovascular diseases rank as the first cause of death in Spain. Their demographic, health and social impact is increasing and it is likely to continue to do so in the next decades. Appropriate treatment for high blood cholesterol and other major risk factors is crucial in cardiovascular disease prevention. Individual risk stratification is essential to determine follow-up periodicity and treatment. Priorities for the control of cholesterolemia and the consequent cardiovascular risk are based on risk stratification. In primary prevention, the therapeutic objective in high risk patients has been established as LDL-cholesterol < 130 mg/dl. In secondary prevention, drug treatment is indicated when LDL-cholesterol > or = 130 mg/dl and the therapeutic objective is LDL-cholesterol < 100 mg/dl. Statins are first line drugs for treatment of high blood cholesterol. In moderate-severe hypertriglyceridemia or low HDL-cholesterol, fibrates are preferred. In acute coronary syndrome, hypolipemiant treatment, should be started as soon as possible, when indicated. Secondary prevention programmes that continually provide good clinical and risk factor control should be provided to coronary heart disease patients.

[The risk of suffering a cardiovascular disease in the making of decisions. From evidence to the clinic]

The importance of the atherosclerotic cardiovascular disease (which is multifactorial in its origin) in Spain and the need for and efficient management of the treatments make especially useful to consider the overall cardiovascular risk of the individual in order to take clinical decisions towards the follow-up and treatment of the disease. Current evidence from cardiovascular risk situations supports this strategy of considering all the risk factors as a whole instead of evaluating each of them separately. This paper tries to revalidate this approach with the most reliable of the available evidence from case studies. The global cardiovascular risk is suggested to be evaluated by a risk chart based on Framingham's study. A revision of the clinical priorities in cardiovascular disease prevention is made. Finally, some views on ordinary clinical cases are given, suggesting the treatment based on a global risk evaluation, considering and opposing evidence and recommended guidelines from the most common Spanish guides on prevention of cardiovascular diseases, evaluating the potential benefit of treatment for the patient, and making a clinical decision.

[Environmental factors during early life and socioeconomic status in the present: which is more important for cardiovascular mortality in Spain?]

BACKGROUND

To examine whether provincial mortality from ischaemic heart disease and cerebrovascular disease in Spain in 1991-1995 is associated with infant mortality in 1930-1934, independently of illiteracy (an estimator of socioeconomic status) in 1991.

MATERIAL AND METHODS

Population-correlation study.

RESULTS

Infant mortality is correlated with mortality from ischaemic heart disease (r = 0.38; p < 0.01) and cerebrovascular disease (r = 0.41; p < 0.01). When adjusting for illiteracy rate in 1991, the correlation of infant mortality with ischaemic heart disease mortality is r = 0.01 (p = 0.93), and with cerebrovascular disease mortality is r = 0.25 (p = 0.08).

CONCLUSIONS

Ischaemic heart disease and cerebrovascular disease mortality are moderately associated with infant mortality during the 1930s. This association might be explained by present socioeconomic status.

[The decline in moderate alcohol consumption has been associated with a decrease in heavy drinkers in Spain in the 1987-1993 period]

BACKGROUND

To examine whether the decline in alcohol consumption among moderate drinkers, which has occurred in Spain in the period 1987-1993, has been associated with changes in the proportion of heavy drinkers and abstainers.

SUBJECTS AND METHODS

The units of analysis have been the 17 administrative regions of Spain. Alcohol consumption data have been taken from the 1987 and 1993 National Health Interview Surveys.

RESULTS

A decrease of 10 g/week in mean alcohol consumption among male moderate drinkers has been associated with a decrease of 1.2% (95% CI: 0.7-1.7%) in the proportion of heavy drinkers. The association was also observed among women, those over and below 45 years of age, and was stronger for wine than for other alcoholic beverages.

CONCLUSION

The decrease in moderate consumption of alcohol has probably had a beneficial effect on the health of the Spanish population.

Association of moderate consumption of alcohol with rates of heavy drinking and abstinence in Spain

BACKGROUND

Moderate consumption of alcohol reduces general mortality among middle-aged and elderly persons through a reduction in cardiovascular risk. Furthermore, higher consumption of wine is associated with lower cardiovascular mortality in northern Spain. This information may be used to promote moderate consumption of alcoholic beverages in Spain. However, alcohol consumption is influenced by the drinking habits of the individual's social environment. Therefore, we examine the relation between average consumption of alcohol and the prevalence of heavy drinkers, who most often have adverse effects from alcohol, and the prevalence of abstainers, who do not benefit from alcohol, in Spain.

METHODS

Spain's 17 administrative regions are the units of analysis. Alcohol consumption data were taken from the 1993 National Health Survey. Data were analyzed using weighted correlation coefficients and linear regression.

RESULTS AND CONCLUSIONS

Mean alcohol consumption among moderate drinkers showed a positive correlation with the proportions of men (r = 0.63; p = 0.007) and women (r = 0.58; p = 0.015) whose alcohol intake was above the 90th percentile of consumption distribution. Similar results were yielded when median rather than mean consumption was used, and when heavy drinking was defined as the consumption of 210 g and 140 g of alcohol per week, in men and women, respectively. The association also was observed across all ages and all types of beverages. However, no statistically significant association was seen between mean and median alcohol consumption and the proportion of abstainers.

SIGNIFICANCE

Moderate consumption of alcohol is associated with the prevalence of heavy drinkers in all regions of Spain. Therefore, promotion of moderate consumption of alcohol in Spain might be associated with a rise in the prevalence of heavy drinkers, those who most frequently suffer the harmful effects of alcohol.

[Hypertension-related mortality and arterial pressure in Spain]

BACKGROUND

Given the high figures of cardiovascular disease and hypertension in Spain, and the continuity of cardiovascular and total mortality risks at any level of blood pressure, mortality related to hypertension and blood pressure is estimated.

SUBJECTS AND METHODS

Blood pressure distribution from a representative sample of the 35 to 64 years old Spanish population and the relative risks for death coming from valid and reasonably generalizable international studies (MRFIT, Framingham and Chicago Project) were used. The proportions and absolute numbers of cardiovascular and total deaths related to blood pressure and hypertension (categories of the US Joint National Committee VI [JNC VI]) have been calculated in middle-aged men and women.

RESULTS

As many as 42% of the coronary deaths, 46.4% of the stroke deaths and 25.5% of the total deaths are related to hypertension (> or = 140/90 mmHg), most of them in stages 1 and 2. It follows high-normal plus normal blood pressure group (8.3, 10.2 and 6.2% of these deaths, respectively). All together, 17,266 total deaths and 4,502 cardiovascular deaths related to blood pressure took place annually, three-quarters of them in males. Over the last ones, 65.5% are coronary and 34.5% cerebrovascular, prevailing the first ones in both sexes. Eight out of 10 deaths, cardiovascular or total, related to blood pressure are concentrated in the hypertension categories, and two out of 10 in the high-normal or normal blood pressure groups.

CONCLUSIONS

One out of 3 total deaths and one out of 2 cardiovascular deaths are related to blood pressure. One out of 4 total deaths and one out of 2.5 cardiovascular deaths are related to hypertension. A substantial part of these deaths come from stages 1 and 2 hypertension and from high-normal and normal blood pressure group.

Determinants of geographical variations in body mass index (BMI) and obesity in Spain

OBJECTIVE

To identify the factors associated with geographic variations in Body Mass Index (BMI) and obesity in Spain.

DESIGN

Cross-sectional, ecological analysis using data on illiteracy rate (per 1000 population), energy intake (kcal/person/d), sedentary population (%), smoking population (%), alcohol consumption (g/person/d), and percentage of population aged 65 y or over, for Spain's 50 provinces.

SUBJECTS

Non-institutionalized population aged 16y or over.

MEASUREMENTS

Median BMI and percentage of population with obesity, defined as BMI > 30 kg/m2.

RESULTS

There was a clear geographical pattern, with some areas in the south and north-west of the country registering the highest BMI and prevalence of obesity and a north-south pattern on illiteracy per 1000 population. Multivariate regression analysis showed that illiteracy, sedentary lifestyle and energy intake explain 35% and 14% of the variation in BMI and obesity, respectively. Illiteracy proved to be the variable most associated with both BMI (regression coefficient (beta = 0.01; P = 0.005) and obesity (beta = 0.05; P = 0.013). Sedentary lifestyle showed a statistically significant relationship with BMI (beta = 0.01; P = 0.03), but not with obesity (beta = 0.03; P = 0.581). Energy intake exhibited a relationship with BMI (beta < 0.01 P = 0.03) that lost statistical significance when adjusted for age.

CONCLUSION

Geographical variations in BMI in Spain are partly explained by illiteracy, sedentary lifestyle and, to a lesser extent, energy intake, whereas regional variations in obesity are related only to the educational level of the population.

Consumption of fruit and wine and the decline in cerebrovascular disease mortality in Spain (1975-1993)

BACKGROUND AND PURPOSE

This study examines the changes in provincial distribution of cerebrovascular disease (CVD) mortality and its socioeconomic and lifestyle risk factors to identify those factors that have most greatly contributed to the decline in CVD mortality in Spain during the period 1975-1993.

METHODS

We performed a study using data aggregated at a provincial level. Mortality data were taken from official vital statistics, while data on risk factors were obtained from surveys of representative large Spanish population samples. Correlation and multiple linear regression analyses were performed on percent changes in age-standardized CVD mortality from 1975-1979 to 1989-1993 and its potential determinants during the period 1964-1980.

RESULTS

CVD mortality was higher in the southern and eastern (Mediterranean coast) provinces in 1975-1979 and again in 1989-1993. Between these periods there was a 55% decline in CVD mortality, which affected all provinces but was greater in those with a lower CVD mortality (r = -0.31, P = 0.03). The 1964-1980 period witnessed an increase in the intake of most foodstuffs and all types of fats. However, there was a decrease in the consumption of vegetables and legumes and in the proportion of illiteracy among the population older than 45 years. The greatest increase in fruit and fish consumption and the greatest decrease in illiteracy were registered by Spain's northernmost provinces, the same provinces that recorded the greatest decline in CVD mortality. Changes in fruit, wine, and fish intake accounted for 22% of the variation in the decline in CVD mortality. The increase in fruit consumption and decrease in wine consumption showed a statistically significant relationship (P < or = 0.04) with the decline in CVD mortality.

CONCLUSIONS

The increase in fruit and decrease in wine consumption from 1964-1980 may have contributed to the decline in CVD mortality in Spain during 1975-1993.

[Wine consumption and ischemic heart disease mortality in Spain]

BACKGROUND

To identify the determinants of the geographic distribution of ischaemic heart disease (IHD) mortality in Spain.

POPULATION AND METHODS

Ecological study at the provincial level. Data are obtained from the 1976-1980 vital statistics, the 1964-1965 Household Budget Survey and the 1970 Population Census.

RESULTS

Consumption of wine, chicken, fish, and vegetables, as well as illiteracy, explain 47% of IHD mortality. Consumption of wine alone exhibits a statistically significant relationship (p < 0.05) with IHD mortality. Moderate consumption of wine is negatively associated with IHD mortality, whereas higher consumption reveals a positive association.

CONCLUSION

Results are consistent with those from an earlier study in Spain for the 1983-1987 period.

[Cardiovascular mortality in Spain and its autonomous communities (1975-1992)]

BACKGROUND

Given the great relevancy of the cardiovascular diseases, were analyzed the cardiovascular mortality in the Spanish autonomous communities and its trend during the period 1975-1992, to identify communities with a high death risk by these diseases and to as certain the underlying factors.

MATERIAL AND METHODS

The mortality rates standardized by age are calculated for the diseases of the circulatory system (DCS), ischaemic heart disease (IHD) and cerebrovascular disease (CVD). The mortality trend has been quantified through the percentual change annual means, using a log-lineal model.

RESULTS

The Communities of Valencia, Extremadura, Andalusia and Murcia show the highest cardiovascular diseases mortality rates while the Communities of Madrid, Navarra, Castilla and Leon and Aragon present the most decreases. In all the communities a decrease of the mortality by DCS has occurred, that ranges from a percentual decrease annual means higher than 3% in Navarre (-3.7%) and Madrid (-3.4%) to values that they do not reach to the 2% of decrease in Murcia (-1.8%) and Balearic Islands (-1.9%). In males as well as in females, the mortality by IHD and CVD falls in all the communities in the period 1975-1992, though the decrease is much greater for CVD.

CONCLUSIONS

This study demonstrates a consistent fall of the cardiovascular mortality in all the Spanish autonomous communities and some considerable differences in the level and in the trends of the magnitude mortality among these communities during all the studied period.

[Trends in the mortality attributable to tobacco use in Spain, 1978-1992: 600,000 deaths in 15 years]

BACKGROUND

The main objective is to describe time trends and evolution of mortality attributable to tobacco use in Spain in the period 1978-1992.

MATERIAL AND METHODS

Spanish pevalences for never smokers, current smokers and former smokers estimated from national health surveys, and relative risks for death attributed to tobacco use from the Cancer Prevention Study II were used. The proportion and number of deaths attributed to tobacco use in the Spanish population of 35 years and over have been calculated by cause of death, sex and age. The trend in mortality attributable to tobacco use over the period 1978-1992 has also been calculated, expressed as the mean percentage change per year in the standardised mortality rates, estimated by a log-lineal model.

RESULTS

Tobacco consumption caused 46,226 deaths in Spain in 1992. Most of them occurred in males (93.4%). One of every 4 deaths in males, and one of every 50 in females were attributable to tobacco consumption. One third of the deaths attributed to tobacco use were premature deaths (under 65 years). Lung cancer, chronic obstructive pulmonary disease, ischemic heart disease and cerebrovascular disease caused 75% of deaths attributed to tobacco use. Lung cancer was the first specific cause in males, and chronic obstructive pulmonary disease was the main cause in females. A total of 621,678 deaths attributed to tobacco consumption were produced in the period (1978-1992). The main percentage change per year in the mortality rates shows a moderate increment of 0.1% (-0.2% in males +6.7% in females).

CONCLUSIONS

Mortality attributable to tobacco use in Spain represents a high cost in terms of avoidable deaths and shows the limited impact of the interventions directed to tobacco control in Spain. One of every 4 deaths in males and a disturbing and rapidly increasing proportion in females are attributable to smoking.

Trends in hospitalization and mortality for heart failure in Spain, 1980-1993

AIMS

To describe, for the first time, trends in hospitalization and mortality rates for congestive heart failure in Spain during the period 1980-1993.

METHODS AND RESULTS

Data on primary diagnosis of congestive heart failure were taken from the National Hospital Morbidity Survey and the National Vital Statistics. The number of hospital admissions for congestive heart failure rose by 71% (from 42,965 in 1980 to 73,448 in 1993) and hospitalization rates for congestive heart failure increased by 47% (from 348 per 100,000 in 1980 to 511 per 100,000 in 1993). The rise in hospitalizations was limited to persons aged > or = 65 years, and proved greater among women. Congestive heart failure was the leading cause of hospitalization in persons aged > or = 65 years, accounting for 5% of all hospital admissions in this age group. Age-adjusted congestive heart failure mortality declined by 23%. The decline affected all age groups, with the sole exception of the > or = 80-year group in which mortality rose. Nevertheless, congestive heart failure remained the third leading cause of cardiovascular death.

CONCLUSION

Congestive heart failure represents a significant hospital and demographic burden for the Spanish population. The hospital burden increased substantially in the period 1980-1993, and will continue to do so in future with the growth of the elderly population.

Cerebrovascular disease mortality in Spain, 1955-1992: an age-period-cohort analysis

The purpose of this study was to assess the contributions of period and birth cohort effects to changes in cerebrovascular disease (CVD) mortality in Spain over the period 1955-1992. Poisson regression models were fitted to age-and sex-specific CVD mortality rates obtained from National Vital Statistics. In the period 1955-1975, CVD mortality remained stable. In the period 1975-1992, CVD mortality declined by 54% (rate ratio, RR: 0.46; 95% confidence interval, CI: 0.43-0.49) in males and 62% (RR: 0.38; 95% CI: 0.34-0.42) in females. The cohort effect was very small up to the generation born in 1905, moving clearly downward thereafter. CVD mortality for subjects born in the period 1945-1949 was lower than for those born in the period 1905-1909 by 68% (RR: 0.32; 95% CI:0.16-0.63) in males and 82% (RR: 0.18; 95% CI: 0.07-0.45) in females. Among the possible partial explanations for these effects are the decline in ischemic heart disease and rheumatic fever mortality, the drop in salt and alcohol intake, the reduction in smoking among males and blood pressure among females, and the widespread use of antihypertensive treatments in Spain over the last 20 years.

[Projections of the impact of the smoking habit on the health of the Spanish population and on the potential benefits from its control]

BACKGROUND

Smoking continues to be an important public health problem in Spain. With the aim to know some of the health care consequences derived from the evolution of this habit in the Spanish population and to anticipate the health care benefits which would be a result of intervention on the same the estimations of mortality related with smoking and its control in the next few decades were predicted.

METHODS

Mathematic models of simulation of the effects derived from changes in the prevalence of smoking based on the techniques of attributable risk, the multiplicity of the diseases involved and the time of reversal of the risk of death following health care intervention were used.

RESULTS

In absence of intervention on smoking the number of total deaths by the causes under consideration will, in general, increase, from 1987 to 2020. The reduction of 40% in the prevalence of smoking in adult Spanish smokers over a period of 8 years (1992-2000) would potentially decrease the number of cardiovascular deaths by 6,035, deaths by COPD by 394 and the deaths by malignant tumors studied in the year 2020 by 5,237. By the year 2020 the effects of intervention would, in general, be completely manifest. A part of this reduction of mortality would translate in a gaining of 57,323 real years of life in the year 2020. These benefits are also appreciable, although lesser, in the previous years from the beginning of intervention.

CONCLUSIONS

Smoking will continue to be an important public health problem in Spain in the future. The health care benefits which may be derived from correct application of effective control programs of the same would be appreciable.

[An epidemiological study on cardiovascular risk factors in 35-64 years old Spanish population]

BACKGROUND

Cardiovascular disease (CVD), specifically Coronary Health Disease and Cerebrovascular Disease, are the first cause of death in Spain. Information about their main modifiable risk factors (RF) distribution is needed in order to CVD prevention. The purpose of this paper is to estimate these RF prevalence and distribution by age, sex and habitat groups, i.e. tobacco smoking, cholesterolemia, high blood pressure, and obesity in the Spanish population.

METHODS

A random cluster sampling cross-sectional study, stratified by habitat (rural and urban), age and sex, was carried out on 2021 men and women of 35 to 64 years of age in 1989. Definition criteria for variables studied were those from WHO and European Atherosclerosis Society. Additional data for study were treatment and control level of hypertensives, cardiovascular drugs consumption and CVD family history.

RESULTS

Participation rate was 73.3%. Mean cholesterolemia was 211.2 mg/dl (210.1 mg/dl in males and 211.9 mg/dl in females). Mean systolic blood pressure was 132.3 mmHg (133.4 and 131.6 mmHg in men and women, respectively). Mean Quetelet Index was 27.5 kg/m2 (27.2 and 27.6 for men and women). 49.4% of males and 16.7% of females were smokers (25.7% and 78.3% were never smokers, respectively). Prevalence of hypercholesterolemia (> or = 250 mg/dl) was 18.6% in men and 17.6% in women, and that of high blood pressure (> or = 160/95 mmHg) was 21.5% in men (49.1% of them treated, and 26.7% controlled), and 19% in women (60.9% treated and 38% controlled). 18.4% of men and 27.4% of women had a Quetelet Index greater than thirty. 15 to 20% of individuals reported a CVD family history. For all these variables there were generally differences according to age, sex, and habitat.

CONCLUSIONS

Risk factors distributions and prevalences in Spanish middle-aged individuals rank relatively high. This suggest need of further study and control of them to address CVD prevention properly.

[Eat less fat to prevent ischemic cardiopathy. The potential impact of population and individual strategies for controlling cholesterolemia in Spain]

BACKGROUND

The aim of the application of population and individual strategies for the control of cholesterolemia recommended by several commissions of experts in Spain is to obtain marked decreases in mortality by ischemic heart disease. This study is the first to estimate the potential benefits obtained by the application of both strategies in males from 35 to 64 years of age in Spain.

METHODS

Upon fixing the population dietetic aims for the ingestion of fats and cholesterol, the foreseen decrease in mean serum cholesterol was estimated by predictive equations. For individuals at risk, more ambitious objectives were made in regard to decrease in cholesterolemia. The consequent reduction of coronary death risk was obtained for each strategy comparing the foreseen coronary risks by logistic functions for previous serum cholesterol values and those posterior to the health intervention.

RESULTS

The population decrease of saturated fat to 7-10% of total calories of the diet and of the consumption of cholesterol to 300 mg/day would produce a reduction of serum cholesterol of between 6.5 and 21.4 mg/dl (0.2-0.6 mmol/l) which would represent nearly 200 mg/dl (5.2 mmol/l). This would then produce a decrease in coronary deaths of 5.5 to 17.1%. This population strategy must reach 934 to 2,857 people per death avoided. With the individual strategy, the reduction of 55 mg/dl (1.4 mmol/l) in mean cholesterolemia of subjects with more than 250 mg/dl (mean 7.1 mmol/l) or of 36 mg/dl (0.9 mmol/l) in those with more than 200 mg/dl (mean 6.2 mmol/l) would produce a decrease of population coronary death between 3.3 and 12.5% in the first group, and 5.2 to 20% in the second requiring 237 or 454 subjects in each group, respectively per death avoided. The joint application of both strategies would reduce the risk from 8.4 to 24.5%. This would delay the appearance of 570 to 1,640 coronary deaths each year.

CONCLUSIONS

The population strategy for cholesterolemia control provides greater health benefits, within a short term, than those of individual strategy although it must be applied to more subjects per unit of benefit. The joint application of both strategies may produce a modest but appreciable reduction, within a medium term, of coronary death in Spain.

[Guidelines for the elaboration of programs for the primary prevention of cardiovascular diseases. The Working Group for Primary Cardiovascular Prevention]

This paper, elaborated by consensus between experts from Scientific Societies and the Health Administration, is aimed at providing general guidelines for the elaboration and prompting of cardiovascular disease primary prevention programmes, through individual risk factors screening and control. It is expected to be helpful for primary care professionals. After reviewing the rationale and logistics of the programmes starting in the Spanish context, an outline for the risk screening and assessment of the individuals attending the health services is set out. The strategies for high risk individuals control and the periodic health examination of low risk subjects are developed, emphasizing the multifactorial approach. Lastly operational criteria for the management of each risk factor taking simultaneously into account the whole risk picture, embracing definition criteria and consensus recommendations, are stated.

[The relevance of mortality due to circulatory system diseases in Spain]

Cardiovascular diseases is the first cause of death in Spain, as it occurs in most western countries, with a crude death rate of 306 per 100,000 inhabitants in the male population and 351 in the female population in 1987. While this represented a 44.9% of all death causes in 1976, it represented a 42.6% in 1987. Death due to cardiovascular diseases, once corrected for the aging population, has decreased at a yearly rate of 1.26% in males and 1.6% in females from 1968 to 1987 (last year with available date). Most part of the decrease is due to a mean annual decrease of 3% in cerebrovascular mortality since the mid 70s, followed by a reduction in coronary deaths, slightly above 1% annually, since approximately the same time. The changes in life style that have taken place, together with medical and surgical advances and the influence of other factors which have not been so widely studied could be responsible for the potential saving of over 12,000 deaths due to cardiovascular diseases, which would have been added to those occurred in 1987 if mortality rate due to cardiovascular diseases had been the same as in 1976. The difficulty to assign a quantified degree of responsibility changes constitutes a research challenge, not discrediting the preventive action on this facts which are already known.

[Mortality caused by cardiovascular diseases in Spain: where are we going?]

Spain is one of the european countries with a lowest mortality rate by cardiovascular diseases (although they are the leading cause of mortality) and, specifically, by ischemic heart disease. The trends in the last 16 years for which data are available point to a reduction of the former in 1.07% in males and 1.53% in females for the complete study period (1968-1984) and a trend towards the stabilization of the latter (a reduction of 0.45% in males and 1.88% in females from 1978 to 1984). The apparently unfavorable evolution of the classical risk factors of coronary artery disease, however, makes that its future outcome is uncertain. Therefore, their control is a basic aim of the policy for the control of this disease.

[Geriatric emergencies versus adult emergencies: retrospective analysis of medical emergencies at a general hospital]

The aim of the study was to evaluate the process of the attention to emergencies in patients older than 65 years and to compare it with the same process in adult patients. To this end, 965 clinical records of medical emergencies from the Hospital Central de la Cruz Roja in Madrid were retrospectively evaluated, and data were obtained regarding age, the cause for consultation, the investigations performed and their yield, the administration of drug therapy, the major diagnosis at the time of discharge from the service and the clinical course. It was found that all evaluated diagnostic investigations were carried out with equal or higher frequency in patients older than 65 years and that their mean clinical effectiveness was also higher. In addition, it was found that the patients older than 65 years were more commonly admitted to the hospital through the emergency service than the rest of the population. It was concluded, therefore, that the process of attention to emergencies has differential characteristics in the elderly population, and that if the number and proportion of old people increase as it will presumably happen during the two next decades, the cost of attention to emergencies and the number of emergency hospital admissions will also increase.