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Background Very few studies have reported updated data on the incidence, clinical evolution and treatment of inflammatory bowel disease (IBD) in Europe. Aims i) To assess the incidence of IBD in Spain; ii) to describe the main epidemiological and clinical characteristics of patients at diagnosis and the evolution of the disease; and iii) to explore the use of drug treatments in the biological era. Methods Prospective and population-based nationwide registry. Adult patients diagnosed with IBD -Crohn’s disease (CD), ulcerative colitis (UC) or IBD unclassified (IBD-U)- during 2017 in all the 17 Spanish administrative regions were included and will be followed-up for 5 years after diagnosis. Treatment was grouped into 5 categories: mesalazine (oral or topical), steroids (intravenous, oral or topical), immunomodulators (thiopurines, methotrexate or cyclosporine), biologics (anti-TNF, vedolizumab or ustekinumab) and surgery. Results 3627 incident cases of IBD diagnosed during 2017 in 108 hospitals covering over 22 millions of adult inhabitants (about 50% of the Spanish population) comprise the study cohort (Table 1). The overall incidence (cases/100.000 person-years) was 16 for IBD, 7.5 for CD, 8 for UC, and 0.5 for IBD-U. Incidence of CD was somewhat higher in Central Spain, while that of UC was higher in Northern Spain (Asturias and Navarra) (Figure 1). About 46% of patients had CD and 50% UC. Diagnosis delay was longer in CD than in UC (5 vs. 2 months, p < 0.01). The proportion of patients with symptoms at diagnosis was higher in UC than CD (94 vs. 89%, p < 0.01). By contrast, those with CD vs. UC had higher frequency of family history of the disease (18 vs. 13%, p < 0.01), tobacco smoking (38 vs. 12%, p < 0.01) and extraintestinal manifestations (12 vs. 6%, p < 0.01). At diagnosis, 18% of CD patients had structuring or fistulising behaviour, and 69% of UC patients had extensive colitis or left-sided colitis. During a median of 12-month of follow-up, 28% of patients were hospitalised (35% of CD and 22% of UC patients, p < 0.01). A total of 2.6% CD patients progressed to a more severe phenotype, and 2% UC patients developed a more extensive involvement. The cumulative exposure to different treatments is shown in Figure 2. Conclusion The incidence of IBD in Spain is quite high and similar to that reported in Northern Europe. IBD patients require the use of substantial therapeutic resources, which are greater in CD than in UC, and much greater than previously reported. One third of patients are hospitalised in the first year after diagnosis and over 5% undergo surgery. These results highlight the high burden of IBD as well as some of the important challenges faced by clinicians and healthcare systems to manage this costly and complex disease.

Various studies have identified factors associated with risk of mortality in patients with SARS-CoV-2 infection. However, their sample size has often been limited and their results partially contradictory. This study evaluated factors associated with COVID-19 mortality in the population of Madrid over 75 years of age, in infected patients, and in hospitalized patients up to January 2021.This population-based cohort study analyzed all residents of the Community of Madrid born before January 1, 1945 who were alive as of December 31, 2019. Demographic and clinical data were obtained from primary care electronic medical records (PC-Madrid), data on hospital admissions from the Conjunto Mínimo Básico de Datos (CMBD, Minimum Data Set), and data on mortality from the Índice Nacional de Defunciones (INDEF, National Death Index). Data on SARS-CoV-2 infection, hospitalization, and death were collected from March 1, 2020 to January 31, 2021.A total of 587,603 subjects were included in the cohort. Of them, 41,603 (7.1%) had confirmed SARS-CoV-2 infection, of which 22,362 (53.7% of the infected individuals) were hospitalized and 11,251 (27%) died. Male sex and age were the factors most closely associated with mortality, though many comorbidities also had an influence. The associations were stronger in the analysis of the total population than in the analysis of infected or hospitalized patients. Mortality among hospitalized patients was lower during the second wave (33.4%) than during the first wave (41.2%) of the pandemic.Age, sex, and numerous comorbidities are associated with risk of death due to COVID-19. Mortality in hospitalized patients declined notably after the first wave of the pandemic.

Introduction Frailty and sarcopenia are correlates of musculoskeletal aging that represent a state of vulnerability increasing the risk of negative health outcomes. Standardized definitions are lacking for both, and sometimes both concepts are used interchangeably. However, no large study has assessed the coexistence of these 2 entities in a cohort of older community-dwelling people. Methods Data were taken from the Toledo Study of Healthy Aging (TSHA), a study of community-dwelling elderly (≥65 years). The study population consists of 1611 participants with frailty and sarcopenia assessments. For sarcopenia, we used 3 criteria: European Working Group on Sarcopenia in Older People (EWGSOP), the Foundation for the National Institutes of Health (FNIH), and the FNIH fitted to the cut-off points of our population [standardized FNIH (sFNIH)]. Frailty was assessed according to the Fried criteria with cut-off points adjusted to our population. We used logistic regression to assess the relationship between sarcopenia and frailty and measures of diagnostic accuracy to evaluate the potential use of sarcopenia as a diagnostic marker for frailty. Results The mean age of the population was 75.42 years (±5.86). Overall, 72 (4.5%) were frail. In addition, 352 (21.8%), 332 (20.6%), and 453 (28.1%) participants were considered sarcopenic according to the EWGSOP, FNIH, and sFNIH criteria, respectively. The prevalence of frailty among those with sarcopenia was 8.2% (29/352), 15.7% (52/332), and 10.4% (47/453). Moreover, among frail people, the prevalence of sarcopenia was 40.27%, 72.2%, and 65.3% according to the used criteria. Sarcopenia showed a low sensitivity ( 97%) for the diagnosis of frailty, with a low intercorrelation (Cramer V = 0.16, 0.40, and 0.30) between the 3 criteria and frailty. Using multivariate logistic regression, frailty was associated with sarcopenia according to EWGSOP [odds ratio (OR) = 1.67, 95% confidence interval (CI) = 0.95, 2.96], FNIH (OR = 10.61, 95% CI = 5.8, 19.4), and sFNIH (OR = 6.63, 95% CI =3.5, 12.53). Conclusion Frailty and sarcopenia are distinct but related conditions. Sarcopenia is not a useful clinical biomarker of frailty, but its absence might be useful to exclude frailty.

Saliva offers the advantages of simple and non-invasive sampling and a rich source of biomarkers due to the high diversity of its microbiome, proteome and metabolome. The main objective of the SALivAry bioMarkers of mediterraneAN Diet associated with long-tERm protection against type 2 diabetes (SALAMANDER) project is to identify and validate salivary signatures indicative of healthy dietary choices (adoption of a Mediterranean diet) with a positive long-term health outcome (protection against type 2 diabetes) throughout adult life. The project will utilise the UK Biobank, a bank of saliva samples with dietary, lifestyle and health-associated data from 85 000 donors, collected during 2006-2010. UK Biobank data will enable SALAMANDER project researchers to relate past salivary composition and dietary patterns to health status several years later, in order to ascertain the validity of various biomarkers. All subjects will be healthy at baseline and categorised as either healthy (H+) or diagnosed with type 2 diabetes (H-) at follow-up. Compliance (or not) to the Mediterranean diet (D+, D-) will be evaluated with appropriate adjustment factors (e.g. physical activity, use of dietary supplements). Within each of the four D/H groups, 50 subjects will be randomly selected and their salivary microbiome, proteome and metabolome will be analysed by 16SrDNA analyses, nano-LC-MS/MS of tryptic digests and H-1 NMR, respectively. Integration of analytical data will then be performed to define a multimarker signature of a healthy diet associated with protection against type 2 diabetes. The data obtained from UK Biobank samples will be validated using two other population-based cohorts of older subjects in Spain (ENRICA) and France (3-City Bordeaux), enabling verification of whether the identified signatures of biomarkers are conserved as ageing proceeds. The SALAMANDER project aims to advance current knowledge and methods in nutritional epidemiology by identifying objective and non-invasive biomarkers of compliance to a diet associated with prevention of a diet-related disease. It will also provide information on an ageing population, the salivary profiles of which are poorly documented, especially in relation to diet and health.

Introduccion Este trabajo examino la asociacion del autocuidado y del conocimiento de los pacientes acerca del autocuidado con la rehospitalizacion en adultos mayores con insuficiencia cardiaca (IC). Metodos Analisis de casos y controles (116 casos y209 controles) alojado en una cohorte prospective de pacientes de 65 y mas anos de edad ingresados por IC en 4 hospitales espanoles. Los casos eran pacientes rehospitalizados de urgencia en los 6 meses siguientes a la hospitalizacion indice. Los controles fueron pacientes que no se rehospitalizaron durante esos 6 meses. Resultados El numero de actividades de autocuidado se asocio de forma inversa con la frecuencia de reingreso (p tendencia lineal: 0,006). En comparacion con los pacientes que realizaron el autocuidado apropiado, el reingreso hospitalario fue mas frecuente entre los que no paseaban ni realizaban actividad fisica a diario (hazard ratio [HR] 1,55; limites de confianza [LC] 95% 1,04-2,29), y entre los que se saltaban la visita al medico en la fecha programada (HR 1,82; LC 95% 1,10-3,02). El reingreso hospitalario tambien fue mas frecuente entre los pacientes que no tomaban la medicacion a su hora (HR 2,07; LC 95% 1,15-3,72), los que dejaban de tomarla cuando les sentaba mal (HR 1,76; LC 95% 1,08-2,85), y los que no mostraron adherencia al tratamiento farmacologico (HR 1,96; LC 95% 1,29-2,98). Ademas, a menor numero de actividades de manejo de la IC que se conocia que debian realizarse, mayor fue la frecuencia de rehospitalizacion (p tendencia lineal: 0,029). Conclusion A menor autocuidado y menor conocimiento del manejo de la IC, mayor riesgo de reingreso hospitalario.

Introducción: La frecuencia de infección tuberculosa, sobre todo en población infantil, indica la magnitud del reservorio de la enfermedad. El objetivo de este trabajo fue medir la prevalencia de infección tuberculosa en niños de la Comunidad de Madrid y su asociación con la clase social de pertenencia. Material y métodos: Se realizó un estudio transversal de los niños de 6 años escolarizados y residentes en la Comunidad de Madrid, seleccionados mediante muestreo probabilístico. Entre septiembre y junio de 2000, se obtuvo información sobre estrato de residencia, resultado de la prueba de la tuberculina (umbral de positividad de 5 mm), clase social (en 5 categorías) estimada por la ocupación del sustentador principal del hogar, y los estudios realizados por el padre y por la madre. Se realizaron estimaciones al 5 % de confianza (IC 95 %) a partir de una distribución de Poisson. Resultados: Se han estudiado 2.721 niños. La prevalencia de infección tuberculosa en el total de la población de estudio fue 0,62 % (IC 95 %: 0,29-0,95). Por clase social, la prevalencia ha sido 0,42 % (IC 95 %: 0,00-0,85) en la clase I (la más alta), 0,00 % (IC 95 %: 0,00-1,17) en la clase II, 0,77 % (IC 95 %: 0,00-1,86) en la clase III, 0,62 % (IC 95 %: 0,00-1,32) en la clase IV, y 1,57 % (IC 95 %: 0,00-3,40) en la clase V (la más baja). En los padres y madres, la prevalencia de infección tuberculosa más elevada correspondió al grupo que ha completado el bachiller elemental/EGB. Conclusiones: La prevalencia de infección tuberculosa en la Comunidad de Madrid es similar a la observada en otras zonas de España. Los resultados son consistentes con una menor prevalencia en los grupos con nivel socioeconómico más elevado. : Introduction: The frequency of tuberculosis infection, particularly among children, indicates the magnitude of the disease reservoir. The aim of this study was to ascertain the prevalence of tuberculosis infection in children in the Autonomous Community of Madrid and its association with social class. Material and methods: We performed a cross sectional study of 6-year-old schoolchildren living in the Autonomous Community of Madrid, selected through probabilistic sampling. From September 1999 through June 2000, information was collected on residence stratum, tuberculin test (positivity threshold 5 mm), social class (five categories), based on the occupation of the main earner in the family, and the formal education attained by the parents. We calculated 95 % confidence intervals for the prevalence estimates according to a Poisson distribution. Results: A total of 2,721 children were studied. The prevalence of tuberculosis infection for the total study population was 0.62 % (95 % CI: 0.29-0.95). The prevalence of tuberculosis infection was 0.42 % (95 % CI: 0.00-0.85) in social class I (the highest), 0.00 % (95 % CI: 0.00-1.17) in class II, 0.77% (95 % CI: 0.00-1.86) in class III, 0.62 % (95 % CI: 0.00-1.32) in class IV, and 1.57 % (95 % CI: 0.00-3.40) in class V (the lowest). In both fathers and mothers, the highest prevalence of tuberculosis infection was found in the group that had only completed elementary school or basic general education (up to the age of 14). Conclusions: The prevalence of tuberculosis infection in the Autonomous Community of Madrid is similar to that in others areas of Spain. The results of our study are consistent with a lower prevalence in the higher socioeconomic groups.

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/m2), overweight (BMI 25.0–29.9 kg/m2) and obesity (BMI≥30 kg/m2). 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

Objetivos Describir las tendencias en las tasas de hospitalizacion y de mortalidad por insuficiencia cardiaca congestiva (ICC) en Espana en el periodo 1980-1993. Metodos Se han analizado datos con diagnostico primario de ICC de la Encuesta Nacional de Morbilidad Hospitalaria y de las Estadisticas Vitales Nacionales. Resultados El numero de altas hospitalarias por ICC crecio un 71% (de 42.961 en 1980 a 73.442 en 1993) y las tasas de hospitalizacion por ICC crecieron un 47% (de 348 por 100.000 en 1980 a 511 por 100.000 en 1993). El aumento de las hospitalizaciones se produjo solo en personas ≥ 65 anos, y fue mayor en las mujeres. La ICC fue la primera causa de hospitalizacion en personas ≥ 65 anos, y fue responsable del 5% de todas las altas hospitalarias para ese grupo de edad. La mortalidad ajustada por edad por ICC ha descendido un 23%. El descenso ha afectado a todos los grupos de edad, excepto a los ≥ 80 anos, en los que la mortalidad ha aumentado. Sin embargo, la ICC se mantiene como la tercera causa de muerte cardiovascular (25% de todas las muertes cardiovasculares en el periodo 1989-1993 en personas ≥ 45 anos). Conclusiones La ICC representa un gran carga hospitalaria y demografica para la poblacion espanola. La carga hospitalaria ha crecido sustancialmente en el periodo 1980-1993, y continuara en el futuro al aumentar el numero y la proporcion de ancianos.

ResumenObjetivosDescribir la distribución geográfica de la razón varón/mujer (RVM) de mortalidad por enfermedad isquémica del corazón (EIC) y enfermedad cerebrovascular (ECV) en 1991-1995 en España, y examinar si puede explicarse por las diferencias de exposición a factores de riesgo cardiovascular entre varones y mujeres.MétodosLos datos de mortalidad proceden de las Estadísticas Vitales Nacionales. Se calcularon tasas, ajustadas por edad por el método directo, de mortalidad por EIC y ECV en la población de 40 a 79 años en el período 1991-1995. Los datos de consumo de tabaco y alcohol, hipertensión arterial, hipercolesterolemia, diabetes, obesidad, sedentarismo y uso de servicios sanitarios son de la Encuesta Nacional de Salud de 1993, y los de variables socioeconómicas del Censo de Población de 1991. El análisis se realizó usando la correlación de Pearson y la regresión de Poisson.ResultadosLas RVM de mortalidad por EIC y ECV son mayores en las provincias del norte de España, y se correlacionan negativamente con la mortalidad por EIC y ECV. Esta asociación negativa es más fuerte con la mortalidad de las mujeres que de los varones. Entre los factores de riesgo estudiados sólo la RVM del consumo de alcohol se asoció de forma estadísticamente significativa (p < 0,05) con la RVM de mortalidad por EIC y ECV. La RVM del consumo de alcohol explica el 23 y el 14% de la variación provincial de la RVM de mortalidad por EIC y ECV, respectivamente, y su relación dosisrespuesta con la RVM de mortalidad por ambas enfermedades tiene forma de U.ConclusionesLas provincias del norte de España, que son las de menor mortalidad cardiovascular, presentan la mayor sobremortalidad masculina por EIC y ECV, debido principalmente a una menor mortalidad cardiovascular en las mujeres. Según se deriva de la relación dosis-respuesta de la RVM de mortalidad por EIC y ECV con la RVM del consumo de alcohol, un mayor consumo de alcohol en los varones puede contribuir a su mayor mortalidad cardiovascular en relación a las mujeres en algunas provincias españolas.SummaryObjectivesTo describe the geographic distribution of the male/female ratio (MFR) of mortality from ischaemic heart disease (IHD) and cerebrovascular disease (CVD) in 1991-1995 in Spain, and to examine wether the differences between men and women in exposure to cardiovascular risk factors could explain such distribution.MethodsMortality data come from National Vital Statistics. Age-adjusted mortality rates for the period 1991-1995 were calculated for IHD and CVD using the direct method, in population aged 40 to 79 years. Data on tobacco and alcohol consumption, hypertension, hypercholesterolemia, diabetes, obesity, sedentariness, and health services use come from the 1993 Spanish National Health Survey, and socioeconomic data from the 1991 Population Census. Data were analyzed by correlation and Poisson regression methods.ResultsMFR of mortality from IHD and CVD are higher in the provinces of the north of Spain, and are correlated negatively with mortality from IHD and CVD. This negative association is stronger for mortality in women than in men. Among the risk factors examined, only MFR of alcohol consumption showed a significant (p < 0.05) association with MFR of mortality from IHD and CVD. MFR of alcohol consumption explains 23 and 14% of the provincial variation in MFR of mortality from IHD and CVD, respectively, and showed a U shaped relationship with MFR of mortality for both diseases.ConclusionsProvinces in the north of Spain, which register the lowest cardiovascular mortality, show the highest MFR of IHD and CVD mortality, because of the lower mortality in women than in men. As derived from the dose-response relationship between MFR of IHD and CVD mortality and the MFR of alcohol consumption, a higher alcohol consumption in men could contribute to a higher MFR of cardiovascular mortality in some Spanish provinces.

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.Cross-sectional surveys of representative samples of the non-institutionalized population in Spain in 1987, 1995 and 1997.14,676 and 7004 adults aged 25-64 who were representative of the Spanish population in 1987 and 1995/1997.Body mass index (BMI) calculated from self-reported weight and height. Overweight is defined as BMI = 27-29.9 kg/m2 and obesity as BMIor = 30 kg/m2.Between 1987 and 1995/97, the prevalence of overweight in the Spanish population aged 25-64 increased by 2.2% (P0.01); the increase was greater in men (3.8%; P0.01) than in women (0.6%; P0.05). The largest increases in the prevalence of overweight were seen in men (5.2%; P0.01) and women (2.3%; P0.05) aged 25-34. During the same period, the prevalence of obesity increased by 3.9% (P0.01), 4.6% in men (P0.01) and 3.2% in women (P0.01). The largest increases were seen in men aged 45-54 (6.5%, P0.01) and in women aged 25-34 (2.2%, P0.05). By educational level, the prevalence of overweight increased significantly in men with fewer than 12 y of education (4.7%, P0.01). Obesity increased by 4.6% (P0.01) and by 4.9% (P0.01) in men and women with fewer than 12 y of education, respectively.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.

Background. Information on the impact of tobacco and alcohol consumption on the use of health services is scant and partially inconsistent. This paper examines the relationship between tobacco and alcohol consumption and the use of health care services in Spain. Methods. Data were drawn from the 1993 Spanish National Health Survey, covering a random 21,120-person representative sample of Spain's noninstitutionalized population ages 16 years and older. Information was obtained through home-based interviews. Results. Compared with never smokers, male smokers of more than 20 cigarettes/day tend to be hospitalized more frequently (odds ratio (OR) 1.31; 95% confidence limits (CL) 0.89–1.93) and make greater use of hospital emergencies (OR 1.51; 95%CL 1.13–2.01; P < 0.01). Among female smokers of more than 20 cigarettes/day, hospitalizations (OR 1.62; 95%CL 0.80–3.26) and medical visits (OR 1.35; 95%CL 0.79–2.30) are also higher than among never smokers, although the associations do not reach statistical significance. Compared with never smokers, ex-smokers of both sexes make greater use of health care services (P < 0.01 for most services). There is a negative dose–response relationship (P < 0.001) between alcohol consumption and utilization of hospital and ambulatory services, for both sexes. Results are reasonably consistent across all age groups and are observed after adjustment for the principal confounding factors. We have found no evidence of a tobacco–alcohol interaction with the use of health care services. Conclusions. Smokers and ex-smokers make greater use of health care services. Control of smoking might reduce the use of such services and the ensuing human and economic costs. However, as alcohol consumption increases, the use of health care services decreases. This finding should not be used to promote even the moderate consumption of alcoholic drinks.

Energy balance is influenced by understudied genetic, social and other environmental factors. The frequency of family meals (FFM) may be one of these factors since it is associated with a healthier dietary pattern in children and adolescents. The objective of this review is to evaluate the scientific evidence on the association between FFM and the risk of childhood and adolescent overweight. The electronic literature search identified 394 articles published during 2005-2012. Of these, 15 studies gave precise information of the studied association, of which four were longitudinal. We found great variability regarding the measurement of FFM. Six out of 11 cross-sectional studies and 1 out of 4 longitudinal studies found statistically significant inverse associations between FFM and being overweight, mainly in children, with odds ratios ranging from 0.11 to 0.93. Of those, only one adjusted for all the potential confounding factors considering socio-demographic, physical activity- and diet-related variables. Therefore, this review found inconsistent and weak evidence of an inverse association between FFM and risk of childhood overweight. In conclusion, further research is needed to establish whether family meals have an effect on childhood overweight. These studies ideally should have longitudinal or experimental designs, a clear and standardized definition of the exposure under study, a measure of the exposure based on direct observation or validated questionnaires and an adequate adjustment for potential confounders.

Knowledge of the socio-demographic distribution of eating behaviours can aid our understanding of their contribution to the obesity epidemic and help to address healthy eating interventions to those who can benefit most. This cross-sectional study assessed the frequency of self-reported eating behaviours among 11,603 individuals representative of the non-institutionalized Spanish population aged ≥ 18 years in the period 2008-2010. In the adult population of Spain, 24.3% had lunch and 18.2% had dinner away from home3 times per month. About three-fourths of adults did not plan the amount of food to be eaten, and did not choose light foods and/or skim dairy products. Also, 26% did not trim visible fat from meat, and 74.7% usually ate while watching television. Compared with individuals with primary or less education, those with university studies were more likely to remove fat from meat (age- and sex-adjusted odds ratio [aOR] 1.25; 95% confidence interval [CI] 1.08-1.44), and to choose light food and/or skim dairy (aOR 1.50; 95% CI 1.30-1.77), and less likely to eat while watching television (aOR 0.54; 95% CI 0.47-0.63). In conclusion, the prevalence of several obesity-related eating behaviours is high in Spain, which indicates a deficient implementation of dietary guidelines. Socioeconomic inequalities in eating behaviours should also be addressed.

This is the first study to report the prevalence of general obesity and abdominal obesity (AO) in the adult population of Spain based on measurements of weight, height and waist circumference. The data are taken from the ENRICA study, a cross-sectional study carried out between June 2008 and October 2010 in 12,883 individuals representative of the non-institutionalized population on Spain aged 18 years and older. Anthropometry was performed under standardized conditions in the households by trained interviewers. Overweight was considered as body mass index (BMI) 25-29.9 kg m(-2) , and obesity as BMI ≥ 30 kg m(-2) . AO was defined as waist circumference102 cm in men and88 cm in women. The prevalence of obesity was 22.9% (24.4% in men and 21.4% in women). About 36% of adults had AO (32% of men and 39% of women). The frequency of obesity and of AO increased with age and affected, respectively, 35 and 62% of persons aged 65 and over. The frequency of obesity and AO decreased with increasing educational level. For example, 29% of women with primary education or less had obesity vs. only 11% of those with university studies. The prevalence of obesity was very high in the Canary Islands and in the south of Spain.

The relationship between obesity and the intake of macronutrients and specific foods is uncertain. Thus, there is growing interest in some eating behaviours because they may reflect the joint effect of several foods and nutrients and, thus, increase the likelihood of finding a link to obesity. This study examined the association between selected eating behaviours and excess weight in the general population throughout a systematic review of publications written in English, Spanish or Portuguese identified in a PubMed search up to 31 December 2010. We included 153 articles, 73 of which have been published since 2008. Only 30 studies had a prospective design; of these, 15 adjusted for sociodemographic variables, physical activity and energy or food intake. Moreover, definitions of eating behaviours varied substantially across studies. We found only small or inconsistent evidence of a relationship between excess weight and skipping breakfast, daily eating frequency, snacking, irregular meals, eating away from home, consumption of fast food, takeaway food intake, consumption of large food portions, eating until full and eating quickly. In conclusion, this review highlights the difficulty in measuring human behaviour, and suggests that a more systematic approach is needed for capturing the effects of eating behaviours on body weight.

This study examined the association of self-care behavior and patients' knowledge about self-care with rehospitalization among older adults with heart failure (HF).Case-control comparison (116 cases and 209 controls) nested in a prospective cohort of patients aged 65 years and older admitted for HF at 4 Spanish hospitals. Cases were patients experiencing a first emergency rehospitalization in the 6 months following the index hospital admission. Controls were patients who did not undergo a rehospitalization during such time-period.The number of self-care behaviors was inversely associated with the frequency of readmission (p for linear trend: 0.006). Compared with patients showing the appropriate self-care behavior, hospital readmission was more frequent among those who did no go for a walk daily or did not engage in any daily physical activity (hazard ratio [HR] 1.55; 95% confidence limits [CL] 1.04-2.29), and among those who did not keep their medical appointments (HR 1.82; 95% CL 1.10-3.02). Hospital readmission was also more frequent among patients who: failed to take their medication at the scheduled time (HR 2.07; 95% CL 1.15-3.72); stopped taking their medication when it disagreed with them (HR 1.76; 95% CL 1.08-2.85); and failed to adhere to their drug treatment (HR 1.96; 95% CL 1.29-2.98). Furthermore, the fewer the number of behaviors which patients knew to be required for self-care, the greater the frequency of rehospitalization (p for linear trend:0.029).A lower degree of self-care and of patients' knowledge about self-care predicted a higher risk of hospital readmission.

To assess the impact of a physical activity program on obesity in primary school children.Cluster-randomized controlled trial with 10 intervention and 10 control schools.A total of 1044 children, mean age 9.4 years (s.d.=0.7) at baseline, of the Province of Cuenca, Spain.Recreational, non-competitive physical activity program conducted after school hours on school premises. The program consisted of three 90-min sessions per week, for 24 weeks.Body mass index (BMI), triceps skin-fold thickness (TST) and percentage body fat. Secondary measures were blood lipids and blood pressure. Measurements were made at the beginning (September 2004) and at the end of the program (June 2005). Since schools rather than children were randomized, mixed regression models were used to adjust for individual-level covariates under cluster randomization.There were no differences in BMI between the intervention and control groups. Compared with controls, intervention children showed a decrease in TST in both boys (-1.14 mm; 95% confidence interval (CI) -1.71 to -057; P0.001) and girls (-1.55 mm; 95% CI -2.38 to -0.73; P0.001), as well as a reduction in the percentage of body fat in girls (-0.58%; 95% CI -1.04 to -0.11; P=0.02). Furthermore, the intervention boys exhibited a decrease in apolipoprotein (apo) B levels (-4.59; 95% CI -8.81 to -0.37; P=0.03) and an increase in apo A-I levels (13.57; 95% CI 7.95-19.20; P0.001). Blood lipid results in girls were very similar. No changes in total cholesterol, triglycerides or blood pressure were associated with the intervention in either sex, except for an increase in diastolic blood pressure (1.55 mm Hg; 95% CI 0.19-2.91; P=0.03) in the intervention versus control boys.An after-school program of recreational physical activity reduced adiposity, increased apo A-I and decreased apo B in primary school children.

Objectives To estimate the impact of gastroesophageal reflux (GER) symptoms on the utilization of healthcare services and work absenteeism in Spain. Methods A cross-sectional study on 2,500 subjects representative of the Spanish population from 40 to 79 years of age. Data were collected via a telephone interview in January 2002 using Locke s questionnaire after its cross-cultural adaptation and validation for telephone use in Spain. Results GER is responsible for 296.8 doctor consultations (95% CI: 245.3-348.7) per 1,000 inhabitants per year, for 24 esophagogastrointestinal radiographic studies per 1,000 inhabitants per year (95% CI: 18-30), for 32.4 (95% CI: 25.5-39.3) high digestive endoscopies per 1,000 inhabitants per year, and for the loss of 201 (95% CI: 0-411.1) working days per 1,000 employed inhabitants with GER per year. In relation to medication intake, GER resulted in 4,092 (95% CI: 3,300-5,133) treatment days with H2 antagonists per 1,000 inhabitants per year, 9,030 (95% CI: 7,846-10,332) treatment days with proton pump inhibitors per 1,000 inhabitants per year, and 1,082 (95% CI: 519-1,549) treatment days with prokinetics per 1,000 inhabitants per year. Conclusions GER has a large impact on the utilization of healthcare resources and work absenteeism in Spain, in contrast to the widespread belief that it is an illness of little importance.

To produce and validate for telephone use in Spain a cross-cultural adaptation of the gastroesophageal reflux questionnaire (GERQ) developed by Locke et al.The Spanish version of the questionnaire was developed through translation, assessment of comprehensibility, back translation, and appraisal of applicability. Subsequently, reproducibility was measured by a test-retest procedure in 125 patients, and concurrent validity was evaluated by comparing self-reported questionnaire data against a gastroenterologist's findings from clinical interviews with 50 patients.The Spanish version showed itself to be easily understandable and widely applicable. Reproducibility for the two cardinal symptoms of gastroesophageal reflux disease (heartburn and acid regurgitation) as measured by the kappa index (95% confidence interval), was 0.85 (0.73-0.97) and 0.81 (0.70-0.92), respectively. With respect to the process of concurrent validation, kappa values (95% confidence interval) for heartburn and acid regurgitation were 0.85 (0.68-1) and 0.91 (0.79-1), respectively. Median kappa for all questions on the questionnaire was 0.75 (range: 0.42 a 1) in the reproducibility analysis and 0.83 (range: 0.44 a 1) in the concurrent validity analysis.The reproducibility and concurrent validity of the Spanish version of the GERQ is excellent and comparable to that of the original English version.

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 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.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.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.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.

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

To describe the geographic distribution of the male/female ratio (MFR) of mortality from ischaemic heart disease (IHD) and cerebrovascular disease (CVD) in 1991-1995 in Spain, and to examine wether the differences between men and women in exposure to cardiovascular risk factors could explain such distribution.Mortality data come from National Vital Statistics. Age-adjusted mortality rates for the period 1991-1995 were calculated for IHD and CVD using the direct method, in population aged 40 to 79 years. Data on tobacco and alcohol consumption, hypertension, hypercholesterolemia, diabetes, obesity, sedentariness, and health services use come from the 1993 Spanish National Health Survey, and socioeconomic data from the 1991 Population Census. Data were analyzed by correlation and Poisson regression methods.MFR of mortality from IHD and CVD are higher in the provinces of the north of Spain, and are correlated negatively with mortality from IHD and CVD. This negative association is stronger for mortality in women than in men. Among the risk factors examined, only MFR of alcohol consumption showed a significant (p0.05) association with MFR of mortality from IHD and CVD. MFR of alcohol consumption explains 23 and 14% of the provincial variation in MFR of mortality from IHD and CVD, respectively, and showed a U shaped relationship with MFR of mortality for both diseases.Provinces in the north of Spain, which register the lowest cardiovascular mortality, show the highest MFR of IHD and CVD mortality, because of the lower mortality in women than in men. As derived from the dose-response relationship between MFR of IHD and CVD mortality and the MFR of alcohol consumption, a higher alcohol consumption in men could contribute to a higher MFR of cardiovascular mortality in some Spanish provinces.

This paper identifies the variables associated with alcohol-related fatal traffic crashes (AFTC) in Spain. In addition, and for the first time in this country, these variables are used to describe the trend in AFTC, and to study the relationship between AFTC and alcohol consumption over the period 1976-1993. To this end, official data were obtained from the Traffic Department (Dirección General de Tráfico), the National Statistics Institute (Instituto Nacional de Estadística), and from international publications on trends in alcohol consumption. Nighttime fatal crashes (NFC) and male-driver single-vehicle nighttime fatal crashes (MNFC) were strongly associated with AFTC rates in Spain. A further finding was the decrease in NFC and MNFC rates during the period 1978-1993, though this decrease proved of a lower magnitude than that observed for daytime crashes. No relationship was observed between alcohol consumption at the population level and NFC or MNFC rates. The fatal crash rate, particularly the daytime rate, showed a rise with wealth level, as measured by gross domestic product and national private consumption, and an inverse relationship with the unemployment rate. The relationship between the fatal crash rate and economic variables was due, in most part, to changes in vehicle-km travelled.

To examine the relationship between smoking and subjective health in Spain.Datacome from the 1993 National Health Survey. Analyses were performed with logistic regression, adjusting for the main confounding factors.Among those less than 25 years, there is a dose-response relationship (p = 0.0001)between cigarette consumption and suboptimal health (fair, pooror very poor health).Smoking controlactivities should inform on the worse subjective health of youngsmokers, for whom other effects of tobacco smoking are less relevant because they appear to happen in the distant future.

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-cholesterol130 mg/dl. In secondary prevention, drug treatment is indicated when LDL-cholesterol (130 mg/dl and the therapeutic objective is LDL-cholesterol100 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.

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-cholesterol130 mg/dl. In secondary prevention, drug treatment is indicated when LDL-cholesterolor = 130 mg/dl and the therapeutic objective is LDL-cholesterol100 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.

In this article we are discussing a few of the contributions by the Austro-British philosopher Karl R. Popper, one of our most influential contemporary thinkers, whose epistemological and socio-political theories have also penetrated the sphere of epidemiology. We are focusing mainly on the so-called problem of induction. We sustain, in line with Popper, that the scientific method does not use inductive reasoning, but rather hypothetical-deductive reasoning. Although the movement from the data evaluating a hypothesis to a conclusion on the latter goes from the specific to the general, that is, in an inductive direction, the induction does not exist as a reasoning process or inference. That is, there is no method that enables us to infer or to verify hypotheses or theories (we cannot explore all of the possible situations to see whether the theory stands up), or even to render them very probable. Besides, scientists look for highly informative theories, not highly probable ones. What we actually do is to propose a hypothesis as a tentative solution to a problem, to confront the prediction deduced from the hypothesis with actual experience, and evaluate whether the hypothesis is rejected or not by the facts. As theories cannot be verified, we can only accept them if they withstand an attempt to reject them. Consequently, the test of a theory consists of criticism or a serious attempt at falsification, that is, the elimination of error within a theory, in order to reject it if it is false. The objective is, thus, the search for true theories. For this purpose, the scientific method uses a systematic set of methodological (not logical) rules, that is, decisions. These methodological rules or principles can be summed up in two: [symbol: see text]be inventive and critical!, that is, propose bold hypotheses and subject them to severe tests of experience. Logic plays its role mainly by allowing us to deduce from a hypothesis the predictions to be confronted with the facts or evidence. This is applicable both to statistical inference as well as to causal inference. We argue that the criteria of causality used in epidemiology are none other than rules of the method designed for the same purpose: they are concerned with eliminating or reducing errors (chance, bias...) on testing a causal hypothesis. Consequently, the so-called ausal inference, the step from evidence to causal theory, is not a logical inductive or probabilistic process but rather a decision based on the evaluation of a causal hypothesis thanks to methodological rules such as the criteria of causality. We believe that the interest of the debate between the Popperian and the inductivist epidemiologists is not merely a matter of words, as, if we are aware that we do not operate inductively, that we cannot establish firmly hypotheses, not even affirm them probabilistically, we will presumably adopt a humbler attitude and look more for the errors in our theories than for their facile examples of confirmation.

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-cholesterol130 mg/dl. In secondary prevention, drug treatment is indicated when LDL-cholesterolor = 130 mg/dl and the therapeutic objective is LDL-cholesterol100 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.

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.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.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 agedor = 45 years could still be further reduced by 60% and 30% respectively. In the period of 1989-1993 heart failure hospitalizations were correlated (p0.05) with ischaemic heart disease hospitalizations and the number of beds/1,000 inhabitants. Heart failure mortality showed a statistically significant correlation (p0.05) with ischaemic heart disease mortality, illiteracy and unemployed status.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.

To characterize clinical manifestations of familial hypercholesterolemia (FH) in Spain.A group of 301 cases of FH from central and north regions of Spain.With a mean (SD) cholesterol level of 346 (58) mg/dl, only 7.6% of the patients have xanthomas and 20% ischaemic heart disease. 51% have a familial history of ischaemic heart disease.Different from the results of literature, xanthomas are very infrequent in FH in Spain, so diagnosis should be suspected from other data. The high prevalence of familial history of ischaemic heart disease supports the usefulness of this feature as a marker for diagnosis and prevention.

Evidence-based public health can be viewed as a way of facing community health problems by which the decisions are taken accordingly to the available evidence. A complete multidisciplinary approach should be introduced, with the goal of identifying and articulating the different dimensions which are present when trying to respond to the challenges or problems for the people's health. In addition to clinical medicine, disciplines such as epidemiology, biostatistics, health services research, economics, behavioural sciences, demography, nutrition, gerontology or computing sciences, among others, may contribute to health promotion and disease prevention. This open approach should not be exempt of a captious attitude toward the obtainable information, while it is essential to have a comprehensive spirit to combine this information with the previous experience and the peculiarities of each situation. Searching for evidence begins with a clear operational statement of the problem. This helps to select and obtain the key pieces of information. The information obtained must be judged critically, and related to the specifics of the problem. Lastly, it should be accepted that search for evidence does not mean finding certitude. Idolizing evidence can end up being as inappropriate as the implementation of a health program ignoring the previous information about its potential effectiveness, if such information were available. Many decisions in public health have to be taken conscious that scientific evidence does not rule out uncertainty, as other elements such as the cultural context, the individual preferences and other social factors may have a decisive influence in the success or failure of public health interventions.

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.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.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.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.

To explore if cocaine or heroin smoking was positively associated to acute respiratory complications (ARC).We collected data from medical records for 717 cocaine users who were attended in 14 hospital emergency rooms. The association was studied by logistic regression.The most frequent ARC were respiratory infections and complications with chest pain or dyspnea. Cocaine smokers (OR = 3.3; CI 95% = 1.5-6.9) and cocaine sniffers (OR = 2.5; CI 95% = 1.1-5.6) had greater risk of ARC than cocaine injectors. Heroin smokers (OR = 3.5; COI 95% = 1.8-7.0) and heroin sniffers (OR = 2.8; CI 95% = 1.4-5.6) had greater risk of ARC than non heroin users.These results suggest that cocaine or heroin smoking increases the risk of ARC.

Spain shows an important variation in the geographical distribution of ischaemic heart disease and cerebrovascular disease mortality. In this article, the primary objectives and design of the Four Provinces study are described. In this study we analyzed the contribution of environmental factors (diet, lipid profile and plasma antioxidants), acting in childhood, to explain differences in cardiovascular mortality rates between different provinces in Spain.An ecological design was projected in which the units to study were four Spanish provinces with a wide variation in cardiovascular mortality in adulthood. The design compares diet, anthropometric variables and biological markers (particularly plasma lipids and antioxidant levels) in 6-7-year-old children, between the two provinces with the highest cardiovascular mortality rates and the two provinces with the lowest. The information for each province is collected in a cross-sectional manner in a representative sample of children from each province.Evidence from the literature concerning Northern European countries suggest the contribution of environmental factors during early age in the development of cardiovascular disease in adulthood. The "Four Provinces" study will provide, for the first time, information about the influence of factors in early childhood of cardiovascular risk in a Mediterranean country. The study will also offer interesting data about food intake during school age in four provinces and it will allow us to estimate values of population of the variables of interest in those provinces.