Obesity, and especiallymorbid obesity, increases the risk of cardiovascular as well as non-cardiovascular
diseases. Our objective was to ascertain the trends in morbid obesity in Spain from 1993 to 2006 using
representative data from 106,048 participants in the National Health Surveys. An age-adjusted Poisson
regression model stratified by sex was fitted using morbid obesity as the dependent variable.
An increasing trend in prevalent morbid obesity from 1.8 to 6.1 per thousand participants was found
(increase > 200%). Morbid obesity prevalence was higher in women. After adjusting for age, a
monotonically increasing prevalence of morbid obesity was apparent for both men and women: the
relative increase was 4% per year in women and 12% per year in men. These trends highlight the
importance of preventive actions

Basterra-Gortari, F.J. (Francisco Javier)

Bes-Rastrollo, M. (Maira)

Beunza, J.J. (Juan José)

Garcia-Lopez, M. (Martín)

Martinez-Gonzalez, M.A. (Miguel Ángel)

Toledo, E. (Estefanía)

Universidad de Navarra

Increasing trend in the prevalence of morbid obesity in Spain: from 1.8 to 6.1 per thousand in 14 years

Dadun, University of Navarra

Rev Esp Cardiol. 2011;64(5):424–426Document downloaded from http://www.revespcardiol.org, day 31/05/2012. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Brief reportIncreasing Trend in the Prevalence of Morbid Obesity in Spain:From 1.8 to 6.1 per Thousand in 14 YearsF. Javier Basterra-Gortari,a,b Juan Jose´ Beunza,a Maira Bes-Rastrollo,a Estefanı´a Toledo,a,cMartı´n Garcı´a-Lo´pez,a,d and Miguel A. Martı´nez-Gonza´leza,*aDepartamento de Medicina Preventiva y Salud Pu´blica, Universidad de Navarra, Clı´nica Universidad de Navarra, Pamplona, Navarra, Spainb Servicio de Medicina Interna (Endocrinologı´a), Hospital Reina Sofı´a, Tudela, Navarra, SpaincDepartamento de Medicina Preventiva y Gestio´n de Calidad, Hospital Virgen del Camino, Pamplona, Navarra, SpaindDepartamento de Cardiologı´a, Clı´nica Universidad de Navarra, Pamplona, Navarra, SpainINTRODUCTION prevalence of obesity among patients with ischemic heart disease5Article history:Received 11 May 2010Accepted 29 June 2010Available online 15 March 2011Keywords:ObesityEpidemiologySurveyA B S T R A C TObesity, and especiallymorbid obesity, increases the risk of cardiovascular aswell as non-cardiovasculardiseases. Our objective was to ascertain the trends in morbid obesity in Spain from 1993 to 2006 usingrepresentative data from 106,048 participants in the National Health Surveys. An age-adjusted Poissonregression model stratiﬁed by sex was ﬁtted using morbid obesity as the dependent variable.An increasing trend in prevalent morbid obesity from 1.8 to 6.1 per thousand participants was found(increase > 200%). Morbid obesity prevalence was higher in women. After adjusting for age, amonotonically increasing prevalence of morbid obesity was apparent for both men and women: therelative increase was 4% per year in women and 12% per year in men. These trends highlight theimportance of preventive actions. 2010 Sociedad Espan˜ola de Cardiologı´a. Published by Elsevier Espan˜a, S.L. All rights reserved.Tendencia creciente de la prevalencia de obesidad mo´rbida en Espan˜a:de 1,8 a 6,1 por mil en 14 an˜osPalabras clave:ObesidadEpidemiologı´aEncuestaR E S U M E NLa obesidad, especialmente la obesidad mo´rbida, incrementa el riesgo cardiovascular y de otrasenfermedades. Nuestro objetivo es valorar las tendencias de la obesidad mo´rbida en Espan˜a de 1993 a2006 usando datos representativos de 106.048 participantes (Encuestas Nacionales de Salud). Se realizo´unmodelo de regresio´n de Poisson usando la presencia de obesidadmo´rbida como variable dependiente,estratiﬁcando por sexo y ajustando por edad.Se observo´ un incremento de la prevalencia de obesidadmo´rbida dema´s del 200%, pues se paso´ de 1,8a 6,1/1.000 habitantes. La prevalencia de obesidadmo´rbida es superior enmujeres. Tras ajustar por edad,en ambos sexos se incremento´ signiﬁcativamente la prevalencia de obesidad mo´rbida: el incrementorelativo anual fue del 4% en mujeres y el 12% en varones. Estos incrementos hacen que las medidaspreventivas resulten prioritarias. 2010 Sociedad Espan˜ola de Cardiologı´a. Publicado por Elsevier Espan˜a, S.L. Todos los derechos reservados.Obesity (body mass index [BMI] 30) is associated with anincreased risk of suffering various diseases, including cardiovas-cular disease. The incidence of cardiovascular disease, diabetesmellitus, high blood pressure and mortality is even higher in thosewith a BMI of40 (morbid obesity).1 The prevalence of obesity hasbeen increasing in Spain in recent years,2,3 but the trend formorbidobesity is less well understood. Studies performed in othercountries show a growing trend in the prevalence of this problem;indeed, the prevalence of morbid obesity has been growing fasterthan less serious forms of obesity.4 Patients with heart disease areno exception; the EUROASPIRE study has reported a growing* Corresponding author: Departamento de Medicina Preventiva, Ediﬁcio deInvestigacio´n, Universidad de Navarra, Irunlarrea 1, 31080 Pamplona, Navarra,Spain.E-mail address: mamartinez@unav.es (M.A. Martı´nez-Gonza´lez).1885-5857/$ – see front matter  2010 Sociedad Espan˜ola de Cardiologı´a. Published bdoi:10.1016/j.rec.2010.06.015in recent years.The aimof the presentworkwas to examine the trend ofmorbidobesity in Spain over the last 14 years using data from repeatedcross sectional surveys using the same methodology.METHODSData were taken from the Encuesta Nacional de Salud or(National Health Survey [NHS]), a cross-sectional study of non-institutionalized adults (ie, people over 16 years of age)representative of the Spanish population. Full details of the NHSare reported elsewhere.2 Self-declared body weight and heightdata were taken for 1993 (n = 21,061), 1995 (n = 6,396), 1997(n = 6,396), 2001 (n = 21,067), 2003 (n = 21,650) and 2006(n = 29,478). All data had been previously validated.6 The meanage of the NHS participants was 44.9  18.7 years; 51.4% ofy Elsevier Espan˜a, S.L. All rights reserved.participants were women. The BMI was calculated as body weight (in2with ischemic heart disease in the EUROASPIRE study5. OtherTable 1Description of the National Health Survey Population StudiedMen WomenTotal 48.6 51.4NHS 1993 (n=21,061) 48.3 51.7NHS 1995 (n=6396) 48.3 51.7NHS 1997 (n=6396) 48.5 51.5NHS 2001 (n=21,067) 48.3 51.7NHS 2003 (n=21,650) 48.8 51.2NHS 2006 (n=29,478) 49.1 50.9BMI by age16-26 years 23.63.2 21.83.327-36 years 25.53.4 23.43.937-48 years 26.53.5 24.94.349-63 years 27.13.7 26.84.6>64 years 26.93.6 27.14.4BMI, body mass index; NHS, National Health Survey.Data are percentages or means standard deviation. BMF.J. Basterra-Gortari et al. / Rev Esp Cardiol. 2011;64(5):424–426 425Document downloaded from http://www.revespcardiol.org, day 31/05/2012. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.kilos) / height inmeters . Obesitywas deﬁned as a BMI of30,morbidobesity as a BMI of 40.Prevalence estimates were calculated. For the study of diseaseprevalence trends over time, Poisson regression models wereconstructed using robust estimates of standard error. Morbidobesity was the independent variable, survey year the dependentvariable. Prevalence was calculated per year adjusting for age andsex.RESULTSThe prevalence of obesity (BMI 30) rose from 9.1% in 1993 to15% in 2006, an increase of 65%. Table 1 shows the proportion ofmen and women and the distribution of BMI by sex and age. Therelative increase in more serious obesity was even larger (Fig. 1).From 1993 to 2006, the prevalence of morbid obesity increased bymore than 200% (from1.8 to 6.1/1,000 people). In addition, in 1993,7.7% of Spanish adults had a BMI of30 but<35, while in 2006 thisﬁgure had risen to 11.9%, an increase of 54%.Poisson regression using the survey year as the continuousvariable and adjusting for age and sex showed an increasing trendfor the prevalence of morbid obesity.The adjusted prevalence ratio per calendar year was 1.07 (95%conﬁdence interval [CI] 1.04-1.09) (Table 2), ie, prevalenceincreased in real terms at a rate of 7% per year. When examiningthis increase by sex, the prevalence ratio was 1.04 (95% CI 1.02-1.07) inwomen and 1.12 (95% CI 1.07-1.18) inmen; the interactionsurvey year x sex was signiﬁcant (P = .006). When adjusting thePoisson regression model to assess prevalence by sex, morbidobesity was found to be more prevalent among women (1.72, 95%CI 1.33-2.24). In 1993 the prevalence ratio (women/men) was 3.12(95% CI 1.44-6.78) and in 2006 it was 1.24 (95% CI 0.8-1.91).Table 2 compares the years in terms of different categories,showing data for sex and age. Data for 1993 were taken as areference.DISCUSSIONAccording to the examined NHS data, the prevalence of morbidobesity has increased by more than 200% between 1993 and 2006.Prevalence increased in both sexes, but more so in men, who aregradually catching up. Morbid obesity, which is associated with anumber of complications1, has increased in prevalence more thanother types of obesity since 1993. These ﬁndings agree with resultsfrom other developed countries4,7 and with the results for patients[()TD$FIG]Percentage increase in300250200150100500Percentage relative increasewith respect to 1993NHS1993NHS1995NHS1997NHS2001NHS yearFigure 1. Relative increase (%) in prevalence of the different body mass index categBMI, body mass index; NHS, National Health Survey.studies have also reported a higher prevalence of morbid obesityamong women.8 In the USA it is thought that between 1900 and2000 the prevalence ofmorbid obesitywasmultiplied by a factor of3 among men and 2.3 among women, with women still showingthe greater prevalence.9This important upward trend in the prevalence of morbidobesity in both sexes conﬁrms this problem to be a major part ofthe obesity epidemic affecting Western countries.10 Small incre-ments in BMI would produce larger effects at the extreme of thedistribution. No such increment in morbid obesity would havebeen expected if it were a rare problem; in such a scenario itsprevalence would not be much affected by behavioral changes inthe population that impact upon the general prevalence of obesity.Patients withmorbid obesitymay require bariatric surgery. Theincrease in the number of such surgeries performed11 is a goodindication of the prevalence of morbid obesity.4,8 However, thepriority of public health systems should be the primary preventionof obesity in the population.A possible limitation of this study is the use of self-declaredinformation on body weight and height, which could lead tounderestimation of the true prevalence of morbid obesity.6However, this is unlikely to invalidate the study of the trend overtime because the degree of underestimation would likely remainthe same. More positively, the uniform methodology used in thedifferent surveys, and the use of adjustments, allows for the betterI categoriesNHS2003NHS2006BMI>4035<BMI<4030<BMI<35ories between 1993 and 2006, according to National Health Survey data (raw).assessment of the trend in morbid obesity. Further, the large 2. Basterra-Gortari FJ, Bes-Rastrollo M, Seguı´-Go´mez M, Forga L, Martı´nez JA,Martı´nez-Gonza´lez MA. Tendencias de la obesidad, diabetes mellitus, hiperten-Table 2Morbid Obesity Recorded by National Health Survey, by Year, With 1993 as Reference Data1993 1995 1997 2001 2003 2006 For each year (continuous)aTotalPrevalence, % 1.8 4.1 4.7 5.3 6 6.1Prevalence ratiob 1 (ref.) 2.29 (1.33-3.97) 2.55 (1.51-4.3) 2.81 (1.85-4.28) 3.07 (2-4.73) 3.1 (2.05-4.69) 1.07 (1.04-1.09)WomenPrevalence, % 2.7 5.8 8.2 7.9 8.2 6.8Prevalence ratioc 1 (ref.) 2.11 (1.09-4.08) 2.88 (1.59-5.21) 2.68 (1.63-4.41) 2.73 (1.65-4.52) 2.24 (1.38-3.64) 1.04 (1.02-1.07)MenPrevalence, % 0.9 2.5 1.4 2.8 3.7 5.4Prevalence ratioc 1 (ref.) 2.87 (1.07-7.66) 1.57 (0.49-5.09) 3.13 (1.43-6.85) 3.98 (1.76-8.97) 5.7 (2.72-11.94) 1.12 (1.07-1.18)Age<50 yearsPrevalence, % 1.2 2.8 3.3 3.4 4.2 4.4Prevalence ratiod 1 (ref.) 2.3 (0.99-5.34) 2.75 (1.23-6.14) 2.81 (1.43-5.5) 3.5 (1.73-7.06) 3.61 (1.87-6.94) 1.08 (1.04-1.12)Age 50 yearsPrevalence, % 3 6.7 7.2 8.7 8.8 9Prevalence ratiod 1 (ref.) 2.26 (1.1-4.65) 2.42 (1.21-4.82) 2.87 (1.68-4.9) 2.81 (1.65-4.8) 2.97 (1.74-5.04) 1.06 (1.03-1.09)a The survey year was used as the continuous variable (Poisson regression model).b Adjusted for sex and age (95% conﬁdence interval).c Adjusted for age (95% conﬁdence interval).d Adjusted for sex (95% conﬁdence interval).F.J. Basterra-Gortari et al. / Rev Esp Cardiol. 2011;64(5):424–426426Document downloaded from http://www.revespcardiol.org, day 31/05/2012. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.sample size affords greater statistical power to this study of aproblem of relatively low prevalence in Spain.In conclusion, an increasewas seen in prevalence of obesity, andin particular morbid obesity, between 1993 and 2006 in Spain,both in men and women. This increase in obesity and morbidobesity, which is associated with greater morbidity and mortality,represents a great burden on the Spanish health system and is apublic health problem that must be urgently tackled with effectivepreventive measures.CONFLICTS OF INTERESTNone declared.REFERENCES1. McTigue K, Larson JC, Valoski A, Burke G, Kotchen J, Lewis CE, et al.Mortality andcardiac and vascular outcomes in extremely obese women. JAMA.2006;296:79–86.sio´n e hipercolesterolemia en Espan˜a (1997-2003). Med Clin (Barc). 2007;129:405–8.3. Gutie´rrez-Fisac JL, Banegas Banegas JR, Rodrı´guez Artalejo F, Regidor E. Increas-ing prevalence of overweight and obesity among Spanish adults, 1987-1997. IntJ Obes. 2000;24:1677–82.4. Sturm R. Increases in clinically severe obesity in the United States, 1986-2000.Arch Intern Med. 2003;163:2146–8.5. Kotseva K, Wood D, De Backer G, De Bacquer D, Pyo¨ra¨la¨ K, Keil U, EUROASPIREStudy Group. Cardiovascular prevention guidelines in daily practice: a compar-ison of EUROASPIRE I, II, and III surveys in eight European countries. Lancet.2009;373:929–40.6. Basterra-Gortari FJ, Bes-Rastrollo M, Forga L, Martı´nez JA, Martinez-Gonza´lezMA. Validacio´n del ı´ndice de masa corporal auto-referido en la EncuestaNacional de Salud. An Sist Sanit Navar. 2007;30:373–81.7. Sturm R. Increases in morbid obesity in the USA: 2000-2005. Public Health.2007;121:492–6.8. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesityamong US adults, 1999-2008. JAMA. 2010;303:235–41.9. Freedman DS, Khan LK, Serdula MK, Galuska DA, Dietz WH. Trends andcorrelates of class 3 obesity in the United States from 1990 through 2000.JAMA. 2002;288:1758–61.10. Rose G. Sick individuals and sick populations. Int J Epidemiol. 2001;30:427–32.11. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures.JAMA. 2005;294:1909–17.

Increasing trend in the prevalence of morbid obesity in Spain: from 1.8 to 6.1 per thousand in 14 years

Abstract

Similar works

Full text

Available Versions

Universidad de Navarra

Dadun, University of Navarra