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European Journal of Clinical Nutrition (2002) 56, 992–1003
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ORIGINAL COMMUNICATION
The nutrition transition in Spain: a European
Mediterranean country
LA Moreno1, A Sarrı́a2 and BM Popkin3*
1
EU Ciencias de la Salud, Universidad de Zaragoza, Zaragoza, Spain; 2Departamento de Pediatrı́a, Universidad de Zaragoza,
Zaragoza, Spain; and 3Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina, USA
Background: Mediterranean diets are felt to be healthful diets linked with reduced mortality from diet-related noncommunicable diseases.
Objective: To examine trends in diet, activity, obesity and diet-related noncommunicable diseases for Spain and compare these
with other European countries, particularly those from the Mediterranean area.
Design: A combination of large-scale primary and secondary nationally representative data analysis are used.
Data: Nationally representative data on household food consumption, physical activity, adult obesity, and cause of death are
combined with regionally representative adolescent obesity data, obtained in the last four decades. Comparative diet and
obesity data come from nationally representative comparable data, obtained during the same period.
Results: The Spanish diet has shifted toward a very high level of fat intake, high fruit and dairy intake and moderate vegetable
intake. Dairy and fruit intakes were the highest in Europe, as was the proportion of energy from fat, when we compared with the
available data. Adult overweight and obesity trends show a marked increase in the past decade to levels as high as Italy and far
above France. Overweight for children aged 6 – 7 is above that of even the USA, while adolescent overweight levels are among
the highest in the world. Cardiovascular disease mortality is low, as with Italy and France, and the cancer mortality rate is lower
than Italy and France.
Conclusions: We have observed that, in Spain, relatively high obesity prevalences and dairy intake levels are related to much
lower levels of cardiovascular disease and cancer mortality than are found in other European countries. This unique Spanish
dietary and obesity pattern should be further explored in order to clarify the causal links.
Support: The National Institutes of Health (NIH; R01-HD30880 and R01-HD38700).
European Journal of Clinical Nutrition (2002) 56, 992 – 1003. doi:10.1038/sj.ejcn.1601414
Keywords: Spain; nutrition transition; the Spanish paradox; obesity; physical activity
Introduction
The epidemiological transition, particularly the rapid shift in
morbidity and mortality patterns towards much higher noncommunicable disease rates, has dominated the health profile of an increasingly large number of people in higher
income countries for the last half-century or more. Concurrent shifts in diet, activity and body composition also appear
*Correspondence: BM Popkin, Department of Nutrition, Carolina
Population Center, University of North Carolina, CB no. 8120 University
Square, 123 W Franklin St, Chapel Hill, NC 27516-3997, USA.
E-mail: [email protected]
Guarantor: BM Popkin.
Received 19 July 2001; revised 4 January 2002;
accepted 8 January 2002
to be accelerating in many regions of the world (Popkin,
1998). This analysis provides an understanding of the multidimensional phenomenon of the nutrition transition, a
sequence of characteristic dietary and nutritional patterns
resulting from large shifts in the overall structure of diet,
related to changing economic, social, demographic and
health factors in Spain, a country that modernized later
than most European countries. While Spain was not as
deeply affected as other parts of Mediterranean Europe by
World War II, it was affected by its own civil war in the
period 1936 – 1939 and a subsequent period of isolation with
minimal economic development (the 40 y of the Franco era).
During this period, Spain suffered an international embargo.
After 1975, Spain underwent a rapid transition toward a
democratic system, joined the European Union, and has
experienced rapid economic change.
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This papers builds on previous studies of the dietary and
epidemiological changes among the Spanish population and
focuses on some unique nutritional issues, including the
much higher level of fat intake in the diet, higher obesity
levels, along with related socioeconomic and other health
factors (Serra-Majem et al, 1993a, 1995; Moreno et al, 2000b).
It focuses on the nutrition transition experienced in Spain, a
special European Mediterranean country, during the last 30 –
40 y and points out some important distinguishing features.
The main purpose of this paper is to explore obesity and
dietary intake levels and its relationship with low levels of
cardiovascular diseases and cancer mortality found in Spain.
Methods
A range of primary and secondary economic, dietary intake,
physical activity, anthropometric, cause of death and mortality rate data from published reports and articles is used.
Economic data
Data on urbanization trends were obtained from the Food
and Agriculture Organization (FAO) and data on work force
structure from the International Labor Office (ILO). For
economic trends, we used national income data from the
official estimates of gross national product (GNP) per capita
(Atlas method) from 1960 to 1998 as established by the
World Bank (The International Bank for Reconstruction
and Development). GNP per capita was expressed in 1995
US dollars adjusted for inflation on the basis of consumer
price indices (Bureau of Labor Statistics), to allow for an
easier comparison across the years.
Dietary data
A series of comparable nationally representative household
budget surveys was used to provide a picture of the nutrition
transition in Spain. Household dietary information in Spain
was obtained from three household budget surveys conducted by the National Institute of Statistics in 1964 – 1965,
1980 – 1981 and the latest in 1990 – 1991 (INE, 1995). While
these surveys focus on economic issues, they utilize a systematic sampling and data collection system to collect food
consumption and expenditure data which can be used to
understand shifts in the structure of food intake in the
country. The samples consist of 20 800 – 28 000 households
and data collection took place with a record system over a
full week.
Food consumption in Spain in 1990 – 1991 has been
compared with food consumption data obtained in nationally representative household budget surveys, that have been
included in the DAFNE (Data Food Networking) databank
(Naska et al, 2000). We have also compared these data with
those obtained in national dietary surveys conducted in Italy
(Turrini et al, 1999) and France (Volatier & Verger, 1999).
Energy and macronutrient intakes assessed in the Spanish
household budget surveys have been compared with energy
and macronutrient intakes assessed in some European
national surveys (Becker, 1999; Flynn & Kearney, 1999;
Haraldsdottir, 1999; Hermann-Kunz & Thamm, 1999; Ministry of Agriculture Fisheries and Food, 1991; Turrini et al,
1999; Valsta, 1999; Volatier & Verger, 1999).
Physical activity data
Physical activity data were obtained from the National
Health Surveys (Encuesta Nacional de Salud de España 1997,
1999). These surveys started in 1987, but information on
physical activity patterns was only obtained in the 1993,
1995 and 1997 surveys. The survey sampled the whole
country, but included only the non-institutionalized population. The study sample of those surveys was selected by a
multi-stage stratified sampling scheme, and included 26 100
individuals in 1993, 8400 in 1995 and 8400 in 1997. Information on physical activity patterns in the adult population
described occupational activity and leisure-time activity. We
present leisure-time physical activity data, obtained in the
three surveys by the same question: ‘Please, could you tell
me what of the following possibilities better describe the
majority of your activities during your leisure-time?’ Individuals had four options: (1) I do not perform any exercise, my
leisure-time is sedentary; (2) some physical activity or sport
performed occasionally; (3) regular physical activity, several
times per month; (4) physical training several times per
week.
Anthropometric data
At present, there are no data on anthropometric measurements or the prevalence of obesity in a representative sample
of the child or adult Spanish population. We have obtained
data on body mass index (BMI) for children aged 6 – 7 y and
adolescents aged 13 – 14 y, from the Aragón School Health
Examination Surveys, carried out from 1985 to 1995, Aragón
being a representative region of the whole country, in terms
of socio-economic and health indicators. These surveys
began near the start of the school year and lasted 6 – 9
months. Of the 109 916 children aged 6 – 7 y of age (56 741
males and 53 175 females), 90 997 (45 970 males and 45 027
females) were examined in the nine cross-sectional surveys
conducted between 1985 and 1995 (this represented 82.79%
of the school population in the first school year). Of the
147 251 students (75 478 males and 71 773 females) 13 – 14 y
of age, 106 284 (52 772 males and 53 512 females) were also
examined in the nine cross-sectional surveys conducted (this
represented 72.18% of the school population in the last
school year; Moreno et al, 2000a).
We chose to use the ‘International Obesity Task Force
(IOTF) reference’, since it is appropriate for international
use. First, it is developed based on data from multiple
nations including Brazil, Britain, Hong Kong, The
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Netherlands, Singapore, and the US (Cole et al, 2000).
Second, the BMI cut-offs are linked to adult cut-offs for
overweight and obesity, which are good indicators of risks
for adverse health outcomes. They are derived from sexspecific curves that pass through a BMI of 25 and 30 by age
18 for overweight and obesity, respectively.
We have compared overweight prevalences in Aragón
with those obtained in other countries: Russia, US, Brazil,
China, England and Scotland (Chin & Rona, 2001).
For adults we use secondary analysis of national surveys
from Spain, Italy, France and Germany. In all the cases, to
assess BMI values, they use reported height and weight.
a major reduction in energy expenditure at work (Popkin,
1998).
Cause-of-death data
We present cause-of-death trends as percentages of total
deaths for four disease categories (Instituto Nacional de
Estadı́stica). The four categories chosen to illustrate major
shifts in disease patterns were: (1) infectious and parasitic
diseases (including tuberculosis); (2) diseases of the respiratory system (eg pneumonia and bronchitis); (3) malignant
neoplasms (eg cancers of the stomach, liver, bronchus and
lung); and (4) diseases of the circulatory system (eg, rheumatic heart disease, hypertensive disease, ischemic heart
disease, cerebrovascular disease and diseases of the pulmonary circulation).
All European countries submit annual mortality data to
WHO. For the present study, cause-specific mortality rates by
year for European Mediterranean countries were obtained
from WHO, Geneva (WHO Regional Office for Europe). The
starting year of 1970 was chosen aiming to cover the 8th, 9th
and 10th revision of the International Classification of Diseases (ICD). No major changes in the classification of the
disease groups of interest occurred during the transition
from the 8th to the 10th revision of the ICD.
Food consumption changes
The total amount of food intake per capita per day, calculated from household food intake, fluctuated around 1700 g
between 1964 – 1965 and 1990 – 1991 (Table 1). A shift did
occur in the sources of food. The percentage of plant-food
intake decreased consistently, from 76.1% in 1964 – 1965 to
57.3% in 1990 – 1991. In contrast, the percentage of animal
food intake increased almost two-fold from 23.9 to 42.7% of
per capita daily grams of food intake.
This shift can be clearly seen by examining the intake
trends for each food group. Consumption of cereals and
grain products decreased to half of its 1964 – 1965 level. In
1964 – 1965, per capita intake of cereals accounted for 24% of
total grams of food intake; however, cereals accounted for
only 11% of total intake in 1990 – 1991. Other starchy
staples, including both legumes and potatoes, were also
reduced to half their 1964 – 1965 consumption levels. The
intake of vegetables increased slightly between 1964 – 1965
and 1990 – 1991. The major positive shift was a very large
increase in fruit consumption from 164.8 to 326.7 g per
capita per day in that period. There were also reductions in
consumption of vegetable-based oils and fats, added sugar,
and wine.
Intake of all animal food products increased significantly
from 1964 – 1965 to 1990 – 1991. Meat and poultry consumption increased three-fold in that period. Consumption of fish
and milk food groups also increased from 1964 – 1965 to
1990 – 1991. While the rate of increase for milk and dairy
products did not match that for meat, the absolute increase
for these food products represents the dominant element in
Results
Table 1
Spanish economy
Remarkable changes have occurred in the Spanish economy
and the structure of its workforce over the past 30 – 40 y. GNP
per capita increased dramatically from the early 1960s to the
1990s. The GNP increased in real (deflated) terms approximately four-fold between 1960 and 1997, from 4423 1996 US
dollars in 1960 to 14 799 in 1997. With this rapid shift in
income, associated changes in the population and occupation distributions occurred. In 1950, the Spanish population
was approximately half urban and this increased to 76%
urban by 1995. The proportion of the workforce in energyintensive occupations such as the rural primary-product
sectors of agriculture, forestry and fisheries has halved
during the 1977 – 1993 period, while service sector occupations have increased to over 54% of the workforce and
manufacturing has held steady at about 38% of the workforce. The current occupational structure of Spain is similar
to that of most Western countries. This transition is linked to
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Changes in intake by food groups, 1964 – 1965 to 1990 – 1991
1964 – 1965 1980 – 1981 1990 – 1991
Plant foods (g=capita=day)
Cereals and grain products
Legumes and their products
Potatoes and starches
Vegetables
Fruits
Vegetable oils and fats
Sugar
Wine
Total
Animal foods (g=capita=day)
Meat, poultry and their products
Eggs
Fish and shellfish
Milk and dairy products
Animal oils and fats
Total
Total (g=capita=day)
Percentage of animal food (%)
402
41
292
156
165
62
39
131
1289
236
26
202
163
272
70
36
114
1120
194
23
138
165
327
56
25
69
995
73
33
62
224
14
407
1695
24
169
38
72
380
3
662
1782
37
229
28
88
396
3
743
1739
43
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the animal food component of the diet. Egg intake increased
until 1980 – 1981 and decreased thereafter. Consumption of
animal oils and fat fell considerably during this same period.
Intake trends for major food groups between 1964 – 1965
and 1990 – 1991 are shown in Figure 1. The figure illustrates a
dramatic fall in total cereal intake with a significant rise in
Figure 1 Shifts in food consumption of key food groups in Spain, 1964 – 1991.
Figure 2 A comparison of food consumption patterns in Spain and other European countries.
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fruit intake. As noted above, the intake of meat and milk
food groups also increased considerably from 1964 – 1965 to
1990 – 1991.
The unique features of food intake in Spain are its very
high fruit, milk and milk product intake along with a
relatively low vegetable intake. We combine several sets of
data to compare fruit and vegetable intake across Europe.
This comparative analysis explicitly excluded potatoes from
the vegetable category. In Figure 2 we see that the fruit intake
of Spain is greater than any other country in Western Europe,
for example France. Vegetable intake is also high in Spain but
below that for Greece.
The other unique element of the Spanish diet is the very
high milk and dairy intake. Surprisingly, intake of milk and
milk products in Spain is even above that for Denmark. No
country in Western Europe reports a higher level of dairy
consumption than Spain.
Nutrients
Total energy intake decreased gradually from 1964 – 1965 to
1990 – 1991 (Table 2). Total energy intake was as high as
12.59 MJ (3008 kcal) per capita per day in 1964 – 1965 but,
despite the trends to more sedentary activities, total energy
intake remained 11.02 MJ (2634 kcal) per capita per day in
1990 – 1991.
In terms of individual nutrients, carbohydrates showed
the same pattern as did total energy intake. The change in
the proportion of energy derived from each nutrient is
presented in the first three panels of Figure 3. The decline
in the proportion of energy from carbohydrates (from 53 to
42% of energy intake) and the small increase in protein
intake (from 12 to 14% of energy intake) are seen. Equally
important is the dramatic increase in the proportion of
energy from fat. This level was 32% in 1964 – 1965, increased
to 40% by 1980 – 1981, and has increased slightly since then
to 41.5% in 1990 – 1991. In the 1990 – 1991 period, saturated
fat represent 11.9%, monounsaturated fat 18.8% and polyunsaturated fat 6.8% of total energy intake. These are very
high levels of fat intake and reasonably high levels of
saturated fat intake.
The high level of total fat intake is offset in many ways by
the very large proportion of monounsaturated fat and the
high mono-plus polyunsaturated fat to saturated fat ratio. In
Table 2 Changes in macronutrient and energy intakes, 1964 – 1965 to
1990 – 1991
Carbohydrate (g)
Fat (g)
Protein (g)
Alcohol (g)
Energy
(MJ)
(kcal)
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1964 – 1965
1980 – 1981
1990 – 1991
423
108
87
15
333
131
98
16
294
121
94
10
12.6
3008
12.2
2914
11.0
2634
1964, monounsaturated fat represented 53% of the total fat
intake and by 1991, due to a larger increase in other fats in
the diet, it was still 45% of total fat. The ratio of (mono þ poly)=saturated fat was 2.34 in 1964 and 2.15 in 1991.
Recent surveys of children in Spain from Galicia, Madrid and
Zaragoza found about 44 – 45% of total fat from monounsaturated sources, but a much higher saturated fat intake and
ratios of (mono þ poly)=saturated fat that varied from 1.39 to
2.25 (unpublished results).
In this same figure we compare the macronutrient intake
pattern of Spain with that from other European countries
(Becker, 1999; Flynn & Kearney, 1999; Haraldsdottir, 1999;
Hermann-Kunz & Thamm, 1999; Ministry of Agriculture
Fisheries and Food, 1991; Turrini et al, 1999; Valsta, 1999;
Volatier & Verger, 1999; De Henauw & De Backer, 1999;
Graca, 1999). Comparing the proportion of energy from
carbohydrates, often viewed as one element of the traditional Mediterranean diet, Spanish households consume
42% of their energy from carbohydrates compared with
only 38% in France and 48 – 49% in Italy and Portugal. In
contrast, at the other end of the spectrum, Spain’s 42% of
energy from fat is the highest level of consumption of energy
from fat in Europe, matched only by England in 1990. Italy
and Portugal consume only 29 – 33% of their energy from fat
although the Portuguese data are from a much earlier period
(1984).
Physical activity data
Physical activity data shows that more than 45% of the
Spanish population is completely sedentary during their
leisure-time (Figure 4). However, the proportion of individuals that were completely sedentary during their leisuretime has decreased from 55 to 46% in the 1993 – 1997 period.
The proportion of people that made some physical activity
per week in their leisure-time increased from 4 to 7% in that
period.
Obesity
For the entire country there is good national data on adult
obesity trends and similar data for older children and adolescents is available only for the Aragón region.
Using surveys representing large representative samples
from each country, we see that adult obesity has risen in
Spain and is at levels comparable or even higher than Italy or
France (Figure 5). These levels are below those reported for
Germany and other European countries (Gutierrez-Fisac et al,
2000; Hoffmeister et al, 1994; Maillard et al, 1999; Pagano
et al, 1997). The increase in a decade in Spain from 27% of
males to 34.8% and from 22% of females to 25.6% is
pronounced for males but not females. These rates of
increase in Spain exceed those for Italy.
Over a third of Spanish adult males and a quarter of
women were obese or overweight in the 1995 – 1997
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survey. The obesity levels are higher than those found in
Italy and France but below those of Germany.
In the school-age population of Aragón (Spain), BMI has
increased in all the age and sex groups studied (16.28 –
Figure 3 The proportion of energy from macronutrients: a comparison of European countries.
Figure 4 Shifts in leisure-time activities in Spain, 1993 – 1997.
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Figure 5
A comparison of obesity patterns and trends in Spain with other European countries.
16.96 kg=m2 in males aged 6 y, 16.42 – 17.17 kg=m2 in males
aged 7 y, 16.32 – 16.91 kg=m2 in females aged 6 y, and 16.56 –
17.17 kg=m2 in females aged 7 y). The patterns and trends for
child and adolescent overweight prevalence are equally significant (Figures 6a and b). By 1995 – 1996, in Aragón over a
third of boys and girls aged 6 – 7 were overweight. The levels
are somewhat lower for adolescents aged 13 – 14; however,
there is a noted increase over the 1985 – 1996 period in
adolescent overweight.
In Figure 7a and b we utilize the International Obesity
Task Force’s (IOTF) proposed standards for overweight
(equivalent to a BMI of 25 or greater) discussed earlier. It is
important to note that the IOTF standards are based on both
several higher-income countries (the US, The Netherlands
and England) and a number of middle income ones (Singapore, Brazil, Hong Kong).
These results are compared with data for the same age
group for Russia, the US, Brazil and China and aged 7 – 8 and
9 – 11 for England and Scotland. For children aged 6 – 7, the
Spanish prevalence of overweight ( > 33%) is far greater than
that found for any other country. In fact, the increase
measured by prevalence points over a 10 y period is greater
in Spain than the total found in China, England and Scotland. The rates of increase among adolescents are equally
large in Aragón; however, in comparative terms the US has a
far higher level of adolescent overweight and Scottish and
English adolescents have only slightly lower overweight
prevalence levels.
European Journal of Clinical Nutrition
Spain has a very high ratio of overweight prevalence
among older children (34% in males and 36% in females in
1995 – 1996) compared with adolescents (21% in both sexes
in 1995 – 1996). Only in the US, England and Scotland are
there such marked higher prevalences among teenagers but
in Spain, Brazil, and China it is the opposite — adolescent
overweight prevalence is higher.
Causes of death
Diseases of the circulatory system have been the leading
cause of death in Spain since 1980. Cancer is the second
leading cause of death. After 1980, the proportion of deaths
by diseases of the circulatory system has begun to decrease,
representing 45.83% of all deaths in Spain in 1979 and
37.58% of all deaths in 1997, while those related to cancer
have increased (Figure 7).
This shift from cardiovascular to cancer mortality is
seen throughout Europe; however, cardiovascular diseases
(CVD)-related mortality rates are still higher in all countries. Age-standardized mortality rates from diseases of the
circulatory system in European Mediterranean countries
are shown in Figure 8. From 1970 to the late 1990s, we
can observe a decrease in mortality from diseases of the
circulatory system in all the countries, except Greece
(despite a decrease after 1987, mortality rates were higher
in 1997 than in 1970). The increase in Greece’s CVD
mortality is important to note. The decline is relatively
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Figure 6 (a) A comparison of children aged 6 – 7: obesity patterns and trends in Aragón, Spain with other countries. Note: data for England and Scotland
is for 7 – 8-y-olds. (b) A comparison of adolescent (aged 13 – 14): obesity patterns and trends in Aragón, Spain with other countries. Note: data for
England and Scotland is for 9 – 11-y-olds. Source: Chin and Rona, 2001.
larger in Spain (from 435=100 000 in 1970 to 239=100 000
in 1996), placing Spain second lowest to France in this
mortality rate category.
Age-standardized mortality rates from cancer in European
Mediterranean countries are shown in Figure 9. In 1996, agestandardized mortality rates from cancer in these countries
ranged from 163 to 192=100 000. The countries with the
lowest mortality rates from cancer in 1970 (Greece, Portugal
and Spain) have tended to increase their mortality rates. In
contrast, mortality rates in countries with high rates in 1970
(France and Italy) were relatively unchanged in the late
1990’s from those in the 1970s.
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Figure 7
Trends in the causes of death in Spain, 1980 – 1997.
Figure 8
Comparison of mortality from cardiovascular diseases, 1970 – 1998.
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Figure 9 Comparison of mortality from cancer, 1970 – 1998.
Discussion
The nutrition transition in the last decades has been
described in different developing countries (Popkin, 1998;
Kim et al, 2000; Monteiro et al, 1995; Romieu et al, 1997; Vio
& Albala, 2000). In this paper, we analyzed the nutrition
transition in an industrialized country of the European
Mediterranean region. The case of Spain is different from
other European countries, due to different political conditions. During this century, Spain has experienced important
socioeconomic and consequently food behavior modifications; from the post-war period, without radical changes
(1940 – 1960), to a period of expansion and development
(1961 – 1975; Serra-Majem et al, 1993a, b). From an economic
point of view, Spain has experienced a rapid transition when
compared with northern European countries, but a slow
transition when compared with lower-income countries.
For example, South Korea has increased its GNP 17 times
in 34 y (Kim et al, 2000) and Spain has increased it four times
in 37 y.
Dietary and epidemiologic changes among the Spanish
population in the last decades have been previously analyzed
(Serra-Majem et al, 1993a,b; Moreno et al, 2000b). What is
unique about this paper is the full exploration of not only
diet and obesity but also related economic and physical
activity and mortality patterns and a comparison with
other related countries. From this paper we get a full picture
of Spain and its relative position and unique characteristics.
For the food intake analysis, we utilize the household food
consumption surveys that exist for many European countries
but are rarely examined (Trichopoulou, 1992). The data are
nationally representative and reliable. Their actual levels
most likely overstate nutrient and food intake levels as
they do not allow for wastage during the processing and
consumption stages. Moreover, these surveys report dietary
intake data per capita only; and per capita intakes do not
reflect household members’ intakes equally. These limitations prevented us from adjusting on the fact that the
Spanish population has aged. That means that we underemphasized trends related to decreased intake and overemphasized trends related to increased intake. There is a
possibility reported elsewhere in Europe that higher fat
foods and total fat in general are undermeasured more in
the 1990s than earlier; however there is no literature on the
measurement of other food components (Heitmann et al,
2000; Lafay et al, 1998).
The dietary trends found that a very high level of energy
from fat, increased meat and especially dairy intake, very
high fruit intake, and quite low vegetable intake, define the
Spanish diet. The dairy and fruit intake undoubtedly are
among the highest found in Europe, far above other Mediterranean countries. Similarly, the high proportion of monounsaturated fat and the high ratio of monounsaturated plus
polyunsaturated fat to saturated fat provides an important
dimension to the Spanish diet.
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1002
On average, in the European Union, nearly three-quarters
of the population participate in some kind of physical
activity (Vaz de Almeida et al, 1999). In general, the highest
proportions of participants were found in the Nordic countries and the lowest in the southern ones.
Despite the fact that data on obesity in adults have been
obtained from self-reports that lead to underestimation of
the true prevalence, adult obesity is very high, as is adult
overweight status (34.8% overweight and obesity in males
and 25.6% in females; Gutierrez-Fisac et al, 2000). Trends
show marked increases in adult male obesity in the past
decade or two. The overweight levels for children aged 6 – 7
from the Aragón region of Spain are much higher than in
many other countries and adolescent obesity levels are high
moreover, it has been observed that the increase in BMI is
parallel to an increase in the percentage of body fat assessed
by anthropometry (Moreno et al, 2001a) and also parallel to
trends towards a central pattern of fat distribution (Moreno
et al, 2001b).
The overweight problem may relate partly to the energy
density of the diet (Bray & Popkin, 1998), but it equally
could result from the other component of energy balance,
physical activity and inactivity. It has been pointed out that
increasing prevalence of obesity may be mostly attributed to
reduction of physical activity (Vioque et al, 2000; Martı́nezGonzález et al, 1999). One key component of inactivity is
television viewing, which has been associated with obesity in
Spanish adults and adolescents (Vioque et al, 2000; Moreno
et al, 1998). Moreover, the concepts ‘Controling weight’ and
‘Being fit’ are not perceived to be as important in Spain as
elsewhere in the European Union (Holgado et al, 2000).
The most noticeable feature of the Spanish nutrition
transition is the decrease in mortality from diseases of the
circulatory system, parallel to an increase in dietary fat
intake and an increase of fruit intake, but we must take
into account that mortality data may reflect either a change
in the incidence of the disease or a change in medical care
that improves survival, lowering the case-fatality rate. The
increasing trend in fat consumption is due primarily to a
sharp increase in consumption of meat and dairy products.
According to the well known relation between dietary fat,
serum cholesterol and cardiovascular diseases (Ascherio et al,
1996), a significant increase in incidence and mortality from
diseases of the circulatory system should have been detected
in Spain. The unexpected trends observed have been termed
the ‘Spanish paradox’ (Serra-Majem et al, 1995). This paradox
most likely stems from the interaction of multiple synergistic
and antagonistic risk and protective factors for CVD. Of
much current interest is the role of antioxidants and phytochemicals that may be the keys to understanding the paradoxical trends on mortality from diseases of the circulatory
system in Spain as well as in France, Italy and Portugal. The
pattern of fruit consumption in Spain reflects a 4.1% annual
increase during 1964 – 1980 and 2.0% during 1981 – 1991,
which resulted in a net increase of 162 g fruit per capita per
day during a 25 y period. There is a puzzling element to this
European Journal of Clinical Nutrition
‘Spanish paradox’, namely that the other Mediterranean
country with high fruit intake and high total fruit and
vegetable intake is Greece. Yet the CVD mortality for
Greece is rising while that for Spain is declining. Also it is
important to note the high proportion of monounsaturated
fat in the diet.
Concerning the observed trends on the mortality from
cancer, Serra-Majem et al (1993a) analyzed trends in consumption of fat and fat-containing foods in relation to
trends in mortality for ovarian, breast, colorectal and prostate cancer in certain European countries and suggested that
trends of increased fat consumption appeared to antedate
trends of increased rates of ovarian and colorectal cancer,
and to a lesser extent, breast cancer. Other authors have also
reviewed relations between diet and cancer in Spain (Benito
& Cabeza, 1993).
Given the low mortality rates from the main causes of
death in Spain, identifying the characteristics of the Spanish
diet would help us to better understand how to promote a
healthier diet. Additional research is needed to explore the
full set of determinants of the Spanish dietary pattern and
the subsequent health consequences in terms of diet-related
chronic diseases.
Acknowledgements
The study was supported in part by grants from the National
Institutes of Health (NIH; R01-HD30880 and R01-HD38700).
We are grateful to Samara Nielsen, in particular, and also
Youfa Wang for research assistance. We also thank Ms
Frances Dancy for her administrative assistance and Mr
Tom Swasey for assistance with the graphics.
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