Mediterranean diet and diabetes risk in a cohort study of individuals with prediabetes: propensity score analyses.

AIMS: Randomized controlled trials have demonstrated the efficacy of several dietary patterns plus physical activity to reduce diabetes onset in people with prediabetes. However, there is no evidence on the effect from the Mediterranean diet on the progression from prediabetes to diabetes. We aimed to evaluate the effect from high adherence to Mediterranean diet on the risk of diabetes in individuals with prediabetes. METHODS: Prospective cohort study in Spanish Primary Care setting. A total of 1184 participants with prediabetes based on levels of fasting plasma glucose and/or glycated hemoglobin were followed up for a mean of 4.2 years. A total of 210 participants developed diabetes type 2 during the follow up. Hazard ratios of diabetes onset were estimated by Cox proportional regression models associated to high versus low/medium adherence to Mediterranean diet. Different propensity score methods were used to control for potential confounders. RESULTS: Incidence rate of diabetes in participants with high versus low/medium adherence to Mediterranean diet was 2.9 versus 4.8 per 100 persons-years. The hazard ratios adjusted for propensity score and by inverse probability weighting (IPW) had identical magnitude: 0.63 (95% confidence interval, 0.43-0.93). The hazard ratio in the adjusted model using propensity score matching 1:2 was 0.56 (95% confidence interval, 0.37-0.84). CONCLUSIONS: These propensity score analyses suggest that high adherence to Mediterranean diet reduces diabetes risk in people with prediabetes.

Socioeconomic position and health services use in Germany and Spain during the Great Recession.

OBJECTIVE: The relationship of socioeconomic position with the use of health services may have changed with the emergence of the economic crisis. This study shows that relationship before and during the economic crisis, in Germany and in Spain. METHODS: Data from the 2006 and 2011 Socio-Economic Panel carried out in Germany, and from the 2006 and 2011 National Health Surveys carried out in Spain were used. The health services investigated were physician consultations and hospitalization. The measures of socioeconomic position used were education and household income. The magnitude of the relationship between socioeconomic position and the use of each health services was estimated by calculating the percentage ratio by binary regression. RESULTS: In Germany, in both periods, after adjusting for age, sex, type of health insurance and need for care, subjects belonging to the lower educational categories had a lower frequency of physician consultations, while those belonging to the lower income categories had a higher frequency of hospitalization. In the model comparing the two lower socioeconomic categories to the two higher categories, the percentage ratio for physician consultation by education was 0.97 (95%CI 0.96-0.98) in 2006 and 0.96 (95%CI 0.95-0.97) in 2011, and the percentage ratio for hospitalization by income was 1.14 (95%CI 1.05-1.25) in 2006 and 1.12 (95%CI 1.03-1.21) in 2011. In Spain, no significant socioeconomic differences were observed in either period in the frequency of use of these health services in the fully adjusted model. CONCLUSION: The results suggest that the economic crisis did not alter accessibility to the health system in either country, given that the socioeconomic pattern in the use of these health services was similar before and during the crisis in both countries.

Socioeconomic position and childhood-adolescent weight status in rich countries: a systematic review, 1990-2013.

BACKGROUND: Childhood obesity is a major problem in rich countries due to its high prevalence and its harmful health consequences. An exploratory analysis conducted in the PubMed database highlighted that the number of papers published on the relationship between socioeconomic position (SEP) and childhood-adolescent weight status had risen substantially with respect to an earlier review which had covered the period 1990-2005. METHODS: To describe the findings on the relationship between SEP and childhood-adolescent weight status in papers published in rich countries from 1990 through 2013, studies were identified in the following databases: PubMed; Web of Knowledge (WOK); PsycINFO; Global Health; and Embase. We included observational studies from the 27 richest OECD countries, which covered study populations aged 0 to 21 years, and used parental education, income and/or occupation as family SEP indicators. A total of 158 papers met the inclusion criteria and reported 134 bivariable and 90 multivariable analyses. RESULTS: Examination of the results yielded by the bivariable analyses showed that 60.4% of studies found an inverse relationship, 18.7% of studies did not found relationship, and 20.9% of studies found a relationship that varied depending on another variable, such as age, sex or ethnic group; the corresponding percentages in the multivariable analyses were 51.1, 20.0 and 27.8%, respectively. Furthermore, 1.1% found a positive relationship. CONCLUSION: The relationship between SEP and childhood-adolescent weight status in rich countries is predominantly inverse and the positive relationship almost has disappeared. The SEP indicator that yields the highest proportion of inverse relationships is parents' education. The proportion of inverse relationships is higher when the weight status is reported by parents instead using objective measurements.

The Association of Geographic Coordinates with Mortality in People with Lower and Higher Education and with Mortality Inequalities in Spain.

OBJECTIVE: Geographic patterns in total mortality and in mortality by cause of death are widely known to exist in many countries. However, the geographic pattern of inequalities in mortality within these countries is unknown. This study shows mathematically and graphically the geographic pattern of mortality inequalities by education in Spain. METHODS: Data are from a nation-wide prospective study covering all persons living in Spain's 50 provinces in 2001. Individuals were classified in a cohort of subjects with low education and in another cohort of subjects with high education. Age- and sex-adjusted mortality rate from all causes and from leading causes of death in each cohort and mortality rate ratios in the low versus high education cohort were estimated by geographic coordinates and province. RESULTS: Latitude but not longitude was related to mortality. In subjects with low education, latitude had a U-shaped relation to mortality. In those with high education, mortality from all causes, and from cardiovascular, respiratory and digestive diseases decreased with increasing latitude, whereas cancer mortality increased. The mortality-rate ratio for all-cause death was 1.27 in the southern latitudes, 1.14 in the intermediate latitudes, and 1.20 in the northern latitudes. The mortality rate ratios for the leading causes of death were also higher in the lower and upper latitudes than in the intermediate latitudes. The geographic pattern of the mortality rate ratios is similar to that of the mortality rate in the low-education cohort: the highest magnitude is observed in the southern provinces, intermediate magnitudes in the provinces of the north and those of the Mediterranean east coast, and the lowest magnitude in the central provinces and those in the south of the Western Pyrenees. CONCLUSION: Mortality inequalities by education in Spain are higher in the south and north of the country and lower in the large region making up the central plateau. This geographic pattern is similar to that observed in mortality in the low-education cohort.

[Geographic Patterns of Mortality and Socioeconomic Inequalities in Mortality in Spain]. / Patrones geográficos de la mortalidad y de las desigualdades socioeconómicas en mortalidad en España.

BACKGROUND: Estimates of socioeconomic inequalities in mortality coming from individual data sources were only available from Madrid, the Basque Country and the city of Barcelona. The aim of this study was to show the geographical pattern of mortality in different socio-economic groups, as well as that of inequalities in mortality in the whole Spanish territory. METHODS: All people aged 25 and older in the 2001 census were followed for seven years and two months to determine their vital status (196 470 401 person-years at risk and 2,379,558 deaths). The socioeconomic variable was educational level. Age-adjusted mortality rate was estimated for women and men in every province and in each category of educational level. Inequalities in mortality in each province have been estimated by the ratio of mortality in subjects with primary or lower level of education compared to subjects with university education. RESULTS: In women, the lowest rate ratios -between 1.06 and 1.16- are observed in Palencia, Segovia, Guadalajara, Avila and Castellon and the highest -between 1.53 and 1,75- in Malaga, Las Palmas, Ceuta, Melilla and Toledo. In men, the lowest rate ratios -between 1.00 and 1.12- are observed in Guadalajara, Teruel, Cuenca, La Rioja and Ávila and the highest -between 1.47 and 1,73- in Las Palmas, Cantabria, Murcia, Melilla and Ceuta. CONCLUSIONS: The geographical pattern of mortality rates in Spain varies by educational level. Inequalities in mortality by education have the lowest magnitude in central peninsular provinces.

Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level.

OBJECTIVE: This study aimed to investigate the relationship between education and different indicators of material wealth with mortality, and to analyze whether this relationship varies with the leading causes of death. METHODS: All persons aged 65 and older residing in Spain in 2001 were followed up for 7 years to determine their vital status. The relationship between mortality and four indicators of socioeconomic position (education, number of rooms in home, surface area of home and number of vehicles) was estimated in three age groups: 65-74, 75-84 and 85 and older. Rate ratios and relative index of inequality (RII) were calculated for general mortality and for the leading causes of death by Poisson regression. RESULTS: In women, the mortality rate ratio for low vs. high educational level was 1.48 for persons aged 65-74, 1.43 for those aged 75-84 and 1.40 for those aged 85 and older. The respective rates for men were 1.30, 1.25 and 1.29. For the indicators of material wealth, the differences between morality rates in the lower vs. the higher socioeconomic categories decline with age. Mortality differences by the leading causes of death decline with age, except in the case of cancer in women and cardiovascular and digestive mortality in men according to educational level. CONCLUSIONS: Relative socioeconomic differences in mortality in the older Spanish population decrease with age using indicators of material wealth but not using educational level. The variation in the pattern of mortality by cause of death by level of education may be responsible for these findings.

The role of population change in the increased economic differences in mortality: a study of premature death from all causes and major groups of causes of death in Spain, 1980-2010.

BACKGROUND: An increase has been observed in differences in mortality between the richest and poorest areas of rich countries. This study assesses whether one of the proposed explanations, i.e., population change, might be responsible for this increase in Spain. METHODS: Observational study based on average income, population change and mortality at provincial level. The premature mortality rate (ages 0-74 years) was estimated for all causes and for cancer, cardiovascular disease and external causes across the period 1980-2010. In the years analysed, provinces were grouped into tertiles based on provincial income, with the mortality rate ratio (MMR) being estimated by taking the tertile of highest-income provinces as reference. Population change was then controlled for to ascertain whether it would modify the rate ratio. RESULTS: In all-cause mortality, the magnitude of the MRR for provinces in the poorest versus the richest tertile was 1.01 in 1980 and 1.12 in 2010; in cardiovascular mortality, the MMRs for these same years were 1.08 and 1.31 respectively; and in the case of cancer and external-cause mortality, MMR magnitude was similar in 1980 and 2010. The magnitude of the MMR remained unchanged in response to adjustment for population change, with the single exception of 1980, when it increased in all-cause and cardiovascular mortality. CONCLUSION: The increase in the difference in premature mortality between the richest and poorest areas in Spain is due to the increased difference in cardiovascular mortality. This increase is not accounted for by population change. In rich countries, more empirical evidence is thus needed to test other alternative explanations for the increase in economic differences in mortality.

Patrones geográficos de la mortalidad y de las desigualdades socioeconómicas en mortalidad en España / Geographic patterns of mortality and socioeconomic inequalities in mortality in Spain

Fundamentos: Las estimaciones sobre desigualdades socioeconómicas en mortalidad a partir de registros individuales de defunciones y población son escasas y proceden únicamente de la la ciudad de Barcelona, la Comunidad de Madrid y el País Vasco. El objetivo del presente estudio fue mostrar el patrón geográfico de mortalidad en diferentes grupos socioeconómicos, así como el de las desigualdades en mortalidad en el conjunto del territorio español. Métodos: Se realizó el seguimiento de todos los individuos mayores de 25 años del censo de población 2001 durante siete años y dos meses para conocer su estado vital (196.470.401 personas-año a riesgo y 2.379.558 defunciones). Se calculó la tasa de mortalidad ajustada por edad en hombres y mujeres por provincia y nivel de estudios. Las desigualdades en mortalidad provinciales se estimaron mediante la razón de tasas de mortalidad en los sujetos con nivel de estudios primarios o inferiores respecto a los sujetos con estudios universitarios. Resultados: En mujeres, las razones de tasas más bajas -entre 1,06 y 1,16- se observaron Palencia, Segovia, Guadalajara y Ávila. Las más altas -entre 1,53 y 1,75- en Málaga, Las Palmas, Ceuta, Toledo y Melilla. En hombres, las razones de tasas más bajas -entre 1,00 y 1,12- se observan en Guadalajara, Teruel, Cuenca, La Rioja y Ávila y las más altas -entre 1,47 y 1,73- en Las Palmas, Cantabria, Murcia, Melilla y Ceuta. Conclusiones: El patrón geográfico de las tasas de mortalidad en España varía según el nivel educativo. Las desigualdades en mortalidad muestran menor magnitud en las provincias del centro peninsular (AU)

Background: Estimates of socioeconomic inequalities in mortality coming from individual data sources were only available from Madrid, the Basque Country and the city of Barcelona. The aim of this study was to show the geographical pattern of mortality in different socio-economic groups, as well as that of inequalities in mortality in the whole Spanish territory. Methods: All people aged 25 and older in the 2001 census were followed for seven years and two months to determine their vital status (196 470 401 person-years at risk and 2,379,558 deaths). The socioeconomic variable was educational level. Age-adjusted mortality rate was estimated for women and men in every province and in each category of educational level. Inequalities in mortality in each province have been estimated by the ratio of mortality in subjects with primary or lower level of education compared to subjects with university education. Results: In women, the lowest rate ratios –between 1.06 and 1.16- are observed in Palencia, Segovia, Guadalajara, Avila and Castellon and the highest -between 1.53 and 1,75- in Malaga, Las Palmas, Ceuta, Melilla and Toledo. In men, the lowest rate ratios -between 1.00 and 1.12 - are observed in Guadalajara, Teruel, Cuenca, La Rioja and Ávila and the highest -between 1.47 and 1,73- in Las Palmas, Cantabria, Murcia, Melilla and Ceuta. Conclusions: The geographical pattern of mortality rates in Spain varies by educational level. Inequalities in mortality by education have the lowest magnitude in central peninsular provinces (AU)

Low mortality in the poorest areas of Spain: adults residing in provinces with lower per capita income have the lowest mortality.

The objective of this study is to ascertain whether income inequality and per capita income of area of residence show a relationship with mortality in Spain. Data are from a nation-wide prospective study with a 7-year mortality follow-up covering all persons living in Spain's 50 provinces in 2001. In total 28,944,854 subjects aged 25 years or over at baseline were studied. Rate ratio for total mortality and cause-specific mortality, according to provincial income inequality and per capita income in two age groups, 25-64 years (adult population) and 65 years and over (elderly population). Provincial income inequality was not related to total mortality or cause-specific mortality. Total mortality rate ratios among residents of the poorest versus the richest provinces were 0.89 (95% CI 0.95-0.93) in men and 0.91 (0.87-0.96) in women, among the adult population; and 1.02 (0.97-1.08) in men and 1.08 (1.02-1.16) in women, among the elderly population. With the exception of cardiovascular-disease mortality for which no association with per capita income was observed, adult residents of the poorest provinces registered the lowest mortality rate ratio for other causes of death. Elderly residents of the poorest provinces registered the highest mortality rate ratio for cardiovascular disease and the lowest mortality rate ratio for cancer and external causes. Aside from cardiovascular-disease mortality, the lowest mortality for most causes of death was registered by residents of the poorest provinces. Nevertheless, these findings need to be confirmed by similar studies using smaller areas as the unit of analysis.

Patrón socioeconómico en la alimentación no saludable en niños y adolescentes en España / Socioeconomic pattern in unhealthy diet in children and adolescents in Spain

OBJETIVO: Investigar la posible asociación de patrones alimentarios relacionados con la obesidad y la posición socioeconómica en la población infantil y adolescente española. DISEÑO: Estudio descriptivo transversal. Participantes: Los datos proceden de la Encuesta Nacional de Salud de 2007, realizada a una muestra representativa española de 0 a 15 años. En este estudio se han analizado 6.143 sujetos de 5 a 15 años. Mediciones principales: Se ha estimado la prevalencia de omisión de desayuno, la prevalencia de bajo consumo de fruta y verdura y la prevalencia de alto consumo de comida rápida, snacks y bebidas azucaradas. Los indicadores de posición socioeconómica han sido el nivel de estudios y la clase social de la persona que aportaba más ingresos económicos al hogar. En cada consumo de alimentos se han estimado las diferencias socioeconómicas mediante la razón de prevalencia, tomando como referencia la categoría socioeconómica más alta. RESULTADOS: Tanto en la infancia como en la adolescencia la magnitud de la razón de prevalencia muestra un gradiente socioeconómico inverso en todos los consumos de alimentos investigados: la menor y la mayor razón de prevalencia se observa en los sujetos de familias de posición socioeconómica más alta y más baja, respectivamente. CONCLUSIÓN: En la población infantil y adolescente española la alimentación no saludable relacionada con la obesidad muestra un patrón socioeconómico claro

OBJECTIVE: To investigate the possible association of dietary patterns associated with obesity and socioeconomic status in Spanish children and adolescents. DESIGN: Cross-sectional study. Participants: Data were drawn from the 2007 National Health Survey, conducted on a representative sample of Spanish 0-15 years. In this study we have analyzed 6143 subjects from 5 to15 years. Main measurements: It has been estimated prevalence of breakfast skipping, the prevalence of low consumption of fruit and vegetable and the prevalence of high fast food, snacks and sugary drinks consumption. Socioeconomic status indicators were educational level and social class of primary household earner. In each type of food consumption socioeconomic differences were estimated by prevalence ratio using the higher socioeconomic status as reference category. RESULTS: Both in childhood and adolescence, the magnitude of the prevalence ratio shows an inverse socioeconomic gradient in all foods consumption investigated: the lowest and highest prevalence ratios have been observed in subjects from families of higher socioeconomic status and lower, respectively. CONCLUSION: Unhealthy food related with obesity show a clear socioeconomic pattern in Spanish children and adolescents

[Socioeconomic pattern in unhealthy diet in children and adolescents in Spain]. / Patrón socioeconómico en la alimentación no saludable en niños y adolescentes en España.

OBJECTIVE: To investigate the possible association of dietary patterns associated with obesity and socioeconomic status in Spanish children and adolescents. DESIGN: Cross-sectional study. PARTICIPANTS: Data were drawn from the 2007 National Health Survey, conducted on a representative sample of Spanish 0-15 years. In this study we have analyzed 6143 subjects from 5 to 15 years. MAIN MEASUREMENTS: It has been estimated prevalence of breakfast skipping, the prevalence of low consumption of fruit and vegetable and the prevalence of high fast food, snacks and sugary drinks consumption. Socioeconomic status indicators were educational level and social class of primary household earner. In each type of food consumption socioeconomic differences were estimated by prevalence ratio using the higher socioeconomic status as reference category. RESULTS: Both in childhood and adolescence, the magnitude of the prevalence ratio shows an inverse socioeconomic gradient in all foods consumption investigated: the lowest and highest prevalence ratios have been observed in subjects from families of higher socioeconomic status and lower, respectively. CONCLUSION: Unhealthy food related with obesity show a clear socioeconomic pattern in Spanish children and adolescents.

Decreasing income inequality and emergence of the association between income and premature mortality: Spain, 1970-2010.

This study evaluates the relationship between income and mortality in Spain over a long period of declining in income inequality. The ratio between income in the richest and poorest provinces was 2.74 in 1970 and 2.10 in 2010. Pearson correlation coefficients for the association between provincial income and the measures of mortality were estimated, as well as absolute and relative differences between the mortality rates of the poorest and richest provinces. The correlation coefficient between income and infant mortality decreased from -0.59 in 1970 to -0.17 in 2010, and lost significance from 1995 onwards. The coefficient for premature all-cause mortality increased from -0.04 in 1970 to -0.40 in 2010, and acquired significance beginning in 2005. The coefficient also increased in mortality from cardiovascular, respiratory and digestive diseases. No association was found between provincial income and cancer mortality or mortality from injuries. The findings on premature mortality do not support the theory that decreasing income inequality will lead to reduced inequalities in mortality.

Sports facilities in Madrid explain the relationship between neighbourhood economic context and physical inactivity in older people, but not in younger adults: a case study.

BACKGROUND: Neighbourhood characteristics may contribute to differences in physical inactivity. PURPOSE: To evaluate whether the availability of sports facilities helps explain the differences in physical inactivity according to the economic context of the neighbourhood. METHODS: 6607 participants representative of the population aged 16-74 years, resident in Madrid (Spain) in 2005, were analysed. Using ORs calculated by multilevel logistic regression, the association between per capita income of the neighbourhood of residence and physical inactivity was estimated, after adjusting for age, population density, individual socioeconomic characteristics and the availability of green spaces. The analysis was repeated after further adjustment for the availability of sports facilities to determine if this reduced the magnitude of the association. RESULTS: Residents in the neighbourhoods with the lowest per capita income had the highest OR for the prevalence of physical inactivity. In participants aged 16-49 years, after adjusting for the availability of sports facilities, the magnitude of the OR in the poorest neighbourhoods with respect to the richest neighbourhoods increased in men (from 2.22 to 2.35) and declined by 13% in women (from 2.13 to 1.98). In contrast, in the population aged 50-74 years, this adjustment reduced the magnitude of the OR by 21% in men (from 2.00 to 1.80) and by 53% in women (from 2.03 to 1.48). CONCLUSIONS: The poorest neighbourhoods show the highest prevalence of physical inactivity. The availability of sports facilities explains an important part of this excess prevalence in participants aged 50-74 years, but not in younger individuals.

Socio-economic position, family demands and reported health in working men and women.

BACKGROUND: This study evaluates the extent to which domestic workload explains socio-economic differences in poor self-reported health in women and men. METHODS: In total, 6284 men and women who were employed and living with a partner were selected from the 2003 Spanish Health Interview Survey. The indicators of family demands investigated were person responsible for housework, number of persons in the household and the presence of at least one child under 15 years of age in the household. The measures of socio-economic position were educational level and household income, and the measures of health status were poor perceived health and limitation of activity due to disease. RESULTS: Household size and presence of a child under 15 in the home were not related with the measures of health status. The indicator about the person who does the housework was related with poor perceived health and with activity limitation. Specifically, the worst health status was seen in respondents who lived in homes where the partner or other family members did the housework. In general, the relation between indicators of socio-economic position and measures of health status was not modified after taking into account the person who does the housework. CONCLUSION: Among working people with a partner, persons who work and do their own housework do not have poorer perceived health than those living in homes where other people do the housework. This indicator of family demands does not explain the socio-economic differences in self-reported health.

A proposal of measures for monitoring social disparities in health using AIDS and liver disease mortality before and after HAART.

BACKGROUND: To assess the more appropriate measures for monitoring health differences and evaluating the impact of interventions based on the real burden of the health problem in the population and on the best alternative for communication with policymakers and with society at large. METHODS: Disparity in mortality from acquired immunodeficiency syndrome (AIDS) and liver disease were measured in two cohorts of Spanish men: before and after the introduction of highly active antiretroviral therapy (HAART). Men were grouped into managers/professionals/technicians, clerks/service workers/manual workers and unemployed. The mortality rate difference and the mortality rate ratio in clerks/service workers/manual workers and in unemployed vs. managers/professionals/technicians were estimated. Moreover, various summary measures of absolute disparity were also calculated. RESULTS: Between the first and second period, the AIDS mortality rate difference decreased from 21.9 to 5.9 per 100,000 person-years in clerks/service workers/manual workers and from 117.2 to 59.3 in unemployed, whereas the liver mortality rate difference increased from 4.7 to 6.4 and from 37.4 to 48.9, respectively. The AIDS mortality rate ratio increased by 11% in clerks/service workers/manual workers and by 50% in unemployed, while the liver disease mortality rate ratio increased by almost 400% in both groups. The summary measures of disparity decreased in AIDS mortality and increased in liver disease, although the magnitude of the change varied from one measure to another. CONCLUSIONS: The findings in unemployed men were the most important from the public health perspective; however, they could not be adequately identified with either mortality rate ratios or summary measures of absolute disparity.