J. de Irala

Mediterranean Diet and Stroke: Objectives and Design of the SUN Project

Purpose: The Mediterranean diet has been postulated as a protective factor against different diseases including stroke. Thus, an epidemiological study in a Mediterranean country, such as Spain, focused on diet may offer new insights of the potential benefits of this nutritional pattern to prevent the onset of cerebrovascular diseases. Methods: The SUN (“Seguimiento Universidad de Navarra”) project is a prospective study among Spanish university alumni, aimed to identify the dietary determinants of stroke, coronary disease and other disorders. Two pilot studies have been developed. The first pilot study was focused on the understanding of the questionnaire. The second study used a random sample to assess the response proportion and the feasibility of using a mailing system for following-up the cohort. The first informative results are expected to be available after the first four years of following-up the cohort (2005). Here, we report the description of the baseline diet of the first participants in the cohort using data from 1587 men and 2260 women. Results: The outcome of our pilot studies ensure the feasibility of a mail-based cohort. In the baseline assessment, we found a high consumption of olive oil (18.5 g/person/day), red wine (28.8 g/person/day), legumes (102.5 g/person/day), vegetables (507.8 g/person/day) and fruits (316.7 g/person/day), with a great between-subject variability. Also, the values for cereals (170.4 g/person/day), dairy products (239.3 g/person/day) and meat and meat products consumption (186 g/person/day) in this cohort were estimated. The coefficients of variation ranged in women from 56 (for vegetables) to 240% (for red wine) and in men from 62 to 180% (for these same two items)/reflecting a wide heterogeneity in the diet of participants. Conclusions: Although the participation was not high (22% according to the estimates of the pilot study), it was comparable to the proportion found in large previous cohorts such as the Nurses-II Health Study (24%). The sharp contrast in dietary habits between the US and Spain together with the high between-subjects variability we have found in our Spanish cohort provides an exceptional opportunity to assess the aspects of the Mediterranean diet, which may be protective against stroke and other neurological disorders.

Analysis of content about sexuality and human reproduction in school textbooks in Spain

OBJECTIVES The spread of sexually transmitted infections (STIs) inadolescents and teenage pregnancy rates are increasing. A decrease in the average age of youths first sexual experience has also been noted. Sexual education programmes in schools have an important role to play in addressing these issues. The objective of this study was to analyse the content of textbooks in the areas of sexuality and human reproduction in order to evaluate the extent to which these textbooks promote healthy reproductive lifestyles, as well as avoidance of risk behaviour among adolescent students. STUDY DESIGN Descriptive study of the content of school textbooks. METHODS The study sample consisted of 12 textbooks (approximately 80% of all the textbooks used in Spanish secondary schools) which were edited in 2002. Content analysis evaluated the extent to which these books demonstrated reliable scientific information about: (a) condom effectiveness; (b) consequences, prevention and treatment of STIs; (c) family planning methods; (d) assisted reproductive technologies; and (e) the promotion of healthy reproductive lifestyles. RESULTS All textbooks presented inaccurate information in the areas studied. One hundred and fifty one quotes were identified that facilitated incomplete perception of sexuality or risky behaviour. On average, 12.6 incorrect messages were identified in each textbook. CONCLUSIONS The textbooks examined are neither appropriate nor sufficiently comprehensive for adolescent education on issues of sexuality. Results suggest a need for alternative textbooks based on better scientific evidence. It is essential that textbooks empower adolescents to make healthy decisions through the promotion of useful life skills that provide a more integrated concept of sexuality. There is a need for approaches to sexual education to integrate values commonly held by parents of the youth that use such texts.

Los trastornos del comportamiento alimentario en España: ¿estamos preparados para hacerles frente desde la salud pública?

os trastornos del comportamiento alimentario (TCA) incluyen la anorexia nerviosa, la bulimia nerviosa y un tercer grupo denominado «trastornos del comportamiento alimentario no especificados» (TCANE). La alarma social creada1 contrasta con el desarrollo incipiente de la epidemiología de los TCA y la escasez de evaluaciones adecuadas de intervenciones preventivas2. En la actualidad vamos disponiendo de una cuantificación más rigurosa de su frecuencia, y nuestro país destaca internacionalmente en publicaciones sobre la prevalencia de los TCA3,4, hasta afirmarse que no son necesarios más estudios de prevalencia en España5, aunque faltan estudios de incidencia sobre muestras representativas5,7. La prevalencia encontrada es preocupante. En las chicas escolarizadas de 12 a 21 años, parece que el 4-5% padece algún TCA (diagnosticado por psiquiatra). En varones son más escasos los estudios y la prevalencia es menor, pero puede llegar al 0,9%. Debido a problemas metodológicos de difícil solución, la prevalencia poblacional es probablemente superior a lo objetivado8. La prevalencia real de TCA en chicas de estas edades podría alcanzar un 6-7%. Además, quienes reúnen todos los criterios internacionales para ser clasificadas como «caso» son el extremo de un espectro continuo. Si se considera en estas chicas la presencia de enfermedad en una escala más continua con progresivas intensidades (a modo de análisis de sensibilidad9), se hallan prevalencias del 11-16% para las puntuaciones de 30 o más en el EAT (Eating Attitudes Test). La magnitud del problema es evidente, pues está afectando, en mayor o menor medida, al menos a una de cada 610 chicas de estas edades. Frente a la epidemiología descriptiva del problema, el desarrollo de la epidemiología analítica es menor. Hay varios estudios de casos y controles importantes, que han valorado los factores de riesgo de anorexia10, bulimia11 y trastornos por atracones12. Identifican el perfeccionismo, el riesgo general de enfermedad psíquica (en pacientes y familiares) y la autoevaluación negativa como determinantes de los TCA. Entre otros, los problemas de alcohol y otras drogas en los padres, el poco contacto entre padres e hijos y las discusiones entre los padres aparecen como factores de riesgo de bulimia y atracones. No obstante, hay limitaciones inherentes al diseño de casos y controles, ya que es posible que se dé un recuerdo diferencial de los sucesos del pasado o un fenómeno de causalidad inversa al interpretar equivocadamente las consecuencias precoces del TCA como si fuesen sus determinantes causales. Una información más fiable13 se obtiene con diseños de cohortes prospectivas, donde se confirma el papel de los rasgos psicológicos de vulnerabilidad (perfeccionismo14, neuroticismo15,16, baja autoestima17,18). También está cada vez más claro el efecto de determinantes externos o ambientales19. Entre ellos, destacan los factores familiares (incluyendo los antecedentes de TCA en la familia, el estado civil de los padres y los conflictos familiares)20,21 y las influencias que llegan a través de los medios de comunicación22. El «bombardeo» mediático que presenta la delgadez como ideal y sinónimo del éxito ha crecido de forma paralela al aumento de los TCA. Las impresiones iniciales de los clínicos que atendían a las pacientes con TCA o los datos de estudios transversales23 se han visto confirmados recientemente en dos estudios de cohortes prospectivas6,24. La exposición a los medios de comunicación precede a la aparición de los TCA6; la duración total de la exposición, el tipo de revista, la clase de emisión de radio que se escucha o el tipo de programas televisivos que se ven predicen el mayor riesgo. Aunque varios estudios no encuentran asociación del riesgo de TCA con el tiempo total dedicado a ver television6,22,23, cuando se valora el tipo de programa (telenovelas, películas, videoclips musicales), sí se halla una asociación positiva con correlatos de TCA, como autoinducirse el vómito, usar laxantes o la insatisfacción con el propio cuerpo22-24. Tratar de parecerse a modelos o actrices que se ven en estos medios duplica el riesgo de iniciar una conducta purgativa23. En una muestra representativa de chicas navarras seguidas prospectivamente durante 18 meses, el riesgo de desarrollar un TCA (confirmado por psiquiatra) era el doble para la categoría superior de exposición a programas de radio y

Are Smoking Habits Changing Among Spanish Health Professionals? Results from the SUN Cohort 1999–2008

Introduction Smoking by health professionals is a very negative habit not only for their own health, but also because it diminishes their capacity to influence their smoker patients to quit their habits. Objective The aim of this study was to assess the trend of the smoking prevalence, as well as the impact of the 2005 Spanish Smoking Act, among healthcare professionals. Methods Participants were asked about their smoking consumption in the baseline and the follow-up questionnaires in a Spanish dynamic prospective cohort of university graduates (the SUN Project) from 1999 to 2008. Non-conditional logistic regression models were fit to assess the relationship between type of profession and prevalence of smoking. Results The proportion of current smokers at the entrance into the cohort was 16.4% for physicians, 20.8% for pharmacists, 23.4% for nurses and 24% for other university graduates. The risk of being current smoker (adjusted OR [95% CI]) was lower in physicians (0.68 [0.61–0.76]) but not in pharmacists (0.94 [0.84–1.06]) or nurses (0.94 [0.84–1.05]) compared to other university graduates. All professional groups presented a statistically significant decline of smoking prevalence from 1999 to 2008. This decline might be at least partly due to the impact of the Spanish legislation on their smoking habits. Conclusion This study shows a decline in smoking prevalence among Spanish physicians. This decline has reached lower levels than what is current among other professionals and the general population. However, there is still a high number of smokers among health professionals, thus more efforts are needed to achieve lower levels of tobacco consumption.

The Sooner, the Worse? Association between Earlier Age of Sexual Initiation and Worse Adolescent Health and Well-being Outcomes

This cross-sectional study assesses the association between age of sexual initiation during adolescence and a selection of well-being outcomes regarding that first relationship. High-school adolescents from El Salvador (2,686) and from Peru (3,399) replied to a paper-pencil questionnaire. Those who were sexually initiated replied to several questions regarding their age at sexual initiation, condom use, satisfaction and reasons/circumstances for that sexual relationship. Approximately 19% of participants were sexually initiated (n = 1,179). After retaining participants with valid responses and with sexual initiation ages between 13 and 17, the final sample for this paper consisted of 996 sexually initiated participants (526 Salvadorians and 470 Peruvians). Multiple logistic regression analyses showed that those who initiated sex at earlier ages had worse outcomes compared to those who initiated at older ages. Specifically, they had lower odds of having used a condom, of having good memories of that experience and of having had that first relationship because they were in love. Conversely, they had higher odds of having had that first sexual relationship as a result of peer pressure (“Most of my friends already had sex”), because of partner pressure (“I was afraid to lose him/her,” “My partner told me he/she would leave me” or “I did not know how to say no to a person who insisted”), or as a consequence of different forms of impaired autonomy (“I was under the influence of alcohol or drugs” or “As a consequence of seeing sexual images”). Results show that sex at earlier ages is associated with worse adolescent health and well-being outcomes.

O5-6.6 Infertility and mediterranean dietary pattern: a nested case-control study

Introduction Infertility affects approximately 15% of couples during their reproductive lifetime. We aimed to investigate associations between different dietary patterns (DP) and difficulty for getting pregnant in the SUN Project. Methods Using data from the SUN (Seguimiento Universidad de Navarra) dynamic prospective cohort of university graduates, we conducted a nested case-control analysis of 485 cases and 1670 controls aged 20–45 years. Cases were female participants who referred having consulted a doctor due to difficulties for getting pregnant. Controls were female participants not having consulted for this reason and having at least one child. Cases and controls were matched according to age. We performed principal component analyses with orthogonal varimax rotation to determine the main DPs in our cohort. We divided our sample according to quartiles of the empirically-identified DPs and conducted conditional logistic regression models. Results Out of 9811 women enrolled with 20–45 years of age, 485 referred having consulted a doctor due to difficulty to getting pregnant. Two main DPs were identified: a Western DP and a Mediterranean-type DP. Once potential confounders were adjusted for, no significant association was observed for a higher adherence to the Western DP (OR 1.09 (95% CI 0.75 to 1.57)). After adjusting for potential confounders, women with a higher adherence to the Mediterranean-type DP had a lower risk for consulting for difficulty to getting pregnant (OR 0.62 (95%: 0.39 to 0.99)). Conclusion Our data suggest that a higher adherence to the Mediterranean-type DP might have a protective effect on infertility.

Prevención del consumo de tabaco, protección del aire respirable y promoción de la salud en relación al tabaquismo: avanzamos hacia un nuevo futuro

La experiencia en otros paises sobre las protestas de la poblacion ante cualquier medida restrictiva del tabaquismo, nos muestra que parecen abundantes solamente al principio. Sin embargo, esta primera impresion que ademas se ve reforzada por la atencion que suscitan en los medios de comunicacion enseguida cambia y se percibe rapidamente que las voces de aceptacion, entre las que se incluyen muchos fumadores, siempre son mayoritarias. La aceptacion mayoritaria de medidas protectoras y preventivas como las promulgadas en la nueva Ley Foral es mayor en la medida en que la poblacion es adecuadamente informada sobre las motivaciones que las inspiran. Es imprescindible que el fumador se sienta apoyado en sus esfuerzos para dejar de fumar. En esta labor educativa es necesario proponer medidas concretas y realistas al fumador para ayudarle a abandonar el tabaquismo. En el medio universitario, por ejemplo, hemos conseguido una aceptacion inusitada, por mas del 80% de los empleados, de nuevas medidas de proteccion del aire respirable gracias a la elaboracion de un programa de informacion continuada durante el ano previo a la introduccion de los cambios. Asimismo, el Gobierno de Navarra lleva tiempo impulsando muchas iniciativas conducentes a informar y concienciar a la poblacion sobre aspectos no solamente sanitarios sino tambien sociales relacionados con el tabaquismo. Es consciente, por otra parte, de la necesidad de ayudar a los fumadores y pone a su servicio diferentes modalidades de ayuda en los centros de Atencion Primaria de Salud.