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Vol. 72. Issue 11.
Pages 916-924 (November 2019)
Original article
DOI: 10.1016/j.rec.2018.10.010
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Excess Weight in Spain: Current Situation, Projections for 2030, and Estimated Direct Extra Cost for the Spanish Health System
Exceso de peso en España: situación actual, proyecciones para 2030 y sobrecoste directo estimado para el Sistema Nacional de Salud
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Álvaro Hernáeza,b,c, M. Dolores Zomeñob,d,e, Irene R. Déganof,g, Silvia Pérez-Fernándezf,g, Alberto Godayc,d,h,i, Joan Vilaf,j, Fernando Civeirag,k, Ricardo Mourec,l, Jaume Marrugatf,g,
Corresponding author
jmarrugat@imim.es

Corresponding author: Institut Hospital del Mar d’Investigacions Mèdiques-IMIM. Dr. Aiguader 88, 08003 Barcelona, Spain.
a Grupo de Investigación en Riesgo Cardiovascular, Nutrición y Envejecimiento, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
b Facultad de Ciencias de la Salud Blanquerna, Universitat Ramón Llull, Barcelona, Spain
c CIBER de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
d Grupo de Investigación en Riesgo Cardiovascular y Nutrición-REGICOR, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain
e Programa de Doctorado en Alimentación y Nutrición, Facultat de Farmàcia, Universitat de Barcelona, Barcelona, Spain
f Grupo de investigación REGICOR, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain
g CIBER de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
h Servicio de Endocrinología, Hospital del Mar, Barcelona, Spain
i Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
j CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
k Unidad de Lípidos y Arteriosclerosis, Servicio de Medicina Interna, Hospital Universitario Miguel Servet, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
l Departamento de Bioquímica y Biomedicina Molecular, Institut de Biomedicina IBUB, Universitat de Barcelona, Barcelona, Spain
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Table 1. Characteristics of Studies Included in the Systematic Review Search
Table 2. Estimate of Cases of Overweight and Nonmorbid and Morbid Obesity in Spanish Adults and Their Additional Direct Cost (2006, 2016)
Table 3. Estimate of Cases of Overweight and Nonmorbid and Morbid Obesity in Spanish Adults in 2030 and Their Additional Direct Cost if Excess Weight Progresses at Current Rates or Holds Steady at 2016 Levels
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Abstract
Introduction and objectives

Excess weight promotes the development of several chronic diseases and decreases quality of life. Its prevalence is increasing globally. Our aim was to estimate the trend in excess weight between 1987 and 2014 in Spanish adults, calculate cases of excess weight and its direct extra costs in 2006 and 2016, and project its trend to 2030.

Methods

We selected 47 articles in a systematic literature search to determine the progression of the prevalence of overweight, nonmorbid obesity, and morbid obesity and average body mass index between 1987 and 2014. We projected the expected number of cases in 2006, 2016, and 2030 and the associated direct extra medical costs.

Results

Between 1987 and 2014, the prevalence of overweight, obesity, and morbid obesity increased by 0.28%/y (P=.004), 0.50%/y (P <.001) and 0.030%/y (P=.006) in men, and by 0.10%/y (P=.123), 0.25%/y (P=.078), and 0.042%/y (P=.251) in women. The mean body mass index increased by 0.10 kg/m2/y in men (P <.001) and 0.26 kg/m2/y in women (significantly only between 1987 and 2002, P <.001). We estimated 23 500 000 patients with excess weight in 2016, generating 1.95 billion €/y in direct extra medical costs. If the current trend continues, between 2016 and 2030, there will be 3 100 000 new cases of excess weight, leading to 3.0 billion €/y of direct extra medical costs in 2030.

Conclusions

Excess weight in Spanish adults has risen since the creation of population registries, generating direct extra medical costs that represent 2% of the 2016 health budget. If this trend continues, we expect 16% more cases in 2030 and 58% more direct extra medical costs.

Keywords:
Overweight
Obesity
Morbid obesity
Systematic literature search
Medical extra costs
Projection
Abbreviations:
BMI
Resumen
Introducción y objetivos

El exceso de peso potencia algunas enfermedades crónicas y reduce la calidad de vida, y su prevalencia crece en todo el mundo. El objetivo es estimar la evolución del exceso de peso entre 1987 y 2014 en población española adulta, calcular los casos de exceso de peso y sus sobrecostes médicos directos en 2006 y 2016, y proyectar su tendencia a 2030.

Métodos

Se seleccionaron 47 artículos en una búsqueda bibliográfica sistemática para determinar la progresión de las prevalencias de sobrepeso, obesidad y obesidad mórbida y del índice de masa corporal promedio entre 1987 y 2014. Con estos datos, se estimó el número de casos en adultos españoles en 2006, 2016 y 2030 y sus sobrecostes directos.

Resultados

Entre 1987 y 2014, las prevalencias de sobrepeso, obesidad y obesidad mórbida aumentaron el 0,28%/año (p=0,004), el 0,50%/año (p<0,001) y el 0,030%/año (p=0,006) en los varones y el 0,10%/año (p=0,123), el 0,25%/año (p=0,078) y el 0,042%/año (p=0,251) en las mujeres. El índice de masa corporal aumentó 0,10 puntos/año en varones (p<0,001) y 0,26 en mujeres (significativamente solo entre 1987-2002, p <0,001). Se estimaron 23.500.000 casos de exceso de peso en 2016, cuyo sobrecoste médico directo supuso 1.950.000.000 euros/año. De mantenerse la tendencia, entre 2016 y 2030 aparecerán 3.100.000 nuevos casos de exceso de peso, y se alcanzará en 2030 un sobrecoste médico directo de unos 3.000.000.000 euros/año.

Conclusiones

El exceso de peso en los adultos en España aumenta desde que existen registros, y en 2016 supuso un sobrecoste directo del 2% del presupuesto sanitario. Con esta tendencia, en 2030 se habrá incrementado un 16% el número de casos y un 58% su sobrecoste sanitario directo.

Palabras clave:
Sobrepeso
Obesidad
Obesidad mórbida
Revisión bibliográfica sistemática
Sobrecostes médicos
Previsión
Full Text
INTRODUCTION

Excess weight is a priority concern in public health because it raises mortality (increased 7% to 20%, 45% to 94%, and 176% by overweight, obesity, and morbid obesity, respectively)1 and is the fourth preventable factor that most impairs quality of life.2 The prevalence of excess weight has risen since data were first recorded: in 2014, obesity was present in 10.8% of men and 14.9% of women worldwide, and these figures are expected to jump to 18% and 21%, respectively, by 2025.3

In Spain, excess weight has been analyzed in methodologically heterogeneous population studies, and the trend has only been described in national health surveys, which observed an increase in overweight and obesity of 1.8% and 8.5%, respectively, between 1987 and 2012.4 Likewise, although the individual direct extra medical costs of excess weight are known,5 there is no estimate of the total extra costs for our health system.

This purpose of the study was: a) to determine the trend of excess weight and average body mass index (BMI) in the general Spanish adult population; b) to estimate the prevalence and number of cases of overweight, obesity, and morbid obesity in 2006, 2016, and 2030, and c) to estimate total direct extra costs thereof.

METHODSDesign

The study design consisted of a systematic review search and estimate of trends over time.

Search Criteria

We examined primary literature sources published since 1985 describing the prevalence of excess weight, obesity, or morbid obesity or average BMI (quotient between weight in kg and the square of height in meters) in representative samples of the general Spanish adult population. The study considered overweight to be BMI ≥ 25 and <30, nonmorbid obesity to be BMI ≥ 30 and <40, and morbid obesity to be BMI ≥ 40.

The selection of sources is described in Figure 1. PubMed and Embase were searched for articles that contained body mass index, BMI, overweight, words that started with obes in the title or abstract, or obesity or overweight as MeSH Terms, Spain in the title, abstract, or affiliations or Spanish in the title or abstract, and prevalence in the title, abstract, or as MeSH Term (search performed on 6 March 2017). Only studies including the following were considered: a) general Spanish adult population (≥ 16 years, excluding populations that were only working populations); b) results reported by sex; c) participants’ age range, and d) year of examination. Two of the authors (A. Hernáez and J. Marrugat) reviewed the search titles (n=873) and classified them as relevant or irrelevant. The abstracts of articles with titles classified as relevant by at least 1 author (n=201) were reviewed using the same criterion, and 131 articles were obtained for a full-text review. A review of the literature references cited in these series provided an additional 18 references (n=149). Any discrepancies were resolved by consensus. When aggregate studies of previous series were identified, the data were collected from the individual studies if possible. When several publications were found for the same study, the publication with more participants or more detailed information was retained.

Figure 1.

Literature search strategy.

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A total of 47 articles were included in the review. These articles were then used to extract the prevalences of overweight, obesity, and morbid obesity as well as average BMI, year of data collection, and whether weight and height data were reported by patients or collected by health professionals. The mean age of participants was also calculated or estimated. The quality of the articles was analyzed, according to whether or not the article expressly defined the following: a) volunteers’ age and location; b) sampling method; c) recruitment response rate reported as ≥ 70%; d) anthropometric information for excluded participants; e) definition of overweight, obesity, and morbid obesity; f) exact methodology used to measure weight and height; g) instrumentation used to determine weight and height, and h) measures taken to reduce any observation bias.6 A broader explanation of these aspects is given in the “Determination of Study Quality” section of the supplementary data.

Statistical Analysis

The trends of excess weight over time were calculated using multivariate linear regression models: the prevalences of excess weight or average BMI (separated by sex) were the dependent variables, the year of data collection and the mean age of the individuals were the independent variables, and the contribution of each study was weighted according to sample size.7 For each dependent variable, we studied whether or not the use of patient-reported weight and height data in each study (as a categorical variable) significantly affected model behavior. Likewise, we assessed whether or not the inclusion of nonlinear trends reached statistical significance; when this occurred, possible inflection points were estimated by the break point method.8 Previous trends were depicted by weighting each study equally according to sample size (greater size, larger plot point).9 These analyses were performed using R Software (version 3.4.1).10

Prevalences and Cases of Excess Weight in 2006, 2016, and 2030

The prevalences of overweight, obesity, and morbid obesity in 2006 and 2016 were calculated as described above, and the mean age of the Spanish adult population was estimated for each year from the National Statistics Institute data11 (see “Methods” in the supplementary data). For projections up to 2030, 2 scenarios were considered: a) the current trend persists and b) the prevalences of excess weight holds steady at 2016 values.

The cases of excess weight were calculated by applying the previous prevalences to populations of men and women aged ≥ 16 years in 2006 and 2016 and the projections for 2030.12

Approximate Estimate of Total Direct Extra Medical Costs

Mora et al.5 estimated that direct extra costs due to excess weight in Spain (considering excess costs in these patients due to primary care, specialist, and emergency visits; hospitalizations; laboratory, radiologic, and other types of diagnostic tests; and pharmaceutical prescriptions) were €43.49, €115.13, and €145.64 per year for men and €60.73, €142.95, and €170.07 per year for women with overweight, nonmorbid obesity, and morbid obesity, respectively (compared with persons of normal weight, with the euro value in 2010 taken as a reference).5 The above parameters were adjusted for inflation from 2006 to 2010 (7.91%) and from 2010 to 2016 (5.92%) based on the Consumer Price Index,13 assuming a stable macroeconomic situation with a theoretical annual inflation of 2% from 2016 to 203014 and multiplying by the number of cases previously calculated to estimate the approximate total direct extra costs. A broader explanation of these aspects and the exact values of direct extra costs per person in 2006, 2016, and 2030 is given in the “Methods” section of the supplementary data and Table 1 of the supplementary data, respectively.

RESULTS

The articles considered provide data from 51 studies conducted between 1987 and 2014 (Table 1),4,15–60 which included 149 955 men and 167 159 women. The prevalences of overweight, obesity, and morbid obesity and average BMI appeared in 36, 46, 11, and 29 studies, respectively. The studies were of variable quality (35% were low; 57%, medium; and 8%, high) (Table 2 of the supplementary data).

Table 1.

Characteristics of Studies Included in the Systematic Review Search

Cohort Name  Year  Study region  Age  Overweight  Obesity  Morbid obesity  BMI  Quality  Patient-reported height/weight 
ENPE study15  2014  Spain  25-64  3966  Yes  Yes  No  Yes  High  No 
ANIBES study16  2012  Spain  18-65  1655  Yes  Yes  No  Yes  Medium  No 
General population of Basque Country17  2011  Basque Country  ≥ 18  828  No  No  No  Yes  Low  No 
LisRisk-ERANET study18  2011  Basque Country  17-96  1081  Yes  Yes  No  Yes  Low  Yes 
National Health Survey 20114  2011  Spain  > 18  21 007  Yes  Yes  Yes  No  Medium  Yes 
DOXA study19  2010  Spain  ≥ 18  964  Yes  Yes  No  No  Low  Yes 
Nutrition Survey of the Valencian Community20  2010  Valencian Community  16-90  828  Yes  Yes  No  No  Low  No 
Di@bet.es study21  2009  Spain  ≥ 18  5047  Yes  Yes  Yes  No  Medium  No 
OBEX study22  2009  Balearic Islands  18-55  1081  Yes  Yes  No  No  High  No 
ENRICA study23  2009  Spain  ≥ 18  12 036  Yes  Yes  No  Yes  Medium  No 
European Health Interview Survey for Spain (EHISS)24  2009  Spain  20-82  21 486  Yes  Yes  No  Yes  Low  Yes 
Pharmacies, city of Barcelona25  2009  Catalonia  18-65  650  No  No  No  Yes  Low  No 
HERMEX study26  2008  Extremadura  25-79  2833  Yes  Yes  No  Yes  Medium  No 
IMAP study27  2007  Andalusia  18-80  2270  Yes  Yes  No  Yes  Medium  No 
Health Survey of Madrid 200728  2007  Community of Madrid  ≥ 15  12 190  Yes  Yes  No  No  Low  Yes 
PREDIMERC study29  2007  Community of Madrid  30-74  2268  No  Yes  No  Yes  Medium  No 
Primary care centers, Community of Madrid30  2006  Community of Madrid  31-70  1344  No  Yes  No  Yes  Medium  No 
National Health Survey 20064,31  2006  Spain  ≥ 16  29 476  Yes  Yes  Yes  No  Medium  Yes 
Health Survey of Catalonia 200632  2006  Catalonia  ≥ 15  15 926  No  No  No  Yes  Low  Yes 
EROCAP study33  2004  Spain  ≥ 18  7202  No  No  No  Yes  Low  No 
General population of Castile and León34  2004  Castile and León  ≥ 15  4012  No  Yes  Yes  No  Low  No 
General population of Galicia (SERGAS selection)35,36  2004  Galicia  ≥ 18  2884  Yes  Yes  No  Yes  Medium  Yes 
CANTHABRIA study37  2003  Cantabria  ≥ 18  1197  Yes  Yes  No  No  Low  No 
National Health Survey 20034,38  2003  Spain  ≥ 16  21 650  Yes  Yes  Yes  No  Medium  Yes 
Health Survey of Andalusia 200339  2003  Andalusia  ≥ 16  6708  Yes  Yes  No  No  Low  Yes 
Health Survey of Catalonia 200240  2002  Catalonia  18-74  1104  Yes  Yes  No  Yes  Low  No 
CDC (Canary Island Cohort) study41  2002  Canary Islands  18-75  6729  No  Yes  No  Yes  Medium  No 
General population of Cádiz42  2002  Andalusia  ≥ 15  2640  Yes  Yes  Yes  No  Medium  No 
Nutritional Survey of Catalonia 200243  2002  Catalonia  18-75  2060  Yes  Yes  No  No  Medium  No 
National Health Survey 200138,44  2001  Spain  ≥ 20  17 593  Yes  Yes  Yes  No  Medium  Yes 
General population of Segovia45  2001  Castile and León  35-74  809  No  Yes  No  Yes  Low  No 
REGICOR-2000 study46,47  2000  Catalonia  25-74  2540  Yes  Yes  No  Yes  Medium  No 
CORSAIB study48  2000  Balearic Islands  35-74  1685  No  Yes  No  Yes  Medium  No 
General population of Pamplona49  2000  Chartered Community of Navarre  18-65  782  Yes  Yes  No  No  Low  Yes 
ENIB survey22  1999  Balearic Islands  18-55  1089  Yes  Yes  No  No  High  No 
Cardiovascular Risk Survey of the Valencian Community50  1999  Valencian Community  18-66  716  No  No  No  Yes  Low  No 
General population of Girona51  1997  Catalonia  15-65  18 022  Yes  Yes  Yes  No  Medium  No 
PAN-EU, Spanish arm52  1997  Spain  ≥ 15  1000  Yes  Yes  No  Yes  Medium  Yes 
National Health Survey 1995-19974,38,44  1996  Spain  ≥ 20  9950  Yes  Yes  Yes  No  Medium  Yes 
SEEDO 2000 study53  1995  Spain  25-60  9885  Yes  Yes  No  Yes  Medium  No 
REGICOR-1995 study46,47  1995  Catalonia  25-74  1480  Yes  Yes  No  Yes  Medium  No 
General population of Talavera de la Reina54  1995  Castile-La Mancha  25-74  1330  No  Yes  No  Yes  Medium  No 
Health and Nutrition Survey of the Valencian Community 199455  1994  Valencian Community  ≥ 15  1772  No  Yes  No  Yes  High  Yes 
National Health Survey 19934,38  1993  Spain  > 18  21 061  Yes  Yes  Yes  Yes  Medium  Yes 
General population of Albacete56  1993  Castile-La Mancha  > 18  1322  No  Yes  No  No  Low  No 
Health Survey of Murcia 199257  1992  Region of Murcia  18-65  3087  Yes  Yes  No  No  Medium  No 
Nutritional Survey of Catalonia 199243  1992  Catalonia  18-75  2641  Yes  Yes  No  No  Medium  No 
Guía study58  1991  Canary Islands  ≥ 30  691  Yes  Yes  Yes  No  Medium  No 
General population of Catalonia59  1989  Catalonia  ≥ 15  704  No  Yes  No  Yes  Medium  No 
General population of Catalonia60  1989  Catalonia  35-64  2021  Yes  Yes  No  Yes  Medium  No 
National Health Survey 198744  1987  Spain  ≥ 20  20 040  Yes  Yes  No  Yes  Medium  Yes 

BMI, body mass index.

From 1987 to 2014, the prevalences of overweight, total obesity, and morbid obesity increased by+0.28% per year (P=.004),+0.50% per year (P <.001), and+0.030% per year (P=.006) in men and by+0.10% per year (P=.123),+0.25% per year (P=.078), and+0.042% per year (P=.251) in women (Figure 2). None of the above trends exhibited significant nonlinear behavior or break points (P> .05). The equations of these progressions are shown in Table 3 of the supplementary data.

Figure 2.

Trend for prevalences of overweight (A), obesity (B), and morbid obesity (C) and linear trend analysis in epidemiologic studies in Spanish adults between 1987 and 2014.

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Average BMI values rose linearly between 1987 and 2014 in men (+0.10 per year; P <.001), with no significant break point, and increased between 1987 and 2002 in women (+0.26 per year; P <.001) and did not drop significantly between 2002 and 2014 (–0.14 per year; P=.265) (Figure 3).

Figure 3.

Trend for body mass index between 1987 and 2014, linear trend analysis, and break point determination in epidemiologic studies in Spanish adults.

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There was no difference in the behavior of either trend according to whether weight and height data were reported by patients or were collected by health professionals (P> .05 in all cases).

From 2006 and 2016, more than 3.1 million new cases of excess weight appeared (Table 2), which increased direct extra costs of this disease by €524 million per year up to €1.95 billion in 2016, 2% of the health budget (€95.722 billion according to the latest estimate).61

Table 2.

Estimate of Cases of Overweight and Nonmorbid and Morbid Obesity in Spanish Adults and Their Additional Direct Cost (2006, 2016)

  20062016Differences
  Mean Age, y  Prevalences, %  Population, N  Cases, n  Annual EC per person, €  Total annual EC, €  Mean age, y  Prevalences, %  Population, N  Cases, n  Annual EC per person, €  Total annual EC, €  New Cases, n  Increase in Annual EC, € 
  2006  2016  2006-2016                       
Overweight (BMI 25.0-29.9)
Men  45.2  45.3  18 214 203  8 243 748  40.05  330 162 107  48.4  48.0  18 957 273  9 105 178  46.06  419 384 499  861 430  89 222 392 
Women  46.5  30.1  19 022 087  5 723 746  55.93  320 129 114  49.5  31.0  20 023 208  6 215 204  64.33  399 824 073  491 458  79 694 959 
Total        13 967 494    650 291 221        15 320 382    819 208 572  1 352 888  168 917 351 
Nonmorbid obesity (BMI 30.0-39.9)
Men  45.2  17.4  18 214 203  3 171 093  106.02  336 199 280  48.4  22.1  18 957 273  4 193 349  121.95  511 378 911  1 022 256  175 179 631 
Women  46.5  15.9  19 022 087  3 020 707  131.64  397 645 869  49.5  18.0  20 023 208  3 596 168  151.41  544 495 797  575 461  146 849 928 
Total        6 191 800    733 845 149        7 789 517    1 055 874 708  1 597 717  322 029 559 
Morbid obesity (BMI ≥ 40.0)
Men  45.2  0.53  18 214 203  96 535  134.12  12 947 274  48.4  0.87  18 957 273  164 928  154.26  25 441 793  68 393  12 494 519 
Women  46.5  0.98  19 022 087  186 416  156.62  29 196 474  49.5  1.39  20 023 208  278 323  180.14  50 137 105  91 907  20 940 631 
Total        282 951    42 143 748        443 251    75 578 898  160 300  33 435 150 
Total        20 442 245    1 426 280 118        23 553 150    1 950 662 178  3 110 905  524 382 060 

BMI, body mass index; EC, extra cost.

If the current trend persists, in 2030 there will be about 27.2 million adults with excess weight, with direct extra costs of about €3.08 billion per year (Table 3). This would be approximately an additional 3.1 million cases (and additional €440 million per year of extra costs) compared with the scenario in which the disease stabilizes at 2016 values. Assuming a linear increase, cumulative extra costs between 2016 and 2030 in the worst case scenario would rise to €3.081 billion.

Table 3.

Estimate of Cases of Overweight and Nonmorbid and Morbid Obesity in Spanish Adults in 2030 and Their Additional Direct Cost if Excess Weight Progresses at Current Rates or Holds Steady at 2016 Levels

  2030: At current trend2030: With prevalence of excess weight at 2016 ValuesDifferences
  Mean age, y  Prevalences, %  Population, N  Cases, n  Annual EC per person, €  Total annual EC, €  Prevalences, %  Population, N  Cases, n  Annual EC per person, €  Total annual EC, €  New cases, n  Increase in annual EC, € 
Overweight (BMI 25.0-29.9)
Men  52.9  51.9  19 340 260  10 037 595  60.78  610 085 024  48.0  19 340 260  9 289 127  60.78  564 593 139  748 468  45 491 885 
Women  53.7  32.4  20 644 317  6 682 565  84.88  567 216 117  31.0  20 644 317  6 407 996  84.88  543 910 700  274 569  23 305 417 
Total        16 720 160    1 177 301 141      15 697 123    1 108 503 839  1 023 037  68 797 302 
Nonmorbid obesity (BMI 30.0-39.9)
Men  52.9  28.7  19 340 260  5 552 589  160.91  893 467 096  22.1  19 340 260  4 278 066  160.91  688 383 600  1 274 523  205 083 496 
Women  53.7  20.8  20 644 317  4 302 276  199.79  859 551 722  18.0  20 644 317  3 707 719  199.79  740 765 179  594 557  118 786 543 
Total        9 854 865    1 753 018 818      7 985 785    1 429 148 779  1 869 080  323 870 039 
Morbid obesity (BMI ≥ 40.0)
Men  52.9  1.34  19 340 260  259 159  203.54  52 749 223  0.87  19 340 260  168 260  203.54  34 247 640  90 899  18 501 583 
Women  53.7  1.98  20 644 317  408 757  237.69  97 157 451  1.39  20 644 317  286 956  237.69  68 206 572  121 801  28 950 879 
Total        667 916    149 906 674      455 216    102 454 212  212 700  47 452 462 
Total        27 242 941    3 080 226 633      24 138 124    2 640 106 830  3 104 817  440 119 803 

BMI, body mass index; EC, extra costs.

DISCUSSION

Excess weight is increasingly prevalent among Spanish adults: the data collected indicate that overweight, obesity, and morbid obesity rose significantly in men between 1987 and 2014, whereas obesity increased only slightly in women. The average BMI increased linearly and significantly in men over this period and in women only until 2002. These data are consistent with the rise in overweight and obesity of 1.8% and 8.5% described in national health surveys between 1987 and 2012,4 although they differ from the pattern of BMI increase reported by other studies.3 Possible explanations for this weight gain are that, during the study period, the Spanish population: a) acquired less healthy dietary patterns (higher intake of cookies, industrial pastries, dairy desserts, juice, and soft drinks); reduced their fruit intake at home; and dramatically increased eating out62; b) continued to follow a moderately sedentary lifestyle,63 or c) experienced an increase in employment levels, working hours, and purchasing power (particularly before the financial recession that began in 2009), which would have encouraged less traditional dietary standards or more sedentary lifestyles.64

Excess weight leads to considerably higher direct extra medical costs because these patients use health care more often (mainly due to more primary care, specialist, and emergency medical visits; more hospitalizations; more laboratory, radiologic, and diagnostic tests, and more drug prescriptions), both due to the excess weight itself and due to its multiple associated comorbidities.5,65 According to our estimates, these direct extra medical costs were approximately €1.95 billion in 2016 (2% of the annual health budget), consistent with those described for other health systems (0.7%-2.8%).66 Because direct medical expenses account for about half the total extra cost of obesity in other European systems (which also consider higher costs due to possible sick leave, loss of productivity and performance, the cost of time invested by other health system workers, etc),67 the total extra cost due to excess weight could be around €3.9 billion for 2016. It was estimated that these were approximately €2.5 billion by the late 1990s65 and, therefore, a cost increase of €1.4 billion per year within the next 15 to 20 years is plausible.

The growing prevalence of excess weight could rapidly become unsustainable. If the current trend continues, in 2030 there will be 27.2 million cases of excess weight (3.1 million more cases than if the trend remains steady at 2016 values). This progression could be tackled by multilevel interventions (applying taxes to unhealthy foods, promoting settings that discourage weight gain, implementing educational policies that enhance healthy lifestyles, and organizing better prevention systems),68 such as has been undertaken in North Karelia, Finland.69 New pharmacological strategies (eg, bupropion-naltrexone, liraglutide) could also be useful.70 Apart from the health benefit, maintaining the prevalence of excess weight at current levels (already sufficiently high) would save about €3.0 billion by 2030. Considering that obesity prevention plans in Spain (such as the NAOS Strategy71) did not involve investments of such magnitude, these programs could be financially cost-effective in the short- to mid-term.

Limitations and Strengths

Our review search has several limitations. First, it included studies of uneven methodological quality conducted in 3 different decades. This heterogeneity was partially corrected by using multivariate linear regression models and by weighting the studies according to sample size. Second, the review maximized the number of time points by including studies that enrolled participants aged 15 to 17 years4,18,20,28,31,32,34,38,39,42,51,52,55,59; because these studies did not describe the use of other cutoff points or standards to quantify excess weight in this population, it was deduced that the studies used the same ones as for the adult population, which is not an ideal method. Third, excess weight did not increase significantly in women, probably due to greater dispersion in female prevalences. Fourth, an estimate of the mean age of Spanish adults was used to calculate the prevalences of excess weight because the National Institute of Statistics does not provide this information. Last, total extra cost due to this disease (considering all direct and indirect costs) could not be calculated, and only approximate direct extra medical costs could be estimated because there are no estimates of this parameter in the Spanish health system.

This study has several strengths. This is the first systematic literature search on excess weight trends conducted with all epidemiologic studies among the general Spanish adult population. In addition, it estimates the number of individuals who currently carry excess weight and then provides projections for 2030. Last, it contextualizes the social relevance of the problem by providing estimated figures of current and future direct extra costs.

CONCLUSIONS

The prevalences of overweight, obesity, and morbid obesity have risen since records were first kept in Spain, although the incremental rise among women is not statistically significant. The result is a prevalence of more than 23 million persons with excess weight, with direct extra medical costs of almost 2% of the 2016 health budget. According to this trend, by 2030 there will be about 3.1 million new cases and extra costs of about €3.0 billion per year (more than 3% of the current health budget). Stabilizing excess weight at 2016 levels, which are already alarming, would save almost €3.0 billion by 2030.

FUNDING

This study was funded by AGAUR (University and Research Aid Management Agency) (2014-SGR-240), the Health Department of the Generalitat de Catalunya (SLT006/17/00029), the Carlos III Health Institute (CES12/025, CD17/00122), CIBEROBN (Biomedical Research Center for the Obesity and Nutrition Pathophysiology Network), CIBERCV (Biomedical Research Center for the Cardiovascular Disease Network), and the European Regional Development Fund, as well as Novo Nordisk, which provided an unconditional grant.

CONFLICTS OF INTEREST

None declared.

WHAT IS KNOWN ABOUT THE TOPIC?

  • Excess weight is one of the factors most likely to increase the morbidity and mortality of chronic diseases, most likely to impair quality of life, and most likely to raise health costs.

  • The prevalence of excess weight has risen worldwide since the start of record-keeping.

WHAT DOES THIS STUDY ADD?

  • The prevalences of overweight, obesity, and morbid obesity in Spain increased 0.28% per year (P=.004), 0.50% per year (P <.001), and 0.030% per year (P=.006) in men and 0.10% per year (P=.123), 0.25% per year (P=.078), and 0.042% per year (P=.251) in women, respectively.

  • In 2016, there were 23.5 million cases of excess weight, leading to direct extra costs of €1.95 billion per year (2% of the health budget for 2016).

  • Stabilizing the prevalence of excess weight at 2016 levels would prevent 3.1 million new cases and save €3.0 billion in cumulative direct extra costs by 2030.

Acknowledgments

We appreciate the collaboration of Dr. Francisco Poyato (Novo Nordisk Pharma Spain, Madrid) in the discussion of the results of this work.

Material adicional

Supplementary data associated with this article can be found in the online version, at https://doi.org/10.1016/j.rec.2018.10.010.

References
[1]
E. Di Angelantonio, S.N. Bhupathiraju, Global BMI Mortality Collaboration, et al.
Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents.
Lancet., 388 (2016), pp. 776-786
[2]
GBD 2015 Risk Factors Collaborators.
Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
Lancet., 388 (2016), pp. 1659-1724
[3]
NCD Risk Factor Collaboration (NCD-RisC).
Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19·2 million participants.
Lancet., 387 (2016), pp. 1377-1396
[4]
F.J. Basterra-Gortari, M. Bes-Rastrollo, M. Ruiz-Canela, A. Gea, M.Á. Martinez-Gonzalez.
Prevalence of obesity and diabetes in Spanish adults 1987-2012.
Med Clin (Barc)., 148 (2017), pp. 250-256
[5]
T. Mora, J. Gil, A. Sicras-Mainar.
The influence of obesity and overweight on medical costs: a panel data perspective.
Eur J Heal Econ., 16 (2015), pp. 161-173
[6]
E. Keane, P.M. Kearney, I.J. Perry, C.C. Kelleher, J.M. Harrington.
Trends and prevalence of overweight and obesity in primary school aged children in the Republic of Ireland from 2002-2012: a systematic review.
BMC Public Health., 14 (2014), pp. 974
[7]
D. Bates, M. Mächler, B. Bolker, S. Walker.
Fitting linear mixed-effects models using lme4.
J Stat Softw., 67 (2015), pp. 1-48
[8]
V.M.R. Muggeo.
Estimating regression models with unknown break-points.
Stat Med., 22 (2003), pp. 3055-3071
[9]
Hastie T. GAM: Generalized Additive Models. R package version 1.14-4. 2017. Available at: https://cran.r-project.org/web/packages/gam/gam.pdf. Accessed 17 Oct 2017.
[10]
R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2014. Available at: https://www.r-project.org/. Accessed 9 Nov 2017.
[11]
Instituto Nacional de Estadística. Edad media de la población española según sexo. 2016. Available at: http://www.ine.es/jaxiT3/Datos.htm?t=3199. Accessed 8 Aug 2017.
[12]
Instituto Nacional de Estadística. Cifras de población residente en España. 2016. Available at: http://www.ine.es/dyngs/INEbase/es/operacion.htm?c=Estadistica_C&cid=1254736176951&menu=ultiDatos&idp=1254735572981. Accessed 5 Apr 2018.
[13]
Instituto Nacional de Estadística. Índice de Precios al Consumo. 2017. Available at: http://www.ine.es/jaxiT3/Tabla.htm?t=22553&L=0. Accessed 18 Oct 2017.
[14]
PriceWaterhouseCoopers. La economía española en 2033 (colección España 2033). 2013. Available at: https://www.cuartopoder.es/wp-content/uploads/2013/12/Economia-espanola-en-2033.pdf. Accessed 18 Oct 2017.
[15]
J. Aranceta-Bartrina, C. Pérez-Rodrigo, G. Alberdi-Aresti, N. Ramos-Carrera, S. Lázaro-Masedo.
Prevalence of General Obesity and Abdominal Obesity in the Spanish Adult Population (Aged 25-64 Years) 2014-2015: The ENPE Study.
Rev Esp Cardiol., 69 (2016), pp. 579-587
[16]
A.M. López-Sobaler, A. Aparicio, J. Aranceta-Bartrina, et al.
Overweight and general and abdominal obesity in a representative sample of Spanish adults: findings from the ANIBES Study.
Biomed Res Int., 2016 (2016), pp. 1-11
[17]
A. Aguayo, I. Urrutia, T. González-Frutos, et al.
Prevalence of diabetes mellitus and impaired glucose metabolism in the adult population of the Basque Country.
Spain. Diabet Med., 34 (2017), pp. 662-666
[18]
I. Alegría-Lertxundi, A. Rocandio Pablo, M. Arroyo-Izaga.
Cheese consumption and prevalence of overweight and obesity in a Basque adult population: a cross-sectional study.
Int J Food Sci Nutr., 65 (2014), pp. 21-27
[19]
S. Gallus, A. Lugo, B. Murisic, C. Bosetti, P. Boffetta, C. La Vecchia.
Overweight and obesity in 16 European countries.
Eur J Nutr., 54 (2015), pp. 679-689
[20]
L. Zubeldia Lauzurica, J. Quiles Izquierdo, J. Mañes Vinuesa, J. Redón Más.
[Prevalence of hypertension and associated factors in population aged 16 to 90 years old in Valencia Region, Spain].
Rev Esp Salud Publica., 90 (2016), pp. E9
[21]
C. Marcuello, A.L. Calle-Pascual, M. Fuentes, et al.
Evaluation of health-related quality of life according to carbohydrate metabolism status: a Spanish population-based study (Di@bet.es Study).
Int J Endocrinol., 2012 (2012), pp. 872305
[22]
J.L. Coll, M.M. Bibiloni, R. Salas, J.A. Tur.
Ten-Year Trends (2000-2010) of overweight and obesity prevalence among the young and middle-aged adult population of the Balearic Islands, a Mediterranean region.
Ann Nutr Metab., 67 (2015), pp. 76-80
[23]
J.L. Gutiérrez-Fisac, P. Guallar-Castillón, L.M. León-Muñoz, A. Graciani, J.R. Banegas, F. Rodríguez-Artalejo.
Prevalence of general and abdominal obesity in the adult population of Spain, 2008-2010: the ENRICA study.
[24]
V. Romo-Perez, D. Souto, J. Mota.
Walking, body mass index, and self-rated health in a representative sample of Spanish adults.
Cad Saude Publica., (2016), pp. 32
[25]
M.A. Via-Sosa, C. Toro, P. Travé, M.A. March.
Screening premorbid metabolic syndrome in community pharmacies: a cross-sectional descriptive study.
BMC Public Health., 14 (2014), pp. 487
[26]
F.J. Félix-Redondo, J.M. Baena-Díez, M. Grau, Tormo MÁ, D. Fernández-Bergés.
Prevalencia de obesidad y riesgo cardiovascular asociado en la población general de un área de salud de Extremadura. Estudio Hermex.
Endocrinol Nutr., 59 (2012), pp. 160-168
[27]
R. Gomez-Huelgas, J. Mancera-Romero, M.R. Bernal-Lopez, et al.
Prevalence of cardiovascular risk factors in an urban adult population from southern Spain. IMAP Study.
Int J Clin Pract., 65 (2011), pp. 35-40
[28]
G.R. Costa, M.F. Berjón, J.A. Mochales, R.G. Maleras, A.R. Laso, M.D. Vasallo.
[Epidemiological features of comorbidity and its influence on the use of health services from Health Survey Madrid 2007, Spain].
Rev Esp Salud Publica., 83 (2009), pp. 835-846
[29]
E. Gil Montalbán, B. Zorrilla Torras, H. Ortiz Marrón, et al.
Prevalencia de diabetes mellitus y factores de riesgo cardiovascular en la población adulta de la Comunidad de Madrid: estudio PREDIMERC.
Gac Sanit., 24 (2010), pp. 233-240
[30]
J. Rosado Martín, Martínez López MÁ, T. Mantilla Morató, et al.
[Prevalence of diabetes in an adult population in the region of Madrid (Spain). The Madrid Cardiovascular Risk study].
Gac Sanit., 26 (2012), pp. 243-250
[31]
R. Ortiz-Moncada, C. Álvarez-Dardet, J.J. Miralles-Bueno, et al.
Determinantes sociales de sobrepeso y obesidad en España 2006.
Med Clin (Barc)., 137 (2011), pp. 678-684
[32]
M.J. Pueyo, X. Surís, M. Larrosa, et al.
Importancia de los problemas reumáticos en la población de Cataluña: prevalencia y repercusión en la salud percibida, restricción de actividades y utilización de recursos sanitarios.
Gac Sanit., 26 (2012), pp. 30-36
[33]
A.L.M. De Francisco, J.J. De la Cruz, A. Cases, et al.
Prevalence of kidney insufficiency in primary care population in Spain: EROCAP study.
Nefrologia., 27 (2007), pp. 300-312
[34]
S. Escribano García, A.T. Vega Alonso, J. Lozano Alonso, et al.
Obesity in Castile and Leon, Spain: Epidemiology and Association With Other Cardiovascular Risk Factors.
Rev Esp Cardiol., 64 (2011), pp. 63-66
[35]
R. Perez-Fernandez, A.F. Mariño, C. Cadarso-Suarez, et al.
Prevalence, awareness, treatment and control of hypertension in Galicia (Spain) and association with related diseases.
J Hum Hypertens., 21 (2007), pp. 366-373
[36]
M.J. García-Mendizábal, J.M. Carrasco, B. Pérez-Gómez, et al.
Role of educational level in the relationship between Body Mass Index (BMI) and health-related quality of life (HRQL) among rural Spanish women.
BMC Public Health., 9 (2009), pp. 120
[37]
E. Aguilera-Zubizarreta, T. Ugarte-Miota, P. Muñoz-Cacho, L. Vara-González, S. Sanz-de Castro, CANHTABRI.A. Grupo.
[Prevalence of overweight and obesity in Cantabria (Spain)].
Gac Sanit., 22 (2008), pp. 461-464
[38]
F.J. Basterra-Gortari, J.J. Beunza, M. Bes-Rastrollo, E. Toledo, M. García-López, M.A. Martínez-González.
Increasing Trend in the Prevalence of Morbid Obesity in Spain: From 1.8 to 6.1 per Thousand in 14 Years.
Rev Esp Cardiol., 64 (2011), pp. 424-426
[39]
A. Escolar-Pujolar.
Determinantes sociales frente a estilos de vida en la diabetes mellitus de tipo 2 en Andalucía: ¿la dificultad para llegar a fin de mes o la obesidad?.
Gac Sanit., 23 (2009), pp. 427-432
[40]
G. Buckland, J. Salas-Salvadó, E. Roure, M. Bulló, L. Serra-Majem.
Sociodemographic risk factors associated with metabolic syndrome in a Mediterranean population.
Public Health Nutr., 11 (2008), pp. 1372
[41]
A.C. De León, J.C. Rodríguez, S.D. Coello, et al.
[Lifestyle and treatment adherence of type 2 diabetes mellitus people in the Canary Islands].
Rev Esp Salud Publica., 83 (2009), pp. 567-575
[42]
A. Rodríguez-Martín, J.P. Novalbos-Ruiz, J.M. Martínez-Nieto, L. Escobar-Jiménez.
Life-style factors associated with overweight and obesity among Spanish adults.
Nutr Hosp., 24 (2009), pp. 144-151
[43]
L. Serra-Majem, L. Ribas-Barba, G. Salvador-Castell, et al.
Trends in the nutritional status of the Spanish population: results from the Catalan nutrition monitoring system (1992-2003).
Rev Esp Salud Publica., 81 (2007), pp. 559-570
[44]
V. Salcedo, J.L. Gutiérrez-Fisac, P. Guallar-Castillón, F. Rodríguez-Artalejo.
Trends in overweight and misperceived overweight in Spain from 1987 to 2007.
Int J Obes., 34 (2010), pp. 1759-1765
[45]
M.T. Martínez-Larrad, C. Fernández-Pérez, J.L. González-Sánchez, et al.
[Prevalence of the metabolic syndrome (ATP-III criteria). Population-based study of rural and urban areas in the Spanish province of Segovia].
Med Clin (Barc)., 125 (2005), pp. 481-486
[46]
H. Schröder, R. Elosua, J. Vila, H. Marti, M.I. Covas, J. Marrugat.
Secular Trends of Obesity and Cardiovascular Risk Factors in a Mediterranean Population.
Obesity., 15 (2007), pp. 557-562
[47]
M. Grau, I. Subirana, R. Elosua, et al.
Trends in cardiovascular risk factor prevalence (1995-2000-2005) in northeastern Spain.
Eur J Cardiovasc Prev Rehabil., 14 (2007), pp. 653-659
[48]
F. Rigo Carratalá, G. Frontera Juan, J. Llobera Cànaves, T. Rodríguez Ruiz, I. Borrás Bosch, E. Fuentespina Vidal.
Prevalence of Cardiovascular Risk Factors in the Balearic Islands (CORSAIB Study).
Rev Esp Cardiol., 58 (2005), pp. 1411-1419
[49]
J.J. Elizondo-Armendáriz, F. Guillén-Grima, I. Aguinaga-Ontoso.
[Prevalence of physical activity and its relationship to sociodemographic variables and lifestyles in the age 18-65 population of Pamplona, Spain].
Rev Esp Salud Publica., 79 (2005), pp. 559-567
[50]
M. Guillén, D. Corella, O. Portolés, J.I. González, F. Mulet, C. Sáiz.
Prevalence of the methylenetetrahydrofolate reductase 677C>T mutation in the Mediterranean Spanish population. Association with cardiovascular risk factors.
Eur J Epidemiol., 17 (2001), pp. 255-261
[51]
J.M. Fernández-Real, M. Sáez, J.M. García-Rafanell, et al.
[Ponderal evolution in the Girona population, 1989-1999].
Rev Clin Esp., 203 (2003), pp. 57-63
[52]
M.A. Martínez-González, M.I. Martín-Almendros, M.J. Gibney, J.M. Kearney, J.A. Martínez.
Perceptions about body weight and weight reduction in Spain.
Public Health Nutr., 2 (1999), pp. 557-563
[53]
J. Aranceta, C. Pérez-Rodrigo, L. Serra-Majem, et al.
[Prevalence of obesity in Spain: results of the SEEDO 2000 study].
Med Clin (Barc)., 120 (2003), pp. 608-612
[54]
A. Segura-Fragoso, G. Rius-Mery.
Cardiovascular risk factors in a rural population of Castilla-La Mancha.
Rev Esp Cardiol., 52 (1999), pp. 577-588
[55]
J. Vioque, A. Torres, J. Quiles.
Time spent watching television, sleep duration and obesity in adults living in Valencia, Spain.
Int J Obes Relat Metab Disord., 24 (2000), pp. 1683-1688
[56]
J.A. Divisón-Garrote, J. Massó-Orozco, L. Carrión-Valero, et al.
Evolución de la prevalencia de los factores de riesgo y del riesgo cardiovascular global en población mayor de 18 años de la provincia de Albacete (1992-94 a 2004-06).
Rev Esp Salud Publica., 85 (2011), pp. 275-284
[57]
M.T. Martínez-Ros, M.J. Tormo, C. Navarro, M.D. Chirlaque, D. Pérez-Flores.
Extremely high prevalence of overweight and obesity in Murcia, a Mediterranean region in south-east Spain.
Int J Obes Relat Metab Disord., 25 (2001), pp. 1372-1380
[58]
P.L. de Pablos-Velasco, F.J. Martínez-Martín, F. Rodríguez-Pérez.
Prevalence of obesity in a Canarian community. Association with type 2 diabetes mellitus: the Guía Study.
Eur J Clin Nutr., 56 (2002), pp. 557-560
[59]
P. Plans, H. Pardell, L. Salleras.
Epidemiology of cardiovascular disease risk factors in Catalonia (Spain).
Eur J Epidemiol., 9 (1993), pp. 381-389
[60]
J.R. Banegas Banegas, F. Villar Alvarez, C. Pérez de Andrés, et al.
[An epidemiological study on cardiovascular risk factors in 35-64 years old Spanish population].
Rev Sanid Hig Publica (Madr)., 67 (1993), pp. 419-445
[61]
Ministerio de Sanidad, Servicios Sociales e Igualdad. Informe Anual del Sistema Nacional de Salud. 2016. Available at: https://www.msssi.gob.es/estadEstudios/estadisticas/sisInfSanSNS/tablasEstadisticas/InfAnualSNS2016/7Gast_Sanit.pdf. Accessed 25 May 2017.
[62]
V. Martín-Cerdeño.
1987-2007, dos décadas del Panel de Consumo Alimentario: evolución de los hábitos de compra y consumo en España.
Distrib Consum., (2008), pp. 208-240
[63]
Ministerio de Sanidad, Servicios Sociales e Igualdad. Tendencias de salud en 30 indicadores. 2015. Available at: https://www.msssi.gob.es/estadEstudios/estadisticas/EncuestaEuropea/Tend_salud_30_indic.pdf. Accessed 5 Apr 2018.
[64]
M. Alonso-Pérez, E. Furió-Blasco.
La economía española.
Cah Civilis Esp Contemp., (2010),
[65]
Gabinete de Estudios Sociológicos Bernard Krief. Estudio prospectivo Delphi. Costes sociales y económicos de la obesidad y sus patologías asociadas (hipertensión, hiperlipidemias y diabetes). Madrid: Barnard Krief; 1999. Available at: http://datos.bne.es/edicion/Mimo0001311932.html. Accessed 25 May 2017.
[66]
D. Withrow, D.A. Alter.
The economic burden of obesity worldwide: a systematic review of the direct costs of obesity.
[67]
N. Yates, C.M. Teuner, M. Hunger, et al.
The economic burden of obesity in Germany: results from the population-based KORA studies.
Obes Facts., 9 (2016), pp. 397-409
[68]
G. Sacks, B. Swinburn, M. Lawrence.
Obesity policy action framework and analysis grids for a comprehensive policy approach to reducing obesity.
[69]
E. Vartiainen, T. Laatikainen, M. Peltonen, et al.
Thirty-five-year trends in cardiovascular risk factors in Finland.
Int J Epidemiol., 39 (2010), pp. 504-518
[70]
B.J. Jones, S.R. Bloom.
The new era of drug therapy for obesity: the evidence and the expectations.
Drugs., 75 (2015), pp. 935-945
[71]
AECOSAN (Agencia Española de Consumo Seguridad Alimentaria y Nutrición). Estrategia NAOS: estrategia para la Nutrición, Actividad Física y Prevención de la Obesidad. 2012. Available at: http://www.aecosan.msssi.gob.es/AECOSAN/web/nutricion/seccion/estrategia_naos.htm. Accessed 1 Nov 2017.
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