European Journal of Clinical Nutrition (2001) 55, 430435

2001 Nature Publishing Group All rights reserved 09543007/01 $15.00

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Original Communication
Inuence of sociodemographic factors in the prevalence of obesity
in Spain. The SEEDO'97 Study
J Aranceta1*, C Perez-Rodrigo1, L Serra-Majem2, L Ribas3, J Quiles-Izquierdo4, J Vioque4, M Foz5 and
Spanish Collaborative Group for the Study of Obesity{
1

Community Nutrition Unit, Department of Public Health, Municipality of Bilbao, Bilbao, Spain; 2Department of Preventive Medicine
and Public Health, Faculty of Medicine, University of Las Palmas de Gran Canaria, Las Palmas, Spain; 3Group of Community Nutrition,
Department of Public Health, Faculty of Medicine, University of Barcelona, Barcelona, Spain; 4Department of Public Health, University
Miguel Hernandez, Campus San Juan, Alicante, Spain; and 5Department of Internal Medicine, Germans Trias i Pujol University Hospital,
Badalona, Spain

Objective: To analyse the inuence of social and cultural factors in the prevalence of obesity in the Spanish adult
population aged 25 60 y based on available population data.
Design: Pooled analysis of four cross-sectional nutrition surveys.
Subjects: A total of 5388 free-living subjects aged 25 60 y, respondents of the Nutritional Surveys carried out in
four Spanish regions (Catalunya, Basque Country, Madrid and Valencia) from 1990 to 1994. The samples were
pooled together and weighted to build a national random sample.
Measurements: Weight and height were measured on each individual by trained observers. Age, gender,
educational level, occupation, habitat (rural=urban) and region were considered. Obesity was dened as body
mass index 30 kg=m2. The protocol used in each survey was in accordance with the recommendations of the
Spanish Society for the Study of Obesity (SEEDO). Logisitic regression models were designed to analyse the
inuence of sociodemographic factors in the prevalence of obesity in men and women.
Results: The prevalence of obesity was higher in older age groups in men and women, odds ratio (OR) for every
10 y OR 1.40 (95% CI 1.39 1.41) for men and OR 1.86 (95% CI 1.85 1.87) for women. Logisitic regression
analysis adjusted for age showed higher obesity rates among low educated people, OR 1.80 (95% CI 1.78 1.81)
in men and OR 2.36 (95% CI 2.29 2.42) in women (P<0.001). Among men the odds ratio for the prevalence of
obesity in rural areas was OR 1.87 (95% CI 1.86 1.89), compared to cities. The geographical distribution
showed higher obesity rates in the southeast.
Conclusion: This study supports that obesity is a multifactorial problem. Older women with low educational level
and low income seem to be the most susceptible group to weight gain. Therefore, Public Health Programs should
consider this type of environmental factor when planning strategies aimed at preventing or reducing the problem of
obesity in western societies.
Descriptors: epidemiology; prevalence; adults; cross-sectional studies; sociodemographic factors
European Journal of Clinical Nutrition (2001) 55, 430435

Introduction
*Correspondence: J Aranceta, Community Nutrition Unit, Municipal
Department of Public Health, Luis Brinas 18, 4th oor, 48013 Bilbao,
Spain.
E-mail: bisaludpublica@jet.es
{
The members of The Spanish Collaborative Group for the Study of
Obesity are: J Aranceta, M Barbany, D Bellido, M Carrillo, S Duran,
ML Fernadez-Soto, X Formiguera, M Foz, P Garca-Luna, JL Griera,
JF Martnez Valls, E Morejon, B Moreno, L Serra-Majem, M Serrano Ros
y FJ Tebar.
Guarantor: Spanish Society for the Study of Obesity (SEEDO).
Contributors: The Members of The Spanish Collaborative Group for the
Study of Obesity contributed to the design of the study.
Received 22 February 2000; revised 2 January 2001;
accepted 17 January 2001

Overweight and obesity are becoming a new epidemic in

Western developed countries and are major public health
problems because of their impact on co-morbidity and
associated health cost. This problem is often underestimated but the potential impact on health outcomes is
comparable to that of tobacco (Aranceta, 1998; WHO,
1998). Obesity is a major risk factor for the development
of coronary heart disease, hypertension, type 2 diabetes and
dislipidaemia and has been related to some hormonedependent cancers as well (Pi-Sunyer, 1993; Khan &
Bowman, 1999).

Sociodemographic factors and obesity

J Aranceta et al

Recent data in the USA show an absolute increase of 8%

in the prevalence of obesity in recent years, from 25%
estimated in NHANES II (1976 1980) to 35% in
NHANES III (1990 1994), thus a relative increase of
40% (Kuczmarski et al, 1994). In several countries the
cost of obesity has been estimated to account for between 5
and 7% of the annual health budget (Wolf & Colditz, 1994;
Birmingham et al, 1999; Bernard Krief, 1999).
Data regarding the prevalence of obesity in Spain are
based on regional Nutritional Surveys (Aranceta et al,
1994, 1995; Serra Majem et al, 1996; Quiles Izquierdo &
Vioque, 1996) and local surveys of cardiovascular risk
factors (Tormo Daz et al, 1995). Some estimates have
been based on data from the National Health Survey
considering self-reported height and weight (GutierrezFisac et al, 1994). The Spanish Society for the Study of
Obesity (SEEDO) supported the SEEDO'97 Study. The
results of this study provide a global estimate of the
prevalence of obesity in the country based on pooled
population data. The SEEDO'97 Study considered data
from regional surveys carried out during a time frame of
4 y using the same methodology and similar protocol,
including anthropometric measurements and socio-demographic variables (Aranceta et al, 1998b).
Although there is limited knowledge of factors which
may inuence the variation in the prevalence of obesity, it
is generally accepted that environmental factors as well as
lifestyle play an important role in the onset of obesity,
acting on a genetic substrate (Bouchard, 1996).
A better understanding of population-based data is
required in order to analyse key underlying factors, thus
contributing to the development of effective public health
intervention strategies targeted to prevent or diminish the
problem. Therefore, the aim of this study is to analyse the
inuence of social and cultural factors on the prevalence of
obesity in the Spanish adult population aged 25 60 y,
based on available population data.
Subjects and methods
Sample
This study considers cross-sectional data from four regional
population nutrition surveys carried out between 1990 and
1994 in random samples of the Basque Country (Aranceta
et al, 1995), the Region of Madrid (Aranceta et al, 1994),
Catalunya (Serra Majem et al, 1996) and the Region of
Valencia (Quiles Izquierdo & Vioque, 1996), which were
unique Spanish population studies of obesity recognised by
the SEEDO. All the samples were drafted by multi-step
stratied random sampling procedures by age, gender and
habitat, proportional to population density. Valid response
rates in each survey were 68.9% in Catalunya; 73.4% in the
Basque Country; 71% in the Region of Madrid, and 74% in
the Region of Valencia. Description of non-responders has
been dealt in elsewhere (Aranceta et al, 1994,1995; Serra
Majem et al, 1996; Quiles Izquierdo & Vioque, 1996).

Adults from each representative sample within the age

range 25 60 y were included in the pooled analysis of
this study. The pooled sample has been post-stratied by
region, age group and gender following the procedures
described by Hansen and Cochran (Kish, 1995). In order to
estimate the prevalence of obesity in Spain, a homogeneous
distribution of the problem in every region was assumed.
The sample was weighted according to the distribution
of the Spanish population in the 1991 population census by
age, gender and region. Sample design and weighting was
performed in collaboration with the Department of Statistics of the Institute Carlos III in Madrid.

431

Procedures and variables of the study

All interviewers followed a training period, standardisation
of criteria and methodology before data collection in each
regional survey. During this training, eld workers learned
and practised anthropometric procedures in order to reduce
inter-observer measurement variability. Education level and
occupation were classied according to the scale suggested
by the Task Force on the Measurement of Social Class in
Health Sciences of the Spanish Society of Epidemiology
(Alvarez Dardet et al, 1995) in all the studies. This classication reects the qualication required for a particular job and
corresponding salary, ranging from non-qualied manual
workers to highly qualied business directors with responsibilities for other people's work. To analyse the inuence of
these factors in the prevalence of obesity, they were rearranged according to the following categories: education
low, primary school incomplete or illiterate (<6 y at school);
medium, primary school completed, secondary school or
further education (6 12 y of education); high, high school,
college or university degree (>12 y of education). Socioeconomical level was grouped based on occupation of the
interviewee and household income as follows: low
(100 000 ptas
monthly),
medium
(>100 000
<500 000 ptas) or high (500 000 ptas monthly); habitat
was classied according to the locality population
size:<10 000 inhabitants; between 10 000 and 100 000 inhabitants, or >100 000 inhabitants. Geographical region was
classied into north, northeast, centre and southeast.
Anthropometric measurements
Weight and height were measured on each individual in
underwear, using calibrated electronic scales and standardised stadiometers (Lohman et al, 1988). Subjects were
randomly assigned either to a morning or afternoon interview and measurement. Weight was measured in kilograms, scale measurement error  100 g. Height was
measured standing, bare feet and head in Frankfurt horizontal position, expressed in centimetres, instrumental
measurement error  0.5 cm. Measurement instruments
were regularly calibrated during eld work. These procedures are in accordance with those suggested by the
SEEDO protocol for population surveys assessing the
European Journal of Clinical Nutrition

Sociodemographic factors and obesity

J Aranceta et al

432

Table 1 Prevalence of obesity (BMI30) by sociodemographic factors;

the SEEDO'97 Study
Men

Table 2 Odds ratio for obesity by sociodemographic factors, the

SEEDO'97 Study

Women

Men

Proportion (95% CI) Proportion (95% CI)

Age
25 34 y
35 44 y
45 54 y
>55 y

6.04
10.91
16.62
18.46

(4.07 8.01)
(8.14 13.6)
(13.0 20.1)
(13.6 23.2)

4.49
10.56
25.90
33.76

(2.89 6.09)
(8.14 12.9)
(22.2 29.5)
(28.5 39.0)

Women

Odds ratio (95% CI) Odds ratio (95% CI)

Age
25 34 y
35 44 y
45 54 y
>55 y

1.0
2.13 (2.12 2.15)
2.90 (2.88 2.92)
3.51 (3.48 3.54)

1.0
2.15 (2.14 2.17)
5.28 (5.24 5.32)
5.95 (5.90 5.99)

1.0
1.55 (1.54 1.56)
1.80 (1.78 1.81)

1.0
1.02 (1.01 1.04)
2.36 (2.29 2.42)

Educational levela
Low
Medium
High

16.64 (10.2 24.4)

13.04 (9.4 16.5)
9.01 (5.5 12.4)

23.82 (16.3 31.2)

14.63 (10.5 18.6)
5.52 (1.1 11.0)

Educational levela
High
Medium
Low

Socioeconomic levela
Low
Medium
High

13.21 (8.0 18.3)

11.45 (8.6 14.2)
7.65 (2.9 12.4)

22.13 (15.6 28.6)

13.17 (9.8 16.4)
11.17 (10.6 18.7)

Socioeconomic levela
High
Medium
Low

1.0
1.24 (1.22 1.25)
1.27 (1.25 1.28)

1.0
1.28 (1.26 1.30)
1.38 (1.37 1.40)

Marital Statusa
Single
Couple

15.2 (9.3 17.2)

12.8 (9.1 16.4)

15.2 (10.8 18.7)

19.3 (15.9 26.4)

Marital statusa
Single
Couple

1.0
0.84 (0.82 0.86)

1.0
1.26 (1.24 1.27)

16.79 (7.4 26.1)

14.45 (9.6 19.2)
10.77 (7.7 13.7)

14.09 (4.6 23.8)

17.19 (9.8 22.6)
15.54 (11.6 19.3)

1.0
1.41 (1.40 1.42)
1.87 (1.86 1.89)

1.0
1.08 (1.08 1.09)
0.85 (0.84 0.86)

11.54
8.79
9.27
15.98

16.80
13.20
14.28
17.20

1.0
0.78 (0.78 0.79)
1.08 (1.07 1.09)
1.65 (1.64 1.66)

1.0
0.76 (0.76 0.77)
1.01 (0.98 1.01)
1.12 (1.10 1.13)

Rural urbana
<10 000 inhabitants
10 000 100 000 inhabitans
>100 000 inhabitants
Regiona
North
Northeast
Centre
Southeast
a

(8.8 14.2)
(5.2 12.3)
(5.0 13.4)
(10.6 21.3)

(12.7 20.8)
(8.9 19.0)
(8.5 20.0)
(11.5 23.2)

Age-adjusted prevalence. 95% CI, 95% condence interval.

prevalence of obesity (SEEDO, 1996). Obesity was dened

as BMI30 (BMI body mass index weight in kg
divided by the squared of height in metres) (WHO, 1998;
SEEDO, 1996; Bray et al, 1998; The National Heart, Lung
and Blood Institute Expert Panel on the Identication,
Evaluation and Treatment of Overweight and Obesity in
Adults, 1998).
Data analysis
Statistical analysis of the data was performed using SPSS
(Norusis, 1996), EPIINFO 6.0 (Sullivan et al, 1994;
CSAMPLE module) and SUDAAN (SUDAAN, 1995).
Both EPIINFO and SUDAAN allow calculations for standard errors of the estimators for complex sample designs
and weighting. Proportions and the 95% condence intervals (95% CI) were estimated for stratied samples. Proportions were compared using the w2 statistic (Jenicek &
Cleroux, 1987), considering P-values <0.05 for signicance. All analyses were performed with the weighted
sample. Comparisons of prevalences of obesity by level
of education were performed after adjustment for age in
order to control for its potential confounding effects,
considering the age distribution of the whole Spanish
population as the reference.
Association between obesity and each of the sociodemographic factors considered was analysed by means
European Journal of Clinical Nutrition

Rural urbana
>100 000 inhabitants
10 000 100 000 inhabitants
<10 000 inhabitants
Regiona
North
Northeast
Centre
Southeast
a

Adjusted for age. 95% CI, 95% condence interval for odds ratio
estimated using logistic regression analysis.

of unconditional logistic regression analysis. The models

were designed separately for men and women and adjusted
for age. Interaction between region and the factor of
interest was considered.
Results
The prevalence of obesity (BMI30) in the SEEDO'97
Study was 13.4%, 11.5% in men and 15.2% in women aged
25 60 y. The prevalence of obesity signicantly increased
with age in all the regions considered. The level of education had an inverse relationship with BMI and with the
prevalence of obesity in both males and females, to a
greater extent among women. The lower the level of
education, the higher the prevalence of obesity. This
inverse trend was statistically signicant both in men and
women (P<0.001). Crude prevalences of obesity differed
from those after adjustment by age and educational level.
Women 45 y and older with a low educational level were
the subgroup showing the highest prevalence of obesity.
Socio-economic level was inversely related to the prevalence of obesity, thus lower income subgroups showed
higher proportions of obese people compared to those
better off. These differences were statistically signicant
among women (P<0.001), but not in men (P 0.29). Table

Sociodemographic factors and obesity

J Aranceta et al

1 shows the proportions of obese people by socio-demographic factors by gender. Marital status had a positive
inuence on the prevalence of overweight among women,
thus the proportion of overweight was signicantly higher
among married women. The raw prevalence of obesity was
lower in cities compared to rural areas in the male group
(P<0.05), although not overall (P 0.10). There were
statistically signicant differences in the distribution of
BMI by region (P<0.001), both in men and women. In
the female subgroup, the prevalence of obesity was higher
in the north (16.5%) and southeast (16.4%). In the male
group the prevalence of obesity was higher in the southeast.
Odds ratios for obesity according to sociodemographic
factors are presented in Table 2. The odds ratio (OR) for
every 10 y was, OR 1.40 (95% CI 1.39 1.42) for men,
and OR 1.86 (95% CI 1.85 1.87), for women. After age
adjustment, the prevalence of obesity was higher among
lower educated people, OR 1.80 (95% CI 1.78 1.81),
for men, and OR 2.36 (95% CI 2.29 2.42) for women.
Among men, the odds ratio for the prevalence of obesity in
rural areas was OR 1.87 (95% CI 1.86 1.89), compared
to urban areas.
Discussion
One of the main constraints in analysing the magnitude of
obesity has been discrepancy in the criteria and methodologies used to assess the problem by different authors in
various countries.
Both the World Health Organization Task Force for the
Study of Obesity (WHO, 1998) and the SEEDO (SEEDO,
1996) recommend the use of body mass index (BMI) based
on anthropometric measurements as standard indicator to
estimate the prevalence of obesity in population studies,
despite limitations.
Although prevalence estimates of obesity based on
reported weight and height may be useful, underestimation
may be a serious problem because of the usual underreporting in weight and over-reporting in height. The
Report of the WHO Task Force for the Study of Obesity
recognises the following as main limiting factors for the
comparability of epidemiological studies on the prevalence
of obesity: different criteria to dene obesity (the report
recommends BMI 30); different age groups considered;
time interval for data collection, and comparison of studies based on body measurements with studies based on
reported weight and height (WHO, 1998). The SEEDO'97
Study has pooled population-based studies carried out on
representative random samples. All the studies included
used the same procedures for anthropometric measurements and sociodemographic factors, in accordance with
recommendations by the SEEDO. The studies were carried
out over a 4 y period and allow comparison for the same
age groups (25 60 y). In most studies the prevalence of
obesity is higher among women and increases with age,
particularly in the least educated female subgroup. The

SEEDO'97 study showed a higher proportion of obese

people with increasing age, reaching a peak in the 55
60 y subgroup. Similar differences were also observed in
the Spanish National Health Survey based on self-reported
weight and height (Gutierrez-Fisac et al, 1994). Crude
prevalences of obesity differed from those after adjustment
by age and educational level due to the fact that least
educated people (illiterate, primary school incomplete)
were mostly the older age group with a higher prevalence
of obesity.
The inuence of socio-economic level on the prevalence
of obesity is different in developed and developing countries. Overall, the prevalence of obesity in developed
countries is higher in lower socioeconomic groups (Aranceta, 1998; McDonald et al, 1997; Sunquist & Johansson,
1998; Laurier et al, 1992; Stam-Moraga et al, 1999;
Rosmond & Bjornotorp, 1999; Martikainen & Marmot,
1999), whilst in developing countries the problem is
higher among the better off and particularly among those
groups adopting Western lifestyles, as reported in Samoa
(Van Itallie, 1994) and Latin American countries (Caballero, 2000). Several studies describe socioeconomic status
as an independent factor inuencing BMI and even on
waist hip ratio (WHR; Rosmond & Bjornotorp, 1999). In
the SEEDO'97 Study the prevalence of obesity was higher
in lower socioeconomic groups among women.
Regional differences in the prevalence of obesity have
been described among European regions showing an
increasing trend towards the south and the east (WHO,
1988; WHO MONICA Project, 1998). The same has been
reported within countries and was reected in the
SEEDO'97 Study, although some local studies carried out
in the northwest suggest a high prevalence in this region as
well, with a prevalence of 20.6% for men and 25.4% for
women (Alvarez Torices et al, 1992), gures close to those
reported in the region of Murcia (southeast), 23.7% for
women and 17.3% for men (Tormo Diaz et al, 1995).
Several studies have reported a higher prevalence of
obesity in rural areas compared to cities, as described in
some regions in Canada (Reeder et al, 1997). The Report of
the WHO Task Force for the Study of Obesity suggests that
the rapid urbanisation process has a negative impact on the
prevalence of obesity (WHO, 1998). However, data available in Spain do not show this fact or any clear pattern in
this sense (Aranceta et al, 1998b; Banegas et al, 1993).
Lifestyle and food habits have been reported to play an
important role in the increasing prevalence of obesity in
Western countries. A national survey in Belgium showed a
higher prevalence of obesity among people having higher fat
intakes or higher fat=sugar ratio (Stam-Moraga et al, 1999).
Low physical activity was directly related to a higher
prevalence of obesity. It could be argued that the possible
inuence of sociodemographic factors in food patterns and
other lifestyles might partly explain differences in the prevalence of obesity. The SEEDO'97 Study could not analyse
the inuence of these factors due to nonstandardised data
regarding food intake and physical activity in the different

433

European Journal of Clinical Nutrition

Sociodemographic factors and obesity

J Aranceta et al

434

data sets. However, in regional dietary surveys carried out in

Spain like EINUT-I in the Basque Country (Aranceta et al,
1998a) a signicant inuence of socio-economic level in
food patterns was observed, particularly in the female group.
Lower income women had higher fat intakes and lower
consumption of fruit and vegetables. Older women without
an occupation away from home were less likely to be
involved in sport activities. These patterns have been
described in association with higher obesity rates (StamMoraga et al, 1999). Regression analysis in the EINUT-I
showed a positive association of BMI with age, alcohol and
percentage energy from fat in men. Among women there was
a positive association with age and inverse relationship with
energy intake and level of education (Aranceta et al, 1995).
A number of studies have detected a positive association
between BMI and television viewing among children and
adults (Haapanen et al, 1997; Vioque et al, 2000). In recent
decades the urbanisation process in Western societies has
been associated with lower energy output at work, in
household tasks, increased use of public transportation,
cars and lifts, among other factors (Haapanen et al, 1997;
Coakley et al, 1998). An increased BMI has been reported
among ex-smokers (Flegal et al, 1995; Molarius et al,
1997). Assessing food intake of obese people is one of
the controversial areas of study. Several studies show
under-reporting of food intake in overweight people, thus
resulting in underestimation of energy intake (Braam et al,
1998). This study supports that obesity is a multifactorial
problem. Results show a variation in the prevalence of
obesity with socio-demographic factors. Less educated, low
income women 45 y and older seem to be the most
susceptible group to weight gain. Therefore, public health
programmes should consider this type of environmental
factors when planning strategies aimed at preventing or
reducing the problem of obesity.
Acknowledgements JV was supported by a grant fromt the Fondo
Investigacion Sanitaria (FIS 00=0985).

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