Adherence to dietary guidelines for the Spanish population and risk of overweight/obesity in the SUN cohort

Autoři: Clara Gómez-Donoso aff001;  Miguel Ángel Martínez-González aff001;  J. Alfredo Martínez aff002;  Carmen Sayón-Orea aff001;  Carmen de la Fuente-Arrillaga aff001;  Maira Bes-Rastrollo aff001
Působiště autorů: Department of Preventive Medicine and Public Health, School of Medicine, University of Navarra, Pamplona, Spain aff001;  Biomedical Research Centre Network on Physiopathology of Obesity and Nutrition (CIBERobn), Institute of Health Carlos III, Madrid, Spain aff002;  Navarra Institute for Health Research (IdiSNA), Pamplona, Spain aff003;  Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America aff004;  Department of Nutrition, Food Sciences and Physiology, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain aff005
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article


Dietary guidelines play a key role in setting standards for nutrition policies and promoting healthy eating. Like other public health guidelines, they are often influenced by political and economic factors that could place other concerns ahead of the population’s health. In order to determine their effectiveness on obesity prevention, we prospectively examined the association between adherence to the latest available national dietary guidelines and the incidence of overweight/obesity in a Spanish cohort study. A sample of 11,554 participants of the “Seguimiento Universidad de Navarra” (SUN) cohort, initially free of overweight or obesity, was included in the study. The Spanish Society of Community Nutrition (SENC) food pyramid (FP) score was computed based on the ratio of consumed to recommended daily servings of grains, fruits, vegetables, dairy, protein-rich foods, olive oil, red and processed meat, sweets, salty snacks and spreadable fats, fermented alcoholic beverages and water. The same approach was followed to calculate the SENC hydration pyramid (HP) score, considering the intake of water and different kind of beverages. Adherence was calculated at baseline and after 10 years of follow-up. Cox proportional hazards models were used to assess the incidence of overweight/obesity (BMI ≥25 kg/m2). During a median follow-up of 10.3 years, 2320 incident cases were identified. The highest level of adherence to the SENC FP score was modestly associated with a reduced risk of overweight/obesity (multivariable-adjusted HR for the fifth quintile vs. the first quintile = 0.78; 95% CI: 0.67–0.91; p-trend: 0.007). No consistent trends were found for the SENC HP. In a large prospective cohort of Spanish university graduates, we found an inverse linear association between adherence to the SENC FP and overweight/obesity risk, whereas this was not the case for the HP.

Klíčová slova:

Beverages – Body Mass Index – Diet – Food – Food consumption – Obesity – Physical activity


1. Noncommunicable diseases: Key facts. 2018 June [cited 20 November 2018]. Available from:

2. Bennett J, Stevens G, Mathers C, Bonita R, Rehm J, Kruk M et al. NCD Countdown 2030: Worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4. The Lancet. 2018;392:1072–1088.

3. Serra Majem L, Aranceta J, Mataix J. Documento de consenso: guías alimentarias para la población española [Dietary guidelines for the Spanish population]. Barcelona SG-Editores 1995. p:1–318. In Spanish.

4. SENC. Guías Alimentarias para la Población Española: recomendaciones para una dieta saludable. [Dietary guidelines for the Spanish population: recommendations for a healthy diet]. Madrid, IM&C, S.A. 2001. p:1–502. In Spanish.

5. Dapcich V, Salvador Castell G, Ribas Barba L, Pérez Rodrigo C, Aranceta Bartrina J, Serra Majem L. Guía de alimentación saludable [Healthy food guide]. Sociedad Española de Nutrición Comunitaria. Madrid: 2004. In Spanish.

6. Grupo Colaborativo de la Sociedad Española de Nutrición Comunitaria (SENC): Aranceta Bartrina J et al. Guías alimentarias para la población española (SENC, diciembre 2016); la nueva pirámide de la alimentación saludable [Nutrition guidelines for the Spanish population; the new healthy food pyramid]. Nutr Hosp. 2016;33:1–48. In Spanish with English Abstract.

7. Aranceta-Bartrina J, Partearroyo T, López-Sobaler AM, Ortega RM, Varela-Moreiras G, Serra-Majem L, Pérez-Rodrigo C; Collaborative Group for the Dietary Guidelines for the Spanish Population (SENC). Updating the Food-Based Dietary Guidelines for the Spanish Population: The Spanish Society of Community Nutrition (SENC) Proposal. Nutrients. 2019;11:pii: E2675. doi: 10.3390/nu11112675 31694249

8. Peeters A. Obesity and the future of food policies that promote healthy diets. Nat Rev Endrocrinol. 2018 Jul;14:430–437.

9. de Oliveira Otto M, Padhye N, Bertoni A, Jacobs D, Mozaffarian D. Everything in Moderation—Dietary Diversity and Quality, Central Obesity and Risk of Diabetes. PLoS ONE. 2015;10:e0141341. doi: 10.1371/journal.pone.0141341 26517708

10. de Oliveira Otto MC, Anderson CAM, Dearborn JL, Ferranti EP, Mozaffarian D, Rao G, Wylie-Rosett J, Lichtenstein AH; on behalf of the American Heart Association Behavioral Change for Improving Health Factors Committee of the Council on Lifestyle and Cardiometabolic Health and Council on Epidemiology and Prevention; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Stroke Council. Dietary diversity: implications for obesity prevention in adult populations: a science advisory from the American Heart Association. Circulation. 2018;138:e160–e168. doi: 10.1161/CIR.0000000000000595 30354383

11. Sociedad Española de Epidemiología. Alcohol y salud pública: hecho y datos. Posicionamiento oficial de la Sociedad Española de Epidemiología [Alcohol and public health: facts and figures. Official positioning paper of the Spanish Society of Epidemiology]. November 2016. In Spanish. Available from:

12. Fresán U, Gea A, Bes-Rastrollo M, Ruiz-Canela M, Martínez-Gonzalez MA. Substitution Models of Water for Other Beverages, and the Incidence of Obesity and Weight Gain in the SUN Cohort. Nutrients. 2016;8:E688. doi: 10.3390/nu8110688 27809239

13. Barrio-Lopez MT, Bes-Rastrollo M, Sayon-Orea C, Garcia-Lopez M, Fernandez-Montero A, Gea A, Martinez-Gonzalez MA. Different types of alcoholic beverages and incidence of metabolic syndrome and its components in a Mediterranean cohort. Clin Nutr. 2013;32:797–804. doi: 10.1016/j.clnu.2012.12.002 23305606

14. Sayon-Orea C, Bes-Rastrollo M, Nuñez-Cordoba JM, Basterra-Gortari FJ, Beunza JJ, Martinez-Gonzalez MA. Type of alcoholic beverage and incidence of overweight/obesity in a Mediterranean cohort: the SUN project. Nutrition. 2011;27:802–8. doi: 10.1016/j.nut.2010.08.023 21146360

15. Nestle M. Food company sponsorship of nutrition research and professional activities: a conflict of interest? Public Health Nutr. 2001;4:1015–22. doi: 10.1079/phn2001253 11784415

16. Fabbri A, Chartres N, Bero L. Study sponsorship and the nutrition research agenda: analysis of cohort studies examining the association between nutrition and obesity. Public Health Nutr. 2017;20:3193–99. doi: 10.1017/S1368980017002178 28851466

17. Chartres N, Fabbri A, Bero LA. Association of industry sponsorship with outcomes of nutrition studies: a systematic review and meta-analysis. JAMA Intern Med. 2016;176:1769–77. doi: 10.1001/jamainternmed.2016.6721 27802480

18. Mandrioli D, Kearns CE, Bero LA. Relationship between research outcomes and risk of bias, study sponsorship, and author financial conflicts of interest in reviews of the effects of artificially sweetened beverages on weight outcomes: a systematic review of reviews. PLoS ONE. 2016;359:e0162198.

19. Rey-López JP, Gonzlaez CA. Research partnerships between Coca-Cola and health organizations in Spain. Eur J Public Health. 2018 Aug 29 [Epub ahead of print]. doi: 10.1093/eurpub/cky175 30169613

20. Bes-Rastrollo M, Schulze MB, Ruiz-Canela M, Martinez-Gonzalez MA. Financial conflicts of interest and reporting bias regarding the association between sugar-sweetened beverages and weight gain: a systematic review of systematic reviews. PLoS Med. 2013;10:e1001578. doi: 10.1371/journal.pmed.1001578 24391479

21. Nestle M. Perspective: Challenges and Controversial Issues in the Dietary Guidelines for Americans, 1980–2015. Adv Nutr. 2018;9:148–150. doi: 10.1093/advances/nmx022 29659690

22. Bero L. Developing reliable dietary guidelines. BMJ. 2017;359:j4845. doi: 10.1136/bmj.j4845 29101096

23. Blake P, Durão S, Naude C, Bero L. An analysis of methods used to synthesize evidence and grade recommendations in food-based dietary guidelines. Nutr Reviews. 2018;76:290–300.

24. Molina-Montes E, Uzhova I, Molina-Portillo E, Huerta J, Buckland G, Amiano P et al. Adherence to the Spanish dietary guidelines and its association with obesity in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Granada study. Public Health Nutr. 2014;17:2425–35. doi: 10.1017/S1368980014000688 24762818

25. Rodríguez-Rodríguez E, Aparicio A, Aranceta-Bartrina J, Gil Á, González-Gross M, Serra-Majem L et al. Low Adherence to Dietary Guidelines in Spain, Especially in the Overweight/Obese Population: The ANIBES Study. J Am Coll Nutr. 2017;36:240–47. doi: 10.1080/07315724.2016.1248246 28080834

26. Carlos S, De La Fuente-Arrillaga C, Bes-Rastrollo M, Razquin C, Rico-Campà A, Martínez-González M et al. Mediterranean Diet and Health Outcomes in the SUN Cohort. Nutrients. 2018;10(4):439.

27. Willett W.C. Nutritional Epidemiology, 3rd ed. Oxford University Press: New York, 2012. doi: 10.1097/EDE.0b013e31825afb0b

28. Martin‐Moreno JM, Boyle P, Gorgojo L, et al. Development and validation of a food frequency questionnaire in Spain. Int J Epidemiol. 1993;22:512‐519. doi: 10.1093/ije/22.3.512 8359969

29. de la Fuente-Arrillaga C, Ruiz ZV, Bes-Rastrollo M, Sampson L, Martinez-Gonzalez MA: Reproducibility of an FFQ validated in Spain. Public Health Nutr. 2010;13:1364–1372. doi: 10.1017/S1368980009993065 20105389

30. Moreiras O, Carbajal A, Cabrera L, Cuadrado C. Tabla de composición de alimentos [Food Composition Tables], 16th ed. Madrid: Ediciones Pirámide; 2013.

31. von Ruesten A, Illner A-K, Buijsse B, Heidemann C, Boeing H. Adherence to recommendations of the German food pyramid and risk of chronic diseases: results from the EPIC-Potsdam study. Eur J Clin Nutr. 2010;64:1251–1259. doi: 10.1038/ejcn.2010.151 20717136

32. Bes-Rastrollo M, Pérez Valdivieso JR, Sánchez-Villegas A, Alonso A, Martinez-Gonzalez MA. Validation of self-reported weight and body mass index in the participants of a cohort of university graduates. Rev Esp Obes. 2005;3:183–9.

33. Martínez-González MA, Lopez-Fontana C, Varo JJ, Sanchez-Villegas A, Martinez JA. Validation of the Spanish version of the physical activity questionnaire used in the Nurses’ Health Study and the Health Professionals’ Follow-up Study. Public Health Nutr. 2005;8:920–7. doi: 10.1079/phn2005745 16277809

34. Mozaffarian D. Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity. Circulation. 2016;133:187–225. doi: 10.1161/CIRCULATIONAHA.115.018585 26746178

35. Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Washington (DC). 2015.

36. Hu F. Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol. 2002;13:3–9. doi: 10.1097/00041433-200202000-00002 11790957

37. Mozaffarian D, Rosenberg I, Uauy R. History of modern nutrition science—implications for current research, dietary guidelines, and food policy. BMJ. 2018;:k2392. doi: 10.1136/bmj.k2392 29899124

38. Jessri M, Lou W, L’Abbé M. The 2015 Dietary Guidelines for Americans is associated with a more nutrient-dense diet and a lower risk of obesity. Am J Clin Nutr. 2016;104:1378–1392. doi: 10.3945/ajcn.116.132647 27680992

39. National Health and Medical Research Council. Eat for health: Australian Dietary Guidelines. Summary; Commonwealth of Australia: Canberra, Australia, 2013.

40. Livingstone K, McNaughton S. Diet quality is associated with obesity and hypertension in Australian adults: a cross sectional study. BMC Public Health. 2016;16:1037. doi: 10.1186/s12889-016-3714-5 27716133

41. Health Canada. Canada’s Dietary Guidelines. Ottawa, Canada, 2019.

42. Livsmedelsverket. Swedish Food Guide. Find your Way to Eat Greener, not too much and be Active. Sweden, 2015.

43. Agencia de Salud Pública de Cataluña. Pequeños cambios para comer mejor [Small changes to eat better]. Barcelona, Spain, 2018. In Spanish.

44. Brasil Guia Alimentar para População Brasileira [Dietary Guidelines Brazilian Population], 2 Ed., Vol. 1. 2014. Brasília/DF: Ministry of Health.

45. Monteiro CA, Cannon G, Moubarac J-C et al. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutr. 2018;21:5–17.

46. Fardet A, Rock E, Bassama J, Bohuon P, Prabhasankar P, Monteiro C, Moubarac JC, Achir N. Current food classifications in epidemiological studies do not enable solid nutritional recommendations for preventing diet-related chronic diseases: the impact of food processing. Adv Nutr. 2015;6:629–38. doi: 10.3945/an.115.008789 26567188

47. Kelly B, Jacoby E. Public Health Nutrition special issue on ultra-processed foods. Public Health Nutr. 2018;21:1–4. doi: 10.1017/S1368980017002853 29227217

48. Mendonça RD, Pimenta AM, Gea A, de la Fuente-Arrillaga C, Martinez-González MA, Lopes AC, Bes-Rastrollo M. Ultraprocessed food consumption and risk of overweight and obesity: the University of Navarra Follow-Up (SUN) cohort study. Am J Clin Nutr. 2016;104:1433–1440. doi: 10.3945/ajcn.116.135004 27733404

49. Rico-Campà A, Martínez-González MA, Alvarez-Alvarez I, Mendonça RD, de la Fuente-Arrillaga C, Gómez-Donoso C, Bes-Rastrollo M. Association between consumption of ultra-processed foods and all cause mortality: SUN prospective cohort study. BMJ. 2019; 365:l1949. doi: 10.1136/bmj.l1949 31142450

50. Moodie R, Stuckler D, Monteiro C, Sheron N, Neal B, Thamarangsi T, et al. Profits and pandemics: Prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. The Lancet. 2013;381:670–679.

51. Monteiro CA, Cannon G, Moubarac J-C et al. Dietary guidelines to nourish humanity and the planet in the twenty-first century. A blueprint from Brazil. Public Health Nutr. 2015;18:2311–2322. doi: 10.1017/S1368980015002165 26205679

52. Ministerio de Salud. Guía Alimentaria para la población Uruguaya: para una alimentación saludable, compartida y placentera [Dietary guidelines for the Uruguayan population: for a healthy, shared and enjoyable diet]. Montevideo, Uruguay: Ministerio de Salud, Montevideo; 2016. In Spanish.

53. Ruiz E, Ávila J, Valero T, del Pozo S, Rodriguez P, Aranceta-Bartrina J et al. Macronutrient Distribution and Dietary Sources in the Spanish Population: Findings from the ANIBES Study. Nutrients. 2016;8:177. doi: 10.3390/nu8030177 27011202

54. Arroyo P, Mazquiaran L, Rodríguez P, Valero T, Ruiz E, Ávila JM, Varela-Moreiras G. Informe de Estado de Situación sobre “Frutas y Hortalizas: Nutrición y Salud en la España del S. XXI” (Status Report on Fruits and Vegetables: Nutrition and Health in 21st Century Spain). Fundación Española de la Nutrición. 2018.

55. Mielgo-Ayuso J, Aparicio-Ugarriza R, Castillo A, Ruiz E, Ávila JM et al. Physical Activity Patterns of the Spanish Population Are Mostly Determined by Sex and Age: Findings in the ANIBES Study. PLoS One. 2016;11:e0149969. doi: 10.1371/journal.pone.0149969 26914609

56. Barlow P, Serôdio P, Ruskin G, McKee M, Stuckler D. Science organisations and Coca-Cola’s ‘war’ with the public health community: insights from an internal industry document. Journal of Epidemiology and Community Health. 2018;72:761–763. doi: 10.1136/jech-2017-210375 29540465

57. Fabbri A, Holland T, Bero L. Food industry sponsorship of academic research: investigating commercial bias in the research agenda. Public Health Nutr. 2018 Aug 30:1–9. [Epub ahead of print]. doi: 10.1017/S1368980018002100

58. Thacker P. Coca-Cola’s secret influence on medical and science journalists. BMJ. 2017;357:j1638.

59. O’Connor A. Coca-Cola funds scientists who shift blame for obesity away from bad diets. The New York Times, 2015 August [cited 16 November 2018]. Available from:

60. Nestle M. Soda politics: taking on big soda (and winning). Oxford University Press, 2015.

61. Gea A, Bes-Rastrollo M, Toledo E, Garcia-Lopez M, Beunza J, Estruch R et al. Mediterranean alcohol-drinking pattern and mortality in the SUN (Seguimiento Universidad de Navarra) Project: a prospective cohort study. British Journal of Nutrition. 2014;111:1871–1880. doi: 10.1017/S0007114513004376 24480368

62. National Vital Statistics System, National Center for Health Statistics, CDC. 10 Leading Causes of Death by Age Group, United States– 2016. [cited 16 November 2018]. Available from:

63. Griswold M, Fullman N, Hawley C, Arian N, Zimsen S, Tymeson H et al. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. 2018;392:1015–1035.

64. Savona N, Thompson C, Smith D, Cummins S. Proportional responsibility versus individual responsibility for healthy eating: A complex systems analysis. The Lancet. 2017; 390:S80.

65. Adams J, Mytton O, White M, Monsivais P. Why Are Some Population Interventions for Diet and Obesity More Equitable and Effective Than Others? The Role of Individual Agency. PLoS Med. 2016;13:e1001990. doi: 10.1371/journal.pmed.1001990 27046234

66. Herforth A, Arimond M, Álvarez-Sánchez C, Coates J, Christianson K, Muehlhoff E. A Global Review of Food-Based Dietary Guidelines Adv Nutr. 2019;10:590–605. doi: 10.1093/advances/nmy130 31041447

Článek vyšel v časopise


2019 Číslo 12
Nejčtenější tento týden