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Diet quality and related factors among Spanish female participants in breast cancer screening programs

García-Arenzana, Nicolás MD, MPH1,2; Navarrete-Muñoz, Eva María MPH, PhD3,4; Peris, Mercé MD, MPH5; Salas, Dolores MD, MPH, PhD6; Ascunce, Nieves MD, MPH4,7; Gonzalez, Isabel MD, MPH, PhD8; Sánchez-Contador, Carmen MD9; Santamariña, Carmen RN10; Moreo, Pilar MD11; Moreno, María Pilar MD, PhD11; Carrete, Jose Antonio Vazquez MD, MPH10; Collado-García, Francisca RN9; Pedraz-Pingarrón, Carmen MD, MPH8; Ederra, María MD, MPH4,7; Miranda-García, Josefa MD6; Vidal, Carmen MD, MPH5; Aragonés, Nuria MD, MPH, PhD2,4; Pérez-Gómez, Beatriz MD, MPH, PhD2,4; Vioque, Jesús MD, MPH, PhD3,4; Pollán, Marina MD, MPH, PhD2,4

doi: 10.1097/gme.0b013e3182544925
Original Articles

Objective A healthy diet is particularly important during menopause, a period in which the risk of a number of health problems increases. This study analyzed diet quality as measured by two indices, namely, the Alternate Healthy Eating Index (AHEI) and the Alternate Mediterranean Diet (aMED) index, which measures adherence to a Mediterranean diet, and examined the factors associated with lower diet quality.

Methods This was a cross-sectional study covering 3,564 women aged 45 to 68 years who underwent breast cancer screening at 7 centers (Corunna, Barcelona, Burgos, Palma de Mallorca, Pamplona, Valencia, and Zaragoza). Data on diet were collected using a food frequency questionnaire validated for the Spanish population. We calculated the AHEI out of a total of 80 points and the aMED out of a total of 9 points. Ordinal logistic regression models were fitted, taking diet quality (tertiles of the AHEI and the aMED) as dependent variables. The following were included in the final multivariate models as explanatory variables: sociodemographic characteristics, chronic diseases, and lifestyles that were associated with diet quality, with a P value <0.100 in an initial simple model (adjusted solely for calorie intake and screening center). Interaction between menopause status and the other explanatory variables was checked.

Results The median score for AHEI was 40 of a maximum of 80 points. Lower diet quality was registered by the youngest women (P for trend < 0.001), premenopausal and perimenopausal women (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.01-1.56; and OR, 1.48; CI, 1.20-1.83, respectively), obese women (OR, 1.18; CI, 0.99-1.41), those with a diagnosis of diabetes (OR, 1.35; CI, 1.01-1.79), smokers (OR, 1.41; CI, 1.21-1.66), and women reporting lower daily physical activity (OR, 1.31; CI, 1.12-1.53). Better diet quality was shown by women with higher education (OR, 0.74; CI, 0.62-0.88) and ex-smokers (OR, 0.82; CI, 0.69-0.98). Nulliparity was associated with higher AHEI scores, but only among premenopausal women (OR, 0.50; CI, 0.32-0.78). aMED index varied between 0 and 9 (median 5). Lower scores were associated with younger age (P for trend < 0.001), low socioeconomic level (OR, 1.13; CI, 0.96-1.33), lower educational level (P for trend = 0.008), and low level of daily physical activity (OR, 1.27, CI, 1.08-1.50).

Conclusions The youngest women, the most sedentary women, and those who had a lower educational level and socioeconomic status registered worse diet quality. Ex-smokers and postmenopausal women obtained better scores, probably reflecting a keener concern about leading a healthy life.

From the 1Unidad de Medicina Preventiva, Hospital Universitario Infanta Sofía, San Sebastian de los Reyes, Spain; 2Área de Epidemiología Ambiental y Cáncer, National Center for Epidemiology, Instituto de Salud Carlos III, Madrid, Spain; 3School of Medicine, Universidad Miguel Hernández, Alacant, Spain; 4Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; 5Cancer Prevention and Control Unit, Catalan Institute of Oncology (ICO), Barcelona, Spain; 6Valencia Breast Cancer Screening Programme, Directorate Public Health & Centre for Public Health Research (CSISP), Valencia, Spain; 7Navarra Breast Cancer Screening Programme, Public Health Institute, Pamplona, Spain; 8Castilla-Leon Breast Cancer Screening Programme, D.G. Salud Pública ID e I, Castilla y León, Spain; 9Balearic Islands Breast Cancer Screening Programme, Health Promotion for Women and Childhood, General Directorate Public Health and Participation, Regional Authority of Health and Consumer Affairs, Balearic Islands, Spain; 10Galicia Breast Cancer Screening Programme, Regional Authority of Health, Galicia Regional Government, A Coruna, Spain; and 11Aragon Breast Cancer Screening Programme, Health Service of Aragon, Zaragoza,Spain.

Received November 21, 2011; revised and accepted February 22, 2012.

Funding/support: This study was supported by research grant FIS PI060386 from Spain’s Health Research Fund (Fondo de Investigación Sanitaria), the EPY 1306/06 Collaboration Agreement between Astra-Zeneca and the Carlos III Institute of Health (Instituto de Salud Carlos III), and a grant from the Spanish Federation of Breast Cancer (Federación de Mujeres con Céncer de Mama).

Financial disclosure/conflicts of interest: None reported.

Address correspondence to: Marina Pollán, MD, MPH, PhD, Área de Epidemiologıá Ambiental y Cáncer, National Center for Epidemiology (Pab, 12), Instituto de Salud Carlos III, Monforte de Lemos 5, 28029 Madrid, Spain. E-mail:

©2012The North American Menopause Society