Year 35 nº138 second Quarter 2015
DIET QUALIT Y AND SEDENT ARINESS:
correlation with the weight status of Spain’s
childhood population
Everyday accidents in
Spain: PREVALENCE,
RISK AND
HAZARDOUSNESS
Safety
By MERCEDES CAMARERO
EATING HABITS of a
Spanish university
population and the
correlation with
academic performance
Health Promotion
By A. FERNÁNDEZ MONTERO,
et al
Classification criteria
of COMMUTING
accidents Practical
guide for medical
practitioners
Safety
By M.D. FLORES SARRION, et
Health Promotion By S.F. GÓMEZ, et al
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Year 35 nº138 Second Quarter 2015
DIET QUALITY AND SEDENTARINESS: correlation with the
weight status of Spain’s childhood population
Health Promotion
Child overweightness and obesity pose a huge, worldwide public‐health
challenge. This is a complicated issue to tackle. It is a multi‐factorial
problem acting at many different levels; only those strategies that manage
to bring together all these factors at the various levels of influence on the
persons concerned will be able to reverse the upward trend in childhood
overweightness and obesity. This study aims to describe the correlation
between the children’s weight status and the diet quality and sedentariness
of both the child population and their parents. Based on a sample of 4755
children from 17 Spanish regions, this cross‐sectional study includes
univariate, bivariate and multivariate analysis. The conclusions drawn from
the study are that overweightness bears a relationship to the educational
level of the mother and age; the rest of the variables analysed show no
significant bearing on the childhood population’s weight status.
By S.F. GÓMEZ. Fundación THAO, Barcelona, Spain. Cardiovascular Risk and Nutrition Research Group (CARIN‐ULEC), IMIM (Hospital del
Mar Medical Research Institute), Barcelona, Spain. ([email protected]). C. NICODEMO. Department of Economics, Centre for
Health Service Economics and Organisation, University of Oxford
In the last thirty years there has been a growing rate of chronic non‐communicable diseases in developed countries, with an
especially worrying increase among the childhood population[1]. The World Health Organisation (WHO) estimates that, by
2020, chronic non‐communicable diseases could account for 75% of total deaths in developed countries [2].
Within the childhood population, overweightness and obesity pose a worldwide public‐health problem[1,3], which might well
be working against the otherwise growing life‐expectancy trend[4]. Childhood overweightness and obesity affect not only
developed countries, however; in developing countries this problem coexists with malnutrition[5]. The high rate and
increase in childhood obesity[6,7] pose a stiff challenge for all governments. In Europe the overweight rate in children and
adolescents stands at about 20%, and a third of them suffer from obesity[8]. For this very reason the Vienna Declaration
acknowledges this problem to be a top priority for the member states of the European region of WHO[9].
Childhood obesity poses both short‐ and long‐term problems[10,11]. In children and adolescents a direct relationship has been
observed between cardiovascular risk and the body mass index and waist measurement[12]. There is also by now a sizeable
body of evidence showing that overweight adolescents and children over 8 run a higher risk of becoming obese adults[13].
The persistence of childhood obesity until adulthood significantly increases the risk of cardiovascular diseases [14].
Childhood obesity and overweightness have a multifactorial aetiology, with a confluence of genetic factors[15], lifestyle
factors and environmental influences[16,17,18]; lifestyle factors seem to bear the greatest relation with this problem. There is
therefore a need for more scientific evidence on the origin and causes of overweightness and obesity[19].
Effective prevention strategies targeted at the childhood population, promoting healthy living habits, are now deemed to
be essential to halt the upward trend of overweightness and obesity[20]. Given the multifactorial and multilevel aetiology of
this problem, many countries have stressed the importance of tackling the problem from community‐based‐intervention
(CBI) strategies[21]. Promising CBI results are being obtained in some of these countries, although the evidence is not yet
very solid[22].
Information on the effectiveness of community based programmes to prevent childhood obesity in Europe is limited[23,24]. In
France, from 1992 to 2004, a study was conducted called Fleurbaix Laventie Ville Santé (FLVS) in two intervention towns
(Fleurbaix and Laventie) and two control towns (Boris‐Grenier and Violaines). The remit of the FLVS study was to assess the
efficacy of a CBI targeted at preventing childhood overweightness and obesity. A cross‐sectional analysis of the data
showed a significantly lower rate of childhood overweightness in the intervention towns than in the control towns[25].
The FLVS study prompted the creation in France in 2004 of the EPODE programme (Ensemble Prévenons l'Obésité des
Enfants), a CBI to prevent childhood obesity. In the 2004‐2008 period the successive cross‐sectional data of the EPODE
programme also showed a reduction in childhood obesity in the participating localities[26]. The EPODE methodology has now
been taken up by many countries through the EPODE International Network (EIN), stressing the importance of the
involvement of all social stakeholders at local level, especially politicians with responsibilities for these matters[27].
The main aim of this study is to
ascertain whether diet quality
and sedentariness, both of the
child population and their
parents, bear any relation to the
overweightness and obesity of
this same child population
The Programa Thao‐Salud Infantil (THAO‐Child Health Intervention Programme)
was initially based (2007) on the FLVS and EPODE methodology. It is
implemented by local authorities as a community based programme that aims to
promote healthy habits among the child population (0‐12 years) and their
families. The programme promotes a balanced, varied and pleasant diet plus
regular physical activity; it also addresses other determining factors that are
bound up with childhood overweightness and obesity such as rest time[28] and the
psychological and social aspects[29].
In Spain Thao falls in line with the philosophy and objectives of the NAOS
strategy (standing in Spanish for the Strategy for Nutrition, Physical Activity and Prevention of Obesity), launched in 2005
by the Ministry of Health and Consumer Affairs (Ministerio de Sanidad and Consumo), through the Spanish Agency of
Nutrition and Food Security (Agencia Española de Seguridad Alimentaria and Nutrición: AESAN).
Thao‐Salud Infantil is applied at local‐authority level under the leadership of local politicians and as organised by the «local
coordinator». The local coordinator sets up a local multidisciplinary work team that takes in all key stakeholders such as
educators, health professionals, sports centres, entrepreneurs, restaurateurs, markets, local producers, etc.
The Thao programme is run by a National Coordination team (Fundación Thao), which carries it out according to three main
thrusts: actions, assessment and feedback. To implement this methodology National Coordination draws up materials and
proposes actions, deals with induction and periodical top‐up training (every six months) of local Thao teams and gives
ongoing support to the participating local authorities. It also drives annual programme assessment and deals with media
liaison. The strategies and contents of the Thao programme are vetted by a multidisciplinary committee of experts.
Furthermore, a network made up by the research teams, universities and the Spanish Nutrition Foundation (Fundación
Española de la Nutrición: FEN) collaborates in the programme’s evaluative and scientific aspects.
The results presented herein derive from the data‐culling procedure proposed in the Thao assessment protocol. A total of
17 local authorities from the Thao network took part.
The prime objective is to ascertain whether diet and sedentariness, both of the child population and of their parents, bear
any relation to the overweightness and obesity of the same child population.
The working hypothesis is that a better diet quality and less sedentariness of the child population and their parents help to
bring the child population’s weight status back within normal limits.
Methodology
Study design. Cross‐sectional study.
Reference population. Children aged 8 to 12.
Study population. Children aged 8 to 12, living in any of the opting‐in local authorities prepared to carry out the
assessment protocol put forward by the Thao‐Salud Infantil programme.
Study scope. The geographical scope of the study is the 17 aforementioned local authorities. Within each one we are then
subject to the will to participate of each school and of the parents.
Inclusion criteria
Children aged 8 to 12.
Children living within an opting‐in municipality implementing the Thao‐Salud Infantil programme.
Pupils registered in a school ready to allow the carrying out of plan activities and plan assessment.
Exclusion criteria
Children who have not handed in the parent/guardian consent form authorising their participation in the plan
assessment activities.
Children with reading difficulties that prevent them from answering the questionnaires or high anxiety levels when
readings are to be taken.
Sampling. Convenience sampling. Sampled children must live in one of the opting‐in municipalities and attend one of the
schools therein.
Sample size. The study sample is made up by 4755 children. The parent sample is smaller.
Variables
Sociodemographic: age, gender, parent education, parental jobs.
Anthropometric: weight and height to calculate the Body Mass Index (BMI). Waist measurement readings were also
taken although they were not used in this study in the end. The children’s weight status is assessed in terms of the BMI
and the standardised reference of the International Obesity Task Force (IOTF)[30].
Child‐population behavioural screening: score on the Kidmed scale; score on the Thao sedentariness scale.
Adult‐population behavioural screening: diet quality according to the short Diet Quality Screener (SDQS) questionnaire;
level of physical activity according to an abridged version of Minnesota Leisure‐Time physical Activity Questionnaire
(sMLTPA), and sedentariness according to total hours of screen time.
Data collection
The Thao local coordinator and members of the local team prepared to participate in data collection would be trained up
beforehand. The objective is for the assessment to be made in a completely standardised form across the board.
–Dependent variables (anthropometric):
Weight (type‐approved foot scale SECA 869).
Height (type‐approved height gauge SECA 213).
Waist measurement (type‐approved ergonomic tape measure SECA 200).
–Independent variables (a self‐administered questionnaire):
Child population:
Kidmed scale[31]: a validated diet‐quality assessment scale (adherence to the Mediterranean diet) for children and
adolescents. A 16‐item questionnaire with yes/no answers, giving a final score, running from a minimum of ‐4 points to
a maximum of +12. A classification can also be made into a high‐adherence diet (8 to 12 points), medium adherence (3
to 7 points) and low adherence (‐4 to 2 points).
Thao sedentariness scale: a scale created ad hoc and pilot trialled on the target population to assess the child
population’s sedentariness level. It comprises four items that measure by multiple response the approximate time
(weekday and weekend) spent by the child on each one of the following activities: watching TV/video/DVD, using the
computer, playing with video game console, using the mobile phone.
Adult population:
SDQS diet‐quality questionnaire[32]: a validated scale from a wider‐ranging questionnaire looking into the habitual
intake of certain food items most relevant to the assessment of an adult’s diet.
A total continuous score is obtained, whereby the diet quality can be rated as adequate, adequate in some aspects or
inadequate. The total SDQS score can range from a minimum of 0 to a maximum of 36.
Physical activity questionnaire: short version of the MLTPA (Minnesota Leisure Time Physical Activity) to give a quick
measurement of an adult’s level of physical activity.
Thao sedentariness scale: a scale created ad hoc and pilot trialled on the target population to assess total weekday
and weekend screen time.
–Sociodemographic variables: Included at the start of the aforementioned self‐administered questionnaire.
Data analysis
Univariate, for the description of the sample.
Bivariate, for detecting those variables prone to be adjusted in multivariate models by means of Chi‐squared, Student
T or ANOVA tests depending on the nature of the variables concerned.
Multivariate, logistic regression to ascertain the relation between the independent variables and the dependent
variables.
Ethical Considerations
The signed consent form of the child’s parent or legal guardian, authorising his or her participation herein, was a sine
qua non of said participation.
Information uploaded into the database will be completely anonymous. A code will be allocated to each of the
participating children. This code will be made up of three letters identifying the town, three identifying the school and
four assigned to each child. This code system will allow us to link anthropometric and questionnaire data whenever
they are collected separately. The results will be dealt with confidentially.
The results will be fed back to the parents, legal guardians and indirectly to the children who have decided to take
part in the study.
Study difficulties and restraints:
The lack of any random sample for children from the whole of Spain, since the study would be carried out only within
the municipalities that have opted into the Thao‐Salud Infantil programme.
Use of the Thao sedentariness scale: although it is a very simple, pilot‐trialled scale, it has not yet been vetted
psychometrically.
Logistics: the purchase and distribution of the wherewithal for taking the anthropomorphic readings. To facilitate
distribution thereof this would be done on one of the days when a member of the research team goes to the locality
concerned to train up the Thao local team and coordinator.
The Thao programme promotes a
balanced, varied and pleasant
diet; it also addresses other
determining factors that are
bound up with childhood
overweightness and obesity such
as rest time and psychological
and social aspects
Results
The study sample is made up by 4755 children from 17 Thao municipalities. This
breaks down into 2300 girls (48.4%) and 2455 boys (51.6%). Their ages range from
8 to 12 with a mean age of 10.33.
Of this total sample, according to the IOTF standard, the rate of excess weight in
the population studied is 33.2% (25.6% overweightness + 7.6% obesity).
According to the KidMed index, the level of adherence to the Mediterranean diet
is medium (6.66 points on a scale running from ‐4 to 12). If we estimate the level
of adherence to the Mediterranean diet according to the three categories defined by the KidMed index, we then find that
8.8% of the child population assessed have a low level, 53.1% a medium level and 38.1% a high level.
The study pinpoints a big leeway
for action in terms of the diet of
the childhood population under
study, since their adherence to
the Mediterranean diet is only
medium
We found that the total number of hours spent watching TV or using a computer,
video game console and mobile phone is higher at the weekend than during the
week. We will comment on the figures against WHO’s recommendation of a
maximum 2 hours screen use per day. We then find that 12.9% of the child
population assessed watch TV for over 2 hours a day on weekdays and 30% at the
weekend (12.9% + 3 hours a day and 17.1% + between 2 and 3 hours a day). As
for the computer, 5.2% use it for over 2 hours a day on weekdays and 11.4% at
the weekend. As for the video game console 5.9% use if for over 2 hours a day
on weekdays and 14.8% at the weekend. Mobile phone use is much more residual, although it is surprising to find that over
30% use it on weekdays and at the weekend.
If we lump together total screen use into a single variable to find out whether total weekday and weekend use tops the
recommended 2 hours a day figure, we then find that 27.5% report using screens for over 2 hours a day on weekdays and
69.7% exceed this recommended figure of 2 hours a day at weekends.
The information to hand for some of the proposed variables for the adult population (a total of 724 fathers and 928
mothers) can be summarised as follows:
Most fathers and mothers have secondary school studies (44.5% and 40.9% respectively). 27.9% of the fathers and 23.5% of
the mothers have only primary school studies. 7.5% of the fathers and 5.6% of the mothers have a vocational‐training
diploma and 19.6% of the fathers and 28.9% of the mothers have a degree. Only 0.6% of the fathers and 1.1% of the mothers
report having no studies at all.
When we re‐categorise the parents’ level of studies into level of higher studies (Yes/No) we find that 27.1% of the fathers
report having higher studies while the mothers’ percentage is 34.5. An analysis of the working situation of the parents
shows that most fathers (86.6%) and mothers (68.9%) are in active employment.
In our survey 31.3% of fathers declare themselves to be smokers and 28% ex‐smokers; 40.7% have never smoked. In the case
of the mothers, 28.3% report regular smoking; 23.9% declare themselves to be ex‐smokers and 47.8% have never smoked.
Table 1. Description of the main study variables
Child population variable
N
%
Mean
Gender
4755
Girls
48.4
Boys
51.6
4755
10.33
Age
Weight status
4755
Overweightness
25.6
Obesity
7.6
Excess weight
33.2
4782
6.66
Low
8.8
Medium
53.1
High
38.1
4349
Less than 2 hours a day
72.5
More than 2 hours a day
27.5
4349
Less than 2 hours a day
30.3
More than 2 hours a day
69.7
Level of adherence to the Mediterranean diet
Weekday screen use
Weekend screen use
Adult population variable
N
%
Mean
Father
724
27.1
Mother
928
34.5
Father
729
86.6
Mother
946
68.9
Father
703
31.3
Mother
906
28.3
Father
703
66.4
Mother
890
58.7
Father
703
89.8
Mother
890
83
538
20.39
–Unhealthy
1.3
–Healthy in some aspects
88.3
–Healthy
10.4
657
20.49
–Unhealthy
0.6
–Healthy in some aspects
90.3
–Healthy
9.1
Higher studies
Currently in work
Smoker
Weekday screen use + 2 hours a day
Weekend screen use + 2 hours a day
Diet quality
Father
Mother
Our study shows that 66.4% of fathers report a screen time of more than 2 hours a day, this figure dropping to 58.7% in the
case of the mothers. The weekend figures are 89.8% for fathers and 83% for mothers.
We found that 21.7% of the fathers and 27.5% of the mothers are sedentary; 24.6% of fathers and 27.8% of mothers are
moderately active; 19.2% of fathers and 19.7% of mothers are active; 34.5% of fathers and 25% of mothers are very active.
In the population under study we found that the total score for the fathers’ group (20.39) and for the mothers (20.49) are
very similar. Breaking down this score into three levels according to diet quality, we find that only 1.3% of fathers and 0.6%
of mothers report a healthy diet. The majority of the population, namely 88.3% of the fathers and 90.3% of the mothers,
report an adequate diet although only in some aspects, and 10.4% of the fathers and 9.1% of the mothers follow a diet that
could be classed as healthy. (Table 1)
The bivariate statistical analysis for each variable in relation to weight status throws up statistically significant differences
for the following variables: residence municipality, age, fathers’ smoking habit, mother’s weekday screen use, fathers’
weekend screen use.
A bivariate statistical analysis was also carried out to gauge the degree of association between the parents’ diet and the
children’s level of adherence to the Mediterranean diet, where we found statistically significant differences in the case of
both fathers and mothers. We also found that there is no statistically significant relation in screen use hours, either at the
weekend or on weekdays, between the child population and their parents.
After the bivariate analysis of the variables of interest, a multivariate analysis was then carried out by means of a binary
logistic regression. As already pointed out the dependent variable is the weight status, broken down into the two categories
of normal weight and excess weight. As also pointed out, this study has taken into consideration a host of independent or
explanatory variables, both of the child population and the adult population. The multivariable model has been adjusted
according to these independent variables to explain their effect on weight status.
Table 2 shows the odds ratio, confidence interval andp value for each one of the adjusted independent variables. One of
the most important findings is that the probability of excess weight falls as age rises (OR = 0.86; CI 95%: 0.79‐0.93). We also
found that the probability of suffering from excess weight rises in line with the KidMed score, although after adjusting the
model for the rest of the co‐variables, we found no statistically significant differences. For the rest of the child‐population
explanatory variables adjusted in the model we found no statistically important odds ratio values.
Table 2. Multivariate analysis (logistic regression). Dependent variable (weight status) and independent variables
Child Population Variables
Categories
OR
IC 95%
p
Girl/Boy
1.11
0.97‐1.27
0.122
Age
Per one year of increase
0.86
0.79‐0.93
0.000
Total KidMed score
Per one point of increase
1.027
0.99‐1.06
0.087
Weekday screen use hours
Less than 2 hours a day / More than 2 hours a day
0.88
0.75‐1.04
0.123
Weekend screen use hours
Less than 2 hours a day / More than 2 hours a day
1.02
0.87‐1.19
0.81
Gender
Adult Population Variables
Categories
OR
IC 95%
p
Higher studies father
No / Yes
0.93
0.54 – 1.59
0.779
Higher studies mother
No / Yes
1.64
1.01 – 2.69
0.46
Diet quality father
Per one point of increase
0.98
0.90‐1.09
0.79
Diet quality mother
Per one point of increase
0.99
0.89‐1.11
0.96
Weekday screen use hours father
Per one point of increase
0.94
0.74‐1.20
0.62
Weekday screen use hours mother
Per one point of increase
1.270
0.96‐1.68
0.095
Weekend screen use hours father
Per one point of increase
1.05
0.87‐1.27
0.61
Weekend screen use hours mother
Per one point of increase
1.15
0.90‐1.46
0.26
In the case of the adjusted values of the adult population we found that children whose mothers do not have higher
education studies have a 1.64 times higher probability of excess weight than children whose mothers do have higher
education studies (OR = 1.64; CI 95%: 1.01‐2.69). Although this finding is not statistically significant, it is also important to
point out that children whose mothers report most weekday screen use in their free time have a greater risk of suffering
from excess weight (OR = 1.27; CI 95%: 0.96‐1.68).
Discussion
This study confirms that the rate of childhood overweightness and obesity in Spain is very high, ranking among the highest
of Europe. The study includes a sample of almost 5000 children from 17 municipalities in six different Spanish regions. This
sample is not representative of the whole Spanish childhood population but the figures do bear out the findings of
representative studies like ALADINO conducted by the Spanish Agency of Consumer Affairs, Food Security and Nutrition
(Agencia Española de Consumo, Seguridad Alimentaria and Nutrición) under the overarching NAOS strategy[33], or the study
of Sánchez Cruz[34]. No gender differences are found in this study, confirming too that the endemic is gender neutral.
This is an important epidemic that is hitting the childhood population of this country particularly hard. Urgent action is now
needed and this poses a stiff challenge for public‐health services. Individual interventions show unsatisfactory results
against this global, across‐the‐board problem. Overweightness and obesity figures are the combined result of many factors,
so the only interventions that show some effect on this problem are those that empower the community and act in the
children’s everyday environment. It is also important to point out here that purely school‐based interventions, targeted at
the children only, have also been found to be ineffective in the prevention of childhood overweightness and obesity[35].
This study has been conducted in 17 municipalities of those that have opted into the Thao‐Salud Infantil programme. It is a
community based programme that aims to check the upward trend of childhood obesity, doing so by encouraging healthy
habits among the children and their parents and promoting healthy lifestyles.
In pursuit of this objective an action plan has been drawn up to stimulate a varied, balanced and pleasant food intake;
encourage physical activity and also address other important factors such as rest hours and psychological and emotional
aspects. It is carried out at local authority (municipality) level and lasts at least four years. This plan involves all local
stakeholders (teachers, health professionals, parent‐teacher associations, merchants, monitors, cultural and sporting
organisations, markets, restaurateurs, social organisations, etc.).
It is within the family that most decisions are taken in relation to healthy living habits and it is in the municipality where
most of the acts of daily life are carried out and where interaction occurs with the various stakeholders: education, work,
healthcare, transport, physical activity, leisure, sport, associations, etc; hence the need for action at local level on all
these groups that come into relation with families to favour healthy eating habits throughout the whole population and
especially the child population.
The promotion of healthy eating habits in the local area is tackled by carrying out actions to suit each particular
municipality, involving all stakeholders around a local project coordinator appointed by the local mayor. The local
coordinator is supported in turn by a local Thao team, comprising healthcare professionals (paediatrician, nursing staff,
etc.), dieticians, educators, physical‐activity specialists, representatives of organisations and other professionals and
leading figures within the local community. The actions carried out by the local Thao team are brokered and supported by
the National Coordination team responsible for programme management, scientifically endorsed by the Thao Committee of
Experts.
Adding together total screen
hours of TV, PC, video game
console and mobile phone, we
find that almost 70% of the
childhood population exceed the
recommended screen time at the
weekend and 27.5% on week
days
Specific, municipality‐wide actions are proposed with the school as nerve centre.
These actions are organised under the umbrella of the so‐called Thao Season,
which coincides in time with the school year and within which a specific theme is
dealt with intensely.
Local authorities are also invited to hold a yearly, high‐profile Thao Week, based
on a methodology that helps to plan a whole day or one week dedicated to the
promotion of healthy habits, with special stress on a varied and balanced diet
and regular and fun‐based physical activity, among other determining factors.
Furthermore, the National Coordination of the programme proposes other across‐
the‐board activities that the school and local authority can implement when they deem fitting. These are actions designed
to promote physical activity and healthy eating habits, such as Revaloración del Desayuno (Breakfast Before School) to
encourage children to breakfast before going to school, and the Thaobús programme to encourage the children to walk to
school, etc.
The study confirms that
sedentariness of both the
children and their parents is a
crucial factor in childhood
overweightness and obesity; the
family’s socioeconomic level also
bears a direct relation with
these figures
The local authorities, for their part, can propose other Thao actions or phase in
actions that are already underway, providing they are consistent with the
overarching programme, to ensure which they are previously vetted by the Thao
Committee of Experts.
Programme results are checked annually by culling anthropomorphic data of all
children at school (from 3 to 12 years) (weight and height for calculating BMI,
and waist measurement), plus other indicators such as eating habits and physical
activity by means of questionnaires designed for the 8‐to‐12 child population.
This feedback helps to raise awareness and also favours early detection of
overweight and obese children. These figures are also analysed to determine the
rate of excess weight within each municipality, stratifying the data by schools, gender and age bracket. After four years a
final assessment is made, consisting of a longitudinal analysis of the findings, to gauge the overweightness and obesity
trend in the opting‐in municipalities. Programme assessment is topped up with a monitoring of the trend of eating habits
and physical activity, plus an evaluation of the implementation process in the interests of constant improvement.
All the actions are accompanied by an upfront communication campaign to raise awareness and encourage public
participation, with regular press releases, weekly newssheets, a regularly updated website and constant participation in
social networking sites.
The actions, assessment and communication of the Thao‐Salud programme are described in detail in point 5 hereof.
As already pointed out the problem of overweightness and obesity is a multifactorial problem acting at many levels. Excess
weight has always been associated in the public’s mind with overeating. For some years now scientific evidence has been
showing that the level of physical activity is also crucial. Scientific evidence has also shown that these two major factors
impinge on the problem not only at individual level; the habits of our friends, kith and kin are influential too. More holistic
lines of research, incorporating what we know as ecological studies, have managed to show that other variables of our
physical environment also have a bearing on this problem, such as the presence or absence of cycle lanes in the area where
the children live, the amount of green areas to encourage physical activity or the absence or presence of food shops
offering a variety of healthy products at an affordable price.
This study brings out some of the above aspects. The bivariate analysis shows that aspects such as diet quality, both of the
children and their parents, weekday and weekend screen use hours, the educational level of the parents and other health‐
affecting habits such as smoking seem to have a bearing on childhood overweightness and obesity figures. Many of these
effects disappear upon adjusting the multivariate model, although this may be the result in this case of the small sample
size of parent variables. It would therefore seem likely that, in upcoming studies, the increasing social awareness of this
problem and the availability of improved data collection procedures will facilitate the study of the abovementioned
variables. We need parents to become involved in studies of this type, given that parent lifestyles are known to impinge
heavily on the children’s. In fact, an analysis of the relation between the children’s diet quality and their parent’s shows a
clear link; this is even truer for the total screen hours of both groups.
Other lines of research have managed to show that hours of sleep are also a study variable of childhood overweightness and
obesity; children who sleep less are more prone to overweightness and obesity. Psychological aspects like self‐esteem or
stress, moreover, also seem to bear a clear relation to the epidemic. For this reason future studies will weigh up whether
these variables should now be included, since they might be skewing the results found herein.
Lastly, another noteworthy finding is that the children who score highest in the food quality index are precisely those who
show excess weight. This suggests that future studies will have to factor in too the size of the portions, since eating habits
in general do not seem to bear a straight‐line relationship with childhood overweightness and obesity figures.
Conclusions
The main study conclusions are:
The overweightness and obesity rate is very high in the 17 municipalities that have taken part in this study. There are
important differences between them, but the overall picture is very worrying.
The results in these municipalities confirm that Spain heads the European ranking of childhood overweightness and
obesity.
We have identified a large leeway for action in the diet quality of the children under study herein; their adherence to
a Mediterranean diet is only medium. We would argue that in a Mediterranean environment like Spain’s the intake of
fruit, greens, dried fruit, pulses and fish should be much higher. Conversely the intake of commercial desserts, fast
food and sweets should be reduced.
Very few children fulfil the recommended intake of five rations of fruit and vegetables a day. This means the
overweightness and obesity rate of the population under study herein is likely to increase in the future.
We found that children scoring highest in diet quality also show excess weight. This suggests that quantity as well as
quality now needs to be factored into childhood diet studies.
We consider it logical that the children’s screen use time should increase at the weekends when they have more free
time, but the percentage of children exceeding the WHO’s recommended maximum of 2 hours a day is very high. The
same goes for the parents.
The findings confirm that the sedentariness of both the children and their parents is a crucial factor in childhood
overweightness and obesity figures.
This study confirms that the family’s socioeconomic level also bears a strict relationship with childhood overweightness
and obesity figures.
We found a correspondence between the children’s sedentariness and their parent’s. Diet quality also seems to be
related between the two groups but not so clearly as in the case of sedentariness.
We would argue that more studies are now needed that bring more parents into the trawl. The increased parent
sample would then boost the statistical power of the study.
We believe it to be essential to draw up databases recording more exhaustively the variables of local authority
policies, since these are important variables for the study of chronic non‐communicable diseases such as
overweightness and obesity.
Acknowledgements
First and foremost our thanks go to FUNDACIÓN MAPFRE which awards these research grants year after year, with such a
beneficial effect on Spanish research. These grants are crucial for carrying out projects that would otherwise be
impracticable. We would also like to thank the whole team of FUNDACIÓN MAPFRE that coordinates the handing over of
these grants, as well as the tutors and revisers whose comments ensure work of high scientific quality.
The data for this study was collected in schools within municipalities that have opted into the Thao‐Salud Infantil
programme, coordinated in Spain by Fundación Thao. Thao is a community programme for encouraging healthy lifestyles
among children and their families, with the main remit of preventing childhood obesity.
Our special thanks go to all the local authorities that have participated in the research, ranging from the politicians who
decided to opt into the Thao programme to the Thao local coordinators, local health, education and sports experts, etc,
who unflaggingly put their shoulders behind the endeavour. Schools also played a huge role in this programme. Without
their collaboration it would not have been possible to carry out a research project of this type. Lastly, due credit has to be
given to the parents who gave permission for their children and themselves to take part. And a special gratitude for the
children themselves who always welcomed us in their schools with smiles and enthusiasm.
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Year 35 nº138 Second Quarter 2015
Everyday accidents in Spain: PREVALENCE, RISK AND
HAZARDOUSNESS
Safety
Everyday accidents, an umbrella term for those that occur in the home, at
work, during leisure activities or on the public thoroughfare, represent a
serious public‐health problem in western countries. To gauge their
frequency and gravity in Spain we have drawn up a Weighted Personal‐
Accident Prevalence Index. Combined with other indices, this then allows us
to draw interesting conclusions. For example, the site where most accidents
occur is the home, there are particular persons more at risk than others,
the most frequent accident‐caused deaths are not the most headline‐
grabbing ones and the rate of household and leisure accidents seems to be
bound up not with society’s level of economic and technological
development but rather with the lifestyle.
By MERCEDES CAMARERO. Dra. en Sociología. Departamento de Sociología. Universidad Pablo Olavide.
The government publishes annual figures on traffic and occupational accidents and, with less frequency and detail, on
household and leisure accidents. These figures, when published, are accompanied with hardly any indices that would allow
us to weigh up the gravity of the resulting injuries. The fatality rate is normally calculated plus, with a touch more detail,
the average number of deaths per accident. The economic cost of some accidents is also measured. There is, for example,
an index that expresses the monetary cost of traffic accidents as a percentage of GDP, but health costs are rarely brought
into the equation.
The Personal‐Accident
Prevalence Index encompasses
accidents in the home, in sport‐
and leisure‐areas, in the
workplace or study site and on
roads within built‐up areas and
through‐roads passing through
towns and villages
We have drawn up a specific prevalence index to measure the extent and gravity
of personal accidents: the proportion of people who have suffered an accident in
a one‐year period, weighted by the gravity of the injuries received. This index is
called the Personal‐Accident Prevalence Index (Índice de Prevalencia de los
Accidents Personales: hence IPREAP in Spanish initials), taking in all the
following: accidents in the home, in sport and leisure areas, in the workplace or
study site and on roads within built‐up areas and through‐roads passing through
towns and villages (traffic) and in the street. It is calculated according to the
following formula:
IPREAP = (a * fatal + b * grave + g * less grave + d * slight + e uninjured) *
100,000 population.
assigning the value a =1 and the rest of the terms as coefficients of less than unity1.
The indexing is done in terms of equivalent death units (EDU) and the value of the annual index is interpreted as the health
upset caused by everyday accidents, as likened to the damage caused by x deaths. For example, if the IPREAP in 2012
recorded a value of 105.6 EDUs per 100,000 population, this means that during this year in Spain everyday accidents caused
harm and lesions equivalent to the health upset caused by 105.6 deaths per 100,000 population. The risk and hazardousness
indices are a variety of this first index.
The figures serving as the basis for calculating the index indicators are taken from several different sources. Figure 1 shows
the indicators selected and the data sources used.
Figure 1. Indicators (I) and data sources (S) used to measure the gravity of the injuries
How many accidents and how grave are they?
Nearly four million people (3,783,100) suffered a personal accident in 2012. Three out of ten accidents happened in the
home, one of the places where people tend to feel safest, but also the place where they spend a good part of the day.
Traffic accidents plus other non‐traffic street accidents like falls or bruises show a similar frequency. 19.1 percent of
accidents occur in the street, a slightly higher percentage than traffic accidents. Road‐traffic accidents, accounting for
18.6 percent of accidents, represent only the tip of the iceberg of everyday accidents. There is a notably high incidence of
accidents in two single‐purpose and often custom‐built sites, namely the workplace (17.8 percent) and recreational and
leisure facilities (11.3 percent). (Figure 2, Table 1)
Figure 2. Breakdown of accidents by site. Spain‐2012
Source: National Health Survey (Encuesta Nacional de Salud), Spain 2012 Ministry of Health, Social Services and Equality (Ministerio de
Sanidad, Servicios Sociales e Igualdad: MSSSI).
Table 1. Accident victims in 2012, broken down by gravity and site
Accident site
Accident
victims
Accident victims (%
vertical)
Gravity (% horizontal)
Fatal
Grave
Less grave
Slight
Uninjured
1 HOME
1,075,900
28.4
0.36
9.8
54.4
13.9
21.5
2 TRAFFIC
703,700
18.6
0.27
9.3
66.5
7.5
16.8
3 STREET
720,800
19.1
0.28
7.6
61.9
13.9
16.2
4 WORKPLACE
667,359
17.6
0.07
4.1
55.6
26.3
14.1
5 SPORTS/LEISURE
FAC
428,600
11.3
0.21
5.8
66.8
17.8
9.4
6 OTHER SITES
186,741
4.9
0.31
8.5
64.0
16.3
10.9
3,783,100
100%
100%
TOTAL
% Horizontal
9,661 293,101 2,275,807 584,942
0.25%
7.7%
60.2%
15.5%
619,589
16.4%
Sources: Cause of death statistics , (Defunciones según la causa de la muerte) Spain 2012 (INE), Hospital Morbidity Survey
(Encuesta de Morbilidad Hospitalaria), Spain 2012 (INE), Encuesta Nacional de Salud, (National Health Survey) Spain 2012
(Ministry of Health, Social Services and Equality: Ministerio de Sanidad, Servicios Sociales e Igualdad, MSSSI).
Three out of ten accidents in
Spain in 2012 happened in the
home, one of the places where
we tend to feel safest, but also
the place where we spend most
time
In three out of four accidents the injuries were dealt with on an outpatient
basis, either by receiving treatment from a medical emergency service (60.2
percent) or in a normal health centre/hospital (15.5 percent). In 16.4 percent of
accidents the injuries were so light or their evolution so predictable that no
treatment at all was needed.
Worse fate awaited the 9661 people who died from accidents in 2012. Nearly
300,000 people had to be hospitalised to treat the accident‐caused injuries.
The most frequent accident‐caused deaths are not the most headline‐grabbing ones. Two out of three deaths were caused
by a fall, traffic accident or an accident that obstructed the respiratory tract. Deaths from exposure to smoke, fire or
flames, on the one hand, or electrocution on the other represented, respectively, 1.8 and 0.5 percent of the total. (Figure
3).
Figure 3. Accident‐caused deaths broken down by cause. Spain, 2012
Source: Defunciones según causa de muerte 2012. National Statistics Institute (Instituto Nacional de Estadística: INE)
The official discharge diagnosis of two out of three accident‐caused hospital admissions was a fracture, many of which
called for a surgical operation. Thirty four percent were due to fracture of the femoral neck (known as hip fractures) or
other parts of the femur; 27.7 percent were fractures of the upper limb; 18.6 percent were fractures of the skull, neck and
back and 15.4 percent were fractures of the tibia, fibula or ankle. (Figure 4).
Figure 4. Main hospital discharge diagnosis of accident victims. Spain‐2012
Sources: Encuesta de Morbilidad Hospitalaria, Spain 2012 (INE)
Prevalence and Trend
Everyday accidents in Spain in 2012 represented a health damage equivalent to 105.6 EDUs per 100,000 population.
Although other partial indicators like the incidence rate, the number of deaths per total of accidents show ups and downs
throughout the decade, the prevalence rate, which is statistically the most meaningful, shows a clear downwards trend.
The continual fall from 2003 (IPREAP=130.4 EDUs) to 2012 represents almost a 20 percent decrease. As shown by the
respective prevalence rates, both the extent and gravity of everyday accidents in Spain has fallen steadily over the last
decade. (Table 2)
Table 2. Personal‐Accident Prevalence Index (IPREAP) and its trend over the last decade in Spain, 2003‐2012
Trend during the last decade
No.
index
%
Indices
2003 2006 2009 2012
IPREAP: Personal‐accident prevalence index (equivalent death units –EDU– x 100,000
population)
130.4 128.9 121.4 105,6 ‐19.0%
Sources: Defunciones según la causa de la muerte, Spain 2012 (INE), Encuesta de Morbilidad Hospitalaria, Spain 2012 (INE),
Encuesta Nacional de Salud, Spain: 2003, 2006 and 2012 (Ministerio de Sanidad, Servicios Sociales e Igualdad, MSSSI),
European Survey of Health in Spain, Spain 2009 (Ministerio de Sanidad, Servicios Sociales e Igualdad, MSSSI).
Workplaces remain by far and
away the most dangerous sites
followed by sport‐and leisure‐
facilities; the street, the home
and roads show an average
hazardousness level
Since the IPREAP is equal to the sum of the prevalence indices of each one of the
sites, we can interpret these specific indices (Table 3) as each site’s particular
contribution to the overall sum of accident‐caused damage.
Thus, a home prevalence index standing at 32.2 means that, out of the overall
volume of injuries, i.e., 105.6 EDUs, 32.2 stem from household accidents. Both
traffic accidents and non‐traffic street accidents make an equal contribution to
the overall index, 20.9 and 20.6 EDUs, respectively.
Table 3. Trend of the Personal Accident Prevalence Index (IPREAP) in Spain, broken down by accident site, during the
decade 2003‐2012
Trend during the last decade
IPREAP broken down by accident site (x 100,000 population)
2003 2006 2009 2012 No. index
%
Home
34.2
38.5
31.0
32.2
‐5.8%
Roads and through‐roads in built up areas (traffic)
33.9
28.2
31.0
20.9
‐38.3%
Street (not traffic)
22.5
20.0
19.8
20.6
‐8.4%
Workplace
21.7
22.3
22.1
14.5
‐33.2%
Sport or leisure facility
11.5
13.0
11.3
11.8
+2.6%
Other site
6.5
6.9
6.2
5.7
‐12.3
ILE: Specific labour index x 100,000 employees)
53.1
50.0
54.0
38.8
‐26.9%
18.9
21.5
19.3
20.1
+6.3%
130.4 128.9 121.4 105.6
19.0%
IDOE: Specific sport‐leisure index (per 100,000 personas carrying out physical
activity)
IPREAP: Personal Accident Prevalence Index (x 100,000 population)
Sources: Defunciones según la causa de la muerte, Spain 2012 (INE), Encuesta de Morbilidad Hospitalaria, Spain 2012 (INE),
Encuesta Nacional de Salud, Spain: 2003, 2006 and 2012 (Ministerio de Sanidad, Servicios Sociales e Igualdad, MSSSI),
Encuesta Europea de Salud de Spain, Spain 2009 (Ministerio de Sanidad, Servicios Sociales e Igualdad, MSSSI).
There is a two‐tier trend in these indices: the contributions of traffic and work are falling substantially (‐38.3 percent and
‐33.2 percent, respectively)2, while accidents in other fields of everyday activity are falling only slightly.
Site Hazardousness
We have calculated a site hazardousness index as the site prevalence index’s percentage ratio of the total index divided by
the proportion of accidents that occur in said site. Thus, a percentage hazardousness index close to 100 means that its
hazardousness is about average. If the index exceeds 100 units this indicates higher‐than‐average hazardousness, increasing
in direct proportion to amount by which it tops 100. Conversely, the safest sites are those with an index below 100.
Workplaces remain by far and away the most dangerous sites (index of 208.1 in 2012). Sport and leisure facilities can also
be classed as especially hazardous, although their index is lower than the former (index of 168.1 in 2012). The street, the
home and through‐roads in built up areas have an average hazardousness level, this chiming in with their incidence rate.
(Table 4)
Table 4. Hazardousness index trend of everyday activity areas in the decade 2003‐2012
Site hazardousness index
Trend during the last decade
(Site IPREAP x 100/IPREAP) / % site accidents
2003
2006
2009
2012
No. índex %
Home
97.0
98.3
100.2
107.1
+10.4%
Roads and through‐roads in built up areas (traffic)
134.3
133.8
119.1
106.2
‐20.9%
Street (not traffic)
93.7
94.1
95.5
102.4
+9.3%
Workplace
196.5
189.7
213.4
208.1
+5.9%
Sport or leisure facility
153.4
151.3
157.2
168.1
+9.6%
Other site
101.3
100.7
101.6
109.8
+8.4%
Sources: Defunciones según la causa de la muerte, Spain 2012 (INE), Encuesta de Morbilidad Hospitalaria, Spain 2012 (INE),
Encuesta Nacional de Salud,Spain: 2003, 2006 and 2012 (Ministerio de Sanidad, Servicios Sociales e Igualdad, MSSSI),
European Survey of Health in Spain, Spain 2009 (Ministerio de Sanidad, Servicios Sociales e Igualdad, MSSSI).
The decade‐long hazardousness index trend shows that only traffic hazardousness is falling while the hazardousness of other
sites is on the rise. Traffic hazardousness is falling by about 20 percent while the hazardousness of the home, the street
and sport‐ and leisure‐facilities is increasing by about 10 percent in each case.
Fatalities
The age breakdown of accident‐caused fatality shows that the majority of deaths, 52.5 percent, involved people aged 75
and over. Breaking this down by the various causes, to find out if one affects the elderly more, we find that in 73.3 percent
of fall‐caused deaths the victim was over 75. The percentage rises to 80.6 percent in cases of death caused by an
obstruction of the respiratory tract. There is also a gender skew in the accident fatality rate: 61 percent of the victims in
2012 were male. (Table 5).
Table 5. Breakdown of accident‐caused deaths by gender and age of the victims of the most frequent fatal accidents
All ages:
women
Pop. aged 75 and
over
V01‐X59 All accidental deaths
39.0
52.5
V01‐V99 Transport accidents
22.1
19.0
–V40‐V49 Car occupant injured in transport accident
26.8
15.8
–V01‐V09 Pedestrian injured in transport accident
31.8
37.4
–V20‐V29 Motorcyclist
6.8
3.4
–V84 Farm vehicle
4.4
28.9
–V10‐V19 Cyclist
8.6
13.5
W00‐W19 Falls
49.7
73.3
W20‐W49 Exposure to inanimate mechanical forces
12.1
11.4
W69 Drowning and submersion while in natural water
13.9
16.0
W74 Unspecified cause of accidental drowning and submersion.
18.1
21.9
W75‐W84 Other accidental threats to breathing
52.5
80.6
–W80 Inhalation and ingestion of other objects causing obstruction of respiratory tract
54.5
87.0
–W79 Inhalation and ingestion of food causing obstruction of respiratory tract
43.8
49.7
–W78 Inhalation of gastric contents
56.5
82.4
0
0
X00‐X09 Exposure to smoke fire and flames
32.4
46.5
X44 Accidental poisoning by and exposure to other and unspecified drugs, medicaments
and biological substances
38.0
38.4
19.7
11.1
44.6
64.1
Causes of death
W85‐W99 Exposure to electric current, radiation and extreme ambient air temperature
and pressure
X49 Accidental poisoning by and exposure to other and unspecified chemicals and
noxious substances
X59 Exposure to unspecified factors
Source: Defunciones según causa de muerte 2012. Instituto Nacional de Estadística.
Risk‐prone persons
The IPREAP breakdown by gender and age shows the contribution of each one of the age brackets and gender to the total
index. If we compare this distribution data (column A) with the population distribution data by age and gender (column B),
we see that the likelihood of suffering an accident of a given gravity is not distributed randomly among the total
population. The risk index calculated as the quotient between these two values bears out this idea. When the risk index
values are close to 100 this means that this population subgroup’s probability is similar to the whole population’s. Values
above and below 100 show greater and lower probability, respectively.
Everyday accidents tend to occur more to men than women and much more to the elderly than the rest of the population.
The IPREAP value of males is 114.3; the women’s is 97.2. The female prevalence index is thus 15 percent lower than the
males. As regards age, the differences are greater: the risk index shows sub‐100 values ‐ even dropping below 80 ‐ among
small children and adults approaching retirement age. The index then rises exponentially, however, among the 75s and
over, at which age the index stands at 236.7–. (Table 6).
Table 6. Prevalence index and risk index broken down by gender and age bracket
By gender and age
bracket
Prevalence index
(EDU)
IPREAP structure (%)
(A)
Population structure (%)
(B)
Risk index
(A/B)*100
Both genders
105.6
100
100
100
0‐4 years
3.9
3.7
5.2
71.2
5‐14 years
9.2
8.7
9.8
88.8
15‐24 years
9.4
8.9
10.1
88.1
25‐34 years
14.6
13.8
14.9
92.6
35‐44 years
15.5
14.7
17.0
86.5
45‐54 years
13.0
12.3
14.6
84.2
55‐64 years
9.1
8.6
11.1
77.5
65‐74 years
8.3
7.9
8.4
94.0
75 and over Men
22.5
21.3
9.0
236.7
114.3
100
100
100
0‐4 years
4.6
4.0
5.4
74.1
5‐14 years
10.7
9.4
10.2
92.2
15‐24 years
13.4
11.7
10.5
111.4
25‐34 years
18.5
16.2
15.4
105.2
35‐44 years
20.1
17.6
17.7
99.4
45‐54 years
15.8
13.8
14.9
92.6
55‐64 years
9.3
8.1
11.0
73.6
65‐74 years
6.5
5.7
7.9
72.2
75 and over Men
15.5
13.6
7.1
191.5
97.2
100
100
100
0‐4 years
3.2
3.3
4.9
67.3
5‐14 years
7.8
8.0
9.4
85.1
15‐24 years
5.6
5.8
9.7
59.8
25‐34 years
10.9
11.2
14.4
77.8
35‐44 years
11.1
11.4
16.3
69.9
45‐54 years
10.3
10.6
14.4
73.6
55‐64 years
8.9
9.2
11.2
82.1
65‐74 years
10.0
10.3
8.9
115.7
75 and over Men
29.4
30.2
10.9
277.1
Men
Women
Sources: Defunciones según la causa de la muerte. Spain 2012 (INE), Encuesta de Morbilidad Hospitalaria, Spain 2012 (INE),
Encuesta Nacional de Salud, Spain 2012 (Ministerio de Sanidad, Servicios Sociales e Igualdad, MSSSI).
A comparison of the risk index of the various age brackets and gender throws up interesting insights. Up to the age of 55
men are more likely to suffer an accident than women. After this age the trend switches: women of this age face a higher
risk than their male counterparts.
Another noteworthy finding is that this difference begins to show up in childhood. During early childhood and adolescence
the boys’ risk index is about 8 percent higher than the girls’, in all likelihood because they are more drawn towards risky
activities than girls of the same age bracket. But the difference peaks amongst the youngsters, the population aged 15 to
24. The risk index of the group of young males tops 100 and reaches 111.4, whereas the risk among young women bottoms
out at 59.8. Young males therefore face double the risk of young females. From 25 to 54 years, although the risk for males
is still higher, the gap closes.
After the age of 55 women’s risk becomes higher than men’s. Up to retirement age the difference is not great (12.2
percent), but as from 65 the risk grows, opening a 60 percent gap between 65 and 74 and a 45 percent gap after 75.
Spain in Europe
To give us an idea of how Spain ranks among other European countries we have calculated the Leisure and Household
Accident Prevalence Index for the 28 countries currently making up the European Union. This index, unlike the former, has
been calculated for 2009, the benchmark year of the last European Health Interview Survey. (Table 7, Figure 5)
Table 7. Leisure‐ and Household‐Accident Prevalence Index for the 28 countries of the European Union ‐ 2009
EU‐28 Countries
Leisure/Household Accidents
Index x100,000 population
Ranking
Finland
204.0
1st
France
158.0
2nd
Austria
155.9
3rd
Lithuania
155.3
4th
Italia
150.5
5th
Estonia
148.0
6th
Croatia
131.8
7th
Slovenia
129.9
8th
Luxembourg
127.9
9th
Latvia
126.2
10th
Denmark
123.1
11th
Czech Republic
113.3
12th
Hungary
111.9
13th
Sweden
106.5
14th
UK
104.5
15th
Ireland
103.1
16th
Slovakia
102.0
17th
Belgium
96.9
18th
Germany
94.8
19th
Malta
89.0
20th
Spain
75.1
21st
Netherlands
74.0
22nd
Cyprus
70.1
23rd
Poland
67.0
24th
Greece
66.6
25th
Romania
65.0
26th
Bulgaria
62.9
27th
Portugal
60.0
28th
Sources: Cause of death statistics, EU‐28 2009 (Eurostat), Hospital discharge statistics, EU‐28 2009 (Eurostat), European
Health Interview Survey, 13 EU countries 2009: Belgium, Bulgaria, Czech Republic, Greece, Spain, Cyprus, Latvia, Hungary,
Malta, Poland, Romania, Slovenia and Slovakia (Eurostat), ECHI: European Community Health Indicators 13 EU countries
2009 (Eurosafe), Occupational accident records with downtime, according to duration of downtime EU28 2009, Road Safety
Annual Report.
Figure 5. Household and Leisure Accident Prevalence Index. EU‐28, 2009.
Sources: Cause of death statistics, EU‐28 2009 (Eurostat), Hospital discharge diagnosis, EU‐28 2009 (Eurostat), European Health
Interview Survey, 13 countries of EU 2009: Belgium, Bulgaria, Czech Republic, Greece, Spain, Cyprus, Latvia, Hungary, Malta, Poland,
Romania, Slovenia and Slovakia (Eurostat), ECHI: European Community Health Indicators 13 EU 2009 countries (Eurosafe), Records of
occupational accidents with downtime, by duration of downtime EU28 2009, Road Safety Annual Report.
Finland, with a household and leisure accident prevalence index score of 204 EDUs per 100,000 population, heads the
ranking among a set of high accident‐rate countries. France, Austria, Lithuania and Estonia weigh in with indices of around
150.
A group of 8 countries with a significantly lower accident rate show prevalence indices of about half of the 150 index.
These countries are: three of the four southern countries (Spain with 75.1 and ranking 21, Greece with 66.6 and ranking 25
and Portugal with 60 and ranking 28), the Netherlands, Cyprus and Poland, ranking 22nd , 23rd and 24th, and Romania and
Bulgaria in positions 26 and 27 respectively.
Spain features among the countries with the lowest accident rate, ranking 21 but
at only 15 points from the best ranked country Portugal at 28. But Spain lies
much further from the worst ranking country, with a gap of 129 points from
Finland, a country where everyday accidents unfortunately represent a very
grave health problem. Perhaps one of the common social features among the
countries with the lowest prevalence indices is preservation of a more traditional
lifestyle, above all in the sense of maintaining the primary bonds of kith and kin. Elderly people, for example, are much
more accident prone when they are living alone. The leisure and household accident rate seems to be tied in not so much
with the society’s level of economic and technological development but rather the lifestyle of its members.
Spain ranks among the countries
with the lowest accident rate in
the EU, ranking 21st with a total
of 28
(1) IPREAP = 1 * fatal + 0.0333 * grave + 0.0111 * less grave + 0.0066 * slight + 0.0022 uninjured.
(2) The specific labour index calculated as a percentage of total employees is also falling considerably (26.9 percent).
Acknowledgements
This work has been financed by a FUNDACIÓN MAPFRE research grant.
Databases used for the calculation
Spain
1. Instituto Nacional de Consumo. Ministerio de Sanidad, Política Social e Igualdad (2012): Programa de Prevención de
Lesiones: Detección de accidentes domésticos y de ocio 2011, D.A.D.O. Instituto Nacional de Consumo.
2. Instituto Nacional de Estadística, INE (2009 y 2012): Defunciones según la Causa de la Muerte, INE.
3. Ministerio de Sanidad, Política Social e Igualdad, (2009 y 2012): Encuesta de Morbilidad Hospitalaria, EMH, Instituto
Nacional de Estadística, INE.
4. Ministerio de Sanidad, Política Social e Igualdad, (2009 y 2012): Encuesta Nacional de Salud de España, ENSE, Instituto
Nacional de Estadística, INE.
Europe
5. EUROSAFE (2009): European Community Health Indicators, ECHI., Eurosafe.
6. IRTAD International Traffic Safety Data and Analysis Group (2014): Road Safety Annual Report 2014, OECD/ITF.
7. World Health Organisation, WHO (2014): World Health Statistics 2014, WHO.
8. Health Ministries of Member States (2009): European Health Interview Survey, EHIS, Eurostat.
9. Records of occupational accidents with downtime, by duration of downtime EU28 2009, Road Safety Annual Report.
Year 35 nº138 Second Quarter 2015
EATING HABITS of a Spanish university population and the
correlation with academic performance
Health Promotion
The objective of this study was to analyse the eating habits of a population
of students from the Universidad de Navarra (Navarre University) and
correlate them with their academic performance. This was done by means
of a student questionnaire with 42 questions about sociodemographic and
personal details and their eating habits, customs in university canteens and
cafeterias and their attitude towards a change in eating habits, with the
overall aim of investigating the association between eating habits and
academic performance. A descriptive analysis was made of their eating
habits and a multivariable logistic regression to find out the association
between eating habits and academic performance. The main study
conclusions are that the male students with the worst academic
performance tend to be those with the worst eating habits. The rate of
poor academic results within this university population is highest among
those who eat most often at fast food restaurants.
By A. FERNÁNDEZ MONTERO. Occupational medicine area. Universidad de Navarra ([email protected])
I. ZAZPE. Food, Physiology and Toxicology Science. Universidad de Navarra.
A. SÁNCHEZ TAINTA. Preventive medicine and public health. Universidad de Navarra.
A. RODRÍGUEZ MOURILLE. Occupational medicine area. Universidad de Navarra.
M. MARQUÉS FELIU. Preventive medicine and public health. Universidad de Navarra.
L. MORENO GALARRAGA. Paediatrics Service. Hospital Complex of Navarre (Complejo Hospitalario de Navarra)
The growing epidemic of obesity and overweightness in developed countries, the taking up of poor eating habits,
sedentariness, lack of exercise and the dropping of the Mediterranean diet are all factors leading to a worrying rise in
cardiovascular risk factors in Spain, making it one of the top‐priority public health problems and the main challenge for
population‐based nutrition strategies. [1]
University students are negotiating an information‐intensive and experience‐rich life stage, calling for continual decision
taking on their part. This is therefore a critical education period, during which systematic health promotion and the
acquisition of healthy eating habits will have a big effect on their future health. [2,3]
Finding out the current nutritional situation of this population is therefore crucial and this aspect has by now come in for
widespread study. [4‐8]
The aim of this particular study is to describe the eating habits of a Spanish university population. Moreover, as students,
their overriding concern is to obtain the best possible academic results. It is therefore our aim here to correlate these two
variables to encourage the taking up of a healthy eating regime.
Material and methods
This cross‐sectional study has assessed eating habits and their correlation with academic performance in a random sample
of 1227 undergraduate and postgraduate students of Universidad de Navarra during the academic year 2011/2012.
Questionnaires were handed out personally by previously instructed dieticians‐nutritionists.
The questionnaire comprised 42 questions divided into four blocks: a) sociodemographic and personal details, b) eating
habits, c) customs at university canteens and cafeterias, and d) attitudes towards a change in eating habits.
The eating habits analysed were: number of meals a day; whether any special diet is followed; the intake of salt, olive oil,
greens, fruit, red meat, butter, soft drinks, wine, fish, desserts and dried fruit, their meat preferences plus how often they
eat at fast food joints.
The academic‐performance variable was taken from the pass and failure rate throughout their academic careers, broken
down into three possible responses: «I’ve never failed any subject», «I pass more than I fail» and «I fail more than I pass».
The objective of this study is to
describe the eating habits of a
Spanish university population
and correlate them with
academic performance
The body mass index (BMI) was calculated from the formula: Weight (kg)/Height
(m)2, the students filling in their own details.
A descriptive study was made of the variables,
percentages and a multivariable logistic regression
academic performance, using as reference the poor
more than they pass in comparison with the rest.)
used was STATA 12.1.
expressed as means and
to relate eating habits to
academic results (they fail
The statistical programme
Results
The sample was made up by 479 men (39%) and 748 women (61%), with a mean age of 22 (SD=2), a BMI of 22 kg/m2 (SD=4)
and with 6% of students who fail more subjects than they pass, with a ratio of 0.6%.
From the total questionnaire 0.3% of respondents were excluded because they had not answered all the eating habit
questions and 5.3% because they had wrongly recorded the BMI‐calculating data.
Table 1 shows the gender‐based differences in eating habits. Women tend to eat more meals a day than men (69% of
women eat four or more meals a day as against 58% of the men), and they also try to keep their salt intake down in their
meals (38% of them as compared with 26% of the men). Women are more prone to use olive oil as their main cooking grease
(88% against 81%) and eat more leaf‐ and root‐vegetables (42% of women eat leaf‐ and root‐vegetables two or more times a
day, in comparison with 29% of men). As regards the type of meat, women tend to eat more chicken, turkey or rabbit
(66%), while men eat more read meat (56%). Men also tend to take more fizzy or sweetened drinks (37% have more than one
drink a day, against 22% of women) and eat more fast food than women (16% go to fast food joints more than twice a week,
as compared with 8% of women). All these values show a P< 0.01.
Table 1. Eating habits broken down by gender, N (%)
Men
Women
P
Value
N
476
743
<0.001
21 (4)
14 (2)
3
177
(38)
217
(29)
4
156(33)
282
Number of meals a day
2 or <2
(38)
5
102
(22)
213
(29)
15 (3)
18 (2)
22 (5)
55 (7)
0.058
0.021
Celiac
1 (3)
8 (11)
Hay fever or food intolerance
4 (11)
14 (20)
0
1 (1)
Hypocaloric or for slimming
8 (23)
30 (41)
Low salt
3 (9)
2 (3)
6 or >6
Follows a special diet
Type of diet
Diabetes
Others
19 (54) 18 (25)
Tries to keep down salt intake in meals
125
(26)
282
(38)
<0.001
Uses olive oil as main cooking grease
385
(81)
656
(88)
<0.01
Rations of leaf‐ or root‐vegetables per day
<0.001
1 or fewer
336
(71)
428
(58)
2 or more
139
(29)
316
(42)
0.963
2 or fewer
344
(72)
539
(73)
3 o more
131
(28)
204
(27)
<0.001
<1
190
(40)
391
(52)
1 or more
281
(60)
355
(48)
0.383
417
(88)
663
(89)
Number of fruit intakes (including natural juice) a day
Rations of red meat, hamburgers, sausages, charcuterie a day
Rations of butter, margarine or cream a day
<1
1 o more
Number of fizzy or sweetened drinks (soft drinks, cola drinks, tonics, ginger beer) a day
<1
1 or more
59 (12) 80 (11)
<0.001
296
(63)
584
(78)
177
160
(37)
(22)
<0.001
445
(94)
730
(99)
30 (6)
9 (1)
0.471
<3
368
(78)
566
(76)
3 or more
104
(22)
177
(24)
0.845
Glasses of wine per week
<7
7 or more
Rations of fish per week
Number of times commercial (not home‐made) desserts are eaten a week, such as biscuits,
custard, sweets and cakes
<2
2 or more
Number of times dried fruits are eaten per week
<3
218
345
(46)
(46)
258
(54)
399
(54)
0.009
397
663 (89
76 (16) 81 (11)
(84)
3 or more
Type of meat most frequently eaten
Chicken, turkey or rabbit
Beef, pork, hamburgers or sausages
Number of times fast food is eaten per week
1 or <
<0.001
205
482
(44)
(66)
263
(56)
253
(34)
<0.001
398
676
2 or >
(84)
(92)
74 (16)
61 (8)
The sample breakdown by SEEDO (2000) criteria (Table 2) shows that 9% of women are underweight as compared with 3% of
the men; most of the population studied falls within the normal weight range (84% of women and 77% of men) and only 7%
of the women are overweight or obese; for men this figure is 21%.
Table 2. Sample n breakdown (%) by BMI
BMI (KG/M 2 )
Men
Women
468
719
<18.5
13 (3)
67 (9)
18.5‐24.9
360 (76)
601 (84)
Overweightness degree I
25‐26.9
54 (12)
29 (4)
Overweightness degree II (pre‐obesity)
27‐29.9
32 (7)
8 (1)
Obesity type I
30‐34.9
8 (2)
10 (1)
Obesity type II
35‐39.9
1 (0)
4 (1)
Obesity type III (morbid)
40‐49.9
0 (0)
0 (0)
>50
0 (0)
0 (0)
SEEDO, 2000
N
Underweight
Normal weight range
Obesity type IV (extreme)
Table 3 contrasts the eating habits of those who pass more than they fail with the rest, showing that they have fewer meals
a day: 50% have three or fewer meals a day while this figure for the rest comes out at 35%. They are also seen to eat
significantly less fruit and vegetables. Conversely their intake of sweetened drinks is higher: 40% have two or more a day
compared to 27% of the rest. Moreover, 34% eat fast food twice or more a week as compared with 10% of the rest.
Table 3. Eating habits stratified by poor academic results, N (%)
Normal
Fail more
than pass
P
Value
N
1.138
73
425
34 (49)
686
(62)
36 (51)
22.2
21.4 (1.7)
<0.01
22.2
(4)
23 (3)
0.355
0.041
29 (3)
5 (7)
3
357
(32)
30 (43)
4
407
(37)
17 (24)
5
287
(26)
15 (21)
28 (3)
3 (4)
70 (6)
6 (9)
0.442
0.018
Celiac
9 (9)
0 (0)
Hay fever or food intolerance
17 (0)
0 (0)
Gender
Men
(38)
Women
Age (mean, SD)
(2.4)
BMI (mean, SD)
Number of meals a day
2 or <2
6 or >6
Follows a special diet
Type of diet
Diabetes
0 (0)
1 (10)
33 (35)
4 (40)
5 (5)
0 (0)
31 (33)
5 (50)
380
17 (24)
0.088
954
(86)
56 (81)
0.298
0.005
1 or fewer
688
(62)
55 (79)
2 or more
424
(38)
15 (21)
0.024
798
59 (84)
312
(28)
11 (16)
0.327
534
(48)
29 (42)
576
40 (58)
0.126
981
(88)
66 (94)
130
4 (6)
0.018
<1
810
(73)
42 (60)
1 or more
299
(27)
28 (40)
0.060
<7
1073
(97)
64 (93)
7 or more
34 (3)
5 (7)
0.164
<3
852
(77)
58 (84)
3 or more
257
(23)
11 (16)
0.325
<2
512
(46)
28 (40)
2 or more
600
(54)
42 (60)
0.493
967
(87)
63 (90)
Hypocaloric or for slimming
Low salt
Others
Tries to keep down salt intake in meals
(34)
Uses olive oil as main cooking grease
Rations of leaf‐ or root‐vegetables per day
Number of fruit intakes (including natural juice) a day
2 or fewer
(72)
3 o more
Rations of red meat, hamburgers, sausages, charcuterie a day
<1
1 or more
(52)
Rations of butter, margarine or cream a day
<1
1 o more
(12)
Number of fizzy or sweetened drinks (soft drinks, cola drinks, tonics, ginger beer) a day
Glasses of wine per week
Rations of fish per week
Number of times commercial (not home‐made) desserts are eaten a week, such as
biscuits, custard, sweets and cakes
Number of times dried fruits are eaten per week
<3
3 or more
142
7 (10)
0.991
Chicken, turkey or rabbit
625
(57)
40 (57)
Beef, pork, hamburgers or sausages
470
(43)
30 (43)
<0.001
995
46 (66)
24 (34)
(13)
Type of meat most frequently eaten
Number of times fast food is eaten per week
1 or <
(90)
2 or >
106
(10)
Table 4 measures the risk of getting poor academic results against eating habits, gender and BMI. This shows that eating
fast food twice or more a week multiplies the chance of suffering poor academic results by 5.37 with a CI of 95% (2.87‐
10.04).
Table 4. Risk (OR) of getting poor academic results according to eating habits, gender and BMI*
aOR
CI 95 %
Gender
Men
Ref.
Women
0.92
0.51‐
1.64
<25
Ref.
>=25
1.33
0.65‐
2.75
<4
Ref.
>=4
0.66
0.38‐
1.13
No
Ref.
Yes
2.26
0.86‐
BMI
Number of meals a day
Follows a special diet
5.92
Tries to keep down salt intake in meals
0.96
0.53‐
1.76
Uses olive oil as main cooking grease
0.59
0.29‐
1.17
1 or fewer
Ref.
2 or more
0.72
0.38‐
1.34
2 or fewer
Ref.
3 or more
0.54
0.26‐
1.15
Ref.
Number of fruit intakes (including natural juice) a day
Number of fruit intakes (including natural juice) a day
Rations of red meat, hamburgers, sausages, charcuterie a day
<1
1 or more
1.04
0.60‐
1.82
<1
Ref.
1 or more
0.41
0.15‐
1.12
<1
Ref.
1 or more
1.65
0.94‐
Rations of butter, margarine or cream a day
Number of fizzy or sweetened drinks (soft drinks, cola drinks, tonics, ginger beer) a day
2.90
Glasses of wine per week
<7
Ref.
7 or more
2.80
0.91‐
8.66
<3
Ref.
3 or more
0.61
0.29‐
1.28
<2
Ref.
2 or more
1.32
0.75‐
2.34
<3
Ref.
3 or more
0.56
0.23‐
Rations of fish per week
Number of times commercial (not home‐made) desserts are eaten a week, such as biscuits, custard,
sweets and cakes
Number of times dried fruits are eaten per week
1.37
Type of meat most frequently eaten
Chicken, turkey or rabbit
Ref.
Beef, pork, hamburgers or sausages
0.63
0.35‐
1.13
1 or <
Ref.
2 or >
5.37
2.87‐
10.04
Number of times fast food is eaten per week
* Multivariable logistic regression was employed, taking into account the simultaneous effect of all variables to obtain the
adjusted odds ratio (aOR) and the confidence intervals (CI) of 95%.
Discussion
The study sample was taken from a population of students belonging to the Pamplona campus of Universidad de Navarra,
where the male students with the poorest academic performance were also shown to have the worst eating habits.
Furthermore, students eating more fast food have a higher chance of getting bad academic results.
The eating‐habit questions have been drawn up from the PREDIMED and SUN studies, of international acclaim and used to
produce a host of publications in the past.[10,15]
It is important to point out here that this cross‐sectional study does suffer from some methodological limitations. It does
not record variables like type of residence, level of physical activity, sedentariness, alcohol consumption (except for wine),
previous academic record, hours of study, etc., all of which could counter or enhance any effect of eating habits on
academic results.
As regards the particular feature of these eating habits, the percentage of students taking five meals a day or more, at
28.7%, is considerably higher than the findings of other studies [6,16,17].
8.8% of the study population are on some sort of diet, so it is to be expected that the suppliers of university canteens and
cafeterias should cater for this demand.
In this sample women students have much better eating habits than men. Women, for example, have a much higher daily
vegetable intake, try to keep the salt intake down and use more olive oil as the main cooking grease. They also eat less red
meat, take fewer fizzy or sweetened drinks and prefer chicken, turkey and rabbit, while men tend to plump for red meat.
They also eat at fast food joints less frequently. Conversely, their intake of dried fruit (an important ingredient of the
Mediterranean diet) is lower than the men’s, perhaps due to the mistaken belief that nuts are fattening, a belief disproved
in some studies.
[18]
The overweightness or obesity rate (12.5% in the total sample) is similar to that found by other researchers studying Spanish
university students [4,6,20,21] and lower than the recorded figure for US students[21]. Another noteworthy finding is that the
underweight ratio (BMI<18.5kg/m2) in women (9%) is higher than that found by other authors [4,5]. This is worrying because
the population in question (women under 25) are the most prone to suffer from eating disorders [22,23].
As for the relation between sociodemographic characteristics and academic performance, we find that the lower the age,
the worse the academic performance. This is probably due to the fact that the first year of a university course tends to be
a selection process to weed out all but the best students. Poorly performing students are also seen to take fewer meals a
day, probably due to worse time organisation in the poor students.
As regards food intake, poorly performing students tend to eat less fruit and vegetables. They intake more fizzy and
sweetened drinks and go more often to fast food joints.
Perhaps the most striking result is the observed association between going to fast food restaurants and an increased risk of
suffering poor academic results (OR=5.37; CI 95%= 2.87‐10.04). This might be due to the lifestyle of these students: those
that tend to plump for fast food are probably those most given to going out at night and are therefore likely to study less.
The most striking result is the
observed association between
going to fast food restaurants
and an increased risk of
suffering poor academic results
As for our results, in general those students that have the best eating habits are
those that get the best academic results. This might be because students
incapable of organising their food intake properly are equally scatter‐brained
about their studies.
On the basis of the results of this study, it was decided to initiate a campaign to
improve eating habits. Several activities have been carried out, duly adapted to
the university community, to promote better eating habits, based on:
Encouraging a healthier menu of food and meals in university campus cafeterias and canteens.
Find out what makes this population tick, in order to encourage them to lead a healthier life by means of virtual
communication channels (chats, forums, twitter, youtube, etc).
Initiate a top‐quality teaching activity on nutritional habits that reaches the whole university community across the
board.
Conclusions
The male students in this study were shown to have worse eating habits than the women; the worse performing students
academically were likewise shown to have worse eating habits than the rest.
Students that eat fast food two or more times a week are more likely to perform badly in their academic work as compared
to those who eat in such places at most once a week.
Acknowledgements
This project was carried out under a FUNDACIÓN MAPFRE research grant.
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the PREDIMED. Trial. Am J Kidney Dis. 2012 Apr 26. [Epub ahead of print]. <
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Year 35 nº138 Second Quarter 2015
Classification criteria of COMMUTING accidents Practical
guide for medical practitioners
Safety
Commuting accidents, i.e., those that happen on the way to and from work,
are considered for legal purposes in Spain to form part of the overarching
concept of occupational accident and they are one of the commonest forms.
Their particular characteristics have been fleshed out over time by labour
laws and court judgements. This article runs through the classification
criteria for accidents of this type, as laid down by legal theory and case
history. The objective is to contribute towards the drawing up of a practical
manual to help doctors and other medical practitioners understand
commuting accidents within their proper legal scope.
By M.D. FLORES SARRION, J.R. RIVAS RECIO. Instituto Nacional de la Seguridad Social. Dirección Provincial Valencia.
An occupational accident (OA hereinafter), also called work accident and accident at work, is understood to be any bodily
or mental injury suffered by a paid employee (article115.1 of Spain’s General Social Security Law [Ley General de la
Seguridad Social: LGSS]). The commuting accident(known in Spanish law under the Latin term of in itinere) is considered to
be a particular form of OA, as regulated in LGSS article 115.2,a); it is defined as any accident suffered by a worker «on the
way to or from work», caused by «(…) a sudden or violent action produced by an agent outside the worker’s control (…)». It
is basically an enlargement of the original conception of occupational accident as ruled by courts in the fifties of the last
century to grant greater protection to workers from occupational risks.
The first precedent in Spain is a 1908 judgement handed down by Spain’s Supreme Court (Tribunal Supremo), but the first
to actually use the term in itinere is considered to be the judgement of 01/07/1954. At first the principle of article 115.3
of LGSS was applied strictly, considering OAs to be only those that actually happened in the workplace; over time,
however, the courts came to adopt a more flexible stance to fit in with ongoing social and labour changes, including acts
before and after the actual working day, on condition that some causal nexus should exist between these accidents and the
work carried out. This tended to muddy the waters, with a host of contradictory judgements handed down, forcing the
Tribunal Supremo to dictate theory‐harmonising rulings.
Commuting accidentsare unforeseeable events that happen to the worker on the way from home to work or viceversa,
before beginning the working day or after finishing it. That said, not all pathological events occurring suddenly and
unforeseeably are deemed to be commuting accidents; a sine qua non is their relation with work.
Any accident that occurs in the workplace during working time is assumed a priori to be an OA because it would necessarily
bear a direct relationship to work and because it can be checked by the employer, who bears the onus of proving
otherwise. In a commuting accident, on the other hand, the relation with work is indirect and the employer cannot check
the alleged facts because the event occurred outside the workplace and outside the work time; the onus of proving the
connection between the accident and work therefore rests in this case on the worker. Should the Mutual Insurance
Company of Work Accidents and Occupational Diseases (Mutua de Accidentes de Trabajo and Enfermedades Profesionales:
MATEPSS) reject the worker’s claim for an accident to be recognised as an OA he or she is entitled to appeal to the INSS,
which is also empowered to act ex officio.
Classification criteria of commuting accidents
The decision about whether or not a commuting accidenthas in fact occurred has to take several factors into account.
Firstly, a check has to be made that the basic prerequisites obtain, as derived from the general definition of an
occupational accident in article 115.1 of LGSS: working as the paid employee of another, an injury and a causal relationship
between these two factors.
Although the LGSS specifies that the work must be as the paid employee of another, since the coming into force of the LGSS
in 1994 diverse legislation amendments have brought certain self‐employed or freelance workers under social security
coverage of occupational accidents, albeit with several caveats as we will see later.
The biggest group of paid employees is made up by those registered in the General Social Security Scheme. As an exception
we see that the legislation applying to Spain’s state civil servants (MUFACE)1 excludes the commutingaccident and considers
such to be «non labour» in nature.
Another sine qua non is a current employment contract, so any accident occurring to the unemployed (with no current
contract or labour activity) is excluded from this category; the same goes for an accident occurring to a would‐be worker
going to or coming back from a job interview without actually securing the job.
Self‐employed workers of the Special Self‐Employed Workers’ Scheme (Régimen Especial de Trabajadores Autónomos:
RETA) are not entitled to claim commuting accidents2; conversely, those included in the Economically Dependent Self‐
Employed Scheme (Trabajadores Autónomos Económicamente Dependientes: [TRADE] are entitled to do so3.
Self‐employed farmers of the Special Agrarian Scheme (Régimen Especial Agrario: REA) were brought into RETA on 1
January 20084, as were self‐employed workers of the Special Sea Scheme (Régimen Especial del Mar), who are covered for
an occupational accident only if it occurs during their working activity5.
Secondly, there must be an injury, i.e., bodily harm to the worker, albeit slight and not rendering him or her temporarily
unfit for work, and which has occurred suddenly and unforeseeably (commonly denominated as an accident). This might be:
a) fortuitous (such as tripping over the curb, colliding with another vehicle, etc.) or b) produced by an external agent.
Prima facie an accident is not considered to be labour‐related if the aggressor agent ‐ known or unknown to the victim ‐
bears no relation to the work, even if the accident has occurred on the way to or from said work. Nonetheless, in the
judgement of the sadly notorious case of the worker murdered by the so‐called “Deck‐of‐Cards Killer” (asesino de la
baraja), who was attacked while waiting at the bus‐stop to go home after work, this was in fact recognised as a commuting
accident even though it was in principle a fortuitous act. This ruling was based on the following grounds: «(…) the fact that
it had occurred in the obligatory homeward journey after work; if this journey had not been made, the aggression would
not have occurred (…)»6. The classification of commuting accident also holds true if the victim is attacked by known third
parties bearing a relation to the work7, even if there is civil or criminal liability of the employer, of a work colleague or
third party, unless there is no bearing with the work. A terrorist attack can be considered to be an OA8, and if it happens on
the way to work or the way home could be deemed to be a commuting accident. Injuries suffered by the worker in a
confrontation with the public forces of law and order are not classed as commutingaccidents even if they occur on the way
to work or the way home9.
The commuting accident
eligibility criteria are not
contained in the law itself; they
have been laid down
subsequently by case law as
found necessary for determining
the existence of a commuting
accident
In the case of chronic pathologies (known or unknown), the onset of which
occurs suddenly and acutely on the way to work or the way home, these are not
automatically considered to be an occupational accident as such; in this case it
behoves the worker (or his or her successors if the worker him/herself is dead or
impeded) to prove an unquestionable link with the work.
Supreme‐court case law rejects the classification as commuting accidents of
cardiovascular pathologies the onset of which occurs on the commuting journey:
angina, heart attack, stroke, etc.10, on the grounds either that they are common
illnesses or because there is no clear causal nexus between the injury and work.
For example it rejected a classification of commuting accident11 for a traffic
accident suffered by a worker after a heart attack suffered while he was driving his own car to the company lorry pickup
point to begin his working day; this was on the grounds that the accident had occurred after suffering a common illness
episode bearing no relation to work. The classification of commuting accident was also turned down for a heart attack
suffered upon arriving home without any onset symptoms having shown up during the working day, therefore ruling out any
direct relationship with work12. Conversely, it is considered to be a commuting accident if the onset of the cardiovascular
illness symptoms occurred at work, even though the worker actually died of such on the way home.
Specific Requisites
These requisites are not contained in the law itself; they have been laid down subsequently by case law as found necessary
for determining the existence of a commuting accident. They are all necessary conditions, so the absence of any one rules
out the accident as a commuting accident. There are four of them:
Teleological factor. The main and direct purpose of the journey must to get to or return from work.
Chronological factor. The OA must occur within a reasonable time before arrival at or after departure from the
worksite.
Topographical factor. The accident must occur on the normal and reasonable route to or from work.
Mechanical factor. Normal means of transport (suitability factor).
On most occasions these factors are all so interconnected that they cannot be weighed up separately; several or all of them
may need to be taken into account jointly.
Teleological Factor
This refers to the work‐home journey and the relationship between those two factors: the purpose of this journey must be
solely to get to work or return home therefrom, without any important detours, breaks or alterations. Three variables have
to be analysed here: the starting point, the return point and the journey made between them.
The home or domicile
This is the walled and roofed space called dwelling where workers habitually carry out their family, personal and private
life. This concept has varied over time from the worker’s «habitual domicile» to that which the worker has left or is
heading for ‐ habitual or not ‐ on condition that it bears a direct relation to work. Case law examples that could be cited
are: a) the home of the accident‐suffering worker’s daughter where said worker dined every Saturday after leaving work; b)
the home of the worker’s aged and sick mother‐in‐law where the worker and his wife went often to look after her, often
spending the night there; c) the girlfriend’s house where the worker habitually dined, etc.. Finally, other temporary
domiciles of the worker have also ended up being accepted13, again on condition that the journey was work‐purposed.
Examples in this case are an accident returning from work to the apartment where the worker lives during the summer
months; or an accident while travelling either way between work and the traditional weekend residence14.
Having allowed these enlargements of scope, however, the Supreme Court also ring‐fences them, excluding for example an
accident occurring to a worker while travelling from work to his grandmother’s house15, on the grounds that this represents
a detour in the work‐home journey motivated by a private interest. Other cases that have been turned down as commuting
accidents are: a) a worker living in Barcelona who died in a traffic accident returning from Almería after spending there a
long weekend with his family, the accident occurring between Valencia and Castellón, on the grounds that the domicile in
question was a family rather than personal dwelling where the worker habitually lives; b) when the domicile in question
was not the worker’s habitual residence, «(...) neither was it the ordinary dining or overnighting site and it also involved an
increase in the risk run in the normal commuting journey (…)»; c) in a traffic accident suffered by a worker while driving his
own car with his current partner, returning from the latter’s home while he was still habitually living in his own; d) a
worker heading for his girlfriend’s house, using a non‐habitual route and a non‐habitual means of transport; e) traffic
accident of a worker going to Madrid to work, after turning off to visit his parents in Valladolid, «(…) because acceptance of
such as a commuting accident would entail an unconscionable increase in risk coverage (…)».
A recent Supreme Court judgement of 201316 bucked the current trend by
classifying as a commuting accident a traffic accident suffered by a worker on
Sunday night while driving from the site where he spent the weekend to a city
near his workplace, the two lying 350 kilometres apart. This judgement was
based on the grounds that, despite the excessive distance, the route was
included within the concept laid down in article 115.2.a) of the LGSS. We hence
see that the definition of the worker’s domicile is quite hazy, giving rise to
different interpretations; the strictly work‐related purpose of the journey is always a sine qua non but the arguments
Most commuting accidents are
traffic accidents, and any
worker’s recklessness
disqualifies the driving accident
as a commuting accident
brandished to establish and justify this link vary widely.
Workplace
Although the interpretation of workplace is generally quite strict, as the physical site where the work is performed, there is
a certain lenience when factoring in such variables as accidents occurring on trade‐union journeys17, opening up
geographical eligibility to anywhere that such trade‐union work is carried out. Accidents suffered by presidents and council
members of polling stations, and their deputies,18 also qualify as commuting accidents. In the case of online working, the
domicile is accepted as the workplace on condition that unimpeachable proof be given of the accident/work relation.
Journey
This interrelates domicile and workplace; it is the causal nexus between them. The route followed must be reasonable,
without calling for a longer journey when a shorter or more direct alternative is available. There must be no detours, made
for private or personal interest, such as an accident occurring after leaving work and heading for a restaurant in the
opposite direction to home19; returning to work from a medical appointment, even if with the employer’s blessing20;
detouring from the normal journey to take a child to school on the way to work, or travelling to or from an appointment
with the inland revenue21. There is, however, a certain flexibility in this criteria, such as popping out for a coffee or to
dine, returning to work afterwards, providing neither the distance nor time involved is excessive, a brief detour to greet an
acquaintance, as a common custom22, or to cash the monthly paycheck23.
Most commuting accidents are traffic accidents, and any worker’s recklessness disqualifies the driving accident as a
commuting accident24. Such acts of recklessness are considered to be when the worker, consciously and voluntarily, carries
out a risky or unnecessary act without due precaution. If the accident‐sufferer is a vehicle driver, the disqualifying act
would have to involve a grave breach of the highway code and a wilful and conscious running of risk, such as driving in the
wrong direction or jumping a traffic light (article 65 of the Spanish Road Safety Act: Ley de Seguridad Vial). Other
disqualifying behaviour would be: speeding, at 50 percent more than the speed limit (a very grave infringement under
article 65.5. c of the Ley de Seguridad Vial) or driving at over 60 kph within a built‐up area or at 80 kph on a through‐road
passing through a town or village (an offence under article 379.1 of the Spanish Penal Code). Driving under the influence of
alcohol classifies as recklessness only if the alcohol level in the blood reduces awareness and reaction capacity or if
associated with an act of speeding or dangerous overtaking (a very serious infringement under article 65 of the Ley de
Seguridad Vial and classified as an offence under article 379.2 of the Spanish Penal Code). Driving without a licence is an
infringement under article 384 of the Spanish Penal Code but is insufficient as proof of lack of driving skills, especially when
the person concerned is a habitual driver and if the accident did not stem from this cause. Recklessness of the worker as
pedestrian usually involves crossing a street or road in a dangerous place instead of a pedestrian crossing or other safe
place, since this is to run an unnecessary and avoidable risk, thereby disqualifying the accident from classification as a
commuting accident25.
Chronological or time factor
This brings the time of the accident into relation with the beginning or end of work. The accident has to occur within a
reasonable time before entering or after leaving work and always bearing a relationship to the work26, taking into account
other factors too such as the distance to be covered, the means of transport, the traffic conditions and the existence of any
obligatory roadwork detours, etc.27
OA classification has been turned down for an accident occurring more than an hour after leaving work, on the grounds that
it exceeded greatly the normal homeward commuting time28; judgement there is, however, that has granted OA status on
chronological grounds to a worker, for example, that suffers an accident after forty minutes cleaning himself off after work
and another thirty in taking a refreshing drink in a bar on the homeward journey29. If the accident occurs with a reasonable
and justified delay after the normal start time it does not necessarily forfeit commuting‐accident classification. Excessive
anticipation of the normal start time does not disqualify classification as an occupational accident if the journey is still
work purposed.
Topographical/Geographical Factor
It is essential for the accident to happen at some point of the most suitable, normal and usual journey, even if not the
shortest. The first factor to take into account in assessing the eligibility of the journeyfor OA status is the domicile, which
has already been defined under the teleological factor. Case law does not accept accidents inside the home as commuting
accident, even if the worker is getting ready to go to work, duringsuch activities as showering, getting dressed,
breakfasting or even waiting for the vehicle that is to take him or her to work, etc., on the grounds that the journey has
not yet started or has already finished. Certain difficulties might crop up, however, in weighing up whether the worker can
be considered to have left home or returned thereto, especially in the context of condominium living with many communal
areas around each private residence. In jointly owned dwellings, accidents occurring in communal areas such as stair
landings, stairways, entrance lobbies, lifts and the condominium garage, etc, could be considered to be commuting
accidents on the grounds that the worker concerned has already left his or her own private dwelling. Witness the case of a
female worker coming down the communal stairway to go to work, who slips over in the lobby on a recently washed
floor,fracturing her Colles)30.
A worker’s means of transport
has to be rational and suitable
for any accident suffered
thereon to be eligible for
consideration as a commuting
accident, understanding this to
be a normal and current means
of transport, whether individual
or collective
In single family and standalone dwellings the inner stairways, private garage,
stairs within the house enclosure and also the garden or courtyard before
walking out through the gate onto the street are all considered to be parts of the
home. If such dwellings are grouped into a residential set, the communal areas
would take in the garden area, swimming pool, communal garage and access and
passage zones bound up with all the former, etc.; and anaccident happening
therein would be eligible for consideration as a commuting accident. An accident
occurring in the communal areas, when the worker has already returned home
and started on another activity more or less immediately cannot be classified as
a commuting accident. Examples might be a worker who, after getting home, is
injured in the garage while checking the car battery; or a worker who, after
getting home and changing clothes, goes back to the garage intending to drive to a relative’s house and dies in the garage
from carbon monoxide inhalation.31 New interpretations, notably, have recently been given on the moment of starting the
commuting journey either way. Witness the case of a worker who lives in a house within a larger estate also owned by him,
who, after eating there, gets on a motorbike and suffers an accident before leaving the estate and joining the public road.
In this case the court ruled that, although the worker was still technically on private land, he had already left his house and
begun the commuting journey to work32.
New technologies are an invaluable aid for deciding whether or not the accident spot lies within the normal commuting
journey. There are now applications, for example, that enable us to assess on a street map the journey between two points
to decide whether the journey actually taken was the best and most logical one.
Chronic illnesses with sudden onset inside the home after getting home from work or before leaving for work are classified
as common illnesses rather than occupational accidents.
Mechanical or transport factor
The means of transport used has to be rational and suitable, understanding this to be a normal and current means of
transport, individual or collective. It does not necessarily have to be the same means of transport each time. Normal means
of transport are considered to be public transport such as bus, underground, train, etc, private transport arrangements
such as the worker’s own car or motorbike, or a pushbike as long as this is used on authorised routes properly fitted out for
such. Walking is of course also included. Conversely, any means of transport that unnecessarily increases the risk for the
worker will not be eligible for consideration as such, providing there are other alternative and safer means of transport. An
example of such over‐risky means of transport would be roller skating to work along the road. The categorisation of
commuting accident would not be given to any worker who overlooks a well‐grounded and well‐reasoned contract clause
that bans him or her from using any other means of transport than the collective one laid on by the firm33.
Conclusions
The criteria and interpretations shown by courts tend to adapt over time to changing uses and customs. Although arguments
may differ, however, the common factor is always a demonstrable relation between the injury suffered and the workplace,
the case law of Spanish Supreme Court fleshing out the fine detail in each case.
(1) RD (Royal Decree) 375 of 28 March 2003(2). Article 47 of Royal Legislative Decree 670 of 30 April1987, approving
the amended text of the Retired civil servant Law and Law 14/2000 which brought in the assumption of the
occupational nature of an accident occurring in the workplace during work time.
(2) Article 3 of RD 1273 of 10 October 2003.
(3) Article 26.3 of the Self‐Employed Workers’ Statute 20/2007 of 11 July. (*) “TRADE” workers are those who carry
out an economic or occupational activity for a company or client from which they receive at least 75 percent of their
income.
(4) Law 18 of 4 July 2007.
(5) Article 41.2 of Decree 2864 of 30 August 1974.
(6) Judgement of the Supreme Court 20/02/2006.
(7) Article 115.5,b) TRLGSS.
(8) RD 1576 of 7 December 1990 regulating the concession within the social security system of extraordinary
terrorism‐victim pensions.
(9) Judgement of the Central Employment Court of 16/07/1987
(10) Judgement of the Supreme Court of 30/0/2000, 11/12/2000, and 18/01/2011.
(11) Judgement of the Supreme Court 04/06/2010 and 14/03/2012.
(12) Judgement of the Supreme Court 30/07/2004 and 24/06/2010.
(13) Judgement of the Supreme Court 29/09/1997.
(14) Judgement of the Higher Court of Justice of Madrid, 04/05/2005.
(15) Judgement of the Supreme Court 17/12/1997.
(16) Judgement of the Supreme Court 26/12/2013.
(17) Article 115, 2, b) of TRLGSS.
(18) Article 8.2 RD 421/1991; Article 7 RD 605 of 16 April 1999; and Article 27.1, of the Spanish Electoral System Act
15 of 19 June 1985.
(19) Judgement of the Higher Court of Justice of Madrid 04/05/2005.
(20) Judgement of the Supreme Court 10/12/2009 and Judgement of the Supreme Court 15/04/2011.
(21) Judgement of the Supreme Court 29/03/2007.
(22) Judgement of the Supreme Court 27/06/1966.
(23) Judgement of the Supreme Court 10/02/1960.
(24) Article 115.5.a), LGSS.
(25) Judgement of the Higher Court of Justice of Asturias 27/06/2003.
(26) Judgement of the Supreme Court 29/09/1997.
(27) Judgement of the Higher Court of Justice of Madrid 2005.
(28) Judgement of the Supreme Court 15 July 1986.
(29) Supreme Court 09/04/1969.
(30) Judgement of the Supreme Court 26/02/2008.
(31) Judgement of the Supreme Court 22/03/1981.
(32) Judgement of the Supreme Court 14/02/2011.
(33) Judgement of the Supreme Court 22/12/1987.
Acknowledgements
This work has been financed by a FUNDACIÓN MAPFRE research grant.
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