Walking, biking or sport
857
.........................................................................................................
European Journal of Public Health, Vol. 25, No. 5, 857–863
The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/cku248 Advance Access published on 12 March 2015
.........................................................................................................
Walking, biking or sport: how Spanish women
attending breast cancer screening meet physical
activity recommendations?
Rosana Peiró-Pérez1,2,3, Dolores Salas1,3, Guillermo Vallés1, Ma Soledad Abad-Fernandez4,
Carmen Vidal5, Carmen Sanchez-Contador Escudero6, Nieves Ascunce-Elizaga2,7,
Raquel Zubizarreta8, Carmen Pedraz9, Beatriz Pérez-Gómez2,10,11,
Eva Marı́a Navarrete-Muñoz2,12, Jesús Vioque2,12, Marina Pollán2,10,11, for the DDM-Spain*
1 Cancer and Public Health Area. Fundación Para el Fomento de la Investigación Sanitaria y Biomédica (FISABIO),
Valencia, Spain
2 CIBER Epidemiologı́a y Salud Pública (CIBERESP), ISCIII, Madrid, Spain
3 Breast Cancer Screening Programme, Valencian Public Health Directorate, Valencia, Spain
4 Aragon Breast Cancer Screening Programme, Health Service of Aragon, Zaragoza, Spain
5 Cancer Prevention and Control Unit, Catalan Institute of Oncology (ICO), Barcelona, Spain
6 Balearic Islands Breast Cancer Screening Programme, General Directorate Public Health and Consumer Affairs, Balearic
Islands, Spain
7 Navarre Breast Cancer Screening Programme, Public Health Institute, Pamplona, Spain
8 Galicia Breast Cancer Screening Programme, Regional Authority of Health, Galicia Regional Government, A Coruna,
Spain
9 Castilla-Leon Breast Cancer Screening Programme, General Directorate Public Health, Burgos, Spain
10 Puerta de Hierro Research Institute, Madrid, Spain
11 Cancer and Environmental Epidemiology Unit, National Centre for Epidemiology, Carlos III Institute of Health, Madrid,
Spain
12 School of Medicine, Universidad Miguel Hernández, Alacant, Spain
Correspondence: Rosana Peiró-Pérez, Avda Cataluña 21 Valencia 46020, Tel: +34 96 19 25826, Fax: +34 96 19 25821,
e-mail: [email protected]
*The members of the DDM-Spain are listed in the Acknowledgements.
Background: The aim is to analyse physical activity (PA), the fulfilment recommendation of at least 150 min of
moderate PA, through walking/biking (W&B), sport, both types of PA and the factors associated with inactivity by
Spanish women who attended breast cancer screening programmes. Methods: The DDM-Spain is a multicentre
cross-sectional study involving 3584 women, aged 45–68, attending screening in seven Spanish cities. Data were
collected using a questionnaire, including age, socio-demographic and lifestyle characteristics, family burden and
PA. PA was converted into metabolic equivalent of task (METs), categorized as low 600 METs min per week (m/w),
moderate 600–3000 METs m/w and high 3000 METs m/w. A multivariate logistic regression was performed to
identify variables associated with inactivity for each type of PA. Results: No women achieved a high level of PA
through sport. 79.2% achieved a high or moderate level of PA by W&B. Lack of sport was associated with being
overweight (odds ratio OR = 1.31; 95% confidence interval CI: 1.06 to 1.62), body mass index (BMI) 30 (OR = 1.85;
95% CI: 1.44 to 2.38), smoking (OR = 1.56; 95% CI: 1.22 to 2.00) and living with a disabled person (OR = 1.64; 95%
CI: 1.0 to 2.81), whereas enough sport practice was associated with higher educational or socio-economic level
(SEL). Regarding W&B, inactivity was associated with BMI 30 (OR = 1.91; 95% CI: 1.49 to 2.45) and living with
someone >74 (OR = 1.96; 95% CI: 1.48 to 2.58). Inactivity for both types of exercise was associated with a BMI 30
(OR = 2.13; 95% CI: 1.63 to 2.8), smoking (OR = 1.41; 95% CI: 1.09 to 1.81) and living with someone >74 (OR = 1.69;
95% CI: 1.24 to 2.28). Conclusions: Family burden and BMI 30 are inversely associated with both types of PA.
W&B is the most common type of PA regardless of educational and SEL.
.........................................................................................................
Introduction
here is strong evidence suggesting that physical inactivity
Tincreases the risk of many chronic conditions, such as coronary
heart disease and many types of cancer, including the most common
ones: breast and colorectal tumours. In Europe, 9.3% of breast and
9.8% of colorectal cancers can be attributable to physical inactivity.1
Estimates for Spain are even higher, 13.8 and 14.9%, respectively.1
It is estimated that the decrease in the risk of developing breast
cancer can be as high as 25% in women with a higher physical
activity (PA) and women with post-menopausal status may benefit
from PA to a greater extent.2–4 All types of PA are beneficial in
reducing breast cancer risk; however, the greatest decreases were
found for recreational activity (20% decrease on average), followed
by walking/biking (W&B) for daily transport (14%), household
(14%) and occupational activity (13% decrease).4 Furthermore,
PA done after the age of 50 has a greater effect on the decrease in
risk of breast cancer compared with PA done at an earlier stage or
sustained over a long period of time.5 Moreover, up to a 6%
reduction in risk can be obtained with each hour of PA done per
week.6 It is therefore important to explore the prevalence of physical
inactivity among women attending breast cancer screening and the
characteristics of active and inactive women.
In Spain, physical inactivity during leisure time, although
remaining high, has decreased mainly in women, from 70.7% in
1987 to 42.4% in 2006.7 In Europe, a similar situation can be
858
European Journal of Public Health
Table 1 Description of the DDM participants (%): type of PA, sport, W&B and both; in METs m/w *, according to the PA categories: low,
moderate and high
Sport
Total
Age
45–49
50–54
55–59
60–64
65 and over
Place of residence
Rural
Urban
Education level
Primary school
Secondary school
University
Socio-economic status
Low
Medium
High
BMI = kg/m2
<25
25–29.9
30
Alcohol
No
Yes
Tobacco
Never
Ex-smoker
Current
Being on a diet
No
Yes
Menopausal status
Post-menopausal
Pre-/Peri-menopausal
Diabetes
No
Yes
Osteoporosis
No
Yes
Children at home: <15 years old
0 persons
1 person
>1 person
Seniors at home >74 years old
0 persons
1 person
>1 person
Persons at home: disabled
0 persons
>0 persons
W&B
Both (sport + W&B)
N
Low
Moderate
Low
Moderate
High
Low
Moderate
High
3574
542
989
1006
942
95
76.9
%
71.2
76.2
78.1
78.7
84.2
23.1
%
28.8**
23.8
21.9
21.3
15.8
20.7
%
28.4
21.2
19.3
17.4
17.9
62.0
%
54.4
64.3
62.1
63.7
63.2
17.3
%
17.2*
14.5
18.6
18.9
18.9
15.8
%
20.1
16.5
15.3
13.6
11.6
61.0
%
54.4
64.0
59.9
62.2
66.3
23.2
%
25.5**
19.5
24.8
24.2
22.1
1154
2416
78.2
76.2
21.8
23.8
17.8
22.1
62.4
61.8
19.8**
16.1
13.8
16.8
60.6
61.2
25.6**
22.1
2534
671
364
78.4
73.0
72.8
21.6**
27.0
27.2
20.8
19.4
21.7
61.6
60.7
67.9
17.6**
20.0
10.4
16.5
14.2
13.2
59.9
60.1
70.3
23.5**
25.8
16.5
861
2522
176
82.0
75.7
67.6
18.0*
24.3
32.4
22.9
19.5
27.3
58.7
63.1
61.4
18.5**
17.4
11.4
18.9
14.6
17.0
58.4
61.7
63.6
22.6**
23.7
19.3
1023
1496
1053
71.5
77.1
81.8
28.5*
22.9
18.2
18.9
17.8
26.6
65.9
63.1
56.6
15.2*
19.1
16.8
13.3
13.3
21.8
64.3
62.0
56.3
22.4*
24.7
21.8
1744
1830
80.2
73.7
19.8*
26.3
21.0
20.3
61.9
62.1
17.1
17.5
17.1
14.6
60.8
61.1
22.1
24.3
2066
641
765
78.4
67.9
79.7
21.6*
32.1
20.3
19.2
22.0
24.3
61.5
63.8
62.0
19.4*
14.2
13.7
14.7
15.3
19.5
60.6
61.9
61.8
24.7**
22.8
18.7
2578
981
76.9
76.8
23.1
23.2
20.9
20.0
61.8
62.2
17.2
17.8
16.1
15.1
61.3
59.8
22.6
25.1
2754
820
77.5
74.6
22.5
25.4
19.9
23.4
62.6
60.1
17.6**
16.5
15.5
17.0
61.1
60.5
23.4
22.6
3372
196
76.5
84.2
23.5**
15.8
20.6
23.0
62.2
57.1
17.2
19.9
15.5
21.4
61.4
53.6
23.1**
25.0
3050
468
75.9
82.3
24.1**
17.7
20.7
22.0
61.3
63.9
18.0
14.1
15.8
17.5
60.1
64.3
24.2**
18.2
3307
202
65
76.8
77.7
75.4
23.2
22.3
24.6
20.4
25.7
20.0
62.5
57.9
49.2
17.1**
16.3
30.8
15.5
21.3
16.9
61.6
54.0
50.8
22.9**
24.8
32.3
3194
332
48
76.4
81.3
77.1
23.6
18.7
22.9
19.6
29.8
27.1
62.3
57.5
70.8
18.0*
12.7
2.1
15.1
21.7
20.8
60.8
61.4
70.8
24.1*
16.9
8.3
3432
142
76.5
84.5
23.5**
15.5
20.6
22.5
62.2
57.7
17.2
19.7
15.6
19.7
61.1
57.7
23.2
22.5
MET: metabolic equivalent of task; low 600 METs m/w, moderate 600–3000 METs m/w, high 3000 METs m/w; * P < 0.001,
** 0.001 < P < 0.05.
observed8; however, with regard to walking, 51.9% of Spanish
women walk for 30 min a day, five times a week, the highest
percentage of all European countries. Mobility patterns are also
influenced by gender, a key factor influencing social structure.9,10
Currently this structure imbues gender relationships so that family
burden falls mostly on women who spend more time looking after
their home and family.9 Due to this gender role, differences in
mobility patterns have been seen10 resulting in the fact that
women walk more than men.11
The American College of Sports Medicine and the American
Heart Association recommend a minimum of PA to obtain health
benefits is: around 30 min on five times per week of moderate
activity, 20 min on three days each week of vigorous PA, a
combination of vigorous and moderate.12 The aim of this study is
to quantify and characterize PA practised through W&B, sport or
physical exercise and both combinated, by Spanish women aged
between 45 and 65, who attend breast cancer screening
programmes. The study also aims to analyse socio-demographic
and lifestyle factors associated with physical inactivity and with
the fulfilment of PA recommendation of at least 150 min of
moderate PA.
Material and method
The DDM-Spain13,14 is a multicentre cross-sectional study which
involved 3574 women aged between 45 and 68 in population
Walking, biking or sport
The socio-demographic variables were: age, place of residence
(urban >5000 inhabitants, rural), screening centre, (A Coruña,
Barcelona, Burgos, Mallorca, Pamplona, Zaragoza, Valencia), level
of education (primary completed, secondary education,
University), self-declared socio-economic level (SEL) level (low,
medium, high), related to family burden, under 15 years old at
home (0, 1, >1 person), dependants >74 years (0, 1, >1 person)
or disabled (0, >0 people). Variables related to health such as a
regular alcohol use at least one per month at some point in their
lives (yes, no), tobacco (never smoked, ex-smoker from more than 1
month, current smoker), menopausal status (premenopausal,
regular menstruation, peri-menopausal, lack of menstruation
lasting less than 12 months and post-menopausal no menstruation
for more than 1 year), self-reported health conditions diabetes (yes,
no), osteoporosis (yes, no), any diet followed over the past year?
(yes, no). Body mass index (BMI) was estimated using weight
(kilograms) divided by height (metres) squared.
breast cancer screening centres in Zaragoza (Aragón), Unidad del
Hospital Son Dureta (Palma de Mallorca, Balearic Islands), Unidad
de Burgos (Castilla-León), Unidad del Hospital de Bellvitge
(Barcelona, Cataluña), Unidad de A Coruña (Galicia), Unidad de
Pamplona (Navarra) and the Unidad de Burjasot (Valencia) who
participated in the study between October 2007 and July 2008. A
minimum of 500 women per study was recruited. The programmes
in Pamplona, Burgos and Valencia begin screening at age 45 whilst
the rest began at age 50.
Exclusion criteria: (i) having previously been diagnosed with
breast cancer or another neoplasia (with the exception of nonmelanoma skin cancer), (ii) being unable to respond the questionnaire, (iii) being physically unable to have a mammogram. The
average percentage of participation in the study was 74.5%,
oscillating between 64.7% in A Coruña and 84.0% in Zaragoza.
Women were interviewed at the screening centre by purposetrained interviewers. The questionnaire collected demographic
data, family and personal background information. Women’s
height and weight were measured twice by the interviewer, using
the same devices in all centres, with a third measurement being
taken if the first two were dissimilar, using average values to
compute BMI.15
Statistical analysis
A descriptive analysis of the distribution of the time spent W&B and
doing sport was carried out, considering the above-mentioned
variables. The total amount of all types of PA done each day and
the METs minutes spent per day for each activity was also explored.
The distribution of sport, W&B and both was described, calculated
in METs m/w by level of PA, and in relation to study variables.
Statistically significant differences were assessed using the chisquared test. Factors associated with lack of PA defined as a ‘low’
level of PA (600 METs m/w) were investigated in comparison with
a ‘moderate/high’ level of PA (>600 METs m/w) using multiple
logistic regression model for each type of activity, namely W&B,
sport and overall PA, adjusting socio-demographic characteristics,
lifestyle choices, BMI, menopausal status, diabetes, osteoporosis and
family burden (children, elderly or disabled) and by screening
centre.
Study variables
PA was collected using a questionnaire with 12 questions that has
been validated in the adult population.16 All physical activities were
converted into MET units (metabolic equivalent of task).17 When
measuring PA, 0.9 METs were assigned to sleeping, 2 METs to
eating, 2.5 METs to non-remunerated work at home. Remunerated
work was categorized by intensity of work, from 1.3 METs (almost
always seated) to 3.9 METs (heavy manual labour). W&B for
commuting or leisure time were assigned 3.6 METs. 1.2 METs were
assigned to sedentary activities such as watching television or
reading and 5 METs to sports activities.16 The PA of each person
was categorized following the proposal of the score protocol of the
International Physical Activity Questionnaire International18 and
other authors19 that categorize the recommendations of the
American Collage of Sports Medicine and the American Heart
Association12 as; ‘low’ (not meeting the minimum requirements
for health benefits), when spending 600 METs min per week
(m/w); ‘moderate’ (meets minimum requirements for some health
benefits), spending 600–3000 METs m/w and ‘high’ (maximum
health benefits), spending 3000 METs m/w.
Results
Table 1 shows the PA of the participants per type of activity (sports,
W&B and both combined) measured using the METs m/w
categorized as: ‘low’, ‘moderate’ and ‘high’. With regard to sport,
none of the women reached a high level of PA, 23.1% reached a
moderate level and 76.9% were classified in the lowest category.
Women in the younger age groups did more sports compared
with older women, also those who had higher education, or higher
% Time
Sedentary
activities
10,7%
% METs
Sleeping
34,4%
34,4%
Walking&Biking
9%
Sedentary activities
7,9%
Sleeping
19,1%
Walking&Biking
4,3%
Eating
7,2%
Domestic activities
18,6%
859
Domestic activities
27,2%
Eating
8,7%
Sport 1,2%
Sport
3,6%
Work activities
23,7 %
Figure 1 Distribution of average time and METs daily spent per type of activity.
Work activities
22,8 %
860
European Journal of Public Health
SEL, low BMI, those who drank alcohol, ex-smokers, without
diabetes or osteoporosis, as well as women not living with a
disabled person. With regard to PA through W&B, 62% reached a
moderate level and 17.2% a high level of PA. As women get older,
they increase their METs m/w by W&B. A greater percentage of
women living in rural areas had a high level of PA through W&B,
those with a secondary level of education, with low SEL, those who
were overweighed, never smoked, with a post-menopausal status and
those living with more than one person younger than 15 years and
with no one older than 74 years at home. The overall PA shows that
15.8% of women had a low level, 61% were classified as moderate
level and 23.2% attained high level of PA. Significant differences
remain with regard to a high level of PA: women living in rural
areas, with a secondary education, middle SEL, and with a BMI
between (25–29.9), non-smoking and no antecedents of diabetes
or osteoporosis, living with more than one person younger than
15 years and with no one over 74 years at home.
Figure 1 shows the distribution of time and METs minutes per
day by activity. W&B involves 4.3% of the day time and 9% of the
average METs daily spent, while sports represents 1.2% of time and
3.6% of the METs. Domestic work consumes the highest percentage
of METs spent per day (27.2%) while consuming 18.6% of time, on
average, per day.
Table 2 show the characteristics of the participants according to
the time spent doing sport and W&B. Sixty-seven percentage of
these women did sport for <2 h per week. The largest percentage
of women who did sport for >3 h a week are those with high SEL and
ex-smokers, whilst the smallest percentage are women over 65 years
old, and who live with more than one person >74 or with more than
one disabled person. Twenty-one percentage of them walked or
biked for <21 min per day, while 36.1% of them daily walked or
biked for >60 min. Women who W&B the most were: older than 65
years (44.2%), lived in rural areas (41.1%) and those who lived with
more than one person younger than 15 years (44.2%). Women who
walked/bike the least (<21 min a day) were: 45–49 years (28.4%),
had high SEL (27.3%), and those living with more than one person
older than 74 years (27.1%).
Table 3 shows the factors associated with a low level of PA, from a
multivariate model for each type of PA, W&B, sport and both,
adjusted by city of residence and the rest of the factors presented
in the table. It shows a low level of sport in women who were
overweight (OR = 1.31; 95% CI: 1.06 to 1.62), and obese30
(OR = 1.85; 95% CI: 1.44 to 2.38), for women who smoked
(OR = 1.56; 95% CI: 1.22 to 2.00) and those who lived with a
disabled person (OR = 1.64; 95% CI: 1.0 to 2.81); while those
more active women were middle age (50–54 years old) those who
had higher education and SEL, and those who drank and were exsmokers. Regarding W&B, women at lowest level of PA were those
with a BMI30 (OR = 1.91; 95% CI: 1.49 to 2.45) and those living
with a person >74 years old (OR = 1.96; 95% CI: 1.48 to 2.58);
while the highest level of PA was observed in women 50 to 64
years old. No differences for level of education, SEL, menopausal
status or lifestyle choices can be observed. When the METs m/w for
both types of PA were combined, the multivariate analysis significantly shows that the most inactive women were those with a BMI
30 (OR = 2.13; 95% CI: 1.63 to 2.8), who smoked (OR = 1.41; 95%
CI: 1.09 to 1.81) and those who lived with a person >74 years
(OR = 1.69; 95% CI: 1.24 to 2.28); while a higher and statistically
significant level of PA was observed in the age group of 50–64 years.
Discussion
Our results show that W&B, done during leisure and commuting
time, is the type of PA that most contributes to fulfilling the
minimum recommendations for obtaining health benefits in
Spanish women who attend to breast cancer screening centres.
Seventy-nine percentage of these women met the minimum PA
Table 2 Description of DDM-Spain participants by time spent doing
sport (hour/week) and W&B (minutes/day)
Sport (hours/week)
W&B (minutes/day)
<2
Total
66.9
Age
45–49
61.1
50–54
66.0
55–59
67.3
60–64
70.3
65>
72.6
Place of residence
Rural
68.5
Urban
66.1
Education level
Primary school
69.1
Secondary school
62.6
University
59.6
Socio-economic status
Low
73.4
Medium
65.3
High
57.4
BMI
<25
60.4
25–29.9
66.1
30
74.4
Alcohol
No
71.2
Yes
62.8
Tobacco
Never
68.2
Ex-smoker
56.5
Current
71.5
Being on a diet
No
67.2
Yes
66.3
Menopausal status
Post-menopausal
67.5
Pre-/Peri-menopausal 65.0
Diabetes
No
66.4
Yes
76.0
Osteoporosis
No
66.3
Yes
70.3
Children at home: <15 years old
0 persons
66.8
1 person
69.3
>1 person
67.7
Seniors at home >74 years old
0 persons
66.6
1 person
69.9
>1 person
70.8
Persons at home: disabled
0 persons
66.6
>0 persons
75.4
2–3
>3
<21
21–60
>60
18.7
14.3
20.7
43.2
36.1
19.7
19.8
19.1
16.7
18.9
19.2
14.2
13.6
13.1
8.4
28.4
21.2
19.3
17.4
17.9
33.6
46.7
44.2
44.6
37.9
38.0
32.1
36.5
38.0
44.2
18.1
19.1
13.3
14.8
17.8
22.1
41.2
44.2
41.1
33.8
17.5
20.4
24.7
13.5
17.0
15.7
20.8
19.4
21.7
42.6
42.6
48.9
36.6
38.0
29.4
14.8
20.0
20.5
11.8
14.6
22.2
22.9
19.5
27.3
41.0
43.9
43.8
36.1
36.6
29.0
21.0
20.2
14.5
18.6
13.7
11.1
18.9
17.8
26.6
46.0
42.8
40.9
35.1
39.4
32.5
16.4
21.0
12.4
16.2
21.0
20.3
43.5
43.0
35.4
36.7
19.3
22.6
14.1
12.5
20.9
14.4
19.2
22.0
24.3
41.5
47.1
43.7
39.4
30.9
32.0
18.8
18.5
14.0
15.3
20.9
20.0
43.9
41.1
35.1
38.9
18.8
18.5
13.7
16.5
19.9
23.4
44.1
40.4
36.1
36.2
19.1
12.2
14.5
11.7
20.6
23.0
43.2
42.3
36.2
34.7
18.7
19.2
15.0
10.5
20.7
22.0
42.4
47.2
36.9
30.8
19.0
15.8
16.9
14.3
14.9
15.4
20.4
25.7
20.0
43.7
38.6
35.4
36.0
35.6
44.6
18.7
19.0
20.8
14.7
11.1
8.3
19.6
29.8
27.1
43.2
42.8
50.0
37.2
27.4
22.9
18.9
16.2
14.6
8.5
20.6
22.5
43.2
43.7
36.2
33.8
requirements through W&B, while only 23% of them fulfilled
them minimum recommendations doing sport. Combining both
types of PA, a high percentage of Spanish women (84.2%),
fulfilled the minimum recommendations. Interestingly, around
80% of women in our study walked for >20 min a day whilst
almost 70% dedicated <2 h per week of their leisure time to doing
sports. Inactivity for both types of PA was associated with a higher
BMI, being a smoker and family burden.
Whereas the percentage of women who fulfilled the recommendations through W&B is similar to that found in other study,20 and it is
significantly higher than that found in previous studies that took into
account all types of PA carried out during leisure time.21,22 In some
international comparations,23 75% of Spanish women between the
ages of 40–65 had a moderate or high level of PA, higher
Walking, biking or sport
861
Table 3 Factors associated with low level of PA considering sport, W&B and both activities
Sport
OR
Age
45–49
1
50–54
0.66
55–59
0.69
60–64
0.68
65>
1.02
Place of residence
Rural
1
Urban
0.89
Education level
Primary completed
1
Secondary school
0.78
University
0.74
Socio-economic status
Low
1
Medium
0.78
High
0.66
2
BMI = kg/m
<25
1
25–29.9
1.31
30
1.85
Alcohol
No
1
Yes
0.81
Tobacco
Never
1
Ex-smoker
0.81
Current
1.56
Being on a diet
No
1
Yes
0.93
Menopausal status
Post-menopausal
1
Pre-/Peri-menopausal
1.12
Diabetes
No
1
Yes
1.46
Osteoporosis
No
1
Yes
1.18
Children at home: <15 years old
0 persons
1
1 person
1.37
>1 person
1.47
Seniors at home >74 years old
0 persons
1
1 person
1.32
>1 person
0.83
Persons at home: disabled
0 persons
1
>0 persons
1.64
W&B
Both (sport + W&B)
95% CI
OR
95% CI
OR
95% CI
(0.47–0.92)*
(0.47–1.02)
(0.46–1.02)
(0.50–2.21)
1
0.77
0.63
0.57
0.72
(0.56–1.07)
(0.43–0.92)*
(0.39–0.85)*
(0.35–1.41)
1
0.86
0.71
0.62
0.55
(0.60–1.23)
(0.47–1.08)
(0.40–0.96)*
(0.23–1.21)
(0.73–1.09)
1
1.17
(0.96–1.43)
1
1.16
(0.93–1.45)
(0.62–0.99)*
(0.55–1.01)
1
1.03
1.08
(0.80–1.32)
(0.79–1.48)
1
0.98
0.83
(0.74–1.28)
(0.57–1.19)
(0.62–0.97)*
(0.43–1.02)
1
0.95
1.30
(0.77–1.17)
(0.85–1.97)
1
0.90
1.02
(0.72–1.14)
(0.62–1.63)
(1.06–1.62)*
(1.44–2.38)*
1
1.06
1.91
(0.84–1.34)
(1.49–2.45)*
1
1.14
2.13
(0.88–1.48)
(1.63–2.80)*
(0.67–0.97)*
1
0.94
(0.78–1.13)
1
0.84
(0.69–1.03)
(0.64–1.02)
(1.22–2.00)*
1
0.93
1.24
(0.72–1.19)
(0.98–1.56)
1
0.94
1.41
(0.71–1.24)
(1.09–1.81)*
(0.76–1.14)
1
0.97
(0.79–1.19)
1
0.93
(0.74–1.16)
(0.85–1.48)
1
0.96
(0.73–1.26)
1
0.96
(0.71–1.29)
(0.94–2.35)
1
0.97
(0.65–1.42)
1
1.29
(0.86–1.90)
(0.90–1.58)
1
1.12
(0.86–1.46)
1
1.14
(0.85–1.51)
(0.92–2.08)
(0.76–2.98)
1
1.19
0.97
(0.81–1.74)
(0.47–1.87)
1
1.44
1.36
(0.96–2.14)
(0.64–2.69)
(0.96–1.83)
(0.40–1.89)
1
1.96
1.96
(1.48–2.58)*
(0.91–4.00)
1
1.69
1.80
(1.24–2.28)*
(0.77–3.85)
(1.00–2.81)*
1
1.01
(0.64–1.57)
1
1.17
(0.71–1.85)
This table considers as a reference medium/high intensity >601 METs minutes/per week, compared with lower
intensity (0 to 600 METs m/w). Each of the three regression models, W & B, sport and the combination of both, is
adjusted for all variables shown in the table and by screening centre.
percentage than Belgian women of the same age (46%) and similar to
the Swedish (75%) or the Portuguese (76%). The Euro barometer
showed that in Europe, Spanish women are the population group
that walks the most.8 It is important to note that by studying only
PA done in leisure time, just a small amount of W&B PA carried out
during the day is represented, mainly among women.
Women with higher levels of education and those with a higher
SEL did more sport, but no significant differences were found with
regard to level of education and SEL for W&B, and when both types
of PA were combined. However, a certain social gradient was seen
for W&B going in the opposite direction, that is, the lower the level
of education or SEL, the more these women seemed to walk. Even
though, as stated before, it did not reach statistical significance.
Several studies have found a correlation between PA and obesity,
smoking, alcohol consumption, SEL and level of education,20,22,24,25
although not always in the same direction. Part of these differences
can be due to a different way of assessing PA. Some studies present
the data and associated factors by PA in every setting (work, home,
transport or leisure time),20,25 whilst others only study one of these
areas, mainly PA during leisure time.22,24 In this study, PA through
W&B is the amount of W&B the women do in their leisure and
commuting time, and we have therefore not been able to find similar
studies to compare our data and associated factors with.
Nevertheless our results are in line with studies showing that
862
European Journal of Public Health
commuting time can represent a substantial contribution of the
amount of time spent walking and can subsequently contribute to
meet the PA recommendations.26
In this study, physical inactivity is significantly associated with
‘family burden’, for all types of PA studied. This variable was
included in the analysis to explore the conditions associated with
gender27 confirming that family burden is associated with low PA, as
other studies have observed.28 Comparisons among studies are
hampered by the use of different questions and different ways of
grouping activities. Our study shows that few women of this age
group do sport. Other studies have also found similar results.8
However, walking for whatever reason (to work, for pleasure or
for daily life), is an activity that women do more than men,
according to the observed differences in mobility patterns by
gender.11 It is therefore of interest to specifically analyse W&B to
understand the metabolic rate that women can reach through them
and identify the effect that these activities can have on health, instead
of focussing only on sport or leisure time to define a sedentary or
active lifestyle. It must also be taken into account that a very high
percentage of women reported daily commuting time of 10 min or
more. Ten minutes is the minimum period of time required to
comply with the 30 min PA recommendation per day.29
The association between alcohol and physical exercise may be
explained by the confounding effect of social class, because women
of higher social class in Spain drink more and do more physical
exercise.30 The persistence of the association between alcohol and
PA in the multivariate model may be due to the imperfect
adjustment by socio-demographic characteristics using selfreported information.
Our study has the limitations inherent to cross-sectional studies,
such as the inability to establish causal associations among
the different factors studied and their relationship with PA.
That’s why, it is not possible to establish causal relationships but our
results help to understand the situation of PA of this women group.
In addition, people tend to overestimate their PA when it is selfreported31 being objective estimations of PA slightly lower than
personal accounts.31 But we think, that taking into account the
amount of METs assigned to each activity, the overestimation of
PA in our study, if present, is not a big concern. In this study, an
average MET value was assigned for each activity; walking can vary
between 2 and 12 METs, 4 METs being the suggested value for
walking to work or 3.5 METs for walking for pleasure,17 and an
average MET value of 3.6 was used.16 Also sport varies from 2.5 to
16 METs, being a high intensity activity,17 and an average MET value
of 5 is used here.16
With respect to the possible extrapolation of our results to the
general population of women in the same age ranges, as discussed in
a previous article32 the mere fact of participating in a screening
programme implies adopting a preventive measure and our participants might arguably be more concerned about their health and
adopting healthy
lifestyles
than women
in
general.
Notwithstanding this, coverage of breast cancer screening in Spain
is estimated to have reached practically 100% of the target
population, with high participation rates, something that would
support our study’s external validity. Although we could not avoid
this possible bias, our study included a broad sample of women
representing all SEL, which might minimize this limitation. We
have no data on the women who refused to participate in the
study, and although the participation rate was high, it is
impossible to ascertain to what extent the participants may or
may not represent all the women in this age group. According to
the information provided by the Spanish National Health Survey for
Spanish women in the same age range, our women were very similar
to the national sample in terms of prevalence of alcohol use (52% vs.
53%) or non-smokers (57% vs. 56%). The prevalence of obesity was
higher in our study (29.5% vs. 24.9%), but in the national survey,
BMI was based on self-reported data, thereby implying a substantial
underestimation of being overweight and obese.33 Those our results
perhaps could be extrapolated to all Spanish women in the age range
covered by the study.
It is possible that policies aimed at promoting sport or physical
exercise alone are not sufficient, especially for some population
groups as middle-aged women, given that their leisure time is
decreasing in Spain.34 Policies aimed at facilitating and promoting
W&B routes, walking groups, parks and green spaces or ‘cholesterol
routes’ (informal name for those routes in Spain that spontaneously
people, mostly women, have started to use for walking) will have to
be strengthened that they help to promote W&B.35–38 In addition,
these intervention policies regarding infrastructure have been found
to be cost-effective.39 Therefore, W&B are activities easily implemented that may have a significant impact on health. In fact, as
our study shows, a very high percentage of Spanish women in
menopausal and peri-menopausal status are practicing moderate
or high level of PA, fundamentally by W&B. According to some
studies, this may be having a preventative effect on the development
of breast cancer.1,2,4,40 Environmental and policy approaches can
create or enhance access to PA area; infrastructure initiatives
through urban design and planning on a community and street
scale and active transport policy have proved to be effective.35
However, in order to increase the amount of PA in women, it is
also important to set up macro policies promoting gender equality at
all levels.41 In summary, W&B are the most common type of PA
done by this group of women, regardless of their level of education
and SEL. It is, therefore, a very all-encompassing activity from a
public health point of view that can have a significant role in
promoting healthy life.
Acknowledgements
This study was supported by Research Grant FIS PI060386 and
PI090790 from Spain’s Health Research Fund (Fondo de
Investigación Sanitaria); the EPY 1306/06 Collaboration
Agreement between Astra-Zeneca and the Carlos III Institute of
Health (Instituto de Salud Carlos III) and a grant from the
Spanish Federation of Breast Cancer patients (FECMA 485 EPY
1170–10). Other members of DDM-Spain: Nuria Aragonés,
Virginia Lopez, Gonzalo López Abente, Anna Cabanes, Francisco
Casanova, Isabel González Román, Francisca Collado, Ana Belén
Fernández, Montserrat Corujo, Marı́a Pilar Moreno, Pilar Moreo,
Mercé Peris, Josefa Miranda-Garcı́a, Manuela Alcaraz, Francisco
Ruiz-Perales, Marı́a Ederra, Milagros Garcı́a. This article is part of
Rosana Peiró’s PhD research and will be included in her doctoral
thesis as a compendium of articles.
Conflicts of interest: None declared.
Key points
Spanish women between 45 and 68 years of age walk and
bike more than they do sport.
Most women at this age meet PA recommendations for
health, by W&B both at leisure and commuting time.
None achieve a high level of PA doing sports.
Family burden is associated with physical inactivity, for both
W&B and doing sport.
Women with higher educational and SEL do more sport
than women with lower educational and SEL. There are
no differences in W&B by educational and SEL. This
implies that W&B is a more all-encompassing activity.
Policies aimed at facilitating and promoting W&B routes,
walking groups, parks and green spaces or ‘cholesterol
routes’ should be strengthened as it has been shown that
they help to promote W&B.
Walking, biking or sport
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