Nutrition 22 (2006) 504 511 www.elsevier.

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Applied nutritional investigation

Association of ber intake and fruit/vegetable consumption with weight gain in a Mediterranean population
Maira Bes-Rastrollo, Pharm.D., Ph.D.,a Miguel ngel Martnez-Gonzlez, M.D., M.P.H., Ph.D.,a Almudena Snchez-Villegas, Pharm.D., Ph.D.,a,b Carmen de la Fuente Arrillaga, R.D.,a and J. Alfredo Martnez, Pharm.D., Ph.D.c,*
b a Department of Preventive Medicine and Public Health, University of Navarra, Pamplona (Navarra), Spain Department of Clinical Sciences, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain c Department of Physiology and Nutrition, University of Navarra, Pamplona (Navarra), Spain

Manuscript received June 13, 2005; accepted December 23, 2005.

Abstract

Objective: We assessed the association between ber intake and fruit/vegetable consumption with the likelihood of weight gain in the previous 5 y in a Mediterranean population. Methods: We conducted a cross-sectional analysis of participants (5094 men and 6613 women) in a multipurpose prospective cohort (Seguimiento Universidad de Navarra Study). Diet was measured by using a semiquantitative food-frequency questionnaire that was previously validated in Spain. We calculated the odds ratios of weight gain in the previous 5 y according to quintiles of energy-adjusted ber intake and quintiles of energy-adjusted of fruit/vegetable consumption. We also considered the joint exposure to ber intake and fruit/vegetable consumption. Results: Multivariate-adjusted odds ratios for weight gain across quintiles 1 to 5 of ber intake were 1.00 (reference), 0.86, 0.86, 0.70, and 0.52 (P for trend 0.001) among men and 1.00 (reference), 0.99, 1.08, 1.05, and 0.72 (P for trend 0.005) among women. We also observed a signicant inverse association between total fruit/vegetable consumption and weight gain, but only among men (adjusted odds ratios, 0.78, 0.89, 0.70, and 0.54 for quintiles 2 to 5, P for trend 0.001). The inverse association between fruit/vegetable consumption and weight gain in the previous 5 y was more evident among those with a high intake of total ber, and the benet of total ber was more evident among those with a high consumption of fruits and vegetables. Conclusions: This study provides additional support to the inverse association between ber or fruit/vegetable consumption and weight gain, thus emphasizing the importance of replacing some dietary compounds by such foods and ber-rich products, which may help to avoid weight gain. 2006 Elsevier Inc. All rights reserved.
Obesity; Overweight; Spain; Fiber; Cross-sectional study

Keywords:

Introduction Obesity is a common and growing public health problem in industrialized and developing countries [1], where increasing rates are accompanied by a sharp increase in the

Funding was provided by the Spanish Ministry of Health (grants PI040233 and G03/140) and the Navarra Regional Government. * Corresponding author. Tel.: 0034-9484-25600-6424; fax: 00349484-25649. (J.A. Martnez). E-mail address: jalfmtz@unav.es 0899-9007/06/$ see front matter 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nut.2005.12.006

incidence of type 2 diabetes mellitus, cardiovascular diseases, and some types of cancer such as colorectal cancer in men, cancer of the endometrium, and breast cancer in postmenopausal women [1]. The current prevalence rates show that more than 60% of Americans are overweight or obese [2]. Among European countries, increasing rates of obesity have been also reported [3,4]. The development of obesity is the consequence of a long-term and sustained energy imbalance when energy intake exceeds energy expenditure (determined by basal metabolic rate, thermogenic effect of foods, and cost of

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physical activity) [5]. One cause of obesity is genetic background or susceptibility. Nevertheless, lifestyle factors such as physical inactivity and inappropriate dietary habits may be more important to the alarming increase in its prevalence [6]. In recent decades, the prescription of hypocaloric diets has been promoted with the aim of creating a negative energy balance. However, their effects on weight control over time are not satisfactory, so many researchers try to ascertain the specic inuence of different macronutrients and micronutrients and other non-nutritional elements contained in food items with the goal of devising reasonable strategies to induce weight loss successfully and prevent further weight gain [710]. A high ber intake has been associated with weight loss in some studies [1113]. Although the overall data suggest a potential preventive role of ber-rich diets, components other than ber but included in the same foods (fruits and vegetables) such as antioxidants [14,15] may exert the same effect on weight regulation. However, evidence from epidemiologic studies is limited only to the ber effect. Thus, there are few studies that have assessed the joint effect of ber intake and fruit/vegetable consumption [16]. Further, most previous studies on this topic have focused mainly on women [11,16,17]. This analysis studied the association between ber intake, fruit/vegetable consumption, and the likelihood of weight gain in Spain, a country with a traditional Mediterranean dietary pattern.

committee at the University of Navarra. We considered the response to the initial questionnaire as an informed consent to participate in the study. Assessment of non-dietary and dietary exposures Dietary and non-dietary exposures were assessed through a self-administered questionnaire (baseline questionnaire). This questionnaire included different questions related to lifestyles, with 46 items for men and 54 items for women. Sociodemographic (sex, age, marital status, university degree, or employment), anthropometric (weight, height, body image, or weight change), health-related habits (smoking status, alcohol consumption, use of seatbelt, use of sunscreen, or physical activity), and medical history variables (medication use, cholesterol level, blood pressure, or family history of several diseases) were collected. Dietary exposure was ascertained through a semiquantitative food-frequency questionnaire (136 food items) previously validated in Spain [21]. There were 13 separate items for different fruits and 11 items for vegetable consumption. Nutrient intake scores were computed with an ad hoc computer program that was specically developed for this purpose. A dietitian updated the nutrient databank by using the latest available information included in the food composition table for Spain [22,23]. Nutrient scores were calculated as frequency multiplied by nutrient composition of specied portion size, where frequencies were measured in nine frequency categories (6/d, 4 to 6/d, 2 to 3/d, 1/d, 5 to 6/wk, 2 to 4/wk, 1/wk, 1 to 3/mo, never or almost never) for each food item. The overall glycemic load for each participant was calculated as the glycemic index multiplied by carbohydrate content multiplied by consumption frequency for each food item [24]. Data of food intake were transformed into grams of fruits and vegetables and grams of ber and used as continuous variables. Assessment of variables of interest The outcome of this analysis was the weight change in the previous 5 y, through a specic question, which was collected in the baseline questionnaire. This variable, with 10 different values (no change, weight loss 1 to 2 kg, weight loss 3 to 4 kg, weight loss 5 to 10 kg, weight loss 10 kg, weight gain 1 to 2 kg, weight gain 3 to 4 kg, weight gain 5 to 10 kg, weight gain 10 kg, weight gain because of pregnancy), was grouped in two categories: weight gain of at least 3 kg (unless due to pregnancy) or not. We assessed the reproducibility and validity of the self-reported weight in a subsample of the cohort. The mean relative error in self-reported weight was 1.45% and Pearsons correlation coefcient between measured and self-reported weights was 0.991 (95% condence interval 0.986 to 0.994) [25]. Smoking status was classied as never smokers, former smokers, and current smokers. To quantify the volume of physical activity, an activity metabolic equivalent (MET)

Materials and methods Study population We conducted a cross-sectional analysis in Spain by using the baseline dataset of the Seguimiento Universidad de Navarra (SUN) Project. The SUN Project was designed in collaboration with the Harvard School of Public Health Study during 1998 and the methodology is similar to that used in large American cohorts such as the Nurses Health Study [17] and the Health Professionals Follow-up Study [18]. A detailed description of its methods has been published elsewhere [19,20]. Recruitment of participants started in January 2000. All participants are university graduates. The dataset of the SUN Project incorporated 17 170 participants up to December 2004. Recruitment is ongoing because this is a dynamic cohort study with permanently open recruitment. For the present analyses we assessed 13 473 participants. Subjects who reported excessively high or low values for total energy intake (800 kcal/d in men and 600 kcal/d in women or 4200 kcal/d in men and 3500 kcal/d in women) or those with missing values in other variables of interest were excluded from analysis. Data from 11 707 subjects (5094 men and 6613 women) were analyzed. The study was approved by the human research ethical

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index was computed by assigning a multiple of resting metabolic rate (MET score) to each activity (17 items for activities). METs represent the ratio of energy expended during each specic activity to resting metabolic rate and are independent of body weight [26]. Time spent in each activity was multiplied by the MET score specic to each activity and then summed over all activities to obtain a value of overall weekly METs-hours. Statistical analysis Logistic regression models were tted to assess the relation between ber intake or fruit/vegetable consumption and the probability of weight gain. We considered quintiles of ber intake or quintiles of fruit/vegetable consumption as the exposure and a weight gain of at least 3 kg in the previous 5 y as the outcome because our information came from a categorical variable and this value corresponded to 1 U of body mass index (BMI; kilograms per square meter) in our participants. Odds ratios (ORs) and 95% condence intervals were calculated by considering the lowest quintile of ber intake or fruit/vegetable consumption as the reference category. Tests of linear trend across increasing quintiles of intake were conducted by assigning the medians of intake in each quintile and treating the intake as a continuous variable. The P values for trend were twosided. Dietary intakes were adjusted for total energy intake by using the residuals method [27]. We tted a crude (univariate) OR, an age-adjusted OR, and a multivariate-adjusted OR including the following variables in the model: total energy intake (kilocalories per day), physical activity during leisure time (METs-hour per week), smoking status (never smoker, current smoker, and former smoker), snacking between meals (dichotomous variable), watching television (hours per week), and energy-adjusted total fat intake (grams per day). We did not adjust models for current BMI because we considered that the current BMI could be a collider in the directed acyclic graphs (causal diagrams used for identifying variables that must be measured and controlled to obtain non-confounded effect estimates [28]) between ber intake (or fruit/vegetable consumption) and the outcome (weight change in the previous 5 y), so the adjustment could lead to an overadjustment [29]. Fiber intake and fruit/vegetable consumption were also analyzed as continuous variables in the multivariate models. We used stepwise multiple regression [30] to identify the main variability sources concerning ber intake in the SUN cohort participants. The sample was stratied by gender because we detected an interaction (effect modication) between gender and ber intake using a product term. We also detected an interaction between gender and fruit/vegetable consumption. To test other possible effect modications, analyses were repeated after stratifying participants according to BMI (25 or 25 kg/m2), physical activity during leisure time

(15 or 15 METs-hour per week), sedentary lifestyle (10 or 10 h/wk watching television), snacking between meals (yes or no), and smoking status (current, former, or never). An adjusted model according to the joint exposure to energy-adjusted tertiles of ber intake and fruits and vegetables consumption was tted in the overall sample. The lowest tertile for both exposures was considered the reference category. We used tertiles instead of quintiles in this analyses to simplify the presentation and have enough statistical power for each stratum of the combined classication.

Results Among a study population of 5094 men and 6613 women, 38% of men and 29% of women reported a weight gain of at least 3 kg in the previous 5 y. Fiber intake was higher among older subjects, among participants who engaged in more physical activity, among non-smokers, and among participants who did not snack between meals. A higher ber intake was associated with higher vegetable/fruit consumption, higher carbohydrate intake, and glycemic load but with lower fat intake (Table 1). We observed that total ber and fruit/vegetable intakes were higher among women. The main sources of ber intake in the SUN cohort participants were very similar for men and women (Table 2). Foods that most discriminated between individuals were carrots and oranges (R2 0.39 for men and 0.41 for women). Other important foods according ber content are listed in Table 2. The 12 food items presented in this table explained 89% of total variability in ber intake. Increasing dietary ber intake was strongly associated with monotonically decreasing risk of weight gain in the previous 5 y among men (Table 3). Crude ORs across quintiles 1 to 5 were 1.00 (reference), 0.77, 0.71, 0.53, and 0.37 (P for trend 0.001), and age-adjusted ORs across quintiles 1 to 5 were 1.00 (reference), 0.82, 0.79, 0.62, and 0.48 (P for trend 0.001). This strong association remained after further adjustment for total energy intake, physical activity during leisure time, smoking status, snacking between meals, watching television, and energy-adjusted total fat intake. After adjusting for fruit/vegetable consumption, the effect was slightly decreased, but the P value or the statistical signicance remained statistically signicant (P 0.005). These previous results were very similar when we adjusted for current BMI (data not shown). Among women the inverse association between ber intake and weight gain had a lower magnitude than among men (crude ORs across quintiles 1 to 5 were 1.00 [reference], 1.05, 1.08, 1.07, and 0.81, P for trend 0.018). Only the OR for the fth quintile reached statistical signicance. However, the P value for trend was lower than 0.001 after adjusting for age and equal to 0.005 after multivariate ad-

M. Bes-Rastrollo et al. / Nutrition 22 (2006) 504 511 Table 1 Characteristics of men and women according to quintiles of dietary ber intake Men Q1 No. of subjects Fiber intake (g/day) Median age (y) Median BMI (kg/m2) Median physical activity (METs-h/wk) Median TV watching (h/wk) Current smokers (%) Former smokers (%) Median vegetable consumption (servings/d) Median fruit consumption (servings/d) Median sh consumption (servings/d) Median total energy intake (kcal/d) Median total fat intake (%E) MUFA SFA PUFA Median CHO intake (%E) Median protein intake (%E) Median glycemic load (g/d) Snacking (%) 1018 18 35 25 15 9 31 22 1.5 1.2 0.4 2708 39 16 14 6 41 17 189 38 Q2 1019 1823 41 25 16 9 27 31 1.9 1.6 0.4 2382 38 15 13 5 42 17 171 32 Q3 1019 2327 45 25 16 9 24 34 2.1 1.9 0.4 2267 37 15 13 5 43 18 167 27 Q4 1019 2733 48 25 17 9 19 37 2.6 2.6 0.5 2306 36 15 12 5 43 18 167 24 Q5 1019 33 51 25 20 9 15 43 3.4 3.9 0.6 2509 33 14 10 5 47 18 197 21 Q1 Q2 Women Q3 1323 2428 42 22 11 9 28 25 2.4 2.2 0.4 2169 38 16 13 5 42 18 155 37 Q4 1323 2835 44 22 11 9 25 26 2.9 2.9 0.5 2760 36 15 12 5 44 19 157 37 Q5

507

1322 1323 20 2024 40 42 21 21 7 10 10 9 33 28 20 21 1.6 2.1 1.3 1.9 0.4 0.4 2488 2267 41 39 18 16 15 13 6 5 40 42 17 18 171 159 48 42

1322 35 48 22 14 9 22 26 3.9 4.4 0.6 2402 33 14 10 4 48 18 186 32

BMI, body mass index; CHO, carbohydrate; %E, percentage of energy; METs-h/wk, metabolic equivalents-hour per week; MUFA, monounsaturated fatty acid; PUFA, polyunsaturated fatty acid; Q, quintile; SFA, saturated fatty acid; TV, television.

justment. After also adjusting for fruit/vegetable consumption, the effect was slightly increased (Table 3). The test for interaction (effect modication, product term) between total ber intake and fruit/vegetable consumption was not significant among men (P 0.24) or among women (P 0.63). When we also adjusted for energy-adjusted sh consumption, our estimates for the effect of ber did not materially change (data not shown). In contrast, we observed a signicant inverse association between fruit/vegetable consumption and risk of weight gain in the previous 5 y among men (Table 3). Age-adjusted ORs across quintiles for men were 1.00 (reference), 0.74, 0.82, 0.66, and 0.49 (P for trend 0.001). After multivar-

iate adjustment the association remained statistically significant, but this effect was largely attenuated after adjustment for total ber intake. When we also adjusted for glycemic load, the results were very similar (data not shown). No signicant association was observed between fruit/vegetable consumption and weight gain among women. A stratied analysis was conducted to assess whether the association of total ber intake or fruit/vegetable consumption with likelihood of weight gain was modied by current BMI, leisure time physical activity, sedentary lifestyle, snacking between meals, and smoking status (data not shown). No statistically signicant modications in these associations were found.

Table 2 Main sources of variability concerning ber intake in the Seguimiento Universidad de Navarra cohort participants Men Source of ber Carrots Oranges Spinach Dried fruits Lettuce French beans Whole-grain bread Peas Apples White bread Kidney beans Bananas R2, determination coefcient. R
2

Women Cumulative R 0.25 0.39 0.49 0.58 0.64 0.70 0.74 0.78 0.82 0.85 0.87 0.89
2

Source of ber Carrots Oranges Spinach Dried fruits Lettuce Whole-grain bread Peas Peaches French beans Kidney beans Apples Raisins and plums

R2 0.26 0.14 0.11 0.09 0.07 0.05 0.04 0.04 0.03 0.02 0.02 0.01

Cumulative R2 0.26 0.41 0.52 0.61 0.68 0.73 0.77 0.81 0.84 0.86 0.88 0.89

0.25 0.14 0.10 0.09 0.06 0.06 0.04 0.04 0.04 0.03 0.02 0.02

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Table 3 Odds ratios* for weight gain (3 kg in previous 5 y) according to energy-adjusted quintiles of ber intake and overall fruit/vegetable consumption Men Q1 Fiber intake Median ber intake (g/d) Weight gain 3 kg in previous 5 y (%) Crude OR (95% CI) Age-adjusted OR (95% CI) Multivariateadjusted OR (95% CI) Also adjusted for fruit/vegetable consumption OR (95% CI) Fruit/vegetable consumption Median fruit/ vegetable consumption (servings/d) Weight gain 3 kg in previous 5 y (%) Crude OR (95% CI) Age-adjusted OR (95% CI) Multivariateadjusted* OR (95% CI) Also adjusted for total ber intake OR (95 CI) Q2 Q3 Q4 Q5 P for trend 41 27.8 Q1 Q2 Q3 Women Q4 Q5 P for trend 43 25.7

14 51.3

19 45.6

24 41.7

30 34.7

15 29.1

21 29.2

26 32.6

32 31.3

1 (ref.) 1 (ref.) 1 (ref.)

0.77 (0.650.92) 0.82 (0.690.98) 0.86 (0.711.04) 0.91 (0.741.09)

0.71 (0.590.85) 0.79 (0.660.95) 0.86 (0.701.04) 0.93 (0.741.14)

0.53 (0.440.64) 0.62 (0.510.75) 0.70 (0.570.86) 0.79 (0.620.99)

0.37 (0.300.44) 0.48 (0.390.58) 0.52 (0.420.65) 0.64 (0.460.85)

0.001 0.001 0.001

1 (ref.) 1 (ref.) 1 (ref.)

1.05 (0.881.25) 0.99 (0.831.19) 0.99 (0.821.20) 0.93 (0.761.13)

1.08 (0.911.29) 1.00 (0.841.20) 1.08 (0.891.31) 0.97 (0.791.20)

1.07 (0.901.28) 0.98 (0.821.18) 1.05 (0.861.28) 0.89 (0.711.12)

0.81 (0.680.97) 0.68 (0.570.82) 0.72 (0.580.90) 0.54 (0.400.73)

0.018 0.001 M. Bes-Rastrollo et al. / Nutrition 22 (2006) 504 511 0.005

1 (ref.)

0.005

1 (ref.)

0.001

2.8

3.4

4.2

5.3

7.7

3.1

4.1

4.9

8.7

48.6

39.9

40.7

34.7

27.3

28.4

29.9

31.5

29.1

27.6

1 (ref.) 1 (ref.) 1 (ref.)

0.70 (0.590.84) 0.74 (0.620.89) 0.78 (0.640.94) 0.85 (0.701.04)

0.72 (0.610.86) 0.82 (0.680.98) 0.89 (0.731.08) 1.02 (0.831.26)

0.56 (0.470.67) 0.66 (0.540.79) 0.70 (0.570.86) 0.87 (0.691.11)

0.40 (0.330.48) 0.49 (0.400.60) 0.54 (0.440.67) 0.79 (0.581.07)

0.001 0.001 0.001

1 (ref.) 1 (ref.) 1 (ref.)

1.08 (0.901.28) 1.03 (0.861.23) 1.04 (0.861.25) 1.11 (0.911.35)

1.16 (0.971.38) 1.10 (0.921.31) 1.10 (0.911.33) 1.23 (1.001.52)

1.04 (0.871.24) 0.94 (0.791.13) 0.99 (0.811.21) 1.18 (0.941.49)

0.96 (0.811.15) 0.87 (0.721.05) 0.94 (0.771.15) 1.27 (0.951.69)

0.411 0.051 0.381

1 (ref.)

0.199

1 (ref.)

0.140

CI, condence interval; OR, odds ratio; Q, quintile; ref., reference * Statistical test: non-conditional logistic regression. P for trend: assigning the medians of intake in each quintile and treating the intake as a continuous variable. Adjusted for total energy intake, leisure-time physical activity (metabolic equivalents-hour per week), smoking status (never smoker, current smoker, and former smoker), snacking, watching television, and energy-adjusted total fat intake.

M. Bes-Rastrollo et al. / Nutrition 22 (2006) 504 511 Table 4 Adjusted* odds ratios for weight gain (3 kg in previous 5 y) according to joint exposure to energy-adjusted tertiles of ber intake and tertiles of fruit/vegetable consumption Fiber Low Low Medium High 1.00 (reference) (3036) 0.96 (720) 0.96 (146) Fruits and vegetables Medium 1.00 (827) 1.07 (2361) 0.80 (715) High 0.87 (39) 0.94 (822) 0.69 (3041)

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* Adjusted for gender, total energy intake, leisure-time physical activity (metabolic equivalents per hour per week), smoking status (never smoker, former smoker, and current smoker), snacking, watching television, and energy-adjusted total fat intake. Statistical test: non-conditional logistic regression. Men and women are analyzed together, the reference category is the lower tertile for both exposures. Number of participants for each category are presented within parentheses. P 0.001. P 0.05.

We examined the joint effect of total ber intake and fruit/vegetable consumption by cross-classifying participants according to the two variables. To simplify the presentation, we classied them in tertiles of each exposure instead of using quintiles and considered men and women together (Table 4). The OR for the combination of high intake of total ber and high fruit/vegetable consumption was 0.69 (95% condence interval 0.59 to 0.75, P 0.001). The inverse association between fruit/vegetable consumption and weight gain in the previous 5 y was more evident among those with a high intake of total ber, and the benet of total ber was more evident among those with a high fruit/vegetable consumption. However, the test for interaction (product term) was only marginally signicant (P 0.094).

Discussion In this cross-sectional study of 5094 men and 6613 women, an inverse association was found between high ber intake and risk of weight gain (3 kg in the previous 5 y). This association was stronger for men than for women. The reduction in risk exhibited an important magnitude (48% relative reduction of weight gain for men in the highest quintile of total ber intake). In the same way, we found that an increase in fruit/vegetable consumption was associated with a decrease in weight gain, but this was apparent only among men. The association between total ber intake and weight gain remained statistically signicant in men and women after adjusting for potential confounding factors such as age, physical activity during leisure time, total energy intake, smoking status, snacking between meals, watching television, and energy-adjusted total fat intake. The association between fruit/vegetable consumption and weight gain

nearly disappeared in men and women when we adjusted for total ber intake. This nding suggests that the observed association between fruit/vegetable consumption and a lower likelihood of weight gain is mostly due to the high ber content of fruits and vegetables [31]. The high absolute values of ber intake among participants in our cohort were consistent with those observed in another study with a different population that also followed a Mediterranean dietary pattern [32]. Moreover, we observed that the main sources of ber in the participants of the SUN study, who belong to a Mediterranean country, came from fruits and vegetables (carrots, oranges, spinach, dried fruits, and lettuce). Our data were broadly in agreement with those observed in other studies [16]. Fiber may affect abdominal adipose tissue through its effects on insulin sensitivity. In particular, soluble ber may blunt postprandial glycemic and insulinemic responses in the small intestine [33]. These responses are linked to decreases in hunger and subsequently energy intake [34]. In addition, many short-term studies have suggested that high ber foods induce a greater sensation of satiety [34]. In cross-sectional studies, ber generally has been inversely associated with body weight [35] and body fat [36]; in two longitudinal research studies, ber was inversely associated with BMI changes [13,16]. Another study that examined food patterns derived from exploratory factor analysis has suggested that a pattern rich in reducedfat dairy products and high ber foods may lead to smaller gains in waist circumference [37]. We also found that food items poor in ber [38] but not a typical fat-rich Mediterranean pattern [39] were associated with weight gain. However, there are two studies that did not nd a lower likelihood of weight gain associated with higher ber intake [40,41] but these involved smaller numbers of participants. Inaccurate dietary measurement may have inuenced our observed associations. We also acknowledge that our estimates of total energy intake or consumption of some foods, as measured by the food-frequency questionnaire, may present some degree of measurement error because it seems logical to be expected in nutritional epidemiology [19,27]. However, random errors in dietary assessment are more likely to account for a lack of association but not for a reverse one [42]. Moreover, the semiquantitative foodfrequency questionnaire used in this project showed good validity (only 3% of misclassication between extreme quintiles) [21]. Thus, under the null hypothesis and even assuming that all misclassied participants experienced weight gain (the worst possible scenario), the expected ORs would be 0.97 for men and 0.95 for women. Therefore, it is very unlikely that our observed inverse associations were due to misclassication. This argument combined with the good validity found in self-reported weight in this cohort [25] is also valid and can exclude the possibility that the observed protection by ber is a consequence of a social desirability bias. Because of the observational nature of this study, we

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M. Bes-Rastrollo et al. / Nutrition 22 (2006) 504 511 y nutricin en la prctica sanitaria. Madrid: Daz de Santos; 2003, p 37191. Martnez JA. Obesity in young Europeans: genetic and environmental inuences. Eur J Clin 2000;54:56 60. Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill C, Mohamed BS, et al. A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med 2003;348:208290. Samaha FF, Iqbal N, Seshadri P, Chicano KL Daily DA, McGrory J, et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med 2003;348:2074 81 Skov AR, Toubro S, Renn B, Holmt L, Astrup A. Randomized trial on protein versus carbohydrate in ad libitum fat reduced diet for the treatment of obesity. Int J Obes Relat Metab Disord 1999;23:528 36. Stubbs RJ, Van Wyk MC, Johnstone AM, Harbron CG. Breakfast high in protein, fat or carbohydrate: effect on within-day appetite and energy balance. Eur J Clin Nutr 1996;20:2539. Liu S, Willett WC, Manson JE, Hu FB, Rosner B, Colditz G. Relation between changes in intakes of dietary ber and grain products and changes in weight and development of obesity among middle-aged women. Am J Clin Nutr 2003;78:920 7. Koh-Banerjee P, Chu NF, Spiegelman D, Rosner B, Colditz G, Willett WC, Rimm E. Prospective study of the association of changes in dietary intake, physical activity, alcohol consumption, and smoking with 9-y gain in waist circumference among 16587 US men. Am J Clin Nutr 2003;78:719 27. Ludwig DS, Pereira MA, Kroenke CM, Hilner JE, Van Horn L, Staltery ML, Jacobs DR. Dietary ber, weight gain, and cardiovascular disease risk factors in young adults. JAMA 1999;282:1539 46. Park HS, Park JY, Yu R. Relationship of obesity and visceral adiposity with serum concentrations of CRP, TNF- and IL-6. Diabetes Res Clin Pract 2005;69:29 35. Rexrode KM, Pradhan A, Manson JE, Buring JE, Ridker PM. Relationship of total and abdominal adiposity with CRP and IL-6 in women. Ann Epidemiol 2003;13:674 82. He K, Hu FB, Colditz GA, Manson JE, Willett WC, Liu S. Changes in intake of fruits and vegetables in relation to risk of obesity and weight gain among middle-aged women. Int J Obes Relat Metab Disord 2004;28:1569 74. Liu S, Manson JE, Stampfer MJ, Rexrode KM, Hu FB, Rimm EB Willett WC. Whole grain consumption and risk of ischemic stroke in women. JAMA 2002;284:1534 40. Hu FB, Rimm EB, Stampfer MJ, Ascherio A, Spiegelman D, Willett WC. Prospective study of major dietary patterns and risk of coronary heart disease in men. Am J Clin Nutr 2000;72:91221. Martnez-Gonzlez MA, Snchez-Villegas A, de Irala-Estvez J, Mart A, Martnez JA. Mediterranean diet and stroke: objectives and design of the SUN project. Nutr Neurosci 2002;5:6573. Snchez-Villegas A, Delgado-Rodrguez M, Martnez-Gonzlez MA, de Irla Estvez J. Gender, age, socio-demographic and lifestyle factors associated with major dietary pattern in the Spanish project SUN (Seguimiento Universidad de Navarra). Eur J Clin Nutr 2003;57:285 92. Martn-Moreno JM, Boyle P, Gorgojo L, Maisonneuve P, FernndezRodrguez JC, Salvini S, Willett WC. Development and validation of a food frequency questionnaire in Spain. Int J Epidemiol 1993;22: 5129 Mataix J. Tablas de composicin de alimentos. 4th ed. Granada: Universidad de Granada; 2003.(Food composition tables) Moreiras O. Tablas de composicin de alimentos. 9th ed. Madrid: Ediciones Pirmide; 2005. (Food composition tables) Snchez-Villegas A, Martnez-Gonzlez MA, Toledo E, de Irala J, Martnez JA. Inuencia del sedentarismo y el hbito de comer entre horas sobre la ganancia de peso. Med Clin (Barc) 2002;119:46 52. Bes-Rastrollo M, Prez JR, Snchez-Villegas A, Alonso A, MartnezGonzlez MA. Validacin del peso e ndice de masa corporal autodeclarados de los participantes de una cohorte de graduados universitarios (Validation of the self-reported weight and body mass index

cannot prove that the reported associations are causal because residual confounding may have affected the observed associations. However, we controlled for the known factors that affect weight gain. Another limitation of our study is the reliance on selfreported weight gain in the previous 5 y. A substudy in our cohort showed that self-reported weight can be considered sufciently valid among highly educated participants, as other similar cohorts have also shown [43]. We did not control for confounding due to socioeconomic status (SES), but we are condent that SES of the participants cannot be a major confounder in our analyses because our population was very homogeneous with regard to SES. A recommended procedure to adjust for SES is to adjust for educational level, but all our participants had attained the same educational level (i.e., we used restriction instead of multivariate adjustment to control for confounding by SES). Fiber intake (or fruit/vegetable consumption) and weight gain are time-dependent variables. In this context, it is not possible to ascertain with complete certainty whether changes in ber or fruit/vegetable consumption precede changes in weight. However, the outcome variable, weight gain in the previous 5 y, has a certain prospective character. We observed a Pearsons correlation coefcient of 0.450 between energy-adjusted ber intake and energyadjusted total fat intake (P 0.01). Nevertheless, our estimates for the effect of energy-adjusted total fat intake did not support an independent effect of fat on weight gain (adjusted ORs for quintiles 2 to 5 among men: 0.94, 1.10, 1.06, and 1.01, P for trend 0.744; and 0.94, 0.95, 0.94, and 0.87 among women, P for trend 0.276).

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Acknowledgments The authors are indebted to participants of the SUN Study for continued cooperation and participation. They thank the other members of the SUN Study Group: M. Segu-Gmez, J. de Irala, A. Alonso, R. M. Pajares, M. Serrano, M. Delgado-Rodrguez, M. Marques, A. Mart, M. Muoz, F. Guilln-Grima, and I. Aguinaga.

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