Prevalence and Factors Related to Physical Activity in Spanish Adults with Obesity and Overweight: Analysis of the European Health Surveys for the Years 2014 and 2020

(1) Background: To analyze the prevalence of physical activity (PA) according to the presence of overweight or obesity and other sociodemographic factors in the Spanish adult population. (2) Methods: Cross-sectional study using the European Health Interview Surveys for Spain from 2014 and 2020. (3) Results: In overweight and obese people, the percentage of those who reported not performing any type of PA remained constant between 2014 and 2020, while a statistically significant increase was observed in the percentage of people who walked for 10 min a day and exercised at least 2 days a week. The probability of being obese with respect to normal weight was higher in individuals who reported not engaging in PA during leisure time (OR 1.42; 95% CI 1.31–1.53), those who did not walk 10 min a day at least 2 days a week (OR 1.25; 95% CI 1.15–1.35), and those who did not exercise at least 2 days a week (OR 1.42; 95% CI 1.32–1.53). The probability of being overweight was higher in individuals who reported not performing PA during leisure time (OR 1.07; 95% CI 1.02–1.15) and in those who did not exercise at least 2 days per week (OR 1.15; 95% CI 1.09–1.22). (4) Conclusions: Small increases in PA have been observed in both overweight and obese individuals from 2014 to 2020.


Introduction
Overweight and obesity are multifactorial conditions involving biological, psychosocial, socioeconomic, and environmental components [1,2].In turn, they are associated with noncommunicable diseases such as type II diabetes [3], hypertension, stroke, cardiovascular disease [1], and some types of cancer [4], all of which generate a very high economic cost for the health system [5].
Obesity is the most prevalent chronic disease worldwide [6] and is clearly increasing in frequency [7].According to recent studies comparing various countries in Europe, approximately half of the European population is overweight or obese, and this is especially visible in women and persons with a low socioeconomic status [8].
Regular physical activity (PA) is associated with positive effects against excess weight [9] and even long-term obesity [10].However, global PA levels have declined in recent decades [11].In Spain, 36.41% of adults report spending their free time almost entirely sedentary [12].
Despite global recommendations on regular PA [13], there is still a need for improvement in public health interventions.In Spain, the PREDIMED-Plus trial, which evaluated the effect of an intervention with weight loss goals in 6872 participants, observed an increase in sedentary lifestyle, especially in people with higher body mass index (BMI), as well as an association between sedentary lifestyle and metabolic syndrome [14].Therefore, in a population with a higher BMI, PA seems to play an important role in the prevention of associated comorbidities.
Recent reviews of the literature show that the programs that are most successful in the management of obesity are those in which the condition has been treated not only through regular PA but also through education on food and nutrition.Thus, significant improvements have been found in functional capacity, eating habits, weight loss, physical condition, and even in plasma variables [15,16].
Determining PA levels in overweight or obese adults is of special interest when designing future strategies for health promotion and disease prevention in this group.Therefore, the aim of this study was to analyze the association between PA and obesity/overweight in the Spanish adult population through the European Health Interview Surveys for Spain (EHISS) from 2014 and 2020.We specifically analyzed PA according to weight categories and the effect of gender, age, and other sociodemographic and clinical variables on adherence to PA.Finally, we analyzed the risk of overweight and obesity with respect to normal weight based on the various sociodemographic and health variables included in the study.

Study Design and Data Source
The study was cross-sectional with descriptive and analytical components and based on data from the 2014 and 2020 EHISS [17].
The EHISS is carried out approximately every 4 years and collects self-reported information on health in a representative sample of individuals aged 15 years and over residing in Spain.This information includes sociodemographic characteristics, self-reported illness, use of medications and health services, and lifestyle.Participants were selected in 3 stages.The first-stage units are the census tracts (37,000), which are grouped into 7 strata according to the size of the municipality in which they are located.Second-stage units are dwellings, which include all residents in the household.Third-stage units are individuals (1 for each household) who are randomly selected from all residents aged 15 years and over in the household.The surveys were carried out in the home by means of a computer-assisted personal interview and were supplemented, if necessary, by telephone interviews.Interviews were conducted over a 12-month period, from January to December 2014 for EHISS2014 and from July 2019 to July 2020 for EHISS2020.Efforts were made to ensure that interviews were conducted throughout the year in such a way that the number of participants was homogeneous every week and that all periods of the year were equally represented.It is important to note that from March to July 2020, interviews were conducted by telephone owing to the SARS-CoV-2 pandemic.Further details on the surveys can be found on the website of the National Institute of Statistics [18].

Population and Study Variables
The study was based on data from participants aged 18 to 104 years in EHISS2014 and in EHISS2020.
Three variables were used to evaluate PA: "Frequency of PA in leisure time", "Number of days per week an individual goes walking for at least 10 min", and "Number of days per week an individual does sport".For the first variable, the survey asks how often participants engage in PA during their free time.Those who responded, "I don't exercise.Leisure time was occupied in a sedentary manner" were classified as "No-PA"; and those who answered "Occasionally", "I do PA several times a month", or "I do sports or go training several times a week" were classified as "Occasional or frequent PA".For the second and third variables, questions were used that asked how many days a week they walked 10 min at a time and did sport, respectively.Both variables were categorized into "One or no days" and "Two or more days".
Weight was assessed using the body mass index (BMI), which was calculated based on self-reported weight and height.BMI was categorized into "normal weight" (BMI between 18.5 and <25 kg/m 2 ), "overweight" (BMI between 25 and < 30 kg/m 2 ), and "obesity" (BMI ≥ 30 kg/m 2 ).Participants who did not answer the weight and/or height question or with BMI < 18.5 were excluded from the study.
In addition to the variables age, gender, and cohabitation as a couple (No/Yes), the maximum level of education was evaluated.To this end, a variable with 3 categories (primary or no education, secondary education, higher education) was developed based on the information from the survey.
Health information included self-perceived health and some self-reported chronic diseases (chronic obstructive pulmonary disease (COPD), diabetes, cardiovascular disease, stroke, cancer, mental illness, and high blood pressure).Three questions were used for each disease: 1. Have you ever had the disease? 2. Have you suffered from the disease in the last 12 months?3. Was the disease diagnosed by a doctor?Participants who answered yes to all 3 questions were classified as "Yes".In addition, data were recorded on health limitations (if any) and the extent of these limitations during the previous 6 months.Active smoking and alcohol consumption were also collected.The questions used to create all these variables are detailed in Table S1.

Statistical Analysis
Participants were described according to the study variables.Quantitative variables were expressed as mean and standard deviation (SD) and qualitative variables as frequencies and percentages.The assumption of normality of the quantitative variables was tested using the Kolmogorov-Smirnov test.
We evaluated whether there were differences in the study variables between the EHISS2014 and EHISS2020 depending on the weight category, using the chi-square test for the qualitative variables and the t test for independent samples in the quantitative variables.
We evaluated whether there was an association between weight category (normal weight, overweight, or obesity) and the 3 PA variables using the chi-square test.We stratified the analysis by the independent variables.
To assess whether PA was independently associated with weight category, odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated using a multivariable multinomial logistic regression model in which the dependent variable was weight categories and the category "normal weight" was a reference category.The independent variables were the 3 PA variables.In addition, other variables that were potentially associated with weight category were included in the models.To be included, the variables had to show a statistically significant bivariate association with weight category or be considered relevant after a review of the scientific literature.Wald's test was used to decide which variables remained in the model.Various interactions between variables were tested.
The statistical analysis was performed with the program IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY, USA).

Ethical Aspects
All participants in the EHISS2014 and EHISS2020 gave their informed consent to participate in the surveys.
The anonymized databases of the EHISS2014 and EHISS2020 are freely accessible and free to download from the Spanish Ministry of Health website.According to Spanish law, approval by an ethics committee is not necessary for epidemiological studies based on anonymized publicly accessible data [17].

Results
The data used in this study were from the 20,178 participants aged 18 years or over in the EHISS2014 and 19,826 participants in the EHISS2020.Table 1 shows the distribution of the study variables in overweight and obese individuals in the two surveys analyzed.Among overweight individuals, 61.8% perceived their health to be good or very good in 2014, and this percentage rose significantly to 65.8% in 2020.The percentage of people who reported having COPD, diabetes, and mental illness decreased significantly between 2014 and 2020, while the percentage of individuals with cancer increased.In 2014, 53.4% of people with obesity considered their health to be good or very good, and in 2020 this percentage had increased to 58.0% (p < 0.001).Between 2014 and 2020, only the percentages of people with mental illness decreased significantly, whereas the percentage of people with cancer also increased.The prevalence of smoking and alcohol consumption decreased from 2014 to 2020 in participants with overweight and obesity.Also, in both groups, the percentage of those who reported no PA remained constant between 2014 and 2020, while the percentage of people who walked 10 min a day and exercised at least 2 days a week increased significantly.

Differences by Gender and Age in Self-Reported PA in People with Obesity
Figure 1 shows that, among the obese population, a higher percentage of men than women (all p < 0.001) reported some PA in their leisure time (57.4% vs. 44.6% in 2014 and 57.3% vs. 44.6% in 2020), walking 10 min a day at least 2 days a week (74.9% vs. 68.8% in 2014 and 82.2% vs. 77.3% in 2020), and doing sport at least 2 days a week (29.5% vs. 23.2% in 2014 and 37.3% vs. 28.7% in 2020).     2 shows the prevalence of PA variables stratified by sociodemographic characteristics and weight categories.The percentage of people who reported PA (walked) and did sports at least 2 days a week was significantly higher (p < 0.05) in people with normal weight and lower in people with obesity in all categories of the variables analyzed.Among men with normal weight, 72.9% reported some PA during their leisure time, 84.5% walked 10 min a day at least 2 days a week, and 52.8% exercised at least 2 days a week.Among men who were obese, these percentages were significantly lower (p < 0.001), namely, 57.4%, 78.4%, and 33.3%, respectively.A similar trend was found in women.Among women with normal weight, 65.3% reported some PA during their leisure time, 84.3% walked 10 min a day at least 2 days a week, and 45.1% did sports at least 2 days a week; among obese women, the percentages were significantly lower (p < 0.001), namely, 44.6%, 72.8%, and 25.8%, respectively.
The percentage of people who reported PA in their leisure time, walking, and exercising at least 10 min a week was significantly higher (p < 0.05) in men, in younger individuals, and in those with a higher educational level in all three weight categories.
The percentage of people reporting PA and who walked and exercised at least 2 days a week was significantly higher (p < 0.05) in people with normal weight and lower in people with obesity in all categories of all clinical and lifestyle variables (Table 3).Likewise, people who perceived themselves as being in "good or very good" health or who did not have any of the clinical conditions analyzed reported performing PA in their leisure time, walking, and doing sport at least 10 min a week in all three weight categories.a p-value for the difference in the percentages of individuals who perform some PA between individuals with normal weight, overweight, and obesity (Chi-squared).b p-value for the difference in the percentages of individuals who walk 10 min a day at least 2 days a week between individuals with normal weight, overweight, and obesity (Chi-squared).c p-value for the difference in the percentages of individuals who do sports at least 2 days a week between individuals with normal weight, overweight, and obesity (Chi-squared).d Significant difference in the percentage of individuals who perform some PA between the categories of the variable, in those who have normal weight (Chi-squared).e Significant difference in the percentage of individuals who walk 10 min at least 2 times a week between the categories of the variable, in those who have normal weight (Chi-squared).f Significant difference in the percentage of individuals who do sports at least 2 times a week between the categories of the variable, in those who have normal weight (Chi-squared).g Significant difference in the percentage of individuals who perform some PA between the categories of the variable, in those who are overweight (Chi-squared).h Significant difference in the percentage of individuals who walk 10 min at least 2 times a week between the categories of the variable, in those who are overweight (Chi-squared).i Significant difference in the percentage of individuals who do sports at least 2 times a week between the categories of the variable, in those who are overweight (Chi-squared).j Significant difference in the percentage of individuals who perform some PA between the categories of the variable, in those who have obesity (Chi-squared).k Significant difference in the percentage of individuals who walk 10 min at least 2 times a week between the categories of the variable, in those who are obese (Chi-squared).l Significant difference in the percentage of individuals who do sports at least 2 times a week between the categories of the variable, in those who have obesity (Chi-squared).a p-value for the difference in the percentages of individuals who perform some PA between individuals with normal weight, overweight, and obesity (Chi-squared).b p-value for the difference in the percentages of individuals who walk 10 min a day at least 2 days a week between individuals with normal weight, overweight, and obesity (Chi-squared).c p-value for the difference in the percentages of individuals who do sports at least 2 days a week between individuals with normal weight, overweight, and obesity (Chi-squared).d Significant difference in the percentage of individuals who perform some PA between the categories of the variable, in those who have normal weight (Chi-squared).e Significant difference in the percentage of individuals who walk 10 min at least 2 times a week between the categories of the variable, in those who have normal weight (Chi-squared).f Significant difference in the percentage of individuals who do sports at least 2 times a week between the categories of the variable, in those who have normal weight (Chi-squared).g Significant difference in the percentage of individuals who perform some PA between the categories of the variable, in those who are overweight (Chi-squared).h Significant difference in the percentage of individuals who walk 10 min at least 2 times a week between the categories of the variable, in those who are overweight (Chi-squared).i Significant difference in the percentage of individuals who do sports at least 2 times a week between the categories of the variable, in those who are overweight (Chi-squared).j Significant difference in the percentage of individuals who perform some PA between the categories of the variable, in those who have obesity (Chi-squared).k Significant difference in the percentage of individuals who walk 10 min at least 2 times a week between the categories of the variable, in those who are obese (Chi-squared).l Significant difference in the percentage of individuals who do sports at least 2 times a week between the categories of the variable, in those who have obesity (Chi-squared).

Results of the Multinomial Logistic Regression Analysis to Identify PA Variables and Variables Independently Associated with Overweight and Obesity
As can be seen in Table 4, after adjusting for the multivariate model, there is an association between weight class and PA.Thus, the probability of being obese with respect to normal weight was higher in individuals who reported no PA during their leisure time (OR 1.42; 95% CI 1.31-1.53),those who did not walk 10 min a day at least 2 days a week (OR 1.25; 95% CI 1.15-1.35),and those who did not exercise at least 2 days a week (OR 1.42; 95% CI 1.32-1.53).In addition, the probability of being overweight with respect to normal weight was higher in individuals who reported no PA during their leisure time (OR 1.07; 95% CI 1.02-1.15)and in those who did not exercise at least 2 days per week (OR 1.15; 95% CI 1.09-1.22).The risk of overweight (OR 2.32; 95% CI 2.21-2.43)and obesity (OR 1.84; 95% CI 1.77-1.93)with respect to normal weight was higher in men than in women.
A higher risk of overweight and obesity compared to normal weight was observed in people with a lower level of education, in people who lived with a partner, and in people with asthma, diabetes mellitus, and high blood pressure.Smokers showed a lower risk of overweight and obesity than persons with normal weight.

Discussion
When we compared two independent and representative samples of the Spanish adult population obtained in the years 2014 and 2020, we found that, among overweight and obese people, the prevalence of PA remained constant between 2014 and 2020, while the percentage of people who walked 10 min a day and exercised at least 2 days a week increased significantly.These results are consistent with trends in leisure-time PA among the Spanish general population, which improved slightly from 1987 to 2020 [19].A contrary trend has been reported in other countries, where the proportion of people with obesity and sedentary behaviors increased significantly during the same period [20].This could be due to differences in the measurement of PA according to national health surveys, as well as sociocultural and environmental factors.
Previous research has shown differences in indicators of leisure-time PA and its relationship with BMI between men and women [21][22][23][24][25][26][27][28].According to the 2022 Living Conditions Survey in Spain [23], the percentage of men who do regular physical exercise in their free time is higher than that of women.Also in Spain, 11,883 NUTRiMDEA cohort participants were interviewed using the International Physical Activity Questionnaire, finding a significantly higher metabolic equivalent value minutes per week among men than women (2910 vs. 2207; p < 0.001) [26].In the US, the analysis of the National Health and Nutrition Examination Survey (NHANES) between 2009 and 2018 reported that males had a higher PA score (70.6% vs. 54.9%,p < 0.001) than females [27].Guthold R. et al. conducted a pooled data study of population-based surveys investigating the prevalence of insufficient PA, which included PA at work, at home, for transport, and during leisure time (i.e., not doing at least 150 min of moderate-intensity, or 75 min of vigorous-intensity PA per week, or any equivalent combination of the two).A total of 358 surveys, across 168 countries, including 1.9 million participants, were analyzed finding that the global age-standardized prevalence of insufficient PA was 31.7% (95% CI 28.6-39.0) in women and 23.4%, (95% CI 21.1-30.7) in men [28].
Our results are similar: they indicate a higher percentage of men than women with obesity who reported PA in their free time.According to some, the reasons for physical exercise tend to differ by gender: while men are motivated by competitive activities, women tend to be motivated by aesthetic aspects [29], possibly explaining why the association with gender differences goes beyond personal attitudes and motivations, affecting areas such as lifestyle and other social determinants of health.In this sense, the association between female gender and low socioeconomic status, sedentary lifestyle, and obesity has been shown in other countries [30][31][32][33], as has the increase in inequalities in obesity according to educational level in women but not in men [34].This would explain, in part, the more frequent sedentary leisure we observed among obese women than among obese men.
In general, PA levels are lower in overweight and obese populations than in people with normal weight, as demonstrated by studies in Spain [35] and elsewhere [33,36].Our results are consistent with the findings of these studies.
We found that 33.3% of men and 25.8% of women reported doing sport at least 2 days per week.While measurement of PA in leisure time differs according to the study, the percentages are clearly similar.Zhang et al. [37] report figures of up to 30.6% for obese individuals who declared themselves to be physically active.Nevertheless, this finding remains controversial.While some authors report very poor levels of PA in the obese population (less than 16 min a day, of which less than 3 min was vigorous activity) [38] or even no activity in a high percentage of this group (78.2% in men and 68.3% in women) [39], we identified a study that shows high levels of PA among obese people (up to 47% of obese individuals performed more than 300 min per week of moderate-vigorous activity) [13].In terms of its effects, metabolically healthy obesity has been described in the most active individuals, in contrast with metabolically unhealthy obesity in the most sedentary [40], with "metabolically healthy obesity" defined as normal blood pressure, adequate cholesterol levels, relatively low visceral adipose mass, and preserved insulin sensitivity."Metabolically unhealthy obesity" is the term used for persons with multiple cardiovascular risk factors [41], although the definition has been scientifically disputed [42].
There is a circular relation between having obesity and not moving or not moving and acquiring overweight and obesity.Furthermore, being physically active can contribute to a metabolically healthy profile even in the presence of obesity.However, metabolically healthy obesity is a transient condition, and PA alone may not be sufficient for its maintenance [43].
The effect of age and other sociodemographic and clinical variables on adherence to PA were also considered in this study.The profile we found for active people, regardless of BMI, was younger males with a high educational level.In this regard, PA is expected to decrease with age owing to biological mechanisms [44].In terms of educational level, our results are in line with others highlighting increases in PA with educational level in obese people [45].
Studies conducted in Spain, Germany, the US, and Australia, among others countries, have reported that greater adherence to PA practice (action and maintenance stages) was related to better academic level and higher economic income [46][47][48][49].This was confirmed in a literature review conducted by O'Donoghue et al., reporting that low socioeconomic status (low educational levels and low economic income) was comprised of factors associated to low levels of PA [50].
Our results show that a high proportion of individuals with overweight (65.8%) and obesity (58.0%) self-perceived their health as good or very good.Previous studies conducted in our country show that most participants in health surveys tend to respond that their health is good or even very good.In fact, data of the EHISS2020 showed that over 75% of the general population considered their health as good or very good [18].According to recent data of the World Health Organization, the mean percentage of the population living in member countries of the European Union who self-assessed their health as good or very good was 66.5%.The equivalent figure for Spain in that database was almost 7% higher (72.4%) [51].
The possible overrating of self-perceived health in population surveys, beside obesity status, can be in part caused by cultural factors and social desirability of answers [52].Furthermore, previous investigations conducted in Spain agree in finding high prevalence of good self-rated health among people with overweight and obesity [53,54].
We observed an increased risk of overweight and obesity in people who live with a partner.Tzotzas et al. reported that among Greek adults, marital status was significantly associated with obesity and abdominal obesity status in both genders [55].Furthermore, marriage or living in a couple contributes to an increased risk of overweight and obesity in other countries [56][57][58].Future investigations must confirm this relationship and explore possible explanations.
Given these results, it seems necessary to redouble efforts to promote regular PA in the obese and overweight population.A recent review of the literature reports that interventions in overweight or obese adults currently involve PA, diet, or both, with the common goal of weight loss and improved quality of life [59].
The Scientific Committee of the Spanish Agency for Food Safety and Nutrition [60] states that any amount of PA is better than none and concurs with the WHO recommendations of at least 150 to 300 min of moderate aerobic activity per week (or the equivalent, i.e., between 75 and 150 min of vigorous activity) for all adults.Given that an association has been found between increase in resistance exercise and reduction in body mass, specifically in the obese population, and not as much with aerobic exercise [61], it would be interesting to investigate resistance exercises in this population, without neglecting other types of PA.In fact, current recommendations for lowering and maintaining body weight include muscular resistance training as part of the exercise prescribed.In the case of excess weight and obesity, the American College of Sport Medicine [62] recommends a minimum of 200 to 300 min of moderate-to vigorous-intensity PA per week.Gutt et al. [63] stress the importance of progressive prescribing in adults with obesity, starting with at least 150 min per week of moderate-intensity aerobic PA and progressively adding combined muscular endurance exercises that involve large muscle groups.It is necessary to insist on the long-term maintenance of PA habits to ensure that they yield optimal results.
In our opinion, beside the recommendations made by Scientific Societies and public health authorities, several special considerations are important for improving PA among people with overweight and obesity.First, prevalent obesity-related comorbidities must be considered before prescribing exercise to maximize patient safety.Second, the recommendation for these populations is to "start low and go slow".Third, it is a good idea to spread out aerobic activity over the week versus all the time in one day.Fourth, it is recommended to use wearable exercise trackers such as smartwatches, cellular smartphones, pedometers, heart rate monitors, etc. Physicians and patients could potentially use these technological advances to improve their relationships further.Also, utilizing technology to have doctorpatient check-ins regarding their exercise may increase the adherence of obese individuals to exercise programs.Fifth, nurses, physicians, and anyone else involved in the healthcare setting with obese patients should employ motivational interviewing techniques to ensure that patients are meeting their exercise goals [64,65].
Our study is limited by its cross-sectional design, which prevents us from establishing causality.Moreover, since self-reporting of weight and height has not been validated in the EHISS, the proportion of obese people may have been underestimated in our study [66].Even so, surveys with self-reported BMI data have been used very frequently in epidemiological research [67,68] owing to the strong correlation between self-reported data and measured data [69].
The usefulness of health surveys in collecting information on PA has been addressed in various studies [70][71][72].However, they are affected by the need to use more than a single question and the possibility of recall and social desirability biases and selection bias due to nonparticipation.These biases have been shown to result in overestimates of PA and underestimates of sedentary behavior [70][71][72].
As strengths, it is worth highlighting the use of lifestyle variables and self-perception of health and multiple sociodemographic variables that cannot be obtained from medical records.In addition, the EHISS is a structured survey that enables the comparison of two periods with a large sample.
Only small increases in PA were observed among overweight and obese individuals between 2014 and 2020.The prevalence of PA measured with the three questions was lower in overweight and obese individuals than in those with normal weight.Women engage in PA less frequently than men in all weight classes.

Figure 1 .
Figure 1.Proportion of men and women with obesity who reported doing PA in free time or reported doing sports or walking 10 min/2 or more days per week, in 2014 and 2020.

Figure 2
Figure2shows that among obese people, the age group in which PA is most frequent during leisure time and participants walk 10 min a day and do sport at least 2 days a week is those aged 45 to 64 years, both in 2014 and 2020.The difference for the other age groups was significant in all cases.

Figure 2 .
Figure 2. Differences by age group between obese people reported doing PA in free time or reported doing sports or walking 10 min/2 or more days per week, in 2014 and 2020.

Table 1 .
Distribution according to study variables of people with overweight or obesity included in the European Health Interview Surveys for Spain (EHISSs) conducted in 2014 and 2020.

Table 2 .
Prevalence of physical activity in leisure time, engagement to walking ≥ 2 days per week and to practice sport ≥2 days per week among subjects with normal weight, overweight, and obesity and gender-age-matched subjects according to sociodemographic variable.

Table 3 .
Prevalence of physical activity in leisure time, engagement to walking ≥ 2 days per week and to practice sport ≥2 days per week among subjects with normal weight, overweight, and obesity and gender-age-matched subjects according to clinical variables and lifestyles.

Table 4 .
Risk of overweight and obesity according to a multinomial model adjusted for sociodemographic and health variables.