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

Abstract

OBJECTIVE: A healthy diet is particularly important during menopause, a period in which the risk of a number of health problems increases. This study analyzed diet quality as measured by two indices, namely, the Alternate Healthy Eating Index (AHEI) and the Alternate Mediterranean Diet (aMED) index, which measures adherence to a Mediterranean diet, and examined the factors associated with lower diet quality. METHODS: This was a cross-sectional study covering 3,564 women aged 45 to 68 years who underwent breast cancer screening at 7 centers (Corunna, Barcelona, Burgos, Palma de Mallorca, Pamplona, Valencia, and Zaragoza). Data on diet were collected using a food frequency questionnaire validated for the Spanish population. We calculated the AHEI out of a total of 80 points and the aMED out of a total of 9 points. Ordinal logistic regression models were fitted, taking diet quality (tertiles of the AHEI and the aMED) as dependent variables. The following were included in the final multivariate models as explanatory variables: sociodemographic characteristics, chronic diseases, and lifestyles that were associated with diet quality, with a P value <0.100 in an initial simple model (adjusted solely for calorie intake and screening center). Interaction between menopause status and the other explanatory variables was checked. RESULTS: The median score for AHEI was 40 of a maximum of 80 points. Lower diet quality was registered by the youngest women (P for trend < 0.001), premenopausal and perimenopausal women (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.01-1.56; and OR, 1.48; CI, 1.20-1.83, respectively), obese women (OR, 1.18; CI, 0.99-1.41), those with a diagnosis of diabetes (OR, 1.35; CI, 1.01-1.79), smokers (OR, 1.41; CI, 1.21-1.66), and women reporting lower daily physical activity (OR, 1.31; CI, 1.12-1.53). Better diet quality was shown by women with higher education (OR, 0.74; CI, 0.62-0.88) and ex-smokers (OR, 0.82; CI, 0.69-0.98). Nulliparity was associated with higher AHEI scores, but only among premenopausal women (OR, 0.50; CI, 0.32-0.78). aMED index varied between 0 and 9 (median 5). Lower scores were associated with younger age (P for trend < 0.001), low socioeconomic level (OR, 1.13; CI, 0.96-1.33), lower educational level (P for trend = 0.008), and low level of daily physical activity (OR, 1.27, CI, 1.08-1.50). CONCLUSIONS: The youngest women, the most sedentary women, and those who had a lower educational level and socioeconomic status registered worse diet quality. Ex-smokers and postmenopausal women obtained better scores, probably reflecting a keener concern about leading a healthy life.

Full text

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Menopause: The Journal of The North American Menopause Society
Vol. 19, No. 10, pp. 000/000
DOI: 10.1097/gme.0b013e3182544925
* 2012 by The North American Menopause Society
Diet quality and related factors among Spanish female participants
in breast cancer screening programs
Nicola ´s Garcı ´a-Arenzana, MD, MPH,1,2Eva Marı ´a Navarrete-Mun ˜oz, MPH, PhD,3,4
Merce ´ Peris, MD, MPH,5Dolores Salas, MD, MPH, PhD,6Nieves Ascunce, MD, MPH,4,7
Isabel Gonzalez, MD, MPH, PhD,8Carmen Sa ´nchez-Contador, MD,9Carmen Santamarin ˜a, RN,10
Pilar Moreo, MD,11Marı ´a Pilar Moreno, MD, PhD,11Jose Antonio Vazquez Carrete, MD, MPH,10
Francisca Collado-Garcı ´a, RN,9Carmen Pedraz-Pingarro ´n, MD, MPH,8Marı ´a Ederra, MD, MPH,4,7
Josefa Miranda-Garcı ´a, MD,6Carmen Vidal, MD, MPH,5Nuria Aragone ´s, MD, MPH, PhD,2,4
Beatriz Pe ´rez-Go ´mez, MD, MPH, PhD,2,4Jesu ´s Vioque, MD, MPH, PhD,3,4
and Marina Polla ´n, MD, MPH, PhD2,4
Abstract
Objective: A healthy diet is particularly important during menopause, a period in which the risk of a number of health
problems increases. This study analyzed diet quality as measured by two indices, namely, the Alternate Healthy Eating Index
(AHEI) and the Alternate Mediterranean Diet (aMED) index, which measures adherence to a Mediterranean diet, and examined
the factors associated with lower diet quality.
Methods: This was a cross-sectional study covering 3,564 women aged 45 to 68 years who underwent breast cancer screening at
7 centers (Corunna, Barcelona, Burgos, Palma de Mallorca, Pamplona, Valencia, and Zaragoza). Data on diet were collected using a
food frequency questionnaire validated for the Spanish population. We calculated the AHEI out of a total of 80 points and the
aMED out of a total of 9 points. Ordinal logistic regression models were fitted, taking diet quality (tertiles of the AHEI and the
aMED) as dependent variables. The following were included in the final multivariate models as explanatory variables: sociodemo-
graphic characteristics, chronic diseases, and lifestyles that were associated with diet quality, with a P value G0.100 in an initial
simple model (adjusted solely for calorie intake and screening center). Interaction between menopause status and the other explan-
atory variables was checked.
Results: The median score for AHEI was 40 of a maximum of 80 points. Lower diet quality was registered by the youngest
women (P for trend G 0.001), premenopausal and perimenopausal women (odds ratio [OR], 1.25; 95% confidence interval [CI],
1.01-1.56; and OR, 1.48; CI, 1.20-1.83, respectively), obese women (OR, 1.18; CI, 0.99-1.41), those with a diagnosis of diabetes
(OR, 1.35; CI, 1.01-1.79), smokers (OR, 1.41; CI, 1.21-1.66), and women reporting lower daily physical activity (OR, 1.31; CI,
1.12-1.53). Better diet quality was shown by women with higher education (OR, 0.74; CI, 0.62-0.88) and ex-smokers (OR, 0.82; CI,
0.69-0.98). Nulliparity was associated with higher AHEI scores, but only among premenopausal women (OR, 0.50; CI, 0.32-0.78).
aMED index varied between 0 and 9 (median 5). Lower scores were associated with younger age (P for trend G 0.001), low
socioeconomic level (OR, 1.13; CI, 0.96-1.33), lower educational level (P for trend = 0.008), and low level of daily physical activity
(OR, 1.27, CI, 1.08-1.50).
Conclusions: The youngest women, the most sedentary women, and those who had a lower educational level and socio-
economic status registered worse diet quality. Ex-smokers and postmenopausal women obtained better scores, probably reflecting
a keener concern about leading a healthy life.
Key Words: Diet quality Y Menopause Y Women Y Lifestyle Y Spain.
Received November 21, 2011; revised and accepted February 22, 2012.
From the1Unidad de Medicina Preventiva, Hospital Universitario Infanta
Sofı ´a, San Sebastian de los Reyes, Spain;
Ambiental y Ca ´ncer, National Center for Epidemiology, Instituto de Salud
Carlos III, Madrid, Spain;3School of Medicine, Universidad Miguel
Herna ´ndez, Alacant, Spain;4Consortium for Biomedical Research in Epi-
demiology and Public Health (CIBER en Epidemiologı ´a y Salud Pu ´blica
CIBERESP), Instituto de Salud Carlos III, Madrid, Spain;5Cancer Pre-
vention and Control Unit, Catalan Institute of Oncology (ICO), Barcelona,
Spain;6Valencia Breast Cancer Screening Programme, Directorate Public
Health & Centre for Public Health Research (CSISP), Valencia, Spain;
7Navarra Breast Cancer Screening Programme, Public Health Institute,
Pamplona, Spain;
D.G. Salud Pu ´blica ID e I, Castilla y Leo ´n, Spain;9Balearic Islands Breast
Cancer Screening Programme, Health Promotion for Women and Child-
hood, General Directorate Public Health and Participation, Regional
2A´rea de Epidemiologı ´a
8Castilla-Leon Breast Cancer Screening Programme,
Authority of Health and Consumer Affairs, Balearic Islands, Spain;
10Galicia Breast Cancer Screening Programme, Regional Authority of
Health, Galicia Regional Government, A Coruna, Spain; and11Aragon
Breast Cancer Screening Programme, Health Service of Aragon,
Zaragoza, Spain.
Funding/support: This study was supported by research grant FIS
PI060386 from Spain’s Health Research Fund (Fondo de Investigacio ´n
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 (Feder-
acio ´n de Mujeres con Ce ´ncer de Mama).
Financial disclosure/conflicts of interest: None reported.
Address correspondence to: Marina Polla ´n, MD, MPH, PhD, A´rea de
Epidemiologı ´a Ambiental y Ca ´ncer, National Center for Epidemiology
(Pab, 12), Instituto de Salud Carlos III, Monforte de Lemos 5, 28029
Madrid, Spain. E-mail: mpollan@isciii.es
Menopause, Vol. 19, No. 10, 2012 1
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

Page 2

D
eases. The importance of healthy eating is accentuated in
women after menopause, a period of increased risk for the
development of diet-related diseases, such as diabetes, osteo-
porosis, cardiovascular disease, or certain types of cancer.1<4
Diet is a complex mixture of nutrients, among which syn-
ergic effects may be generated. As a result, overall indicators
of diet quality have been developed in the literature, based
on nutritional requirements and guidelines shown to be bene-
ficial for health.5,6The Alternate Mediterranean Diet (aMED)
index is a variation of the Mediterranean Diet index which
was created to measure adherence to the Mediterranean diet7,8;
and the Healthy Eating Index and its subsequent revision,
the Alternate Healthy Eating Index (AHEI), were developed
to measure adherence to the US Department of Agriculture
Food Guide Pyramid and the 1995 Dietary Guidelines for
Americans, based on preventive nutritional criteria.7Both
the aMED and the AHEI have been shown to be associated
with better survival and lower risk of chronic disease and
breast cancer in clinical and epidemiological studies.7<10
Information regarding diet quality in perimenopausal and
postmenopausal Spanish women is scarce. Accordingly, this
article assesses diet quality, using the above-mentioned in-
dexes, and explores the factors associated with lower diet
quality among women attending breast cancer screening pro-
grams in Spain, taking advantage of the information provided
by the participants in a multicenter cross-sectional study.
iet is a key health factor. A number of studies have
reported associations between differences in dietary
patterns and the appearance of various chronic dis-
METHODS
The Determinantes de la Densidad Mamogre ´fica en Espan ˜a
(DDM-Spain) study was a cross-sectional multicenter study
based on 3,584 women, aged 45 to 68 years, recruited from
seven specific screening centers within the Spanish breast
cancer screening program network. The study explores the dis-
tribution of different reproductive and lifestyle factors among
these women, the prevalence of high breast density, and the
relationshipbetween these two.Allwomenaged50to69years,
regardless of nationality or legal status, are screened under
these government-sponsored programs every 2 years. In some
regions, women between 45 and 49 years of age are also in-
cluded. The seven Spanish Autonomous Regions participat-
ing in the study selected one screening unit where attendance
to screening was high and whose population could be consid-
ered as representative of the whole Autonomous Region. The
selected units were located in Zaragoza (Aragon), Son Dureta
Hospital(PalmadeMallorca,BalearicIslands),Burgos(Castile-
Leo ´n), Bellvitge Hospital (Barcelona, Catalonia), Corunna
(Galicia), Pamplona (Navarre), and Burjasot (Valencia). Mean
overall screening participation in the selected centers was 75%,
whereas the estimated participation for the whole country was
67%. Women were recruited from October 2007 to July 2008,
with a minimum enrollment of 500 women per program.
Whereas the Pamplona, Burgos, and Valencia programs ini-
tiated screening at age 45 years, the remaining programs did so
at age 50 years. The study was approved by the ethical com-
mittee of the Instituto de Salud Carlos III, and all participants
signed an informed consent form.
The exclusion criteria were as follows: (1) previous diag-
nosis of breast cancer or some other neoplastic disease (with
the exception of nonmelanoma skin cancer), (2) inability to
answer the questionnaire, and (3) physical incapacity to un-
dergo screening mammography. Women who agreed to par-
ticipate signed an informed consent and were subsequently
interviewed. The overall participation rate in this study was
74.5%, ranging from 64.7% in Corunna to 84.0% in Zaragoza.
Ten women were diagnosed with breast cancer in the following
months and were excluded from the analysis. We also excluded
nine women who reported a somewhat implausible mean daily
energy intake for a complete year (G800 or 94,000 kcal/d) as
well as one woman who was receiving parenteral nutrition,
thereby yielding a final sample of 3,564 women.
Study variables
Sociodemographic, reproductive, and lifestyle data were
obtained by trained interviewers administering a structured,
face-to-face questionnaire. The questionnaire included two
specific questions about menopause. Postmenopause status
was self-reported and defined as absence of menstruation in
the last 12 months. Those women who reported 1 to 9 men-
struations in the last 12 months were considered perimen-
opausal, and those reporting 10 or more were included as
premenopausal. Dietary intake was estimated with the aid of
a 117-item semiquantitative food frequency questionnaire
(FFQ), similar to that used by Willett et al11in the Nurses’
Health Study and adapted and validated for use in the Spanish
adult population.12,13In addition, an anthropometric exami-
nation of all participants was conducted following stand-
ardized procedures, using two measurements to record weight
in kilograms and height in centimeters and then calculating
the mean of the two. In any case where these two measure-
ments differed by more than 0.5 cm, a third measurement was
made. Body mass index (BMI) was estimated as weight in
kilograms divided by the square of height in meters.
The FFQ recorded the consumption of each type of food,
specifying the use of standard portions or rations by reference
to new frequency categories, ranging from Bnever or less than
once per month[ to Bsix or more times a day.[ Based on the
replies to each item, the mean daily intake of each nutrient
was calculated for each woman, with the frequency of use of
any given food being multiplied by the nutritional composi-
tion of the specified portion of that food, using the US
Department of Agriculture’s Food Composition Tables14and
other tables published for Spanish foods15as the primary
source, and supplementing the information for some of the
nutrients on the basis of scientific publications.16<19
Food quality indices were estimated using the latest up-
dates published for both the AHEI and aMED,9which mod-
ify the original criteria of these indices.7,8To calculate the
new AHEI, account must be taken of the estimated intake of
nine items, namely, foods and nutrients that are drawn from
2
Menopause, Vol. 19, No. 10, 2012
* 2012 The North American Menopause Society
GARCI´A-ARENZANA ET AL
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

Page 3

the FFQ and to which scores are allocated according to an
ideal consumption of each. Each item can be scored from 0 to
10 points, with the criteria for attaining the maximum score
being as follows: leafy green and other vegetables (including
legumes but excluding potatoes), five rations per day; fruit,
four rations per day; nuts and soybean products, one ration per
day; ratio of white meat (chicken and fish) to red meat, Q4:1;
cereal fiber, 15 g/day; proportional intake of trans fatty acids,
0.5% or less of energy intake; polyunsaturated fats ratio, 1
or greater; moderate alcohol intake, 0.5 to 1.5 rations per day;
and prolonged use of multivitamin complexes, 5 years. For
study purposes, we decided to adapt the AHEI by eliminating
this last component because data were available on the use
of multivitamin complexes only in the preceding year. In this
study, therefore, the maximum score attainable on this modi-
fied index was 80 points.
For the aMED index, we used a relative scale based on
comparison with the study population’s median intake of the
following eight food groups: leafy green and other vegetables
(excluding potatoes), legumes as an independent group, fruit
and nuts, dairy products, cereals, meat and meat products,
fish, alcohol, and the median of the ratio of monosaturated to
saturated fats in the study population. Participants reporting an
intake that was higher than the median scored 1 point. In all
other cases, they were scored 0 except for consumption of red
and processed meat, which was scored 1 point in cases where
intake was lower than the median, and alcohol consumption,
which was scored 1 point if daily consumption ranged from
5 to 25 g/day. aMED scores range from 0 to 9 points.
The following were considered as possible variables asso-
ciated with diet quality: age, educational level, self-reported
socioeconomic level (low or lower-middle, middle, upper-
middle or upper), smoking status (never-smoker, ex-smoker,
andcurrentsmoker),physicalactivity(low,moderateandhigh),
number of children, and other, similarly self-reported health-
related variables, such as menopause status and having diabetes
and osteoporosis. Consideration was also given to the presence
of overweight and obesity, respectively defined as a BMI of
25 to 29.9 kg/m2and a BMI equal to or higher than 30 kg/m2,
as possible explanatory variables.
Statistical analysis
Descriptive statistics for the principal sociodemographic
and dietary variables were calculated. The results are shown in
percentages for qualitative variables and in means and SDs for
quantitative variables. The correlation between the aMED and
AHEI was studied using the Spearman correlation coefficient.
AHEI and aMED quality index scores were ranked in
descending order and categorized into three groups (0, 1, 2),
using tertiles (AHEI) or predefined cutoffs (aMED, cutoffs 4
and 6). In this way, for each of these indexes, the first group
(category 0) included women with better-than-average diet
(highest scores for AHEI index, scores between 6 and 9 in the
case of aMED). The intermediate group (category 1) com-
prised women with an average-quality diet (second tertile for
AHEI, scores between 4 and 5 for aMED). Finally, the third
group (category 3) corresponded to those women with worse-
than-average diet (lowest scores for AHEI, scores G4 in the
case of aMED). For each quality index, AHEI and aMED,
sociodemographic and lifestyle factors associated with a lower
diet quality, as defined by the categorized variable, were
identified using mixed ordinal logistic regression models. In
these models, the above-mentioned explanatory variables were
deemed to be fixed effects. In addition, a random intercept
was included for each center to enable variability associated
with the screening centers themselves to be taken into account.
For each quality index, the final model included age, calories,
menopause status, and all factors that were associated with diet
quality in the model only adjusted by calories and screening
center (P G 0.100). Ordinal logistic regression, also known as
the proportional-odds model, assumes that odds ratios (ORs)
remain constant, irrespective of the cutoff chosen to dichoto-
mizethe ordinal classificationofdietqualityintwo groups. The
model simultaneously estimates as many equations as the num-
ber ofcategoriesinthe dependent variable(3inour case) minus
one. Fulfillment of the assumption of proportionality of ORs
was verified using the Brant test and the test of constant ef-
fects across categories. For the independent ordinal variables,
TABLE 1. Sociodemographic characteristics and lifestyles among
Spanish women who participated in the breast cancer screening
program (DDM-Spain study; N = 3,564)
Age, mean (SD), y
Educational level, n (%)
ePrimary
Secondary
9Secondary
Missing
Socioeconomic level, n (%)
Low/lower-middle
Middle
Upper-middle or upper
Missing
Body mass index, n (%)
G25 kg/m2
25-29.9 kg/m2
Q30 kg/m2
Missing
Menopause status, n (%)
Premenopausal
Perimenopausal
Postmenopausal
Number of children
0
1
2
Q3
Physical activity, n (%)
Low
Moderate
High
Missing
Smoking status, n (%)
Never-smoker
Ex-smoker
Current smoker
Diabetes, n (%)
Missing
Osteoporosis, n (%)
Missing
Daily energy intake, mean (SD), kcal/d
56.2 (5.5)
1,207 (33.9)
1,321 (37.1)
1,030 (28.9)
6 (0.2)
857 (24.0)
2,516 (70.6)
176 (4.9)
15 (0.4)
1,018 (28.6)
1,486 (41.7)
1,045 (29.3)
15 (0.4)
419 (11.8)
397 (11.2)
2,748 (77.1)
321 (9.0)
545 (15.3)
1,709 (48.0)
989 (27.7)
847 (23.8)
1,848 (51.9)
865 (24.3)
4 (0.1)
2,062 (57.8)
638 (17.9)
864 (24.3)
196 (5.5)
6 (0.2)
467 (13.1)
56 (1.6)
2,053 (480)
Menopause, Vol. 19, No. 10, 2012 3
DIET QUALITY IN SPANISH WOMEN
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

Page 4

the possible dose-response relationship was assessed on the
basis of the statistical significance obtained when the relevant
variable was included as a continuous variable in the model.
Finally, to study possible differences in the factors asso-
ciated with diet quality by menopause status, the multivar-
iate model was then adjusted separately in premenopausal/
perimenopausal and postmenopausal women, and the heteroge-
neityof the effectsinthesetwogroupswas evaluated,computing
the statistical significance of the corresponding interaction terms.
RESULTS
Table 1 shows the sociodemographic characteristics and
lifestyles of the female participants. The breakdown was as fol-
lows: mean (SD) age was 56.2 (5.5) years; 77.1% were post-
menopausal; most women presented with overweight (41.7%)
and obesity (29.3%); more than half, 51.9%, reported engag-
ing in moderate daily physical activity; and 24.3% were current
smokers.
Table 2 shows the median intake values and interquartile
range (IQR) for each of the AHEI and aMED components
among our women, along with the median score obtained by
participants for each of the items on this indicator. The women
in the DDM-Spain study scored a median of 40.3 (IQR,
34.8-46.8) of 80 points on the AHEI, with a range from 14.4 to
74.9. The items that registered the best scores were daily intake
of leafy green vegetables and fruit and, in particular, percent-
age of energy provided by trans fats. In all, 72.8% of women
obtained the maximum score for this item (10 points), and not
one scored 0 (Q4% of energy provided by such fats). A total
of 23.0% of women reported a daily alcohol intake of 5 to
25 g/day, scoring 1 point on the aMED alcohol item (the only
fixed item on this index that does not depend on the sam-
ple itself). It should be noted that 44.5% of women drank no
alcohol, which, on the AHEI, translates as 0 points for this
item. The median aMED score was 5 (IQR, 4-6), ranging from
0 to 9.
Tables 3 and 4 show the results of the multivariate analy-
sis for factors associated with lower diet quality, using the
AHEI (Table 3) and aMED (Table 4) indicators. The corre-
lation between the two indices was 0.470 (P G 0.001).
The principal factors associated with lower AHEI scores
are outlined below. The simple model presents OR only ad-
justed by calories and screening center. The final model was
adjusted also by the rest of factors that showed an association
in the previous model. Obesity was associated with lower
diet quality in the simple model and bordered on statistical
significance when adjustment was made for the remaining
covariates in the final model (P = 0.058). Premenopausal
(OR, 1.25; CI, 1.01-1.56) and perimenopausal (OR, 1.48; CI,
1.20-1.83) women likewise registered lower scores, even af-
ter adjustment for age. There was a negative correlation be-
tween age and diet quality in the whole sample (P for trend
G 0.001). The association was stronger in premenopausal/
perimenopausal women (OR, 0.62; CI, 0.47-0.82) than in
postmenopausal women (OR, 0.86; CI, 0.79-0.94; P for inter-
action G 0.001). Women with the most modest socioeconomic
TABLE 2. Distribution of daily intake (median and range) of the components of the AHEI and aMED indices among Spanish female
participants in breast cancer screening programs (DDM-Spain study; N = 3,564)
AHEI Index
Item
Intake,
median (IQR)
AHEI score,
median (IQR)
Criteria for minimum
AHEI score
Criteria for maximum
AHEI score
Leafy green vegetables including legumes, servings/da
Fruit, servings/d
Nuts and soy protein, servings/d
Cereal fiber, g/d
Ratio of white to red meat
Trans fat, % of energy
P:S ratiob
Alcohol, servings/d
Total score
3.45 (2.54-4.39)
3.23 (2.28-4.48)
1.00 (0.00-0.13)
0.00 (0.00-50.00)
1.57 (1.06-2.44)
0.39 (0.28-0.53)
0.55 (0.46-0.66)
0.13 (0.00-0.57)
Y
7 (5-9)
8 (6-10)
0 (0-2)
0 (0-2)
4 (3-6)
10 (10-10)
5 (4-6)
1 (0-9)
40 (35-47)
0
0
0
0
0
Q5
Q4
Q1
Q15
Q4
e0.5
Q1
0.5-1.5
80
Q4
0
0 or 92.5
0
aMED Index
ItemIntake, median (IQR) Criteria for 1 point
Leafy green vegetables, servings/da
Legumes, servings/d
Fruit, servings/d
Nuts, servings/d
Whole grains, servings/d
Red and processed meats, servings/d
Fish, servings/d
M:S ratioc
Alcohol, g/d
Total score
AHEI, Alternate Healthy Eating Index; aMED, Alternate Mediterranean Diet; IQR, interquartile range.
aPotatoes not included.
bRatio of polyunsaturated to saturated fatty acids.
cRatio of monosaturated to saturated fatty acids.
3.18 (2.31-4.09)
0.14 (0.14-0.43)
3.23 (2.28-4.48)
0.02 (0.00-0.13)
0.14 (0.07-1.00)
0.71 (0.49-0.99)
0.75 (0.55-1.01)
1.77 (1.51-2.09)
0.85 (0.00-5.68)
5 (4-6)
Greater than median intake (servings/d)
Greater than median intake (servings/d)
Greater than median intake (servings/d)
Greater than median intake (servings/d)
Greater than median intake (servings/d)
Less than median intake (servings/d)
Greater than median intake (servings/d)
Greater than median ratio
5-25 g/d
4
Menopause, Vol. 19, No. 10, 2012
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Page 5

TABLE 3. Factors associated with a worse diet quality, according to the AHEI, among Spanish female participants in breast cancer screening programs (DDM-Spain study)
n
Lower AHEI, %
Simple modela
Final modelb
Premenopausal-perimenopausalc
Postmenopausald
Pintere
OR
95% CI
P
OR
95% CI
P
OR
95% CI
P
OR
95% CI
P
BMI
G25 kg/m2
1,021
34
1.00
Y
Y
1.00
1.00
Y
Y
1.00
Y
Y
0.580
25-29.9 kg/m2
1,490
31
1.00
0.86-1.17
0.970
1.00
0.85-1.17
1.000
1.05
0.77-1.45
0.747
1.02
0.85-1.23
0.824
Q30 kg/m2
1,048
36
1.27
1.08-1.49
0.005
1.18
0.99-1.41
0.058
1.27
0.89-1.82
0.181
1.21
0.99-1.48
0.067
Ptrend
f
0.004
0.053
0.170
0.051
Age (categorical)
G50 y
550
44
1.71
1.40-2.09
G0.001
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
50-54 y
981
32
1.00
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
55-59 y
1,000
31
0.90
0.76-1.06
0.209
Y
Y
Y
Y
Y
Y
Y
Y
Y
Q60 y
1,038
31
0.92
0.79-1.09
0.348
Y
Y
Y
Y
Y
Y
Y
Y
Y
Ptrendf
G0.001
Age per 5 yg
Y
Y
Y
Y
Y
0.83
0.77-0.89
G0.001
0.62
0.47-0.82
0.001
0.86
0.79-0.94
0.001
G0.001
Menopause status
Premenopausal
419
39
1.41
1.16-1.71
0.001
1.25
1.01-1.56
0.039
Y
Y
Y
Y
Y
Y
Y
Perimenopausal
397
36
1.22
1.00-1.48
0.048
1.48
1.20-1.83
G0.001
Y
Y
Y
Y
Y
Y
Postmenopausal
2,748
32
1.00
Y
Y
1.00
Y
Y
Y
Y
Y
Y
Y
Y
Children
Yes
3,251
34
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
0.045
No
323
29
0.74
0.60-0.92
0.007
0.79
0.64-0.99
0.042
0.50
0.32-0.78
0.002
0.93
0.72-1.20
0.579
Educational level
ePrimary
1,208
32
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
0.097
Secondary
1,326
36
0.95
0.82-1.10
0.481
0.95
0.81-1.11
0.526
0.81
0.54-1.21
0.297
1.00
0.85-1.19
0.978
9Secondary
1,034
32
0.74
0.63-0.87
G0.001
0.74
0.62-0.88
0.001
0.78
0.52-1.18
0.240
0.71
0.58-0.86
0.001
Ptrendf
G0.001
0.001
0.302
0.002
Socioeconomic level
Low/lower-middle
860
34
1.21
1.05-1.40
0.010
1.24
1.06-1.45
0.006
0.91
0.64-1.28
0.570
1.24
1.05-1.48
0.012
0.218
Middle
2,521
34
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
Upper-middle/upper
178
25
0.75
0.56-0.99
0.044
0.81
0.61-1.09
0.164
0.82
0.48-1.40
0.465
0.82
0.57-1.16
0.255
Ptrendf
G0.001
0.003
0.954
0.004
Diabetes
No
3,372
33
1.00
Y
Y
1.00
Y
Y
Y
Y
Y
1.00
Y
Y
Y
Yes
196
40
1.35
1.02-1.77
0.033
1.35
1.01-1.79
0.042
Y
Y
Y
1.32
0.98-1.78
0.065
Osteoporosis
No
3,051
34
1.00
Y
Y
1.00
Y
Y
Y
Y
Y
Y
Y
Y
Y
Yes
467
27
0.81
0.67-0.97
0.024
0.90
0.75-1.09
0.301
Y
Y
Y
Y
Y
Y
Smoking status
Never-smoker
2,067
33
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
0.993
Current smoker
867
40
1.31
1.12-1.52
G0.001
1.41
1.21-1.66
G0.001
1.31
0.95-1.81
0.100
1.37
1.14-1.65
0.001
Ex-smoker
640
27
0.80
0.67-0.94
0.008
0.82
0.69-0.98
0.027
0.79
0.56-1.12
0.185
0.84
0.68-1.03
0.094
Physical activity
Low activity
849
35
1.26
1.08-1.46
0.003
1.31
1.12-1.53
0.001
1.32
0.93-1.89
0.120
1.26
1.06-1.50
0.010
0.662
Moderate activity
1,855
34
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
High activity
866
31
0.79
0.68-0.92
0.002
0.80
0.68-0.94
0.006
0.81
0.58-1.12
0.197
0.78
0.65-0.93
0.007
Ptrendf
G0.001
G0.001
0.011
0.000
AHEI, Alternate Healthy Eating Index; OR: odds ratio; BMI, body mass index.
aEffect of each variable adjusted only by daily calorie intake (kcal/d) and for screening center as a random-effects term.
bFinal multivariate model included all variables associated with diet quality in the simple model (P G 0.100) also adjusted by calories and screening center.
cSame adjustment variables as the final model except menopause status, diabetes, and osteoporosis because of the few premenopausal and perimenopausal women with these pathologies in the sample.
dSame adjustment variables as the final model except menopause status.
eTest for interaction between menopause status and the explanatory variable.
fTest for linear trend for ORs where the explanatory variable is ordinal.
gAge as a continuous variable: OR for an increase of 5 years.
Menopause, Vol. 19, No. 10, 2012 5
DIET QUALITY IN SPANISH WOMEN
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

Page 6

TABLE 4. Factors associated with a worse quality of diet, according to the aMED index, among Spanish female participants in breast cancer screening programs (DDM-Spain study)
n
Lower aMED (0-3), %
Simple modela
Final modelb
Premenopausal and
perimenopausalc
Postmenopausald
Pintere
OR
95% CI
P
OR
95% CI
P
OR
95% CI
P
OR
95% CI
P
BMI
G25 kg/m2
1,021
38
1.00
Y
Y
1.00
1.00
Y
Y
1.00
Y
Y
0.622
25-29.9 kg/m2
1,490
37
1.01
0.87-1.18
0.856
1.02
0.87-1.20
0.814
1.00
0.72-1.38
0.988
1.03
0.86-1.24
0.753
Q30 kg/m2
1,048
41
1.22
1.03-1.45
0.020
1.19
1.00-1.43
0.051
1.21
0.84-1.74
0.300
1.17
0.95-1.43
0.140
Ptrend
f
0.033
0.128
0.341
0.126
Age (categorical)
G50 y
550
45
1.48
1.16-1.88
0.001
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
50-54 y
981
37
1.00
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
55-59 y
1,000
36
0.91
0.77-1.07
0.249
Y
Y
Y
Y
Y
Y
Y
Y
Y
Q60 y
1,038
38
0.89
0.75-1.05
0.163
Y
Y
Y
Y
Y
Y
Y
Y
Y
Ptrendf
G0.001
Age per 5 yg
Y
Y
Y
0.86
0.80-0.93
G0.001
0.73
0.55-0.98
0.003
0.87
0.80-0.95
0.002
0.061
Menopause status
Premenopausal
397
43
1.25
1.01-1.54
0.037
1.18
0.94-1.47
0.148
Y
Y
Y
Y
Y
Y
Y
Perimenopausal
419
42
1.16
0.95-1.43
0.147
1.34
1.08-1.67
0.009
Y
Y
Y
Y
Y
Y
Postmenopausal
2,748
37
1.00
Y
Y
1.00
Y
Y
Y
Y
Y
Y
Y
Y
Children
Y
Y
Y
Y
Y
Y
Yes
3,251
38
1.00
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
No
323
37
0.84
0.68-1.05
0.129
Y
Y
Y
Y
Y
Y
Y
Y
Y
Educational level
ePrimary
1,208
37
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
0.135
Secondary
1,326
40
0.95
0.82-1.11
0.523
0.88
0.75-1.03
0.114
0.73
0.48-1.11
0.146
1.00
0.85-1.19
0.963
9Secondary
1,034
38
0.84
0.71-0.99
0.035
0.78
0.65-0.93
0.006
0.78
0.51-1.19
0.246
0.77
0.63-0.94
0.010
Ptrendf
0.037
0.008
0.747
0.003
Socioeconomic level
Low/lower-middle
860
38
1.11
0.96-1.29
0.155
1.13
0.96-1.33
0.155
1.24
0.86-1.79
0.249
1.10
0.93-1.31
0.272
0.751
Middle
2,521
39
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
Upper-middle/upper
178
35
0.81
0.61-1.09
0.161
0.85
0.62-1.15
0.288
0.67
0.37-1.23
0.193
0.95
0.66-1.37
0.788
Ptrendf
0.039
0.049
0.068
0.255
Diabetes
No
3,372
38
1.00
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Yes
196
40
1.08
0.82-1.43
0.569
Y
Y
Y
Y
Y
Y
Y
Y
Y
Osteoporosis
No
3,051
39
1.00
Y
Y
1.00
Y
Y
Y
Y
Y
1.00
Y
Y
Y
Yes
467
30
0.75
0.63-0.91
0.003
0.78
0.64-0.94
0.009
Y
Y
Y
0.77
0.64-0.94
0.010
Smoking status
Never-smoker
2,067
37
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
0.740
Current smoker
867
45
1.36
1.17-1.59
G0.001
1.44
1.22-1.70
G0.001
1.37
0.99-1.91
0.059
1.41
1.16-1.70
90.001
Ex-smoker
640
34
0.85
0.71-1.01
0.065
0.88
0.73-1.05
0.147
0.92
0.65-1.30
0.627
0.85
0.69-1.05
0.134
Physical activity
Low activity
849
43
1.32
1.13-1.55
0.001
1.27
1.08-1.50
0.004
1.19
0.83-1.72
0.348
1.30
1.09-1.56
0.004
0.586
Moderate activity
1,855
37
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
1.00
Y
Y
High activity
866
35
0.82
0.70-0.97
0.017
0.79
0.68-0.93
0.005
1.06
0.76-1.47
0.751
0.74
0.62-0.89
0.001
Ptrendf
90.001
G0.001
0.630
90.001
aMED, Alternate Mediterranean Diet; OR, odds ratio; BMI, body mass index.
aEffect of each variable adjusted only by daily calorie intake (kcal/d) and by screening center as a random-effects term.
bFinal multivariate model included all variables associated with diet quality in the simple model (P G 0.100) also adjusted by calories and screening center.
cSame adjustment variables as the final model except menopause status and osteoporosis because of the few premenopausal and perimenopausal women with this pathology in the sample.
dSame adjustment variables as the final model except menopause status.
eTest for interaction between menopause status and the explanatory variable.
fTest for linear trend for ORs where the explanatory variable is ordinal.
gAge as a continuous variable: OR for an increase of 5 years.
6
Menopause, Vol. 19, No. 10, 2012
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GARCI´A-ARENZANA ET AL
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

Page 7

levels displayed lower diet quality (OR, 1.24; CI, 1.06-1.45),
as did those with diabetes (OR, 1.35; CI, 1.01-1.79). Almost
all women with diabetes were postmenopausal, as were those
women with osteoporosis. For this reason, these two con-
ditions were not considered when the model was fitted using
only premenopausal/perimenopausal women. Participants who
smoked and those who engaged in less physical activity also
displayed lower diet quality (OR, 1.41; CI, 1.21-1.66; and
1.31; CI, 1.12-1.53 respectively). In contrast, the following
characteristics were associated with a better AHEI score:
higher educational level (OR, 0.74; CI, 0.62-0.88), reporting
more daily physical activity (OR, 0.80; CI, 0.68-0.94), and
ex-smoker status (OR, 0.82; CI, 0.69-0.98). The association
with osteoporosis observed in the simple analysis lost statisti-
cal significance in the multivariate analysis. Nulliparity also
showed association with a higher AHEI score (OR, 0.79; CI,
0.64-0.99), but this association was seen only in premenopausal/
perimenopausalwomen(OR,0.50; CI,0.32-0.78)after splitting
the analysis by menopause status (P for interaction = 0.045).
In the case of the aMED index, premenopausal and peri-
menopausal women tended to have lower diet quality (OR,
1.18; CI, 0.94-1.47; and OR, 1.34; CI, 1.08-1.67 respectively).
In the same way, lower scores were observed among the youn-
gest women (P for trend G 0.001). As with the AHEI index, the
effect of age was greater in premenopausal/perimenopausal
women (OR, 0.73; CI, 0.55-0.98) compared with those who
were postmenopausal (OR, 0.87; CI, 0.80-0.95), with a P for
interaction in the edge of statistical significance (P = 0.061).
Poorer aMED scores were seen in women with lower educa-
tion (P for trend = 0.008) and those with lower socioeco-
nomic level (P for trend = 0.049), as well as those who were
current smokers (OR, 1.44; CI, 1.22-1.70) and women re-
porting less daily physical activity in the preceding year (OR,
1.27; CI, 1.08-1.50). When the analysis was carried out sep-
arately by menopause status, this association showed up only
among postmenopausal women (P for trend G 0.001), but the
test of heterogeneity was not statistically significant (P for
interaction = 0.586). Finally, women with osteoporosis had
better aMED index scores (OR, 0.78; CI, 0.64-0.94).
DISCUSSION
This study furnishes information on diet quality in the
largest sample of Spanish perimenopausal and postmeno-
pausal women reported to date. Our results indicate differences
indietqualityaccordingtowomen’sage,educationalandsocial
level, obesity, diabetes, and presence of other unhealthy habits
such as smoking or healthy habits such as physical activity.
Both the AHEI and aMED have been extensively used in
the scientific literature to assess diet quality. Both indices have
been improved on the originals by correcting some items on
the basis of findings in nutritional epidemiology, such as the
elimination of potatoes from the leafy green vegetable food
group. These updates have shown their enhanced usefulness
by being more strongly associated with health markers and
disease development than were the original indices.9Con-
sequently, it has been reported that higher AHEI and aMED
scores not only reduce the risk of developing cardiovascular
diseasesinthegeneralpopulation7,9but are alsoassociated with
lower incidence of breast cancer in postmenopausal women.10
When it comes to interpreting the results obtained with both
indicators, it is important to bear in mind that whereas the
AHEI uses fixed criteria for its scores, the aMED allocates
scores according to the median values obtained in that partic-
ular study. Accordingly, high AHEI scores indicate healthy
diets that have been shown to be beneficial for health in sci-
entific studies, whereas high aMED values indicate Bmore
Mediterranean[ diets than the average of the study sample
itself.
The association between sociodemographic characteristics,
lifestyle, and diet quality has been widely studied in the lit-
erature, but there are few studies that focus on perimenopausal
and postmenopausal women. Smoking and doing little or no
daily physical activity are associated with lower diet quality,
based on both indices in our study. The association between
smoking,20<25low physical activity,20,21,23,25and poor diet
quality is in line with data described in the literature, reflecting
behavior patterns in which several rather unhealthy lifestyles
are involved. Our data indicate better diet quality among ex-
smokers than among nonsmokers, a result reported previ-
ously only by a study conducted on obese postmenopausal
women26; similarly, better indicators of diet quality were
observed among postmenopausal women and those who have
osteoporosis, a finding never reported before. These associa-
tions might reflect the concern about health felt by women
who have quit smoking because of a conscious decision in
favor of a healthier life and a higher awareness of the impor-
tance of a healthy diet, after undergoing the physiological
changes of menopause or, alternatively, after being diagnosed
with a disease such as osteoporosis, the progress of which is
highly influenced by diet.
Some of the studies reviewed also highlight an association
between good diet quality and higher age,22,25,27as occurred
in our study. This association might reflect the fact that these
women are aware that an improvement in diet quality may
help prevent or minimize the effects of aging-related diseases.
Alternatively, these results might be accounted for by a pro-
gressive worsening of diet in more recent generations, as has
been suggested by some authors.28To our knowledge, this is
the first study to find an interaction between age and meno-
pause status with regard to the quality of the diet. Our results
indicate that increased age is associated with better diets much
more strongly in premenopausal than in postmenopausal
women, which may indicate a greater concern with healthy
diet at ages closer to the time of menopause.
When the AHEI was used, diabetes and one of its most
important risk factors, namely, obesity, were both associated
with lower diet quality; with the aMED index, however, only
obesity seemed too be associated with lower diet quality. The
relationship between obesity and lower diet quality in women
is well known, having been described in both interna-
tional22,27and Spanish-based studies.23The inverse associa-
tion between diet quality, as measured by the AHEI, and risk
Menopause, Vol. 19, No. 10, 2012 7
DIET QUALITY IN SPANISH WOMEN
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

Page 8

of developing diabetes has already been reported in a pro-
spective study that covered more than 80,000 US nurses.29
Although our study’s cross-sectional design prevents us from
making a proper assessment of the direction of the associa-
tion, the FFQ referred to the preceding 12 months, so that our
results would suggest that diabetic women in the study failed
to follow the dietary guidelines that form part of the standard
treatment for this disease.
The results published by other authors confirm better diet
quality in women with a higher socioeconomic30,31and/or
higher educational21,23,24,30level. The higher cost of health-
ier diets is one of the reasons that has been most cited to
explain socioeconomic inequalities in diet quality.32,33For its
part, the association between poor diet quality and low edu-
cational level has also been linked to such women’s lack of
knowledge about and lack of control over their own diets.34,35
Better diet quality was also observed among nulliparous
premenopausal and perimenopausal women than among those
who had borne children. The only study published that ana-
lyzes this association agrees with our results and was con-
ducted on pregnant women.36Interestingly, this association
was not found in our study among postmenopausal women.
The correlation between the two indices used, albeit sig-
nificant, is more modest than could be expected (r = 0.470).
The principal explanation for this would obviously be the
difference in the items included in the two scales. Further-
more, as mentioned above, whereas aMED scores depend
on the intake of the sample itself for their reference value,
the AHEI relies on an ideal external pattern as its reference.
For instance, intake of nuts was insufficient in 72.7% of the
women in the study according to the fixed values of current
Spanish guidelines,37and 75% of women scored less than 3
of 10 points in the AHEI BNuts and soy protein[ item; how-
ever, by virtue of its design, approximately half the women
scored the maximum value (1 point) in this item on the aMED
index because they exceeded the median intake of nuts in the
study population. In this respect, the use of an index with an
external reference (the AHEI) and one that takes consump-
tion within the study itself as its reference (the aMED) implies
complementary approximations that go some way to solving
the difficulty posed by assessing diet quality with a single
index.5,6In our study, the consistency of results using the
AHEI and aMED should be stressed: mean AHEI scores by
aMED tertile were consistent, with 34.72 (SD, 6.70) for the
first aMED tertile, 42.78 (SD, 6.82) for the second tertile, and
50.65 (SD, 7.43) for the tertile of best diet quality. Fur-
thermore, the factors associated with quality measured with
both indices are generally the same, and the ORs invariably
go in the same direction, which may reinforce our findings,
and using two indexes should facilitate comparison with other
studies using only one of these indexes, particularly for fac-
tors such as age and menopause status.
Our study has the limitations inherent in all cross-sectional
studies, such as the inability to establish causal associations
with a clear time sequence among the different factors studied
and their relationship with diet quality. FFQs also display
limitations, inasmuch as it has been reported that some women
may overestimate the consumption level of foods socially
considered healthy and underestimate the consumption of
foods socially considered less acceptable.38In the case of our
questionnaire, however, when the FFQ was compared with
four 7-day diet records, the mean correlation coefficients for
validity and reproducibility at 1 year for nutrient intake were
0.47 and 0.40, respectively, whereas a similar version adapted
for an older population also showed good biochemical valid-
ity for carotenoids and vitamin C.12
With respect to the representativeness of the study pop-
ulation and the possible extrapolation of our results to the gen-
eral population of women in the same age ranges, one also has
to bear in mind that the mere fact of participating in a screen-
ing program implies adopting a preventive measure: these par-
ticipants might arguably be more concerned about their health
and adopting healthy lifestyles than women in general. It has
been claimed that women who do not participate in such pro-
grams may have different sociodemographic characteristics,
such as belonging to higher classes that make use of private
services or to very low social classes that do not participate
because of fear, ignorance, or timetable difficulties.39Notwith-
standing this, however, coverage of breast cancer screening in
Spain is estimated to have reached practically 100% of the
target population in all Autonomous Regions (Comunidades
Auto ´nomas) in 2006, and participation rates are high,40some-
thing thatwouldsupportour study’sexternalvalidity.Although
we could not avoid this possible bias, our study included a
broad sample of women representing all socioeconomic levels,
which might minimize this limitation. Furthermore, the per-
centage of overweight and obese women was high. 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 female participants may or may
not represent all the women in this age range who undergo
screening. According to the information provided by the
SpanishNationalHealthSurveyforSpanishwomeninthesame
age range,41our women were very similar to the national sam-
ple in terms of prevalence of alcohol consumption (52% vs
53%), prevalence of nonsmokers (57% vs 56%), prevalence
of intense physical activity (12% vs 14%), and use of hormone
treatment (2.5% vs 3.0%). The prevalence of obesity was
higher in our study (29.5% vs 24.9%), but in the national sur-
vey, BMI was based on self-reported data, which implies a
substantial underestimation of overweight and obesity.42
CONCLUSIONS
TherearesignificantdifferencesinthedietqualityofSpanish
women who participate in breast cancer screening programs,
depending on their sociodemographic characteristics and life-
styles. Screening attendance provides an excellent opportunity
for education and advice regarding modifiable health determi-
nants, such as diet. Health promotion campaigns highlighting
the advantages of adopting a varied and balanced diet, along
with recommendations to engage in daily physical activity,
would be especially important among this sector, particularly
8
Menopause, Vol. 19, No. 10, 2012
* 2012 The North American Menopause Society
GARCI´A-ARENZANA ET AL
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

Page 9

among those younger than 50 years having a lower educational
level and more modest socioeconomic level, because these
women display a less healthy dietary pattern and a higher prev-
alence of smoking and sedentarism.
Acknowledgments: We thank the participants in the DDM-Spain
study for their contribution to breast cancer research.
Other members of DDM-Spain: Virginia Lope,2,4Gonzalo
Lo ´pez-Abente,2,4Anna Cabanes,2,4Francisco Ruiz-Perales,6Maria
Soledad Laso,6Manuela Alcaraz,6Milabros Garcı ´a-Lo ´pez,4,7
Francisco Casanova,8Montserrat Corujo,10Ana Bele ´n Ferna ´ndez,10
and Soledad Abad.11
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Menopause, Vol. 19, No. 10, 2012 9
DIET QUALITY IN SPANISH WOMEN
Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.