Eur J Nutr (2015) 54:679689
DOI 10.1007/s00394-014-0746-4
ORIGINAL CONTRIBUTION
Overweight and obesity in 16 European countries
Silvano Gallus Alessandra Lugo Bojana Murisic
Cristina Bosetti Paolo Boffetta Carlo La Vecchia
Received: 2 December 2013 / Accepted: 22 July 2014 / Published online: 5 August 2014
Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose In Europe, only a few population-based studies
have been conducted on obesity in different countries at the
same time using homogeneous methodologies. We provide
updated information on the prevalence of overweight and
obesity in Europe, using data from a pan-European survey.
Methods We considered data from a representative cross-
sectional study conducted in 2010 in 16 European countries
(i.e., Albania, Austria, Bulgaria, Czech Republic, Croatia,
England, Finland, France, Hungary, Ireland, Italy, Latvia,
Poland, Romania, Spain, and Sweden), using a uniform
protocol and comparable methods, on a total of 14,685
adults (aged C18 years) providing information on self-
reported height and weight.
Results Almost half of the interviewed European
adults (47.6 %) were overweight or obese (54.5 % in men
and 40.8 % in women), and 12.8 % (14.0 % in men and
11.5 % in women) were obese. Obesity prevalence was
lower in Western/Southern (11.1 %) than in Central/East-
ern (12.4 %) and Northern European countries (18.0 %). It
ranged from 7.6 % in Italy to more than 20 % in Croatia
(21.5 %) and England (20.1 %). Prevalence of obesity
S. Gallus (&)
B. Murisic
C. Bosetti
Department of Epidemiology, IRCCS - Istituto di Ricerche
Farmacologiche Mario Negri, Via Giuseppe La Masa 19,
20156 Milan, Italy
e-mail: silvano.gallus@marionegri.it
A. Lugo
C. La Vecchia
Department of Clinical Sciences and Community Health,
Universita` degli Studi di Milano, Milan, Italy
P. Boffetta
Institute for Translational Epidemiology and Tisch Cancer
Institute, Ichan School of Medicine at Mount Sinai, New York,
NY, USA
significantly increased with age and decreased with level of
education. As compared to never smokers, obesity was less
frequent in current smokers and more frequent in male, but
not female, ex-smokers.
Conclusions The lowest prevalence of obesity was
observed in Mediterranean countries, particularly in Italy
and France. Intervention to control obesity in Europe
should focus on subgroups with higher prevalence of
obesity, including adults of lower socioeconomic status
and male ex-smokers.
Keywords Overweight
Obesity prevalence

Pan-European survey
Europe
Introduction
Obesity is one of the leading causes of preventable mor-
bidity and mortality from cardiovascular diseases, diabetes,
cancer, and several other chronic diseases [17]. The
prevalence of obesity worldwide nearly doubled over the
last three decades [3]. This rise was even more pronounced
in the USA [2], and today, one in three adults is obese and
more than two in three adults are overweight or obese [4,
8].
Obesity also increased in several European countries
over the past two decades [3, 7]. Many countries in Europe
periodically monitor the prevalence of overweight and
obesity by conducting local or national surveys [6, 9],
whose estimates are also available in the online databases
of international organizations [6, 7, 911], or are consid-
ered and compared in several reviews [3, 1214]. However,
not all of these surveys are based on representative samples
of the target populations. Furthermore, biased comparisons
may arise in such databases or reviews due to different
123
680
year(s) of data collection and different methods used in
various studies [6, 12, 15]. These sources of bias include as
follows: (1) sampling methods (representative vs. non-
representative; quota sampling vs. multistage random
sampling; household vs. individual surveys); (2) study
design (face-to-face vs. telephone vs. mail or internet-
based interview); (3) target population (overall population
vs. specific agesex groups); (4) sample size; and (5) body
mass index assessment (measured vs. self-reported) [7].
Therefore, substantial discrepancies in terms of obesity
prevalence were reported when using different datasets
from the same European country [10, 12], and comparisons
of obesity rates between European countries may be
misleading.
More reliable comparisons can be generated from pan-
European studies, conducted in different countries at the
same time using homogeneous methods. However, the few
existing pan-European studies [1622] have various limi-
tations. Many are relatively outdated [1618], some com-
pare only a few European countries [19], some are based
on non-representative samples of the adult population [18,
22], or provide nonstandard anthropometric estimates that
can be difficult to interpret [21].
Taking advantage of a survey conducted on national
representative samples from 16 European countries using
the same protocol and comparable methods, we here pro-
vide a comprehensive evaluation and comparison of prev-
alence patterns of overweight and obesity across Europe
[15, 23, 24].
Methods
We derived data from a face-to-face cross-sectional survey
designed to study economic aspects of smoking in Europe
[15, 23, 24]. The survey was coordinated by DOXAthe
Italian branch of the Worldwide Independent Network/
Gallup International Association (WIN/GIA), and was
conducted between January and July 2010 in 18 European
countries (i.e., Albania, Austria, Bulgaria, the Czech
Republic, Croatia, England, Finland, France, Greece, Hun-
gary, Ireland, Italy, Latvia, Poland, Portugal, Romania,
Spain, and Sweden). Each country included a sample size of
around 1,000 individuals, representative of their general
population aged 15 or over in terms of age, sex, geographic
area, and socioeconomic characteristics. In several countries
(Albania, Croatia, Hungary, Italy, Poland, and Romania),
we used a multistage sampling method; in Austria, England,
Finland, France, and Ireland, we used a quota method for the
selection of the entire sample; for most of the remaining
countries, we used a stratified random method. Participation
rate varied according to the sampling method used. It ranged
between 15 % in Spain and 79 % in Hungary, and was 49 %
123
Eur J Nutr (2015) 54:679689
overall. In the data processing phase, statistical weights were
generated to balance the sample of respondents to assure
representativeness of the corresponding national popula-
tions in terms of age, sex, and socioeconomic characteristics.
Full details of the survey methodology and participation rate
are reported elsewhere [15, 23]. A copy of the English ver-
sion of the questionnaire is available online [23].
The surveys included information on self-reported
height (cm) and weight (kg). Reliable data on height and
weight were not available from Portugal, which was
therefore excluded from this analysis. Moreover, we
excluded the Greek sample, since it was based on subjects
aged 1565 years only. Consequently, we based our study
on 15,619 adults aged C18 years. We further excluded 934
adults (6.0 %) who did not provide data on their height and
weight. Thus, our analysis was based on a total of 14,685
adults (7,107 men and 7,578 women) from 16 European
countries.
We computed body mass index (BMI) as the ratio
between weight (kg) and height (m2). BMI was categorized
into four groups, according to the standard classification by
the World Health Organization [5], i.e., underweight
(BMI \ 18.5 kg/m2), normal weight (BMI between 18.5
and 24.9 kg/m2), overweight (BMI between 25.0 and
29.9 kg/m2), and obesity (BMI C 30.0 kg/m2). We then
categorized obesity into three classes, according to its
severity (I class obesity: BMI between 30.0 and 34.9 kg/m2;
II class obesity: BMI between 35.0 and 39.9 kg/m2; and III
class obesity: BMI C 40.0 kg/m2).
Education was categorized into three levels (low/inter-
mediate/high), according to the country-specific school
system. An additional question referring to the years or
level of education allowed us to assess reproducibility of
the education classification. With reference to geographic
area, countries were categorized in Northern (England,
Finland, Ireland, and Sweden), Western/Southern (France,
Italy, and Spain), and Central/Eastern Europe (Albania,
Austria, Bulgaria, Croatia, Czech Republic, Hungary,
Latvia, Poland, and Romania).
The study protocol was approved by the Institutional
Review Board of the Istituto di Ricerche Farmacologiche
Mario Negri in Milan, Italy.
Statistical analysis
Statistical weights were used to generate prevalence esti-
mates representative of the general population. To calcu-
late the results for the whole sample, we applied a
weighting factor, with each country contributing in pro-
portion to its adult population.
We computed overall and country-specific percent
prevalence of overweight and obesity, in the total popula-
tion and separately in men and women. For each country,
Eur J Nutr (2015) 54:679689 681

we further computed sex-specific prevalence of overweight Table 1 Mean values for weight, height, and BMI for 14,685
and obesity, standardized by four categories of age (1829, European adults, and percent distribution according to levels of BMI,
overall, and by sex
3049, 5069, and C70 years), using the direct method,
considering the population of the European Union (EU) as Total Sex
the reference population. Men Women
We estimated the odds ratios (OR), overall and sep-
arately for men and women, and corresponding 95 % Number of adults 14,685 7,107 7,578
confidence intervals (CI), for obesity versus normal Mean height (cm); 169.6 9.5 175.8 7.5a 163.5 6.7a
mean SD
weight/underweight for individual-level characteristics
Mean weight (kg); 73.0 15.3 80.3 14.0a 66.0 12.9a
using a multi-level (two-levels) logistic random effects mean SD
model (random intercept) in order to account for the Mean BMI (kg/m2); 25.3 4.6 26.0 4.2a 24.7 4.8a
heterogeneity between countries. Country effects were mean SD
considered as random, and age, education, and tobacco BMI (kg/m2); %
smoking status as adjusting variables. ORs and the Underweight 2.6 1.3 3.9
corresponding 95 % CIs for geographic area were esti- (BMI \ 18.5)
mated by unconditional multiple logistic regression Normal weight 49.8 44.2 55.3
(18.5 B BMI \ 25)
models, including terms for age, education, and tobacco
Overweight 34.8 40.5 29.3
smoking. All the ORs for the total population were (25.0 B BMI \ 30.0)
estimated after further adjustment for sex. The analyses Obesity (BMI C 30.0) 12.8 14.0 11.5
were conducted using the GLIMMIX procedure in SAS I class 10.0 11.4 8.5
9.2 (SAS Institute). (30.0 B BMI \ 35.0)
II class 2.0 1.7 2.3
(35.0 B BMI \ 40.0)
Results III class (BMI C 40.0) 0.8 0.9 0.7
Mean and prevalence estimates were computed weighting each country
Table 1 shows the distribution of 14,685 European adults, in proportion to the country-specific adult population
according to self-reported anthropometric characteristics. SD standard deviation
a
The mean height was 169.6 cm (175.8 cm in men and Comparison between sexes: p \ 0.001
163.5 cm in women), the mean weight was 73.0 kg
(80.3 kg in men and 66.0 kg in women), and the mean BMI
was 25.3 kg/m2 (26.0 kg/m2 in men and 24.7 kg/m2 in overweight/obesity rates from 43.5 to 47.9 % overall (from
women). Overall, 2.6 % of the European adult population 50.0 to 52.2 % in men and from 36.8 to 44.9 % in women)
was underweight (1.3 % of men and 3.9 % of women), and obesity rates from 11.1 to 14.3 % overall (from 12.8 to
49.8 % was normal weight (44.2 % of men and 55.3 % of 13.7 % in men and from 9.3 to 14.9 % in women).
women), 34.8 % was overweight (40.5 % of men and Table 3 shows the ORs for obesity versus normal
29.3 % of women), and 12.8 % was obese (14.0 % of men weight/underweight according to selected individual-level
and 11.5 % of women). Overall, 10.0 % had I class obes- characteristics and geographic area. Compared with men,
ity, 2.0 % II class, and 0.8 % III class obesity. the OR for female obesity was 0.56 (95 % CI 0.500.63).
Figure 1 shows the percent prevalence of overweight Obesity prevalence increased with age, the ORs being
and obesity in each European country. Overall, the highest 3.82 for 2544, 8.89 for 4564, and 9.37 for C65 years
prevalence estimates of overweight/obesity were observed compared with \25 years old (p for trend \0.001). Adults
in Hungary (65.4 %), Croatia (58.2 %), and England with higher education had a significantly lower obesity
(56.0 %) and the lowest ones in Italy (38.5 %), France prevalence: compared with low education, the ORs were
(41.7 %), and Albania (43.5 %). The highest prevalence 0.67 for intermediate and 0.57 for high level of education
estimates of obesity were in Croatia (21.5 %), England (p for trend \0.001). When compared to never smokers,
(20.1 %), and Finland (18.9 %) and the lowest ones in Italy the OR was 0.59 (95 % CI 0.520.68) for current smokers
(7.6 %), Hungary (9.8 %), and Poland (10.3 %). Figure 2 and 1.06 (95 % CI 0.921.23) for ex-smokers. Compared
and Table 2 show the overweight/obesity and obesity rates with adults from Northern Europe, those from Western/
by sex in each country. Southern Europe (OR 0.47, 95 % CI 0.410.53) and
Table 2 also shows the age-standardized prevalence Central/Eastern Europe (OR 0.69, 95 % CI 0.600.80)
estimates overall and by country. For both sexes, the were less frequently obese. The OR estimates were con-
standardization did not substantially change our results sistent in both men and women, except for those for
except in case of Albania, where standardization increased smoking status, where male (OR 1.56), but not female ex-

123
682 Eur J Nutr (2015) 54:679689

Fig. 1 Percent prevalence of

overweight
(25 B BMI \ 30 kg/m2) and
obesity (BMI C 30 kg/m2)
among adults from 16 European
countries. Countries are colored
according to their prevalence of
overweight/obesity (light
relatively low prevalence; dark
relatively high prevalence).
Prevalence estimates for the
overall population were
computed weighting each
country in proportion to the
country-specific adult
population

smokers (OR 0.75), were more likely to be obese com-
pared with never smokers.
Discussion
In our comprehensive evaluation of overweight and obesity
of European adults in 2010, we found that obesity preva-
lence was 12.8 % (14.0 % in men and 11.5 % in women),
and the proportion of adults reporting a BMI C 25 kg/m2
was 47.6 % (54.5 % in men and 40.8 % in women). When
compared to the 2010 obesity prevalence estimates in the
USA, our European estimates were less than half (14.0 vs.
35.5 % in men and 11.5 vs. 35.8 % in women, respec-
tively) [4]. Even the highest obesity rates observed (24.8 %
in UK men and 19.9 % in Croatian women) were sub-
stantially lower than those from the USA [3, 4, 8].
Northern European countries showed relatively high
rates of obesity, whereas Western/Southern Europe had
lowest prevalence rates. For each considered country,
Table 4 shows the comparison between obesity preva-
lence from our study and other available estimates from
recent studies conducted using self-reported and measured
assessment of height and weight. Considering Northern
European countries, our data confirm that in England
obesity prevalence exceeded 20 % [6, 7, 14, 25, 26], it
was almost as high in Finland [6, 7, 14, 27] but sub-
stantially lower in Sweden [6, 7, 28]. We also found a
low obesity prevalence rate in Ireland, in broad agreement
with a World Health Organization (WHO) database [6]
but two-fold lower than the estimate found in an Office of
Economic Cooperation and Development (OECD) report
[7].
There are inadequate data on obesity from most Eastern
European countries, usually from limited quality studies
[6]. One of the added values of the present study is that it
provides valuable information on countries where no reli-
able data on obesity prevalence are available. Our study
confirms high obesity rates in Latvia, particularly among
women, [6, 7, 12] and in Croatia [6, 29], and a relatively
favorable obesity pattern in Austria [6, 7, 30, 31]. Com-
pared with obesity rates found in previous studies, our
estimates are lower in Poland [6, 7, 19] and, in particular,
in the Czech Republic [6, 7, 14], Albania [32, 33], and
Hungary [6, 7]. In Hungary, however, we found the highest
overweight/obesity prevalence among the 16 considered

123
Eur J Nutr (2015) 54:679689 683

Fig. 2 Percent prevalence of

obesity (BMI C 30 kg/m2) and
overweight/obesity
(BMI C 25 kg/m2), overall and
by country, in male and female
adults from 16 European
countries. Prevalence estimates
for the overall population were
computed weighting each
country in proportion to the
country-specific adult
population

countries. Thus, the lower prevalence of obesity could be
due to an underreporting of obesity among overweight
adults. Conversely, in Romania, we found higher obesity
rates than in a recent OECD report [6, 7], but in line with
another study based on direct measures of weight and
height [34].
With reference to Western/Southern Europe, we confirm
a low obesity prevalence in France [6, 7, 35, 36] and higher
obesity rate in Spain [6, 7, 37], which was even higher in a
study using direct measures of weight and height [38]. We
observed the lowest obesity prevalence in Italy (around
8 %), in agreement with previous studies [6, 7, 39, 40]. In
contrast, a European report [12] identified Italy among the
countries with the highest obesity rates (22 % in men and
28 % in women). However, that report derived Italian
obesity prevalence estimates from a survey conducted in
19982000 in a rural area from Northern Italy on a rela-
tively small sample, mainly consisting of elderly subjects
[12, 41], thus far from being representative of the Italian
adult population.

123
 684

123
Table 2 Crude and age-standardized percent prevalencea of overweight/obesity (BMI C 25 kg/m2) and obesity (BMI C 30 kg/m2), overall, and by country
Sample characteristics Prevalence (%) of overweight/obesity Prevalence (%) of obesity
Age range Mean age Median age N Men Women Men Women
(years) (years) (years)
Men Women Crude Age- Crude Age- Crude Age- Crude Age-
standardized standardized standardized standardized

Totalb C18 47 46 7,107 7,578 54.5 53.7 40.8 40.5 14.0 13.7 11.5 11.4
Country
Albania 1880 39 38 498 484 50.0 52.2 36.8 44.9 12.8 13.7 9.3 14.9
Austria C18 47 45 406 529 50.0 49.2 39.6 39.9 10.8 10.7 10.3 10.4
Bulgaria C18 47 48 466 509 54.5 52.7 42.8 41.7 13.7 13.3 11.2 11.4
Croatia C18 50 50 428 485 64.3 62.3 52.7 48.8 23.3 22.6 19.9 17.6
Czech Rep. C18 44 43 390 408 56.4 58.6 36.5 39.2 11.8 13.7 11.5 13.4
England C18 49 48 357 429 65.3 63.9 47.1 46.5 24.8 24.2 15.5 15.2
Finland 1879 47 47 434 464 61.7 60.3 47.6 47.1 21.9 20.8 15.8 14.5
France C18 49 49 429 453 44.7 42.7 38.5 36.2 11.7 11.1 12.7 11.5
Hungary C18 45 43 492 510 68.9 68.4 62.0 63.0 11.4 11.2 8.2 9.4
Ireland C18 43 41 455 472 55.0 55.9 38.8 38.9 13.5 14.3 10.9 11.3
Italy C18 49 47 418 459 47.4 46.3 30.1 28.7 7.0 6.5 8.2 7.9
Latvia 1874 44 43 460 528 52.2 55.1 50.9 53.1 13.8 14.9 18.3 20.7
Poland 1879 43 42 411 410 57.1 58.9 38.7 41.2 12.3 13.8 8.3 10.6
Romania C18 46 45 493 493 51.7 53.0 46.0 45.0 15.1 15.8 16.9 16.5
Spain C18 45 42 473 491 61.9 62.0 44.8 48.8 17.7 17.7 10.5 11.4
Sweden C18 52 52 497 454 53.1 53.2 39.0 39.2 10.7 11.2 10.6 11.1
a
Estimates are standardized by age, using the direct method with the population of the European Union as the reference population
b
Prevalence estimates for the overall population were computed weighting each country in proportion to the country-specific adult population
Eur J Nutr (2015) 54:679689
 Table 3 Percent prevalencea of obesity (BMI C 30 kg/m2) and odds ratios (OR)b for obesity versus normal weight/underweight (BMI \ 25 kg/m2) with corresponding 95 % confidence
intervals (CI) according to selected individual-level characteristics and geographic area, overall, and by sex
Total Men Women
N Obesity OR (95 % CI) N Obesity OR (95 % CI) N Obesity OR (95 % CI)
prevalence (%) prevalence (%) prevalence (%)

Sex
Men 7,107 14.0 1c
Eur J Nutr (2015) 54:679689

Women 7,578 11.5 0.56 (0.500.63)

Age
\25 1,950 3.8 1c 991 4.8 1c 959 2.7 1c
2544 5,294 9.4 3.82 (2.934.99) 2,534 11.0 3.65 (2.615.10) 2,760 7.8 3.97 (2.556.18)
4564 4,770 16.6 8.89 (6.8311.56) 2,306 18.8 8.61 (6.1712.02) 2,464 14.5 8.79 (5.6913.60)
C65 2,671 17.8 9.37 (7.1212.33) 1,276 17.9 7.85 (5.5011.2) 1,395 17.8 9.75 (6.2415.24)
p for trend \0.001 \0.001 \0.001
Educationd
Low 4,637 15.9 1c 2,461 15.4 1c 2,176 16.3 1c
Intermediate 6,857 10.6 0.67 (0.590.76) 3,136 12.9 0.87 (0.731.03) 3,721 8.5 0.52 (0.440.63)
High 3,189 10.6 0.57 (0.490.67) 1,509 13.4 0.82 (0.661.03) 1,680 7.8 0.41 (0.320.52)
p for trend \0.001 0.059 \0.001
Smoking status
Never smoker 8,014 13.2 1c 3,278 13.0 1c 4,736 13.4 1c
Current smoker 4,317 9.4 0.59 (0.520.68) 2,443 11.3 0.75 (0.630.90) 1,874 6.9 0.50 (0.400.62)
Ex-smoker 2,354 17.0 1.06 (0.921.23) 1,386 20.6 1.56 (1.291.89) 968 11.3 0.75 (0.590.95)
Geographic areae
Northern Europe 3,562 18.0 1c 1,743 21.5 1,819 14.5
Western/Southern Europe 2,723 11.1 0.47 (0.410.53) 1,320 11.8 0.40 (0.320.48) 1,403 10.4 0.52 (0.430.64)
Central/Eastern Europe 8,400 12.4 0.69 (0.600.80) 4,044 13.3 0.60 (0.490.74) 4,356 11.5 0.78 (0.630.97)
a
Prevalence estimates were computed weighting each country in proportion to the country-specific adult population
b
ORs were estimated using multi-level logistic regression models after adjustment for age, level of education, and smoking status, with country as random effect. ORs for the total population
were further adjusted for sex. Estimates were weighted for statistical weights that consider country-specific adult population
c
Reference category
d
The sum does not add up to the total because of a few missing values
e
ORs were estimated using unconditional multiple logistic regression models after adjustment for age, level of education, and smoking status. ORs for the total population were further adjusted
for sex. Estimates were weighted for statistical weights that consider country-specific adult population
685

123
686 Eur J Nutr (2015) 54:679689

Table 4 Percent prevalence of Country Percent (%) obesity prevalence (study year)
obesity from the present study
(based on self-reported Present Based on self-reported height Based on measured
information on height and study (2010) and weight, or unknown assessment height and weight
weight), and other available of anthropometric measures
estimates, by country and type
of assessment of anthropometric Albania 11.1 30.0a (20072009) [37]
measures 26.5a (2001) [36]
b
Austria 10.5 11.0 (2008) [6]
12.8 (2008) [7]
Czech Republic 11.7 15.1b (2002) [6] 21.0 (2010) [7]
23.1a (2008) [18]
b
Croatia 21.5 22.3 (2003) [6] [20.0 (2003) [33]
England 20.1 22.7b (2002) [6] 26.1 (2010) [7]
23.9a (2006/2009) [18]
24.2a (2004) [30]
Finland 18.9 15.6 (2010) [7] 25.5a (2007) [18]
b
15.7 (2008) [6] 22.4a (20002001) [31]
France 12.2 12.9 (2010) [7] 11.8 (20062007) [40]
16.9b (2007) [6] 13.1 (2006) [39]
Hungary 9.8 17.7b (2004) [6] 28.5 (2009) [7]
Latvia 16.2 16.9 (2008) [7] 13.4 (1997) [16]
15.6b (2006) [6]
Ireland 12.2 13.0b (2002) [6] 23.0 (2007) [7]
Italy 7.6 10.0 (2011) [44]
10.3 (2010) [7]
8.9 (20062010) [43]
9.8b (2005) [6]
Poland 10.3 15.8 (2009) [7]
16.7 (2008) [23]
18.0b (2000/2001) [6]
Romania 16.0 7.9 (2008) [7] 16.8a [38]
b
8.6 (2000) [6]
Spain 14.0 16.0 (2009) [7] 22.9 (20082010) [42]
15.6b (20062007) [6]
a
Weighted mean of sex- Sweden 10.6 12.9 (2010) [7]
specific estimates 12.0b (2009) [6]
b
Unknown assessment of 10.8 (20042005) [32]
anthropometric measures

The relatively low obesity prevalence in Western/
Southern Europe can be explained by the dietary habits of
these countries, i.e., the adherence of their population to a
Mediterranean diet [1, 42], which has been shown to be
effective in controlling obesity [1, 4345]. Indeed,
although in some of those countries diet is rich in cheese
[46] and fats [47], and physical activity is relatively low
[21, 48], compared to Northern and Central/Eastern,
Southern European populations have been shown to con-
sume a higher amount of fruit, vegetables, fish, and a lower
amount of meat, milk, sugar, and soft drinks [1, 46, 49].
However, some countries of the Mediterranean area,
including Spain, are progressively making a transition from
the traditional Mediterranean diet to diets resembling those
eaten in Northern Europe [49]. Thus, in Spain per capita
intake of meat, milk, and vegetables is approaching that of
Northern Europe [1, 46].
Comparing our estimates to those of a pan-European
survey conducted in 1997 in the 15 Member States of the
EU [16], using a sample methodology broadly comparable
to ours, we confirm that over the last one to two decades
there was no substantial rise in obesity in Italy [3, 7, 39]
and Austria [7, 30, 31], whereas obesity prevalence
increased by 27 % in Spain, by 51 % in Sweden, by 53 %
in Ireland, by 68 % in England, by 74 % in France, and by
89 % in Finland. These trends are in agreement with cur-
rent evidence, which shows a moderate increase in obesity
prevalence over the last two decades in Spain [7, 35] and

123
Eur J Nutr (2015) 54:679689
Sweden [7] and a substantial increase in the UK [3, 7, 25,
26], France [7, 35], and Finland [7, 27].
In 1997, there was a relatively low variability in obesity
prevalence among the 15 EU countries (from 7 % in Italy
and France to 12 % in the UK) [16], whereas now we
observe an appreciably larger heterogeneity (from 8 % in
Italy to more than 20 % in Croatia and England), confirm-
ing a trend toward increasing variation across Europe [3].
Overall, European men are more likely to be obese than
women. This is particularly the case in countries with rel-
atively high obesity rates, including England (24.8 % in
men and 15.5 % in women), Finland (21.9 % in men and
15.8 % in women), Spain (17.7 % in men and 10.5 % in
women), and Croatia (23.3 % in men and 19.9 % in
women). This contrasts with the US patterns, where obesity
rates are similar in both sexes [4]. Conversely, we observed
higher obesity rates among women than men in countries
with a relatively low obesity prevalence, such as Italy
(7.0 % in men and 8.2 % in women) and France (11.7 % in
men and 12.7 % in women), as observed in the 2008 global
obesity prevalence estimates (9.8 % in men and 13.8 % in
women) [3]. We also confirm that the OR of being obese
increases with age in both men and women, overall, and in
all countries [14, 39].
Our data confirm that, in high-income countries, adults
with the highest level of education have the lowest prev-
alence of obesity [7, 16, 38, 39, 5052]. Different levels of
socioeconomic development cause international differ-
ences in terms of the direction and strength of the relation
between education and obesity [51]. Thus, in low-income
countries, obesity is more frequent in the highest socio-
economic groups, whereas in middle- to high-income
countries, higher frequency of obesity is observed in
groups with lower socioeconomic levels [53, 54]. The
inverse educational gradient of overweight and obesity in
high-income countries can be explained by the less healthy
diet and the lower level of leisure-time physical activity in
subjects with lower socioeconomic status [38]. In our
population, the inverse relation with education was even
more pronounced in women than in men, consistently with
previous findings [50].
Current smokers are less frequently obese than never
smokers, in agreement with several other studies [55, 56].
Male but not female ex-smokers were more likely to be
obese than never smokers. Weight gain usually follows
smoking cessation, and ex-smokers are generally more
frequently overweight/obese than never or current smok-
ers [5557]. Weight gain after smoking cessation has
been related to increased caloric intake, due to a substi-
tution of food for smoking [58]. Female ex-smokers were
less likely to be obese. This may be due to women being
more careful than men in controlling weight after smok-
ing cessation.
687
The main limitation of our study is the use of self-
reported information on height and weight, which likely
resulted in an underestimate of BMI [59, 60]. In fact,
adults, particularly women, tend to overestimate height and
to underestimate weight [39, 61]. Accordingly, a 2009
report from Switzerland and France showed how the
threshold to define obese adults with self-reported infor-
mation on anthropometric measures should be decreased
from 30.0 to 29.2 kg/m2 to be compared with objectively
measured anthropometric characteristics [62]. Applying
this cutoff to the BMI of our population, the overall
prevalence of obese subjects would increase from 12.8 to
16.8 %, ranging between 11.2 % in Italy and 25.7 % in
Croatia. The ranking of various countries in terms of
obesity prevalence would not substantially change, except
for Hungary which would increase its obesity prevalence
from 9.8 % up to 15.3 %. Furthermore, BMI does not
measure body fat like other metrics that include body
composition and abdominal obesity [8, 63]. Other limita-
tions include those inherent to the cross-sectional study
design. We collected no data on participants genetic,
environmental, and other determinants of overweight/
obesity, including diet, alcohol drinking, and physical
activity. Finally, the differences in the sampling methods
and in the response rates used in various European coun-
tries may have had some impact on outcomes. The
strengths of our study include the large sample size, the
representativeness of adult populations, and the possibility
to reliably compare obesity estimates from various coun-
tries, due to the homogeneous protocols and methods used
to collect individual data in the 16 European countries.
Moreover, the use of a computer-assisted personal inter-
viewing (CAPI) survey administered by trained inter-
viewers allowed us to avoid routing errors and to obtain
more valid and reliable data on height and weight [64].
Furthermore, our analysis adds valuable data on several
Eastern European countries with limited updated informa-
tion on obesity available to date.
In conclusion, obesity patterns in Europe remain sub-
stantially more favorable than those in the USA, although
almost half of our European adult population is overweight
or obese. Obesity rates in Europe vary greatly, with
Northern countries having the highest prevalence and
Western/Southern European countries, including in par-
ticular Italy and France, having the lowest prevalence.
Intervention to control obesity in Europe should focus on
specific subgroups with elevated prevalence of obesity,
including adults of lower socioeconomic status and male
ex-smokers.
Acknowledgments The project Pricing Policies and Control of
Tobacco in Europe (PPACTE) was funded by the European Com-
mission Seventh Framework Programme Grant Agreement HEALTH-
123
688
F2-2009-223323. The work of SG, AL, CB, and CLV is partially
supported by the Italian Association for Cancer Research (AIRC, No.
10068) and the Italian League Against Cancer (LILT), Milan, Italy.
Conflict of interest The authors declare that they have no conflict
of interest.
Ethical standard The study protocol of the PPACTE survey was
approved by the Institutional Review Board of the IRCCS - Istituto di
Ricerche Farmacologiche Mario Negri, Milan, Italy. The proce- 17.
dures for recruitment of subjects, informed consent, data collection,
storage, and protection (based on anonymous identification code)
were in accordance with the current country-specific legislation. The
study has therefore been performed in accordance with the ethical
standards laid down in the 1964 Declaration of Helsinki and its later
amendments.
References
1. WHO (2007) The challenge of obesity in the WHO European
Region and the strategies for response. http://www.euro.who.
int/__data/assets/pdf_file/0010/74746/E90711.pdf. Accessed 17
Sept 2013
2. Austin GL, Ogden LG, Hill JO (2011) Trends in carbohydrate,
fat, and protein intakes and association with energy intake in
normal-weight, overweight, and obese individuals: 19712006.
Am J Clin Nutr 93:836843
3. Finucane MM, Stevens GA, Cowan MJ et al (2011) National,
regional, and global trends in body-mass index since 1980: sys-
tematic analysis of health examination surveys and epidemio-
logical studies with 960 country-years and 9.1 million
participants. Lancet 377:557567
4. Flegal KM, Carroll MD, Kit BK, Ogden CL (2012) Prevalence of
obesity and trends in the distribution of body mass index among
US adults, 19992010. JAMA 307:491497
5. WHO (2000) Obesity: preventing and managing the global epi-
demic. WHO Obesity Technical Report Series 894. World Health
Organization (WHO), Geneva, Switzerland. http://whqlibdoc.
who.int/trs/WHO_TRS_894.pdf. Accessed 24 Oct 2013
6. WHO (2013) WHO global database on body mass index. http://
apps.who.int/bmi/index.jsp. Accessed 18 Sept 2013
7. OECD iLibrary (2012) Health at a glance: Europe 2012, OECD
publishing. 10.1787/9789264183896-26-en. Accessed 18 Sept 2013
8. Ogden CL, Carroll MD, Kit BK, Flegal KM (2014) Prevalence of
childhood and adult obesity in the United States, 20112012.
JAMA 311:806814
9. WHO (2005) The SuRF Report 2; surveillance of chronic disease
risk factors. World Health Organization (WHO), Geneva,
Switzerland. https://apps.who.int/infobase/Publicfiles/SuRF2.pdf.
Accessed 17 Sept 2013
10. WHO (2011) WHO global infobase. https://apps.who.int/info
base/Comparisons.aspx. Accessed 18 Sept 2013
11. International Obesity Taskforce (IOTF) (2013) Obesity preva-
lence worldwide. http://www.iaso.org/iotf/obesity/. Accessed 18
Sept 2013
12. Berghofer A, Pischon T, Reinhold T, Apovian CM, Sharma AM,
Willich SN (2008) Obesity prevalence from a European per-
spective: a systematic review. BMC Public Health 8:200
13. Rabin BA, Boehmer TK, Brownson RC (2007) Cross-national
comparison of environmental and policy correlates of obesity in
Europe. Eur J Public Health 17:5361
14. Doak CM, Wijnhoven TM, Schokker DF, Visscher TL, Seidell
JC (2012) Age standardization in mapping adult overweight and
123
Eur J Nutr (2015) 54:679689
obesity trends in the WHO European Region. Obes Rev
13:174191
15. Gallus S, Lugo A, La Vecchia C et al (2014) Pricing Policies and
Control of Tobacco in Europe (PPACTE) project: cross-national
comparison of smoking prevalence In 18 European countries. Eur
J Cancer Prev 23:177185
16. Martinez JA, Kearney JM, Kafatos A, Paquet S, Martinez-Gonzalez
MA (1999) Variables independently associated with self-reported
obesity in the European Union. Public Health Nutr 2:125133
Molarius A, Seidell JC, Kuulasmaa K, Dobson AJ, Sans S (1997)
Smoking and relative body weight: an international perspective
from the WHO MONICA project. J Epidemiol Community
Health 51:252260
18. Haftenberger M, Lahmann PH, Panico S et al (2002) Overweight,
obesity and fat distribution in 50- to 64-year-old participants in
the European Prospective Investigation into Cancer and Nutrition
(EPIC). Public Health Nutr 5:11471162
19. Perez-Cueto FJ, Verbeke W, de Barcellos MD, Kehagia O,
Chryssochoidis G, Scholderer J, Grunert KG (2010) Food-related
lifestyles and their association to obesity in five European
countries. Appetite 54:156162
20. Eurostat (2013) European health interview survey (EHIS)col-
lection round 2008. http://epp.eurostat.ec.europa.eu/portal/page/
portal/health/public_health/data_public_health/database. Acces-
sed 18 Sept 2013
21. Eurobarometer (2006) Health and food. Special Eurobarometer
246/Wave 64.3. http://ec.europa.eu/health/ph_publication/eb_
food_en.pdf. Accessed 18 Sept 2013
22. Peytremann-Bridevaux I, Faeh D, Santos-Eggimann B (2007)
Prevalence of overweight and obesity in rural and urban settings
of 10 European countries. Prev Med 44:442446
23. Gallus S, Lugo A, La Vecchia C et al (2012) PPACTE, WP2:
European survey on smoking. PPACTE consortium. http://www.
ppacte.eu/index.php?option=com_docman&task=doc_download&
gid=185&Itemid=29. Accessed 12 Mar 2013
24. Gallus S, La Vecchia C (2012) Tobacco control: economic
aspects of smoking. Prev Med 55:546547
25. Howel D (2011) Trends in the prevalence of obesity and over-
weight in English adults by age and birth cohort, 19912006.
Public Health Nutr 14:2733
26. Zaninotto P, Head J, Stamatakis E, Wardle H, Mindell J (2009)
Trends in obesity among adults in England from 1993 to 2004 by
age and social class and projections of prevalence to 2012.
J Epidemiol Community Health 63:140146
27. Lahti-Koski M, Seppanen-Nuijten E, Mannisto S, Harkanen T,
Rissanen H, Knekt P, Rissanen A, Heliovaara M (2010) Twenty-
year changes in the prevalence of obesity among Finnish adults.
Obes Rev 11:171176
28. Sundquist J, Johansson SE, Sundquist K (2010) Levelling off of
prevalence of obesity in the adult population of Sweden between
2000/01 and 2004/05. BMC Public Health 10:119
29. Heim I, Leontic K, Gostovic MJ (2007) Obesity and overweight
in Croatia. Acta Med Croatica 61:267273
30. Grossschadl F, Stronegger WJ (2012) Regional trends in obesity
and overweight among Austrian adults between 1973 and 2007.
Wien Klin Wochenschr 124:363369
31. Grossschadl F, Stronegger WJ (2013) Long-term trends in obesity
among Austrian adults and its relation with the social gradient:
19732007. Eur J Public Health 23:306312
32. Shapo L, Pomerleau J, McKee M, Coker R, Ylli A (2003) Body
weight patterns in a country in transition: a population-based
survey in Tirana City, Albania. Public Health Nutr 6:471477
33. Spahija B, Qirjako G, Toci E, Roshi E, Burazeri G (2012)
Socioeconomic and lifestyle determinants of obesity in a transi-
tional southeast European population. Med Arh 66:1620
Eur J Nutr (2015) 54:679689
34. Mihalache L, Popescu D, Graur M (2010) Prevalence of over-
weight and obesity in a rural population. Rev Med Chir Soc Med
Nat Iasi 114:715720
35. Charles MA, Eschwege E, Basdevant A (2008) Monitoring the
obesity epidemic in France: the Obepi surveys 19972006.
Obesity (Silver Spring) 16:21822186
36. Fillol F, Dubuisson C, Lafay L, Dufour A, Bertin M, Touvier M,
Maire B, Volatier JL, Lioret S (2011) Accounting for the mul-
tidimensional nature of the relationship between adult obesity and
socio-economic status: the French second National Individual
Survey on Food Consumption (INCA 2) dietary survey
(200607). Br J Nutr 106:16021608
37. Marin-Guerrero AC, Gutierrez-Fisac JL, Guallar-Castillon P,
Banegas JR, Rodriguez-Artalejo F (2008) Eating behaviours and
obesity in the adult population of Spain. Br J Nutr
100:11421148
38. Gutierrez-Fisac JL, Guallar-Castillon P, Leon-Munoz LM,
Graciani A, Banegas JR, Rodriguez-Artalejo F (2012) Prevalence
of general and abdominal obesity in the adult population of Spain,
20082010: the ENRICA study. Obes Rev 13:388392
39. Gallus S, Odone A, Lugo A, Bosetti C, Colombo P, Zuccaro P, La
Vecchia C (2013) Overweight and obesity prevalence and
determinants in Italy: an update to 2010. Eur J Nutr 52:677685
40. ISTAT (2012) Smoke, alcohol, obesity: risk factors. http://noi-
italia2013en.istat.it/index.php?id=55&user_100ind_pi1[id_pag-
ina]=740&cHash=59a935e79c6e1717b4e1fb45fdedc326.
Accessed 18 Oct 2013
41. Bartali B, Benvenuti E, Corsi AM, Bandinelli S, Russo CR, Di
Iorio A, Lauretani F, Ferrucci L (2002) Changes in anthropo-
metric measures in men and women across the life-span: findings
from the InCHIANTI study. Soz Praventivmed 47:336348
42. Schroder H, Marrugat J, Vila J, Covas MI, Elosua R (2004)
Adherence to the traditional mediterranean diet is inversely
associated with body mass index and obesity in a Spanish pop-
ulation. J Nutr 134:33553361
43. Schwarzfuchs D, Golan R, Shai I (2012) Four-year follow-up
after two-year dietary interventions. N Engl J Med
367:13731374
44. Nordmann AJ, Suter-Zimmermann K, Bucher HC, Shai I, Tuttle
KR, Estruch R, Briel M (2011) Meta-analysis comparing Medi-
terranean to low-fat diets for modification of cardiovascular risk
factors. Am J Med 124(841851):e842
45. Rossi M, Negri E, Bosetti C, Dal Maso L, Talamini R, Giacosa A,
Montella M, Franceschi S, La Vecchia C (2008) Mediterranean
diet in relation to body mass index and waist-to-hip ratio. Public
Health Nutr 11:214217
46. DAta Food NEtworking (DAFNE) (2005) The pan-European
food data bank based on household budget surveys. http://www.
nut.uoa.gr/dafnesoftweb/Main.aspx?type=multi. Accessed 17 Oct
2013
47. Linseisen J, Welch AA, Ocke M et al (2009) Dietary fat intake in
the European Prospective Investigation into Cancer and Nutri-
tion: results from the 24-h dietary recalls. Eur J Clin Nutr
63(Suppl 4):S61S80
48. Eurobarometer (2014) Sport and physical activity. Special
Eurobarometer 412/Wave EB80.2. http://ec.europa.eu/public_
opinion/archives/ebs/ebs_412_en.pdf. Accessed 25 April 2014
689
49. WHO (2004) Food and health in Europe: a new basis for action.
http://www.euro.who.int/__data/assets/pdf_file/0005/74417/E821
61.pdf. Accessed 17 Sept 2013
50. Devaux M, Sassi F (2013) Social inequalities in obesity and
overweight in 11 OECD countries. Eur J Public Health
23:464469
51. Roskam AJ, Kunst AE, Van Oyen H, Demarest S, Klumbiene J,
Regidor E, Helmert U, Jusot F, Dzurova D, Mackenbach JP
(2010) Comparative appraisal of educational inequalities in
overweight and obesity among adults in 19 European countries.
Int J Epidemiol 39:392404
52. Drewnowski A, Moudon AV, Jiao J, Aggarwal A, Charreire H,
Chaix B (2013) Food environment and socioeconomic status
influence obesity rates in Seattle and in Paris. Int J Obes (Lond).
doi:10.1038/ijo.2013.97
53. Monteiro CA, Conde WL, Lu B, Popkin BM (2004) Obesity and
inequities in health in the developing world. Int J Obes Relat
Metab Disord 28:11811186
54. Jones-Smith JC, Gordon-Larsen P, Siddiqi A, Popkin BM (2012)
Is the burden of overweight shifting to the poor across the globe?
Time trends among women in 39 low- and middle-income
countries (19912008). Int J Obes (Lond) 36:11141120
55. Munafo MR, Tilling K, Ben-Shlomo Y (2009) Smoking status
and body mass index: a longitudinal study. Nicotine Tob Res
11:765771
56. Xu F, Yin XM, Wang Y (2007) The association between amount
of cigarettes smoked and overweight, central obesity among
Chinese adults in Nanjing, China. Asia Pac J Clin Nutr
16:240247
57. Flegal KM, Troiano RP, Pamuk ER, Kuczmarski RJ, Campbell
SM (1995) The influence of smoking cessation on the prevalence
of overweight in the United States. N Engl J Med 333:11651170
58. Williamson DF, Kahn HS, Remington PL, Anda RF (1990) The
10-year incidence of overweight and major weight gain in US
adults. Arch Intern Med 150:665672
59. Grossschadl F, Haditsch B, Stronegger WJ (2012) Validity of
self-reported weight and height in Austrian adults: sociodemo-
graphic determinants and consequences for the classification of
BMI categories. Public Health Nutr 15:2027
60. Spencer EA, Appleby PN, Davey GK, Key TJ (2002) Validity of
self-reported height and weight in 4808 EPIC-Oxford partici-
pants. Public Health Nutr 5:561565
61. Niedhammer I, Bugel I, Bonenfant S, Goldberg M, Leclerc A
(2000) Validity of self-reported weight and height in the French
GAZEL cohort. Int J Obes Relat Metab Disord 24:11111118
62. Dauphinot V, Wolff H, Naudin F, Gueguen R, Sermet C, Gaspoz
JM, Kossovsky MP (2009) New obesity body mass index
threshold for self-reported data. J Epidemiol Community Health
63:128132
63. Ahima RS, Lazar MA (2013) Physiology. The health risk of
obesitybetter metrics imperative. Science 341:856858
64. Galesic M, Tourangeau R, Couper MP (2006) Complementing
random-digit-dial telephone surveys with other approaches to
collecting sensitive data. Am J Prev Med 31:437443
123
Copyright of European Journal of Nutrition is the property of Springer Science & Business
Media B.V. and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.