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Journal of the American College of Nutrition, Vol. 21, No. 6, 523-529 (2002)
Published by the American College of Nutrition

Nutritional Characteristics of a Rural Southern Italy Population: The Ventimiglia di Sicilia Project

Carlo M. Barbagallo, MD, Giovanni Cavera, MD, Michelangelo Sapienza, MD, Davide Noto, MD, Angelo B. Cefalù, MD, Francesco Polizzi, MD, Francesco Onorato, MD, GiovanBattista Rini, MD, Gaetana Di Fede, MD, Michele Pagano, MD, Giuseppe Montalto, MD, Manfredi Rizzo, MD, GianCarlo Descovich, MD, Alberto Notarbartolo, MD and Maurizio R. Averna, MD

Department of Internal Medicine and Geriatrics (C.M.B., G.C., D.N., A.B.C., F.P., F.O., G.B.R., G.M., M.R., A.N., M.R.A.)
Department of Internal Medicine (G.D.F.)
University of Palermo, "Villa Sofia" Hospital (M.S., M.P.)
Palermo, Department of Geriatrics, University of Bologna, Bologna (G.C.D.*), ITALY

Address reprint requests to: Dr. Carlo M Barbagallo, Istituto di Medicina Interna e Geriatria, Policlinico "Paolo Giaccone," Via del Vespro 141, I-90127 Palermo, ITALY. E-mail: carlob{at}unipa.it


   ABSTRACT
TOP
 FOOTNOTES
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 ACKNOWLEDGMENTS
 REFERENCES
 
Objective: Knowledge of alimentary habits among populations permits a better definition of appropriate public health interventions. We designed the epidemiological project "Ventimiglia di Sicilia" to characterize the risk profile in a rural village with low total cholesterol levels and low early cardiovascular mortality but with a large prevalence of overweight and obesity, which previously have been significantly associated with total mortality.

Methods: 488 individuals of age 20 to 69 years were included in the dietary survey conducted by a seven-day food record.

Results: Alimentary habits were characterized by high consumption of total and complex carbohydrates (respectively 52.5 ± 7.6% and 46.6 ± 8.2% of daily energy) and by a low cholesterol intake (92.5 ± 35.0 mg/1000 kcal/day). Fat intake was 34.7 ± 7.7% of daily energy due to a higher consumption of monounsaturated fats in respect to saturated fats (respectively 20.5 ± 5.1% and 10.2 ± 2.9% of daily energy). In particular, in this population there was a large consumption of bread, pasta, fresh vegetables, olive oil and fruits. We also observed an excess of total calories (about 2900 kcal/day in men and 2100 kcal/day in women) not balanced by a high degree of physical activity levels. Furthermore we found a significant higher total and saturated fat consumption in the youngest individuals and in people with higher educational levels.

Conclusions: Dietary habits of Ventimiglia di Sicilia still follow the nutritional characteristics typical of the Mediterranean diet. The high total calorie intake indicates a quantitative more than qualitative problem, which may account the large prevalence of overweight and obesity and may represent a public health issue that needs to be corrected in such a rural population.

Key words: cardiovascular risk, Mediterranean diet, nutritional habits, rural populations, Southern Italy


   INTRODUCTION
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 ACKNOWLEDGMENTS
 REFERENCES
 
Despite a low rate of cardiovascular mortality, the life expectancy of the Mediterranean populations is not that higher than other Western populations and therefore different other conditions may expose these groups to mortality risks [1,2]. We undertook the "Ventimiglia di Sicilia" project to characterize the risk profile in a rural Sicilian village having a life-style which is likely to preserve older traditions. The main resource of this village is agriculture, there is a low incidence of early cardiovascular mortality, and total cholesterol levels are lower than the Italian average [3,4]. Nevertheless we found a large prevalence of body weight disorders and significant associations between overweight, obesity and fat distribution with both all-cause and cardiovascular mortality during the period 1989–1997 [5].

The dietary habits of the Mediterranean populations are known to play an important role in protection against cardiovascular disease [1,6]. The typical Mediterranean diet is thought to be very rich in cereals, vegetables and fruit with a lower content of meat, while the main source of dietary fat is olive oil; additionally, the consumption of red wine is relatively common. This dietary pattern has favorable effects on lipid profile and provides significant sources of antioxidants and might explain its health-protecting action in these populations [7–9]. However, in the recent years, contrasting phenomena have been observed. Despite a worldwide promotion of this nutritional model, a progressive change in local dietary habits has been observed [10]. In Italy, a progressive increase of consumption of meat, fats, milk and dairy products and sugar has been found. This trend seems to be more evident in the north, but even the southern part of the country is not completely free of changes in nutritional habits [11–15].

In this paper we report data regarding macronutrients; our data revealed that, in this rural part of Italy, alimentary habits continue to follow the general outlines of the Mediterranean diet. The influence of age and varied educational levels has been evaluated. Our results also show a very high total calorie intake, which could explain the large prevalence of body weight disturbances found in this population [5].


   MATERIALS AND METHODS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 ACKNOWLEDGMENTS
 REFERENCES
 
The population of the "Ventimiglia di Sicilia" projects was described in detail elsewhere [3,4]. Briefly Ventimiglia di Sicilia is a rural village of about 1800 inhabitants, located in the hilly hinterland 50 km from Palermo. In 1989, all people above the age of five were invited to participate. The general study design included a medical questionnaire, blood pressure, anthropometrical and biochemical measurements and electrocardiogram registration. 1351 subjects (622 males and 729 females) participated in the study with an on-going rate of participation of about 75 percent. All participants were further requested to be included in an additional dietary survey (see below), and 755 subjects did agree to participate with a rate of adherence of about 56 percent. The procedures followed were in accordance with the Helsinki Declaration of 1975, as revised in 1983. In this paper we report data relative to the group of subjects ages 20 to 69 years, represented by 488 individuals (about 60 percent of the participants in this range of age). Clinical characteristics of these subjects are shown in the Table 1. It is noteworthy that this group was representative of the entire Ventimiglia di Sicilia population in the same range of age since no significative difference was found between individuals who participated to the dietary survey and those who did not (data not shown). Education level was determined for all subjects. Four options were given: none (subjects illiterate or not completing the five-year course of primary school), primary school (which represents a five years’ mandatory education period), secondary school (three additional years) and high school (including professional schools) or university. The dietary survey was conducted as follows: a seven-day food record was obtained from each subject, usually in family groups. Subjects were instructed on how to record food intakes and provided with diet scales for weighing food items. During the week of food record compilation, a dietitian daily reviewed with the subjects the correct filing of the data. During this visit, methods of preparation of food, type of fat used and brand names of food items were carefully investigated. Commercially packed foods were analyzed according to the nutritional information provided by the manufacturers. Subsequently, the seven-day record was converted to energy and nutrient intake per day using a computerized database derived from Italian standard food composition tables [16,17]. In order to check the reproducibility over time of the present data, in 1995, six years after the study, we collected further nutritional records in a subgroup of subjects (98 individuals, 20 percent of the total) during a dietary survey performed with different aims but with the same protocol [18]. To avoid seasonal variations of dietary habits, this survey was performed in the same period as the former one (late spring).


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  		Table 1. Clinical Characteristics of the Participants of the Dietary Survey

 
For the statistical analysis, we used the Crunch 4 package by Crunch Software Corporation. Means and standard deviations were calculated for each parameter. The differences of nutrient intake between different groups were compared by using Mann-Whitney rank test, Wilkoxon signed rank test or Kruskal-Wallis rank test when suitable [19].


   RESULTS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
ACKNOWLEDGMENTS
 REFERENCES
 
Dietary habits of the entire population of Ventimiglia di Sicilia are shown in Table 2. We found that this population still follows the general criteria of Mediterranean diet; however, there was a larger intake of food as documented by the total calories figures. Males showed a significantly higher total calorie intake and also a more elevated total and complex carbohydrate consumption but significantly lower total and monounsaturated fat and cholesterol intakes in comparison with females. Dietary fiber intake was also significantly higher in males than in female subjects.


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  		Table 2. Nutrient Intake in Ventimiglia di Sicilia Population (Mean ± SD)

 
Analysis of food eaten demonstrated a large consumption of bread (205.1 g/day on average), pasta (104.3 g/day), fresh vegetables (117.7 g/day), olive oil (414 g/day) and fruits (214 g/day). This population consumed about 100 g/day of meat and derivatives (less of half of that was beef) and only about 19 g/day of fish and 1.4 egg/week (Table 3).


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  		Table 3. Mean Consumption per capita of Principal Categories of Food in the Population of Ventimiglia di Sicilia1

 
Six years after the survey, we checked the same dietary parameters in a subgroup of subjects, and we did not find any difference (Table 4).


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  		Table 4. Nutrient Intake in a Subgroup of the Population of Ventimiglia di Sicilia (98 subjects) in 1989 and in 1995 (Mean ± SD)

 
Among the different ages (Table 5), we observed a significant increase of total and complex carbohydrates intake and a significant decrease of the consumption of total, saturated and polyunsaturated fats. We also observed a non-significant trend to decrease the daily cholesterol intake, whereas monounsaturated fat and fiber intake was not different. Calories intake slightly increased until the ages of 40 to 49 years and then strongly decreased. These behaviors were similar when the population was divided by gender (data not shown).


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  		Table 5. Nutrient Intake in Ventimiglia di Sicilia Population according to Age (Mean ± SD)

 
The population of Ventimiglia di Sicilia was also stratified according to the educational level (see Subjects and Methods section). By this approach (Table 6), a significant increase of the total calories as well as of total, saturated and polyunsaturated fat intake and a significant decrease of total and complex carbohydrates intake were found associated with a higher degree of education. Participants also showed a nonsignificant trend to increase cholesterol intake, which paralleled the higher educational level, but no differences for monounsaturated fat and fiber intake. No gender-related differences were found (data not shown).


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  		Table 6. Nutrient Intake in Ventimiglia di Sicilia Population according to Educational Level (Mean ± SD)

 
Finally we evaluated dietary habits according to the following clinical characteristics of the populations: smoking habits, physical activity, alcohol consumption, body weight, presence of hypertension, dyslipidemias, diabetes. The only relevant difference was the increased total calories intake in those subjects with the highest score of physical activity and of alcohol intake (data not shown).


   DISCUSSION
 
Epidemiological data have classically demonstrated a low incidence of cardiovascular disease in the Mediterranean countries mainly due to the typical nutritional model, providing multiple advantages in terms of cardiovascular protection [1,7,8,20,21]. We designed the "Ventimiglia di Sicilia" project in order to evaluate clinical, genetic and environmental cardiovascular risk factors in a rural Sicilian population which was able to maintain a traditional life-style. In this village we found low mean total and LDL-cholesterol plasma concentrations (respectively about 5 and 3.2 mmol/L) and a rate of early cardiovascular mortality of 0.6 deaths/year/1000 inhabitants in subjects of ages 40 to 64 years in the period 1988–1997, a rate lower than that in the rest of Italy [3–5]; higher cardiovascular mortality rates are still present in both Northern and Southern Europe (respectively 5.1 and 1.9 deaths/year/1000) [22]. Also smoking habits were different in comparison with other western populations. In Ventimiglia di Sicilia, a high prevalence of persons who had never smoked (about 66%) was found, more relevant in women. In the PROCAM Study a prevalence of cigarette smokers ranging from 18.8% to 50.5%, depending on age and gender, has been reported, whereas American populations have a more elevated prevalence of former smokers [23,24]. In this village there was a high overall prevalence of subjects with overweight or obesity (see Table 1); in particular among the early post-menopausal women less than 10% of subjects showed a normal weight [5]. By contrast, overweight and obese subjects are estimated to be respectively 31.6% and 6.5% of the total Italian population, with the higher rates in middle age subjects and in the south of the country [25]. A lower frequency of obese subjects has been also found in other European countries, whereas in the United States the prevalence is very high [23,26,27]. We previously documented significant associations between body weight abnormalities and mortality, highlighting the great importance of overweight as a public health issue in such a rural population of Southern Italy [5]. Nutritional data can give further information regarding the risk profile of this village. In this study we tried to limit the bias in the collection of data usually common in a nutritional survey by using the seven-day food record, which should minimize daily differences [28,29]. The contribution of dietitians, collaborating daily with participants, further reduced any forgetfulness or inaccuracy in the compilation of the food record. An additional survey in a subsample of individuals conducted with different aims but with the same protocol six years later [18] confirmed the reproducibility of our data over time. Present findings show that the dietary habits of the population of Ventimiglia di Sicilia were substantially similar to those of other southern populations of Italy; conversely, we registered a higher carbohydrates and a lower saturated fat intake in comparison with populations living in the northern part of the country [11,13–15,30–32]. Daily cholesterol consumption was limited (about 92 mg/1000 kcal/day) and remained below 300 mg/day in absolute value. In particular it is noteworthy the high intake of monounsaturated fats (more than 20% of total calories/day) related to the exclusive consumption of fresh cooked food and to the use of olive oil as cooking and dressing fat. Bread, pasta, fresh vegetables and fruits were the main foods eaten, and there was a very low consumption of fish, probably due to the geographical position of the village; also, egg consumption was not frequent. However, despite some slight differences in comparison with the traditional Mediterranean diet, such as a small reduction of carbohydrates intake (3% to 5%) and fiber (7–8 g/day) and a limited increase of saturated fats (2% to 3%) and cholesterol (8–10 mg/1000 kcal) consumption, most of the classical characteristics of the Mediterranean diet in this population are still far from being lost [33]. Beyond the quality of dietary habits, we also observed an excess of total calories (about 2900 kcal/day in men and 2100 kcal/day in women), given many other epidemiological studies [34–36]. It is relevant that in the village there is a high prevalence of retired people and home-worker women with a very low degree of physical activity and that there are no sport facilities for leisure. We administered a questionnaire to evaluate physical activity levels in both working and leisure time. Cumulative data demonstrated that in about 56.4% of the entire population physical activity was "absent" or "light," in 41.1% "mild" or "moderate," and only in 2.5% of the population was the physical activity level "heavy," with great differences between genders (Table 1). In other populations, physical activity levels, despite a higher incidence of cardiovascular disease, are higher: recently in a US cohort only about 25% of subjects reported no sports or recreational activity, whereas 43% of individuals were engaged in vigorous sports or recreational activities [24]. The large intake of "healthy" food, not related to a similar energy expenditure, may account for the high prevalence of body weight abnormalities previously found and associated with the mortality of this population. We also evaluated dietary habits according to different characteristics of the population. A parallel significant increase in the total and saturated fat consumption was observed in particular among the younger subjects and in those with higher educational levels, in contrast with the data observed in populations living in United States [35]. At the same time there was an increase of total calorie intake until the fifth decade of life followed by a decrease. This is not in contrast with the reproducibility of the data, but demonstrates that, despite a clear worsening of alimentary habits among the younger subjects, in the same subjects there are no diet modifications over time. The nutritional characteristics of this population, on average, are in line with those of coronary prevention [37], and this may explain the lack of difference found when the population was divided according to the presence of cardiovascular risk factors (data not shown). On the whole, our data confirm that this village still maintains dietary habits having most of the classical protective characteristics of the Mediterranean diet but with a more elevated calorie intake. We believe that the present findings may reflect those of all the rural populations of Sicily and probably of southern Italy, even if different conditions could be present in large cities (e.g., in Palermo) [38]. However, such a rural population requires targeted intervention to decrease calorie intake and, as a consequence, the increased prevalence of body weight abnormalities [5].

In conclusion, our data have demonstrated that dietary habits of Ventimiglia di Sicilia still follow the nutritional characteristics typical of the Italian-style Mediterranean diet. Due to the life-style characteristics of this village it is likely that these dietary habits represent a mirror of those of traditional Sicilian populations. Therefore, despite recent changes in dietary profiles registered in Italy, the alimentary habits of rural populations of Sicily remain one of the nutritional models more favorable for cardiovascular protection. The high total calorie intake indicates a quantitative more than qualitative problem, which may account for the large prevalence of overweight and obesity found in this population [5] and may represent a public health issue in this rural population of Southern Italy.


   ACKNOWLEDGMENTS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 ACKNOWLEDGMENTS
REFERENCES
 
The authors wish to thank the dietitians Rosa Giovanna La Spisa, Concetta Abruscato, Silvia Tripodi, Marcella Guardì and Nunzia Chiovari for the help in the compilation of food records, GianMaria Settepani, Michele Pantaleo Piero Alongi and Giovanni Traina from the Town Council of Ventimiglia di Sicilia and Vincenzo Sucato, Rosa Rini, Mario Vazzano, Gerlando Calandrino, Rosario D’Alessandro and Andrea Corsello (deceased) from the Local Health Unit for the constant support during the study, Dr. Antonio Carroccio from the University of Palermo for the help given in 1995, in the data reproductibility control and Ada Dormi from the University of Bologna for the useful advice in statistical analysis.


   FOOTNOTES
TOP
 FOOTNOTES
ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 ACKNOWLEDGMENTS
 REFERENCES
 
* Deceased. Back

Received December 11, 2000. Accepted September 11, 2001.


   REFERENCES
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 ACKNOWLEDGMENTS
 REFERENCES
 

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