The Gulliver syndrome is a recently proposed phenotype characterized by the simultaneous presence of multiple borderline cardiometabolic abnormalities that may represent an early stage of metabolic dysfunction. However, the contribution of modifiable lifestyle behaviors to this syndrome remains poorly understood. The aim of this study was to investigate the associations between smoking, physical activity, and adherence to the Mediterranean diet and the presence of Gulliver syndrome in a large cohort of Spanish workers.
A cross-sectional study was conducted in 395,660 Spanish workers aged 18–69 years who underwent routine occupational health examinations between 2019 and 2020. Smoking status was categorized as never, former, or current smoking, while physical activity and adherence to the Mediterranean diet were assessed using standardized questionnaires, including the International Physical Activity Questionnaire (IPAQ) and the Mediterranean Diet Adherence Screener (MEDAS). Multivariable logistic regression and multinomial logistic regression analyses were performed to identify independent associations between lifestyle behaviors and Gulliver syndrome and across different cardiometabolic profiles.
The prevalence of Gulliver syndrome was 2.76%. Physically inactive participants exhibited a substantially higher prevalence of the syndrome than physically active individuals (4.43% vs. 0.92%; p < 0.001), while workers with low adherence to the Mediterranean diet had a markedly higher prevalence than those with high adherence (4.28% vs. 0.86%; p < 0.001). In multivariable analyses, physical activity (OR: 0.40; 95% CI: 0.37–0.44) and high adherence to the Mediterranean diet (OR: 0.60; 95% CI: 0.55–0.66) were independently associated with lower odds of Gulliver syndrome. Smoking status was also significantly associated with Gulliver syndrome, with higher adjusted odds among former smokers (OR: 1.17; 95% CI: 1.11–1.23) and current smokers (OR: 1.12; 95% CI: 1.07–1.17) compared with never smokers. Similar inverse associations for physical activity and Mediterranean diet adherence were observed across progressively less favorable cardiometabolic profiles.
Physical inactivity and low adherence to the Mediterranean diet were the modifiable lifestyle factors most strongly associated with Gulliver syndrome. These findings indicate that lifestyle behaviors are associated with the presence of this recently proposed cardiometabolic phenotype. Given the cross-sectional design, prospective studies are needed to determine the temporal and prognostic significance of these associations.
Citation: Mónica Moreno Martínez, Pedro Juan Tárraga López, José Ignacio Ramírez Manent, María Teófila Vicente-Herrero, Mónica Silu Piña DAbreu, Ángel Arturo López-González. Lifestyle behaviors associated with the Gulliver syndrome: Smoking, physical activity, and Mediterranean diet in 395,660 Spanish workers[J]. AIMS Public Health, 2026, 13(4): 1104-1131. doi: 10.3934/publichealth.2026057
The Gulliver syndrome is a recently proposed phenotype characterized by the simultaneous presence of multiple borderline cardiometabolic abnormalities that may represent an early stage of metabolic dysfunction. However, the contribution of modifiable lifestyle behaviors to this syndrome remains poorly understood. The aim of this study was to investigate the associations between smoking, physical activity, and adherence to the Mediterranean diet and the presence of Gulliver syndrome in a large cohort of Spanish workers.
A cross-sectional study was conducted in 395,660 Spanish workers aged 18–69 years who underwent routine occupational health examinations between 2019 and 2020. Smoking status was categorized as never, former, or current smoking, while physical activity and adherence to the Mediterranean diet were assessed using standardized questionnaires, including the International Physical Activity Questionnaire (IPAQ) and the Mediterranean Diet Adherence Screener (MEDAS). Multivariable logistic regression and multinomial logistic regression analyses were performed to identify independent associations between lifestyle behaviors and Gulliver syndrome and across different cardiometabolic profiles.
The prevalence of Gulliver syndrome was 2.76%. Physically inactive participants exhibited a substantially higher prevalence of the syndrome than physically active individuals (4.43% vs. 0.92%; p < 0.001), while workers with low adherence to the Mediterranean diet had a markedly higher prevalence than those with high adherence (4.28% vs. 0.86%; p < 0.001). In multivariable analyses, physical activity (OR: 0.40; 95% CI: 0.37–0.44) and high adherence to the Mediterranean diet (OR: 0.60; 95% CI: 0.55–0.66) were independently associated with lower odds of Gulliver syndrome. Smoking status was also significantly associated with Gulliver syndrome, with higher adjusted odds among former smokers (OR: 1.17; 95% CI: 1.11–1.23) and current smokers (OR: 1.12; 95% CI: 1.07–1.17) compared with never smokers. Similar inverse associations for physical activity and Mediterranean diet adherence were observed across progressively less favorable cardiometabolic profiles.
Physical inactivity and low adherence to the Mediterranean diet were the modifiable lifestyle factors most strongly associated with Gulliver syndrome. These findings indicate that lifestyle behaviors are associated with the presence of this recently proposed cardiometabolic phenotype. Given the cross-sectional design, prospective studies are needed to determine the temporal and prognostic significance of these associations.
Conceptualization: M.M.M; A.A.L.G.; Data collection and analysis: P.J.T.L.; and M.S.P.A; Data curation: M.S.P.A; P.J.T.L. Methodology: M.T.V.H; M.M.M. Validation: J.I.R.M.; Formal analysis: M.T.V.H.; Investigation M.M.M; Draft: M.M.M., P.J.T.L., J.I.R.M., and M.S.P.A; Revision: A.A.L.G. and M.T.V.H. All authors have read and agreed to the published version of the manuscript
The authors declare that there are no competing interests related to this study.
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Mónica Moreno Martínez, Pedro Juan Tárraga López, José Ignacio Ramírez Manent, María Teófila Vicente-Herrero, Mónica Silu Piña DAbreu, Ángel Arturo López-González. Lifestyle behaviors associated with the Gulliver syndrome: Smoking, physical activity, and Mediterranean diet in 395,660 Spanish workers[J]. AIMS Public Health, 2026, 13(4): 1104-1131. doi: 10.3934/publichealth.2026057
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