Content. The double burden of disease in México

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1 Can we and Prevent Malnutrition while Addressing the Challenge of NRCD s? Experiences from Mexico Content The double burden of disease in México What is currently being done in México for preventing and controlling malnutrition? Can undernutrition control strategies: lead to overweight and obesity? address the challenge of unhealthy weight and NRCD s? National Public Health Institute, Cuernavaca, México) México: a middle-income Country GNP per capita (3) : $ 6, 9 US dollars Population: 4 million IMR (2): 28 per LB Life exp. at birth (1): Females: 76 years Males: 71 years The double burden of disease in México High prevalence of stunting but not wasting in children < years High prevalence of anemia, particularly in children 1-2y 48, Stunting Wasting ,1 26,4 21,,1. 16,6 13. * a a 49 Pregnancy Children Women Source: Rivera el all, 1 * 6-11 mo

2 High prevalence of micronutrient deficiencies in children and women Reduction of stunting in 11 years was small relative to comparable Countries years 3-4 years -11 years Women México South America.1 puntos porcentuales 22.4 Iron Zinc puntos porcentuales 4.9 However, overweight and obesity in women increased dramatically during the same period in all socieconomic levels Overweight Obesity Obesity (BMI>3) Overwight (BMI, -29.9) ~ I II III IV V Rivera et al, (2) SES quintiles Changes in the relative importance of macronutrients as energy source between 1988 and 1999 in Mexico Fat CHO Protein Changes in food purchases between 1984 and 1998 () for different food groups North Center Mexico City. South National -3 Fruits & Vegetables Milk Meat Refined CHO Soda Adapted from: Rivera JA et al. Epidemiological and nutritional transition in Mexico: Rapid increase of non-communicable chronic diseases and obesity. Public Health Nutrition. : (1A) , 2 Adapted from: Rivera JA et al. Epidemiological and nutritional transition in Mexico: Rapid increase of non-communicable chronic diseases and obesity. Public Health Nutrition. : (1A) , 2

3 Low intake of fruits and vegetables and high intake of sugar in women What is currently being done in México for preventing and controlling malnutrition? Other foods 167 g 13 g Fats and oils Other cereals 3 g Beans 4 g Wheat bread 46 g Vegetables Fruits 7 g 6 g 8 g 13 g Meats and eggs g 14 g Tortilla and corn products 18 g Sweet beverages and sugar Milk and dairy Non-sweet beverages Ramírez and Rivera, (unpublished) Current large scale strategies favor the control of undernutrition (Progresa): cash transfer with a nutrition component covering ~ million families Distribution of subsidized fortified- milk to ~ million children 1-11 years Nutrition Program for Indigenous population (micronutrient supplements) Fortification of wheat and corn flour with iron, zinc, folic acid and other Mn Food lunch programs: distribute whole milk and high sugar and/or high fat snacks in most public schools (formerly Progresa) Multisectorial Program (MOH, MOE, MSD) Covers million poor families Cash transfers provided if: families attend health clinics regularly, utilize nutrition and education services offered by MOH, children attend school regularly (>8 time) (formerly Progresa) Nutritional supplements designed by Mexican scientists produced by government owned company Contain ~1- energy and ~ of micronutrients deficient in diet provided to: Children 4-23 mo and underweight 2-4 years Pregnant and lactating women Nutrition education component including topics on undernutrition and NRCD s Anemia () has been shown to be effective in reducing anemia after 1 year of intervention * p.p (19.3) a Adjusted by age, using a generalized estimating equation model * P <. Rivera et al, JAMA, 4

4 Increment in height (cm) Growth in length of infants < 6 mo at baseline according to exposure to 27 ** Exposed 1 year 26.4 Exposed 2 years Can undernutrition control lead to overweight and obesity? Poorest Less poor * Adjusted by age and length in 1998, using a random-intercept linear model. ** P <. Rivera et al, JAMA, 4 Adjusted* Income elasticity of demand for food groups in poor Rural households in Mexico Number of foods consummed at least once a by women after 1 y of exposure to Food group Vegetables Fruits Meats Corn products Soda Elasticities** *Adjusting for age, sex, years of education of head of HH **Results only for HH consuming the food group of HH not consuming Mean Min Q1 Median Q3 Max (not exposed) (exposed 1 year) Gonzalez-Cossio et al, Frequency of intake of a traditional vegetable by women after 1 y of exposure to Frequency of intake of beef meat by women after 1 y of exposure to Verdolagas (P <.1) 7.8 Daily 2 to 6 days a Once a Less than once a Never P < Daily 2 to 6 days a Once a Less than once a Never

5 8 6 4 Frequency of intake of soda by women after 1 y of exposure to P <.1 Daily 2 to 6 days a Once a Less than once a Never Can undernutrition control strategies lead to unhealthy weight? YES IF FOOD CHOICES INADEQUATE AND/OR NOT TARGETED: i.e. school lunch programs provide highly-processed high-fat and high-sugar foods in the majority of municipalities to all children Prevalence of unhealthy weight in Mexican children 2-11 y by SES SES Quintiles * According to the obesity taskforce System Aburto et al, Can undernutrition control strategies cause potential adverse effects on obesity? UNLIKELY IF: Adequate food choices for particular groups such as the fortified food supplements for young children because the micronutrient content is high and the energy content is low Some substitution of the low micronutrient diet expected Energy and Nutrient content of supplement for children Energy Protein Iron Zinc Nutrient Vitamin A Vitamin E Vitamin C RDA* 1** 36 Folic Acid Vitamin B 12 *U.S. Recommended Dietary Allowances (RDA s) for children 1-3 years 1 targets children < 2 y in ~ lower income households Prevalence of stunting Prevalence of stunting by age By SES Age in Months Decil SES as well as pregnant and lactating Women Does adequate targeting of undernutrition control strategies protect families from potential adverse effects on obesity? NO; Cash transfer and food supplements for women targets lowest income households, who are already overweight I II III IV V SES quintiles 33 Obesity Overweight Rivera et al, (2) Development of Obesity Fetal Life SES Mother s Nutrition Growth birth weight Do strategies in Mexico follow a Life Course Approach? Emphasis Infancy and Childhood Adolescence Breast Feeding SES Obesity Infection PEM Micronutrients Growth rate Stature Physical Activity Food behaviour Sendentarism Inactivity Smoking Age Adult Life Elderly Established adult risky behaviours Diet/Physical activity, Alcohol Biological risks Socioeconomic status Environmental conditions Accumulated risk Genetic susceptibility to Obesity

6 Conclusions To reduce the risk of unhealthy weight in children and their relatives, interventions aimed at controlling undernutrition through food distribution strategies should provide micronutrient-dense healthy foods to vulnerable population (in both biological and socioeconomic terms) Conclusions High-fat, high-sugar, low-fiber, lowmicronutrient foods should be avoided Income improvements through cash transfers are unlikely to improve the diet enough to make a difference in the absence of effective nutrition education and other programs and policy We should fight malnutrition (under- and overnutrition), not only undernutrition