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Terrie E. Taylor, DO
Malawi-Liverpool-Wellcome Trust Clinical Research Programme
and Blantyre Malaria Project
Blantyre, Malawi
Ire`ne Juhan-Vague, MD, PhD
Haematology Laboratory
Faculty of Medicine
Universite´delaMe´diterrane´e
Jean-Louis Me`ge, MD, PhD
Rickettsia Unit
Faculty of Medicine
Universite´delaMe´diterrane´e
James Mwenechanya, MB
Madalitso Tembo, MB
Malawi-Liverpool-Wellcome Trust Clinical Research Programme
and Blantyre Malaria Project
Georges E. Grau, MD, PhD
georges.grau@medecine.univ-mrs.fr
Experimental Parasitology Unit
Faculty of Medicine
Universite´delaMe´diterrane´e
Malcolm E. Molyneux, MD, FRCP
Malawi-Liverpool-Wellcome Trust Clinical Research Programme
and Blantyre Malaria Project
Funding/Support: This investigation was supported by the French Ministry of Re-
search, the PAL+ Programme, and the UNDP/World Bank/WHO Special Pro-
gramme for Research and Training in Tropical Diseases (TDR).
Acknowledgment: Drs Grau and Molyneux contributed equally to the study.
1. Beales PF, Brabin B, Dorman E, et al. Severe falciparum malaria. Trans Roy Soc
Trop Med Hyg. 2000;94:S1-S90.
2. Lou J, Lucas R, Grau GE. Pathogenesis of cerebral malaria: recent experimental
data and possible applications for humans. Clin Microbiol Rev. 2001;14:810-
820.
3. Combes V, Simon AC, Grau GE, et al. In vitro generation of endothelial micro-
particles and possible prothrombotic activity in patients with lupus anticoagulant.
J Clin Invest. 1999;104:93-102.
4. Freyssinet JM. Cellular microparticles: what are they bad or good for? J Thromb
Haemost. 2003;1:1655-1662.
5. Turner GD, Morrison H, Jones M, et al. An immunohistochemical study of the
pathology of fatal malaria: evidence for widespread endothelial activation and a
potential role for intercellular adhesion molecule-1 in cerebral sequestration. Am
J Pathol. 1994;145:1057-1069.
6. Grau GE, Mackenzie CD, Carr RA, et al. Platelet accumulation in brain mi-
crovessels in fatal pediatric cerebral malaria. J Infect Dis. 2003;187:461-466.
High Prevalence of Obesity
Among the Poor in Mexico
To the Editor: The burden of disease in developing countries
has traditionally been characterized by undernutrition and in-
fectious diseases. However, lifestyle in many developing coun-
tries now parallels that in the developed world, with increas-
ing prevalence of overweight and obesity.
1
It is unclear, however,
how the prevalence of obesity varies across levels of socioeco-
nomic status within such societies. We examined the preva-
lence of overweight and obesity among the rural poor in Mexico
in comparison with a national sample.
Methods. We obtained data from 2 national surveys in
Mexico. The first was conducted in 2000 in 45260 adults as
part of the National Health Survey, which was designed as a
multistage, stratified, and clustered survey, nationally repre-
sentative of the Mexican noninstitutionalized population.
2
The
second survey was conducted in 2003 in 12 873 adults as part
of the Social Welfare Survey, which was designed to be repre-
sentative of the poorest (income 20th percentile), rural (towns
with 2500 inhabitants) communities in 7 Mexican states.
3
These regions had a mean daily per capita income of US $2.
Women were more likely to be sampled because they were more
often at home when the surveys were conducted.
Height and weight in both surveys were measured by trained
and standardized personnel using standard techniques. Body mass
index (BMI) was calculated as weight in kilograms divided by
the square of height in meters. Overweight was defined as a BMI
of 25.0 to 29.9 and obesity as a BMI of 30.0 or higher, in accor-
dance with World Health Organization recommendations.
4
Val-
ues of BMI greater than 60 were excluded as implausible (rep-
resenting 0.05% of individuals). Variables of interest for this
analysis were available for 42800 (94.6%) of the 2000 survey
respondents and 12844 (99.7%) of the 2003 survey respon-
dents. For both surveys, sampling weights took into consider-
ation unequal probabilities of selection resulting from sample
design and nonresponse. Both studies were approved by the Na-
tional Institute of Public Health in Mexico Ethical Review Com-
Table. Prevalence of Overweight and Obesity in Women and Men in Mexico From a Nationally Representative Sample and a Sample of
Low-Income Rural Mexicans
*
% (95% CI)
National Health Survey, 2000† Social Welfare Survey, 2003‡
Women
(n = 29 415)
Men
(n = 13 385)
Women
(n = 9850)
Men
(n = 2994)
Age, 40.8 (40.5-41.1) 43.1 (42.7-43.5) 36.1 (35.7-36.6) 47.8 (47.3-48.4)
Underweight (BMI 18.5) 1.8 (1.6-1.9) 1.9 (1.7-2.1) 1.3 (1.1-1.6) 1.9 (1.4-2.4)
Normal weight (BMI 18.5-24.9) 31.5 (30.7-32.2) 36.9 (35.9-38.0) 39.5 (37.3-41.8) 45.5 (42.8-48.3)
Overweight (BMI 25.0-29.9) 36.5 (36.0-37.1) 40.8 (39.9-41.6) 36.8 (35.6-38.0) 38.9 (36.8-41.1)
Obese (BMI 30.0) 30.2 (29.4-31.0) 20.4 (19.5-21.3) 22.2 (20.4-24.1) 13.6 (11.9-15.3)
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CI, confidence interval.
*
Prevalence estimates adjusted for sampling design.
†Designed as a multistage, stratified and clustered survey, nationally representative of the Mexican noninstitutionalized population.
‡Designed to be representative of the poorest (income 20th percentile), rural (cities or towns with 2500 inhabitants) communities in 7 states of Mexico.
§Data presented as mean (95% CI).
LETTERS
2544 JAMA, June 2, 2004—Vol 291, No. 21 (Reprinted) ©2004 American Medical Association. All rights reserved.
mittee and the 2003 survey was also approved by the Univer-
sity of California, Berkeley Committee on Human Research. All
participants provided written informed consent.
Results. In the 2003 sample from low-income, rural regions
of Mexico, the combined prevalence of overweight and obesity
was nearly 60% in women and more than 50% in men (T
ABLE),
which was slightly lower than the prevalence found in the na-
tionally representative sample from 2000 (67% in women and
61% in men). However, this difference was not significant.
Comment. There is a high prevalence of overweight and obe-
sity in the poorest segment of the Mexican population, and the
prevalence is only slightly lower than that reported for a nation-
ally representative health survey. The survey does not contain
data about differences among regions of Mexico. Although the
data do not permit conclusions about the causes of obesity in
this population, we note that the prevalence of obesity we found
is equal to or higher than in other Latin American countries.
5
Thus, it is likely that the population of the entire region is at risk
for the comorbid conditions that accompany overweight and obe-
sity, including hypertension, insulin resistance, and diabetes, all
of which substantially increase the risk for cardiovascular dis-
ease.
1,4
This high prevalence of obesity coexists with traditional
diseases of the poor, such as linear growth retardation, anemia,
and deficiency of micronutrients in children.
6
Lia C. Fernald, PhD, MBA
fernald@haas.berkeley.edu
Institute for Business and Economic Research
University of California, Berkeley
Juan Pablo Gutierrez, MS
Lynnette M. Neufeld, PhD
Gustavo Olaiz, MD, MPH
Stefano M. Bertozzi, MD, PhD
Instituto Nacional de Salud Pu´ blica
Cuernavaca, Mexico
Michele Mietus-Snyder, MD
School of Nursing
University of California, San Francisco
Paul J. Gertler, PhD
School of Public Health and Haas School of Business
University of California, Berkeley
Funding/Support: This study was supported by the National Institute of Child Health
and Human Development, the Fogarty International Center at the National Insti-
tutes of Health, and the Mexican government.
Acknowledgment: We thank Aurora Franco, Andrey Ryo Shiba, and Francisco Pa-
paqui at the Instituto Nacional de Salud Pu´ blica in Mexico for their supervision of
data collection, and all participants in both studies.
1. Popkin BM. The nutrition transition and obesity in the developing world. J Nutr.
2001;131:871S-873S.
2. Valdespino JL, Olaiz G, Lopez-Barajas MP, et al. National Health Survey 2000,
I: Housing, Population and Utilization of Health Services [in Spanish]. Cuer-
navaca, Morelos, Me´xico: Instituto Nacional de Salud Pu´ blica; 2003.
3. Behrman JR, Todd PE. A Report on the Sample Sizes Used for the Evaluation
of the Education, Health and Nutrition Program (PROGRESA) of Mexico. Wash-
ington, DC: International Food Policy Research Institute; 1999. January 25, 1999.
4. World Health Organization. Physical Status: The Use and Interpretation of An-
thropometry. Geneva, Switzerland: World Health Organization; 1995.
5. Filozof C, Gonzalez C, Sereday M, Mazza C, Braguinsky J. Obesity prevalence
and trends in Latin-American countries. Obes Rev. 2001;2:99-106.
6. Rivera JA, Sepulveda Amor J. Conclusions from the Mexican National Survey
1999: translating results into nutrition policy. Salud Publica Mex. 2003;45(suppl
4):S565-S575.
Changing Patterns of Risk Factors and
Mortality for Coronary Heart Disease Among
Alaska Natives, 1979-2002
To the Editor. Rates of death from coronary heart disease (CHD)
among Alaska Natives have historically been lower than those
among nonnative Alaskans.
1
However, in light of the impact
of Western acculturation (ie, high-fat diet, smoking, and sed-
entary lifestyle) on the prevalence of heart disease among other
Native groups,
2
we investigated the possibility of similar re-
cent trends in CHD mortality and risk factors among Alaska
Natives.
Methods. To compare trends in CHD mortality and differ-
ences in prevalence of CHD risk factors between Alaska Na-
tives and nonnative Alaskans, we analyzed CHD mortality rates
from death certificate data and CHD risk factors from Alaska’s
Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS
has been administered in Alaska since 1991, with sample sizes
initially exceeding 1500 and currently exceeding 2500 partici-
pants annually. The validity of BRFSS measures for CHD risk
factors are well substantiated.
3
The BRFSS and death certifi-
cate data supplement each other in that the former provides
an indication of the relative risk of CHD and the latter pro-
vides actual CHD mortality rate comparisons between Alaska
Natives and nonnative Alaskans.
We used the Alaska Section of Epidemiology death certifi-
cate database for 1980-1989 and Alaska Bureau of Vital Statis-
tics data for 1979 and 1990-2002 to determine CHD mortality
rates. To increase the sensitivity of determining risk for CHD
in the target population, we analyzed CHD (International Clas-
sification of Diseases, Ninth Revision codes 410-414, and 429.2;
10th Revision codes I20-I25) mortality based on any mention
of the condition on the death certificate, limiting our analysis
to Alaska residents aged 40 years or older. Individuals were in-
cluded in the analysis if their race, sex, and cause of death were
Figure. Trends in Coronary Heart Disease Mortality Rates for Alaska
Natives and Nonnative Alaskans by Sex (Age 40 y)—Alaska,
1979-2002
1000
300
600
500
400
700
800
900
200
100
0
Years
Rate per 100
000 Population
Nonnative AlaskanNonnative Alaskan
WomenMen
Alaska Native
Alaska Native
1979-1982 1983-1986 1987-1990 1991-1994 1995-1998 1999-2002
Mortality rates adjusted for age to the 2000 US standard population using the di-
rect method.
LETTERS
©2004 American Medical Association. All rights reserved. (Reprinted) JAMA, June 2, 2004—Vol 291, No. 21 2545
... The previous articles in this supplement (2,3) have illustrated that nutrition transition inordinately affects the most vulnerable population in Mexico. The prevalence of stunting in children aged <5 y (21.4%) is higher among beneficiaries of Mexico's CCT-POP than in the general population (14.1%). ...
... (Estrategía Integral de Atención a la Nutrición in Spanish); IYC, infants and young children; PHC, primary health care; PHCP, primary health care provider. 2 Urban communities (medium, 15,000-50,000, or large, >50,000 inhabitants). Rural communities (<15,000 inhabitants) and rural indigenous communities (<15,000 inhabitants with >80% of indigenous population). ...
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Background: The Integrated Strategy for Attention to Nutrition (EsIAN in Spanish) is a national strategy within Mexico's conditional cash transfer program (initially Progresa, then Oportunidades, then Prospera, CCT-POP) designed to strengthen the health and nutrition component, address the nutrition transition, and improve the health and nutritional status of its beneficiaries, through 3 main components: 1) procurement of functioning equipment to primary health care (PHC) units; 2) providing free micronutrient supplements to beneficiary women and children; 3) implementing a behavior change communication (BCC) strategy and a training system for PHC providers (PHCPs). Objective: We aim to describe the iterative process and evidence-based approach used to design and roll-out the EsIAN at scale, by focusing on the BCC component. Methods: The BCC strategy was developed by following an iterative process through the following phases: situational analysis, formative research and design of the BCC strategy (using the socioecological framework and the social marketing approach), large-scale feasibility study, redesign, and national scale-up. Results: The review and formative research revealed several barriers and issues that limited program coverage, utilization, and acceptance. These included misconceptions about pregnancy and infant feeding, nonalignment of practices with international recommendations, and lack of knowledge on nutrition and related topics, among others. These results were used to identify priority behaviors and elaborate key messages for mothers/caregivers and providers to develop the BCC strategy. The feasibility study resulted in significant improvements in PHCPs' knowledge, counseling (breastfeeding, and supplement use and consumption), and caregivers' complementary feeding behaviors, and highlighted several design and delivery aspects that needed strengthening. Based on these findings, the BCC strategy was adapted prior to a national scale-up. Conclusions: The theory-based iterative approach resulted in the identification of specific actions to target, and approaches to do so, as part of the design and roll-out of the BCC strategy at scale.
... Nuestros resultados concuerdan en la dirección de la asociación reportada previamente, pero la magnitud de la asociación inversa fue heterogénea en los tres países, siendo incluso más alta para Bolivia y Perú. Con anterioridad, los hallazgos de una revisión sistemática y metaanálisis de 13 estudios indicaron que los periodos más largos de lactancia materna se asociaron con una reducción de la obesidad del 26% (IC95%: [22][23][24][25][26][27][28][29][30]. Comprender la magnitud de los efectos de la lactancia materna en distintas poblaciones tiene relevancia, dado que los beneficios, incluso en periodos cortos de lactancia (≥ 3 meses), reducen la obesidad infantil 21 , y a largo plazo puede incluso reducir el riesgo de diabetes tipo 2 en la etapa adulta 22,23 . ...
... Los modelos multivariables ajustados por variables confusoras evidencian, para el nivel socioeconómico, más del 100% de probabilidad de obesidad para el quintil más alto de riqueza en Colombia y para el cuarto quintil en Perú, en comparación con el quintil más pobre, mientras que este patrón no fue el mismo para Bolivia; asociaciones similares se han descrito en los Estados Unidos, México y Brasil [27][28][29] . Adicionalmente, en Colombia se ha documentado un incremento más rápido en las tasas de obesidad y sobrepeso para los índices de riqueza más bajos comparados con los más altos 30 . ...
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... Consequently, the burden of noncommunicable diseases like cardiovascular diseases, diabetes, musculoskeletal disorder, and some cancers is increasing [8][9][10]. e prevalence of these diseases in developing countries is increasing at an alarming rate, particularly in urban areas, and remains one of the major public health concerns [11,12]. ...
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... Consequently, the burden of noncommunicable diseases like cardiovascular diseases, diabetes, musculoskeletal disorder, and some cancers is increasing [8][9][10]. e prevalence of these diseases in developing countries is increasing at an alarming rate, particularly in urban areas, and remains one of the major public health concerns [11,12]. ...
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... One interpretation of f s is as an indicator of protein consumption, with lower values of f s associated with increased protein consumption. Studies on obesity and health in Mexico indicate that the majority of calories in the daily diet of Mexicans come from carbohydrates (>60%), while proteins make up only ~11% of caloric intake (Heien et al., 1989;Fernald et al. 2004;Ruiz-Arregui et al., 2007;Ortiz-Hernández and Gómez-Tello, 2008). Access to high-quality protein sources (f s ) may be more closely tied to socioeconomic status, coastal access, and regional animal husbandry practices than the relative contributions of international and regionally derived foods (l). ...
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In this paper, we study the effect of Progresa, a conditional cash transfer program in Mexico, on the micronutrient and macronutrient consumption levels of program participants. Overall, we find that Progresa has a complicated effect on nutrition outcomes. We find that treatment households increase their vitamin consumption by 15 percent and mineral consumption by 7 percent. Our results indicate that conditional cash transfers may have important positive effects on vitamin A, iron, and possibly calcium, which are under-consumed by a vast majority of the Mexican population. We also find that Progresa increases consumption of processed carbohydrates by 23 percent and saturated fat by about 5 percent. These findings suggest that Progresa has a dual effect on the nutrition outcomes of Progresa eligible households, likely improving macro- and micronutrient consumption levels, but also increasing the consumption of food categories that likely lead to increased prevalence of overweight and obesity.
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Objective We aimed to assess the maternal and family determinants of four anthropometric typologies at the household level in Colombia for the years 2000, 2005 and 2010. Design We classified children <5 years old according to height-for-age Z -score (<−2) and BMI-for-age Z -score (>2) to assess stunting and overweight/obesity, respectively; mothers were categorized according to BMI to assess underweight (<18·5 kg/m ² ) and overweight/obesity (≥25·0 kg/m ² ). At the household level, we established four final anthropometric typologies: normal, underweight, overweight and dual-burden households. Separate polytomous logistic regression models for each of the surveyed years were developed to examine several maternal and familial determinants of the different anthropometric typologies. Setting National and sub-regional (urban and rural) representative samples from Colombia, South America. Subjects Drawing on data from three waves of Colombia’s Demographic and Health Survey/Encuesta Nacional de Salud (DHS/ENDS), we examined individual and household information from mothers (18–49 years) and their children (birth–5 years). Results Higher parity was associated with an increased likelihood of overweight and dual burden. Higher levels of maternal education were correlated with lower prevalence of overweight, underweight and dual burden of malnutrition in all data collection waves. In 2010, participation in nutrition programmes for children <5 years, being an indigenous household, food purchase decisions by the mother and food security classification were also associated with the four anthropometric typologies. Conclusions Results suggest that maternal and family correlates of certain anthropometric typologies at the household level may be used to better frame policies aimed at improving social conditions and nutrition outcomes.
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This article presents and overview of the main results and conclusions from the Mexican National Nutrition Survey 1999 (NNS-1999) and the principal nutrition policy implications of the findings. The NNS-1999 was conducted on a national probabilistic sample of almost 18,000 households, representative of the national, regional, as well as urban and rural levels in Mexico. Subjects included were children < 12 years and women 12-49 years. Anthropometry, blood specimens, diet and socioeconomic information of the family were collected. The principal public nutrition problems are stunting in children < 5 years of age; anemia, iron and zinc deficiency, and low serum vitamin C concentrations at all ages; and vitamin A deficiency in children. Undernutrition (stunting and micronutrient deficiencies) was generally more prevalent in the lower socioeconomic groups, in rural areas, in the south and in Indigenous population. Overweight and obesity are serious public health problems in women and are already a concern in school-age children. A number of programs aimed at preventing undernutrition are currently in progress; several of them were designed or modified as a result of the NNS-1999 findings. Most of them have an evaluation component that will inform adjustments or modifications of their design and implementation. However, little is being done for the prevention and control of overweight and obesity and there is limited experience on effective interventions. The design and evaluation of prevention strategies for controlling obesity in the population, based on existing evidence, is urgently needed and success stories should be brought to scale quickly to maximize impact. The English version of this paper is available too at: http://www.insp.mx/salud/index.html.
Article
The prevalence of obesity in some lower-income and transitional countries is as high as, or even higher than, the prevalence reported in developed nations, and it seems to be increasing rapidly. In most countries, the prevalence of obesity is higher in women than in men, and higher in urban than in rural areas. Preobesity prevalence is very high in most Latin-American countries. Sixty per cent of the population in Venado Tuerto (Argentina) has a body mass index (BMI) of > or = 25 kg m-2, as do 35% of the population in Brazil, 60% in Mexico, 68% in Paraguay and 53% in Peru. Trends are available from Brazil, where marked increases in the prevalence of obesity have occurred, except in women from higher-income groups. Women from the higher-income quartiles in urban regions experienced a marked reduction in obesity prevalence from 1989 to 1997 (12.8 to 9.2%). Although data in children is scant, the prevalence of undernutrition is decreasing and the prevalence of obesity is high also in Latin-American children. The prevalence of obesity is high even in minority Indian groups. Rapid changes in dietary structure (in particular associated with urbanization) and major changes in the levels of physical activity, both occupationally and during leisure time, may explain these changes.
A Report on the Sample Sizes Used for the Evaluation of the Education, Health and Nutrition Program (PROGRESA) of Mexico
  • Jr Behrman
  • Pe Todd
Behrman JR, Todd PE. A Report on the Sample Sizes Used for the Evaluation of the Education, Health and Nutrition Program (PROGRESA) of Mexico. Washington, DC: International Food Policy Research Institute; 1999. January 25, 1999.
I: Housing, Population and Utilization of Health Services [in Spanish]
  • Jl Valdespino
  • G Olaiz
  • Mp Lopez-Barajas
Valdespino JL, Olaiz G, Lopez-Barajas MP, et al. National Health Survey 2000, I: Housing, Population and Utilization of Health Services [in Spanish]. Cuernavaca, Morelos, Mé xico: Instituto Nacional de Salud Pú blica; 2003.
I: Housing, Population and Utilization of Health Services
  • J L Valdespino
  • G Olaiz
  • M P Lopez-Barajas
Valdespino JL, Olaiz G, Lopez-Barajas MP, et al. National Health Survey 2000, I: Housing, Population and Utilization of Health Services [in Spanish].
Instituto Nacional de Salud Pú blica
  • Morelos Cuernavaca
  • Mé Xico
Cuernavaca, Morelos, Mé xico: Instituto Nacional de Salud Pú blica; 2003.
A Report on the Sample Sizes Used for the Evaluation of the Education, Health and Nutrition Program (PROGRESA) of Mexico. Washington, DC: International Food Policy Research Institute
  • J R Behrman
  • P E Todd
Behrman JR, Todd PE. A Report on the Sample Sizes Used for the Evaluation of the Education, Health and Nutrition Program (PROGRESA) of Mexico. Washington, DC: International Food Policy Research Institute; 1999. January 25, 1999.