B
Preventing Obesity in Mexican Children and Adolescents

Ruy López Ridaura, Research Center for Population Health: Chronic Disease Division, Instituto Nacional de Salud Pública (National Institute of Health, INSP)

Simón Barquera, Research Center for Nutrition and Health, INSP

Bernardo Hernández Prado, Research Center for Population Health: Reproductive Health Division, INSP

Juan Rivera, Research Center for Nutrition and Health, INSP

INTRODUCTION

Mexico is among many countries that have experienced a rapid increase over the past two decades in the proportion of children and adolescents with excessive weight. In the decade between the First (1988) and Second (1999) National Nutrition Surveys, there was an increase in the prevalence of Mexican children ages 2–4 years who were either obese or at risk for obesity,1 rising from 21.9 percent to 28.7 percent. This is the only age group in children for which national trend data are available. For older Mexican children, the lack of national trend data limits the evaluation of obesity trends during that decade. However, data from the Second National Nutrition Survey show equally alarming evidence of a growing obesity epidemic in children and youth. Based on the age- and gender-specific body mass index (BMI) charts developed by the Centers for Disease Control and Prevention (CDC) in 2000 (Kuczmarski et al., 2000), 21.1 percent of Mexican children ages 6–11 years have a BMI equal to or greater than the 85th percentile and are considered to be obese (8.8 percent) or at risk for obesity (12.3 percent). Among girls ages 12–19 years, 22.3 percent have a BMI

1

At risk for obesity and obesity are defined as having a BMI equal to or greater than the 85th and 95th percentiles, respectively, of the age- and gender-specific BMI charts developed by the CDC in 2000 (Kuczmarski et al., 2000).



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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary B Preventing Obesity in Mexican Children and Adolescents Ruy López Ridaura, Research Center for Population Health: Chronic Disease Division, Instituto Nacional de Salud Pública (National Institute of Health, INSP) Simón Barquera, Research Center for Nutrition and Health, INSP Bernardo Hernández Prado, Research Center for Population Health: Reproductive Health Division, INSP Juan Rivera, Research Center for Nutrition and Health, INSP INTRODUCTION Mexico is among many countries that have experienced a rapid increase over the past two decades in the proportion of children and adolescents with excessive weight. In the decade between the First (1988) and Second (1999) National Nutrition Surveys, there was an increase in the prevalence of Mexican children ages 2–4 years who were either obese or at risk for obesity,1 rising from 21.9 percent to 28.7 percent. This is the only age group in children for which national trend data are available. For older Mexican children, the lack of national trend data limits the evaluation of obesity trends during that decade. However, data from the Second National Nutrition Survey show equally alarming evidence of a growing obesity epidemic in children and youth. Based on the age- and gender-specific body mass index (BMI) charts developed by the Centers for Disease Control and Prevention (CDC) in 2000 (Kuczmarski et al., 2000), 21.1 percent of Mexican children ages 6–11 years have a BMI equal to or greater than the 85th percentile and are considered to be obese (8.8 percent) or at risk for obesity (12.3 percent). Among girls ages 12–19 years, 22.3 percent have a BMI 1 At risk for obesity and obesity are defined as having a BMI equal to or greater than the 85th and 95th percentiles, respectively, of the age- and gender-specific BMI charts developed by the CDC in 2000 (Kuczmarski et al., 2000).

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary equal to or greater than the 85th percentile and are either obese (5.7 percent) or at risk for obesity (16.6 percent). These data reflect an evolving obesity epidemic, representing an enormous burden for the public health and health care systems in Mexico. The association between childhood obesity and many health risks, in both children and adults, has been consistently found. The major public health impact is the association of childhood obesity with chronic disease risks in adulthood, especially overweight and obesity, type 2 diabetes, hypertension, asthma, hyperlipidemia, cardiovascular diseases (CVD), and certain cancers. Excessive weight at younger ages has also been associated with adverse psychosocial outcomes such as low self-esteem, depression, anxiety, and impaired cognitive function, especially in adolescents, although findings have not always been consistent (Swallen et al., 2005). However, research is currently not available to demonstrate this association in Mexican children and youth. Nutrition-related chronic diseases represent a serious public health problem for the Mexican population. According to the Organization for Economic Cooperation and Development (OECD) 2005 Health Report, one quarter (24.2 percent) of the Mexican adult population is classified as obese (OECD, 2005). Data from the most recent National Health Survey (2000) showed that nearly 8 percent of all Mexican adults over 20 years of age have type 2 diabetes and approximately 30 percent have hypertension (Olaiz et al., 2003). Moreover, type 2 diabetes and CVD are the leading causes of death in the adult Mexican population, and some small studies suggest an increasing incidence of type 2 diabetes and glucose intolerance at younger ages (Cruz et al., 2004; Rodríguez-Moran et al., 2004). Although there has not been a comprehensive evaluation of the economic impact of obesity in Mexico, a recent analysis estimated an attributable cost of diabetes for the public health sector of approximately $317 million U.S. dollars for the year 2005, almost equally distributed between direct and indirect costs (Arredondo and Zuñiga, 2004). The increasing incidence of obesity at younger ages and the scarce public resources in the country will considerably aggravate these economic projections. As in many developing countries, the Mexican population is in the process of an epidemiologic transition and is experiencing a double disease burden. Child mortality rates and the incidence of infectious diseases have decreased. However, statistics show a significant increase in obesity and related chronic diseases such as diabetes, hypertension, and CVD in adults. High rates of malnutrition and related problems are still observed, especially among sub-populations of Mexican children. This paradoxical situation is the result of multiple factors, partly attributed to the uneven development among different segments of the population and increased socioeconomic inequalities (Uauy et al., 2001). A closely related phenom-

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary enon that the Mexican population has experienced over the past few decades is a nutritional transition, that is a shift in the overall structure of dietary patterns and a reduction in energy expenditure. This transition is affecting most of the population, and has been proposed that it is the main driving force of the obesity epidemic and related chronic conditions in developing countries (Popkin, 2001). Given the concern over the growing prevalence of obesity and its impact, the U.S. Congress directed the CDC in 2002 to request that the Institute of Medicine (IOM) develop an action plan targeted to prevent obesity in U.S. children and youth. The IOM convened a multidisciplinary committee to develop a prevention-focused action plan. In 2004, the committee released the report Preventing Childhood Obesity: Health in the Balance (IOM, 2005), which proposed a set of recommendations for a variety of sectors and stakeholders that, when implemented together, would catalyze synergistic actions to effectively prevent the large majority of children and youth in the United States from becoming obese and facilitate the adoption of healthier lifestyles. By making childhood obesity a national priority, this set of recommendations calls on coordinated actions among the government, industry, media, community organizations, schools, and families that together will develop a broad-based public health strategy needed to effectively halt and decrease this growing epidemic (IOM, 2005). Are these recommendations applicable to Mexican–American and Mexican children and youth? Are these recommendations applicable to the particular public health challenges faced by Mexico? Is there any benefit to developing a common binational obesity prevention agenda or strategy? These are the main questions that stimulated the IOM to sponsor a joint U.S.–Mexico workshop—in collaboration with the National Institute of Public Health in Mexico (INSP) and supported by Kaiser Permanente—that will focus on exploring a binational approach to obesity prevention and the adaptation of the IOM report recommendations to Mexican children and youth living in the United States and in Mexico. The purpose of this paper is to review the factors that contribute to obesity in Mexican children and adolescents, provide an overview of current programs addressing this problem, and propose a set of actions that may offer the greatest potential for success in preventing and controlling the epidemic. A companion paper, authored by U.S. colleagues, will address obesity trends and determinants in Mexican–American children and youth (Trowbridge and Mendoza, 2007) and provide a complementary view to the issues presented in this paper. Based on an ecologic perspective, several components and their degrees of influence are context specific. For instance, the acceptance and understanding of “healthy behavior” recommendations are linked closely to cultural values that could be specific for each ethnic group. Also, given that

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary most of the recommendations imply actions at different normative levels, there are substantial differences in the legal, economic, and political contexts that need to be considered carefully in the use of the IOM report model to develop recommendations for Mexican children and youth living on both sides of the U.S.–Mexico border. Approaching obesity prevention among Mexican children and youth as a binational problem could have many advantages. Given the strong link between the population in Mexico and the one that has migrated to the United States, common cultural perceptions and values can be explored as a combined effort to design culturally acceptable recommendations and to define research priorities. Moreover, the permanent relationship, including remittances and transfer of commodities between U.S. migrant workers and their families, might allow the development of coordinated strategies that could impact not only the population living at the border (characterized by a high mobilization across countries) but also the population living in the remote areas (especially the rural areas) of Mexico, where most migrants trace their family roots. Finally, the obesity burden, on one hand, and the evidence of effective programs in the United States, on the other, can potentially improve advocacy efforts in Mexico and vice versa. Therefore, if coordination between countries can be fostered, progress toward effective preventive interventions will be accelerated with benefits and impacts on both sides of the U.S.–Mexico border. DEFINING THE PROBLEM Definition and Measurement of Obesity BMI, which is calculated by dividing weight in kilograms by height in squared meters (kg/m2), is a useful indirect measurement of body fat and unhealthy weight in children ages 2 years and older and adults. It is often used as a screening tool to identify individuals who are obese and those at risk for obesity because the measurements of height and weight are easily obtained compared with skinfold thickness measurements and other complex procedures that require more training and standardization. BMI is one of the best indicators of body fat, which is proposed as the cause component of the health consequences associated with obesity (Mei et al., 2002). Indeed, BMI has been associated consistently with several risk factors, even among children and adolescents. Preliminary results of the association between BMI and chronic disease risk factors among Mexican adolescents based on the National Health Survey (2000) are consistent with analyses from other countries in which CVD risk factors show a dose–response relationship with BMI categories, whereby the normal-weight category shows the lowest risk profile and the obesity category shows the highest risk pro-

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary FIGURE B-1 BMI categories and their association to CVD risk factors in children and adolescents ages 10–19 years, from the Mexican Health Survey (2000). SOURCE: Villalpando et al. (in press). file (Villalpando et al., in press) (Figure B-1). BMI has certain disadvantages. It has been suggested that other indicators, such as waist circumference, waist-to-hip ratio, or skinfold thickness measurements, could have a stronger association with metabolic abnormalities. However, these measurements are not usually obtained for children and youth in health clinics and school systems as readily as weight and height, and are usually not known by parents; thus, BMI is the measurement most commonly used. Although there may be a need to develop ethnic-specific definitions for overweight and obesity, the cut-off points used to define overweight (a BMI between 25 and 29.9 kg/m2) and obesity (a BMI equal to or greater that 30 kg/m2) for adults are widely accepted. However, given that BMI changes with children’s growth and development, it is more appropriate to use age-and gender-specific BMI charts to define obesity and at risk for obesity in children and adolescents. For consistency with the IOM report Preventing Childhood Obesity: Health in the Balance (IOM, 2005) and with the companion paper examining the factors contributing to obesity in Mexican– American children and youth, this paper uses the CDC BMI charts established in 2000 to define obesity and being at-risk for obesity for children

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary and adolescents between the ages of 2–19 years. According to this reference, children and adolescents with a BMI equal to or greater than the 95th percentile are considered obese, and those with a BMI between the 85th and 95th percentiles are considered to be at risk for obesity (IOM, 2005; Kuczmarski et al., 2000). In the absence of a reference population or cut-off points specific for the Mexican population, the authors conclude that the CDC BMI charts are the best available for children and adolescents 2–19 years. In the future, the recently released WHO Child Growth Standards, developed using data collected by the World Health Organization (WHO) Multicentre Growth Reference Study that provide new guidelines for assessing obesity in children ages 0–5 years (WHO, 2006a) could also be used for that age range. Obesity Prevalence and Trends in Children and Youth in Mexico The only national survey that included anthropometric measurements of school-aged children was the Second National Nutrition Survey (Rivera et al., 2001), conducted by the National Institute of Public Health of Mexico between October 1998 and March 1999. The Third National Nutrition Survey 2006 is currently in progress and will provide further data on obesity trends in children, youth, and adults throughout the entire country. The results of the Second National Nutrition Survey were based on a national probabilistic sample of 17,944 households. The sampling methodology and response rates are described in detail elsewhere (Resano-Pérez et al., 2003). The resulting sample is representative at the national level of urban (≥ 2,500 people) and rural (< 2,500 people) sites and of four geographic regions: north (the wealthiest region), south (the poorest region), Mexico City [a large urban center with the greatest socioeconomic status (SES) contrasts], and central (including states that are generally between the north and the south with respect to SES). The study population included children younger than 5 years of age (n = 8,011), school-aged children ages 5–11 years (n = 11,415), and women ages 12–49 years (n = 18,311). The sample represented about 10.6 million children 4 years of age or younger and 15.6 million children ages 5–11 years. In addition to these age ranges, which were employed in the First and Second Mexican National Nutrition Survey and are used in previous publications, for consistency with the IOM report (IOM, 2005) and the companion paper on Mexican–American children, we computed prevalences for the following age ranges (Table B-1): 0–23 months, 2–5 years, 6–11 years, and 12–19 years. However, some of the results presented in this document use the age ranges employed by the National Nutrition Surveys because we obtained them from published material.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary The national prevalence of children at risk for obesity and obese by age, geographic region, and sociodemographic characteristics derived from the National Nutrition Survey 1999 are illustrated in Table B-1. In infants younger than 2 years, the national prevalence of children at risk for obesity [defined as the percent > +2 SD of the WHO/National Center for Health Statistics (NCHS)/CDC reference population] is 5.84 percent. For children ages 2–5 years, the prevalence of obesity (BMI ≥ 95th percentile of the age-and gender-specific CDC BMI charts) was 10.4 percent, and the prevalence of children at risk for obesity (BMI between the 85th and 95th percentile of the CDC BMI charts) was 17.1 percent for a total of 27.5 percent of children in this age category who are either at risk or obese. Both groups present higher prevalence in the north compared with the other regions, and for 2– 5-year-olds, the prevalence was higher in urban versus rural areas and in high versus low SES strata. The only age category for which there are available data from two national surveys (1988 and 1999), allowing for an evaluation of obesity trends, is children younger than 5 years of age. Figure B-2 shows the trend in the proportion of children ages 2–4 years that were over the 85th percentile of the reference population. An increase was evident at the national level (31 percent, from 21.9 percent to 28.7 percent) and in each of the four regions represented in the survey; this increase was especially notable in the north (with the highest SES), which showed an estimated increase over 50 percent (from 20.8 percent to 31.8 percent) in the prevalence of obesity or at risk for obesity (> 85th percentile) over the 11-year period. This increment was mainly driven by the proportion of children who were at risk for obesity rather than the obesity category. Among Mexican children ages 6–11 years, 8.8 percent were classified as obese (> 95th percentile) and 12.3 percent were classified as at risk for obesity (> 85th percentile) at the national level. The magnitude of the regional prevalence followed the children’s SES status. The highest prevalence of obesity was found in the north (12.7 percent), followed by Mexico City (11.4 percent), the central region (8.8 percent), and the south (5.5 percent). The prevalence was higher in those living in urban (11 percent) versus rural areas (3.4 percent), in children whose mothers had a higher level of formal education (e.g., more than high school = 13.2 percent, high school = 11.8 percent, primary school = 7.5 percent, without formal education = 4.8 percent), and in the non-indigenous population (9.4 percent versus 3.4 percent). The prevalence of children at risk of obesity was higher than for the obesity category following the same pattern. The relatively larger prevalence of unhealthy weight in wealthier subpopulations is in contrast with the very small differences in prevalence of unhealthy weight found among the same subpopulations for adult women (Rivera et al., 2002).

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary TABLE B-1 Prevalence of Children at Risk for Obesity and Obese by Age and Selected Geographic and SocioDemographic Characteristics   0–23 months 2–5 years 6–11 years 12–19 years Age category Wt-for-ht (WHO) Age- and gender-specific BMI charts (Kuczmarski et al., 2000) Indicator   At Risk Obese At Risk Obese At Risk Obese Cut-off points > +2 SD 85–95 > 95 85–95 > 95 85–95 > 95 National 5.84 17.1 10.4 12.3 8.8 16.6 5.7 Region               North 7.1 19.5 12 15.5 12.7 18.3 10.1 Center 4.6 17.7 9 11.6 8.8 17.4 7 Mexico City 5.7 13.6 9.7 15.5 11.4 20.7 3.8 South 6.3 16.7 11.3 9.6 5.5 13.4 3.2 Location               Rural 5.6 17.1 10.8 8.6 3.4 12.8 4.2 Urban 6.4 17.2 9.8 13.9 11 18.2 6.3

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Gender               Girls 6.7 18 9.7 12.1 8.5 16.6 5.7 Boys 5 16.3 11.1 12.4 9.1 - - Maternal education               More than high school 7.2 19.3 12.1 14.2 13.2 - - High school 6.8 16 10.3 15.7 11.8 - - Elementary school 4.4 17.4 9.6 11.6 7.5 - - No education 5.4 15 8 8.7 4.8 - - Socioeconomic status               High 5.5 17 11.7 15.4 14.1 19.2 7.7 Medium 6.1 16.2 11.6 14.4 10.5 16.4 7 Low 6.2 17.8 8.6 7.3 2.4 14 2.2 Indigenous ethnicity               No 5.9 17.0 10.6 12.5 9.4 16.7 5.9 Yes 5.2 18.6 9.1 9.9 3.4 15.8 3.2 NOTES: Results from the 1999 Mexican Nutrition Survey. All prevalence is expressed as a percentage considering sampling weights. Definitions for obesity and at risk for obesity use the 85th and 95th age- and gender-specific percentiles from the 2000 CDC BMI charts for all age categories except children ages 0–23 months that were defined using > 2 SD of weight for height from the WHO/NCHS/CDC reference population. For the age category 12–19 years, data are exclusively for women. SOURCE: Rivera et al.(2001).

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary FIGURE B-2 Prevalence of risk of obesity or at risk for obesity by region and year of survey (children ages 2–4 years). SOURCE: Rivera et al. (2001). Undernutrition and Catch-Up Growth in Children and Youth in Mexico The coexistence of under- and overnutrition is a characteristic of the Mexican population, particularly among children and young women. Along with the high prevalence of unhealthy weight in children, the prevalence of stunting ,2 anemia, and micronutrient deficiencies remain public health concerns. Stunting continues to be an important public health problem in children younger than 5 years of age while wasting3 is no longer a widespread problem, decreasing from a national prevalence of 6 percent in 1988 to a prevalence of 2 percent in 1999. At the national level, stunting occurred in almost one of every five children younger than 5 years of age (17.7 percent) while wasting occurred in only 2 percent. The mean height-for-age z-score in this age group was −0.8 ± 1.3 while the mean weight-for-height z-score was +0.2 ± 1.1. Stunting occurs predominantly during the first two years of life. The prevalence increases almost threefold between the first and the second years of life (from about 8 percent to 22 percent) and remains at about 20 percent up to 4 years of age. From 5–11 years, the percent of 2 Stunting is defined as low height for age (< 2 SD of the WHO/NCHS/CDC reference population). 3 Wasting is defined as low weight for age (< 2 SD of the WHO/NCHS/CDC reference population).

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary stunting in children was 16.1 percent, which is mainly the result of stunting during early childhood. The long-term effects of stunting on height are evident in the adult population. On average, Mexican adult women are short (e.g., the mean height of women 12–49 years of age is 152.9 cm). Anemia and micronutrient deficiencies are widespread in most age groups (Villalpando et al., 2003a, b, c). More than one in every four children younger than 5 years (27.2 percent) are anemic, and between one-quarter to one-half have one or more micronutrient deficiencies. The prevalence of iron, zinc, and vitamin A deficiencies are at approximately 52 percent, 33 percent, and 27 percent, respectively. Additionally, more than 25 percent of children have serum ascorbic acid concentrations indicative of low dietary intake of vitamin C. Some micronutrient deficiencies occur predominantly at younger ages. Anemia rates peak in the second year of life, when almost half of all children are affected, but decrease to about 17 percent prevalence at 4 years of age. Iron deficiency affects about two-thirds of all children between 1 and 2 years of age and less than 50 percent between 3 and 4 years of age. The prevalence of anemia in children ages 5–11 years was 19.5 percent; it was slightly higher in rural (21.9 percent) than urban (18.3 percent) areas, higher in indigenous (24 percent) than non-indigenous (18 percent) children, and much lower in Mexico City (11 percent) than in other regions (18 percent to 24 percent). The micronutrient with the highest deficiency prevalence was iron (36 percent), followed by vitamin C (30 percent), vitamin A and zinc (about 20 percent), and folic acid (about 10 percent). Urban areas had a much lower prevalence of iron and zinc deficiencies (38.2 percent and 18.2 percent, respectively) than rural areas (48.3 percent and 40 percent, respectively) (Rivera and Sepúlveda-Amor, 2003). As mentioned earlier, stunting is a public health problem in Mexico, but the prevalence of wasting is within expected values for a healthy population. Results from the Second National Nutrition Survey (Rivera et al., 2001) show that the mean height-for-age z-score is −0.4 from 0–11 months, drops to −1.1 at 12–23 months, and remains at around −1.0 up to 59 months of age. The prevalence of stunting is 8.5 percent from 0–11 months of age, rises sharply to 21.8 percent at 12–23 months, and remains at about that level until 4 years of age. These data indicate that stunting occurs from birth to 23 months of age and that there is no substantial catch-up growth from 23 to 59 months. At the end of the preschool period, the height of children is about 1 SD below the mean value of the reference population, and about 20 percent of children have heights in the lower extreme (< –2 SD) of the reference distribution. In contrast, the mean weight-for-height z-score remains between +0.1 and +0.3 from birth to 59 months of age, indicating that weight relative to height is slightly above the value expected

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary The main preventive actions for children are focused on health promotion, nutrition education, disease control and prevention, early identification of diseases, oral health, vaccination, and miscellaneous actions (e.g., personal hygiene, breastfeeding promotion, and fever control). For adolescents, the program’s preventive actions are focused on physical activity promotion; accident prevention; violence and addiction prevention; oral health; sexual health and education; nutrition education; obesity detection and control; parasite treatment; vaccination; use of preservatives; human immunodeficiency virus and sexually transmitted diseases prevention; visual, auditory, and postural defects; and reproductive health. There are also components for adults. For each preventive action, there is a set of designed activities and objectives personalized for each age group. As part of the promotion strategy, this program has a nationally distributed magazine (sold at newspaper shops) that features health care information related to these actions. In addition, television advertisements focus on healthy lifestyles, nutrition, obesity prevention, and promoting the magazine to the general public. Until now, this program has not been evaluated fully; however, a recent internal baseline survey was designed and implemented to assess the coverage of the main components and to evaluate intermediate program outcomes such as prevalence of anemia, frequency of physical activity, undernutrition, overweight, and obesity. This survey found an inadequate register of the nutritional status in the diverse population groups and of the health promotion activities. It is expected that one-year follow-up surveys will monitor selected outcomes of this integrated health program (Gutiérrez-Trujillo, 2005). Ministry of Health Programs for Noncommunicable Chronic Diseases The Ministry of Health of Mexico has several programs that consider prevention as a relevant component (Ministry of Health, 2006). These programs are not integrated health or nutrition programs but programs focused primarily on the most relevant public health problems, such as obesity, diabetes mellitus, high blood pressure, and cancer. Each of these diseases has a program that includes general management and preventive recommendations that must be followed by the government health service providers. However, most (if not all) of these programs, focus attention on promoting behavioral changes and early detection in adults, especially young adults over the age of 20 years. Obesity prevention during childhood and adolescence has been given much less consideration; rather, the predominant problems of concern for this group are related to food security (undernutrition and micronutrients deficiencies).

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary The following are some recently implemented actions for increasing the awareness and actions related to obesity prevention in children and youth in the public sector: Implementation of regional or state-level programs; evaluation by the state (public) health sector needs to be conducted. Creation of obesity clinics in public pediatric hospitals addressing the clinical care and management of obese children and research focuses on the consequences of obesity. Development of an official memo outlining a future nationwide communication campaign for obesity prevention that in addition to addressing food production, media regulation, and food labeling, is intended to promote healthier lifestyles with special attention to children and adolescents. Addition of obesity prevention among children and adolescents as one of the five priorities for research funding in the last request for proposals by CONACYT, the federal agency that provides oversight for research funding. Moreover, recent efforts by the private sector have been implemented but must still be evaluated. GOALS AND RECOMMENDATIONS In accordance with the recommendations in the IOM report, Preventing Childhood Obesity: Health in the Balance (IOM, 2005), the final goals for obesity prevention among childhood and youth should be to stop the current trend in rising obesity incidence and prevalence and related chronic diseases and ultimately reduce the proportion of children and youth with an unhealthy weight. This ultimate goal necessarily should include increasing the proportion of children and adolescents meeting a healthful diet and appropriate amounts of regular physical activity and following a healthy growth trajectory. In the process of achieving these goals, it is important to define intermediate outcomes that will be needed to evaluate progress of a multi-faceted obesity prevention strategy. Based on the information described in previous sections, the authors propose a series of goals and recommendations for action for a multilevel and nationwide obesity prevention strategy among children and adolescents. An objective of the U.S.–Mexico binational meeting will be to broadly discuss this list of recommendations among key persons from each sector (e.g., academia, government, industry, schools, communities) to reach consensus on the next steps needed to initiate this multilevel strategy. A list of possible intermediate outcomes and goals for discussion during the binational meeting include:

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Increased quantity and quality of physical activity at schools in both planned physical education time and recreational time such as recess. Increased and improved facilities for recreational activities in communities, especially suburban areas. Increased advertising and marketing messages in preferably broadcast, cable, and satellite television, but also in other media such as radio, the Internet, and cell phones, aimed at children, youth, and their parents that promote healthy lifestyles, including healthful diets and regular physical activity. Decreased number of media advertising or marketing campaigns promoting high-calorie and low-nutrient food and beverage products targeted at children and adolescents that increase the risk of positive energy balance (such as refined sugars and saturated and trans fats). Decreased proportion of children and youth who have more than two hours of leisure screen time (including television and video watching) per day. Increased proportion of children and youth consuming more than five portions of fruits and vegetables per day. As stated in the IOM recommendations, in order to achieve these types of intermediate outcomes, a multilevel strategy clearly is needed. However, in contrast to the U.S. context, Mexican society at large (e.g., government, industry, community leaders, schools, families) is far behind on some fundamental aspects needed to build support for this strategy. Three main issues that should be covered as priority steps in developing an effective obesity prevention strategy are: creating awareness among decision makers (including all branches of federal and state powers) as well as among the general public; regulating and enforcing laws; empowering communities so that they can achieve the necessary changes in different environments (e.g., school, community, industry) that, as described in previous sections, are contributing to a net positive energy balance among Mexicans in general, and specifically children and youth. Priority recommendations for action specifically related to the Mexican context are listed below. The recommendations can be viewed as preliminary and will be modified through discussion with different stakeholders. Government Level Underpin the idea of childhood obesity prevention as an urgent national priority, with strong participation and leadership of government at all levels in several actions including:

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Regulations and implementation of media and food, beverage, and restaurant industry policies; Support and funding of obesity prevention programs at federal and state levels with planned evaluations of their health impact; Support and funding of surveillance and monitoring efforts and wide dissemination of their findings not only at the national level, such as the National Nutrition Surveys, but also at the state and county levels; Planning of urban development with an appropriate access and promotion of facilities for recreational activities; Initiation of a widespread nationwide media campaign across print, electronic (e.g., radio, television), and wireless and Internet-based media (e.g., cell phones) to increase awareness of the obesity problem in the population; Expand the training of professionals to design, implement, and evaluate strategies for effectively responding to the obesity epidemic. Review current regulations for food labeling (NOM 051-SECOFI and NOM-086-SSA1-1994), evaluate the impact and consumers’ understanding of food labeling, and make necessary modifications required to support obesity prevention goals. Review current government regulations and guidelines on the use of health claims on food products, especially nutrition-related health claims. Develop incentives or regulations for advertising and marketing to children and youth, especially for food and beverage products high in total calories and in particular for those with a high content of refined carbohydrates, added sugars, and fat. Seek mechanisms such as incentives or regulations to improve the enforcement of policies related to media and the food, beverage, and restaurant industries, including food labeling. Create an advisory committee that, together with the Federal Commission for the Protection from Sanitary Risk (COFEPRIS), will develop and evaluate policies for food labeling, marketing, media control, and dietary guidelines. This committee should include experts from different public and private institutions, as well as industry representatives and consumers. Priority steps should focus on the following areas: Modify food labeling, focusing on the need of acceptance and understanding for the majority of the population. Limited evidence suggests that most of the information contained on food labels is difficult for consumers to understand. Develop communication strategies that are clear and understandable by the general public. Reduce, at minimum, the content of health claims in media-based marketing, especially for those foods that promote “healthy” choices that do not meet basic nutritional guidelines.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Conduct research on advertising and marketing targeted at Mexican children and youth focused on high-calorie, low-nutrient food and beverage products, and limit or eliminate practices that promote these types of products. In collaboration with industry, conduct research on the types and amount of fat that is used and needed in products. Set a limit on the recommended use of dietary fats and oils, particularly saturated fat and trans fats, by the food, beverage, and restaurant industry and fast food available through informal establishments. Regulate media marketing for food products with high content of refined carbohydrates and fat in regards to type of information, and advertising locations. For example, the possibility of setting strict limits in children’s environments, such as schools, parks, and entertainment centers, should be researched and discussed. Evaluate the use of policy instruments such as international trade, subsidies, and taxes for encouraging or discouraging the production and consumption of certain foods to encourage the availability and access to healthful foods such as fruits and vegetables during all seasons and to reduce the consumption of less healthful foods and beverages. Promote the consumption of fruits and vegetables and other familiar healthful foods and beverages through diverse media. Promote a diverse media campaign supporting the consumption of water as a substitute for sweetened beverages (including carbonated soft drinks). School Level Revise the school breakfast program to ensure healthful food and meal options. Regulate the foods and beverages offered to children and youth in and around the school environment. Promote the enforcement of minimally established time that children and youth participate in physical education in both private and public schools, as well as physical education programs that achieve the recommended amounts of moderate to vigorous physical activity. Encourage the organization of local and regional events to promote sports practice in schools. Define minimal spaces at schools to ensure regular physical activity during physical education time and during recess. Revise and improve school curricula to include obesity prevention and healthy lifestyle promotion.

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Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin: Summary Community Level Stimulate community organization and community members’ empowerment to request and influence the modification of norms and environments aimed at achieving healthy lifestyles. Explore the spectrum of available organizations to identify the best strategies for increasing community empowerment and awareness, especially among parents, of the obesity epidemic. Potential community organizations include parents’ societies, religious groups, and non-governmental organizations. In conclusion, Mexico is on the course of an epidemiologic and nutritional transition toward more sedentary lifestyles and obesogenic environments. The present trajectory is moving toward an increasing burden of obesity in children and youth with serious predictable health and economic burdens to the entire population and Mexican society. These risks must be addressed immediately with multi-level interventions undertaken by a variety of stakeholders in government, schools, and communities targeting children and youth in many settings. The response to the growing obesity epidemic in Mexico will require many years and perhaps decades to implement and to evaluate the effectiveness of the results. The joint U.S.–Mexico workshop, for which this and the companion paper from the U.S. context served as background for discussion, should delineate the initial steps of the strategy required to tackle this urgent public health problem. REFERENCES Alsea. 2004. Annual Report. [Online.] Available: http://www.alsea.com.mx [accessed May 5, 2006]. Arredondo A, Zuñiga A. 2004. Economic consequences of epidemiologic changes in diabetes in middle-income countries: The Mexican case. Diabetes Care 27(1):104–109. Arochi R, Tessmann KH, Galindo O. 2004. Advertising to children in Mexico. Young Consumers 6(4):82–85. Bandini LG, Must A, Cyr H, Anderson SE, Spadano JL, Dietz WH. 2003. Longitudinal changes in the accuracy of reported energy intake in girls 10–15 years of age. American Journal of Clinical Nutrition 78(3):480–484. Barker DJ. 1992. Fetal growth and adult disease. British Journal of Obstetrics and Gynaecology 99(4):275–276. Barquera S, Rivera-Dommarco J, Safdie M, Flores-Aldana M, Campos-Nonato I, Campirano F. 2003. Energy and nutrient intake in pre-school and school-age Mexican children: National Nutrition Survey 1999. Salud Pública de México 45(4):540–550. Barquera S, Hotz C , Rivera J, Tolentino L, Espinoza J, Campos I, Shamah T. In press. Food consumption, food expenditure, anthropometric status, and nutrition-related diseases in Mexico. In: Kennedy et al., eds. Double-Burden of Malnutrition in Developing Countries. Rome, Italy: Food and Agricultural Organization. Pp. 161–204.

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