Breastfeeding: crucially important, but increasingly challenged in a market-driven world.

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Letter to the editor: will it be possible to achieve the global nutrition targets in Mexico by 2030?

In May 2012, the 65th World Health Assembly (WHA) approved six global nutrition targets by 2025 aimed to reduce stunting in children under five by 40%, maintain childhood wasting below 5%, halt obesity, cut anemia in women by 50%, lower low birth weight prevalence by 30%, and increase exclusive breastfeeding (EBF) within the first 6 months to 50%. These targets were extended to 2030, with all of them remaining as originally planned, but the EBF one (increased to 70%), wasting and overweight (both objectives set to eliminate them to negligible concern). Mexico is projected to achieve only one of the six nutrition targets (wasting) by 2025, falling far short of the stunting, low birth weight, anemia, and exclusive breastfeeding for the updated goals by 2030. This letter to the editor describes the most recent prevalence of malnutrition among mothers and children in Mexico. It discusses the challenges pregnant women and children under five years of age face exercising their right to good food, nutrition, and development. The authors reflect on the urgent need to make structural changes to achieve the global nutrition targets by 2030, highlighting the paramount importance of addressing the profound structural obstacles in Mexico and how Mexico's government must prioritize poverty reduction, reduce the marked inequalities, enhance the quality of nutritional care and healthcare infrastructure, and implement climate-resilient agricultural practices to address this pressing issue.

Weight gain trajectories patterns from pregnancy to early postpartum: identifying women at risk and timing to prevent weight regain.

BACKGROUND: Woman's weight changes during pregnancy and postpartum contribute to obesity and health outcomes later in life. This study aimed to identify and characterize weight change trajectories from pregnancy to one year postpartum among adult women. METHODS: We used data from an ongoing cohort of healthy adult women (n = 819) with singleton pregnancies from 2007 - 2011. Sociodemographic data, pre-pregnancy body weight, and sedentary and breastfeeding practices were collected using questionaries applied by trained professionals. We applied a group-based trajectory modeling to distinguish weight change measured in the second and third trimesters of pregnancy and at one month, six, and 12 months postpartum. Multinomial regression models were run to characterize each trajectory. RESULTS: We identified six weight change trajectories with the main difference in the patterns followed after one month of delivery. One in three women (36.7%) was classified in some of the three postpartum weight gain trajectories and regained weight from the second trimester of the first year postpartum. Women who followed some of these trajectories were more likely to have higher age, obesity before pregnancy, < 10 years of schooling, and partner, compared with women (10.7%, n = 87) in a postpartum sustained-fast-lost-weight trajectory (p < 0.05). CONCLUSIONS: Women with obesity before pregnancy have higher odds of regaining gestational weight after delivery without reaching their pre-pregnancy weight. The first six months postpartum are crucial to establishing obesity prevention strategies. Further research is needed to evaluate the effect of the interventions that prevent substantial weight gain through reproductive years in high-risk women.

Volviéndonos mejores: necesidad de acción inmediata ante el reto de la obesidad. Una postura de profesionales de la salud.

La creciente epidemia de obesidad ha sido uno de los retos más importantes de salud pública en México durante los últimos años. Con apoyo de la Federación Mundial de Obesidad, en 2021 formamos un grupo de profesionales para identificar y resumir las acciones prioritarias en las que puede enfocarse nuestro país para hacer frente a esta epidemia. Al proceso de desarrollo y discusión de este grupo se sumaron más de 1 000 profesionales de la salud para retomar recomendaciones de documentos y guías de alto nivel previamente publicados. En conmemoración del Día Mundial de la Obesidad, en este 2022 se presenta esta postura como insumo para el desarrollo de acciones en el ámbito profesional y de los diferentes sectores, en la que se incluyen 10 recomendaciones de acción, desde la perspectiva poblacional hasta la atención individualizada, y se enfatiza en la importancia de la participación social, de las intervenciones integrales con visión centrada en la persona y de la sostenibilidad planetaria, además de mejorar la educación y las campañas de difusión, propiciar un ambiente promotor de entornos activos y blindar de conflictos de interés los esfuerzos de prevención y control. La postura hace un llamado para abordar la obesidad de manera seria, con base en la evidencia científica, oportuna e integral, con enfoque de curso de vida, de forma ética y sensible, y sin perpetuar las barreras del estigma de peso en la sociedad.

What will it take to increase breastfeeding?

The introduction for the Supplement in Maternal & Child Nutrition: What will it take to increase breastfeeding? describes the contribution of each of the articles included in this Supplement to the current evidence about the major structural challenges in place to overcome to improve breastfeeding practices, as well as the evidence-based policies and interventions that can be effective at advancing breastfeeding on a large scale to promote, protect and support breastfeeding.

What works to protect, promote and support breastfeeding on a large scale: A review of reviews.

Globally women continue to face substantial barriers to breastfeeding. The 2016 Lancet Breastfeeding Series identified key barriers and reviewed effective interventions that address them. The present study updates the evidence base since 2016 using a review of reviews approach. Searches were implemented using the Epistomenikos database. One hundred and fifteen reviews of interventions were identified and assessed for quality and risk of bias. Over half of reviews (53%) were high- or moderate quality, with the remaining low or critically low quality due to weaknesses in assessment of bias. A large portion of studies addressed high-income and upper-middle income settings, (41%), and a majority (63%) addressed health systems, followed by community and family settings (39%). Findings from reviews continue to strengthen the evidence base for effective interventions that improve breastfeeding outcomes across all levels of the social-ecological model, including supportive workplace policies; implementation of the Baby-Friendly Hospital Initiative, skin to skin care, kangaroo mother care, and cup feeding in health settings; and the importance of continuity of care and support in community and family settings, via home visits delivered by CHWs, supported by fathers', grandmothers' and community involvement. Studies disproportionately focus on health systems in high income and upper-middle income settings. There is insufficient attention to policy and structural interventions, the workplace and there is a need for rigorous assessment of multilevel interventions. Evidence from the past 5 years demonstrates the need to build on well-established knowledge to scale up breastfeeding protection, promotion and support programmes.

Countries' experiences scaling up national breastfeeding, protection, promotion and support programmes: Comparative case studies analysis.

Scaling up effective interventions, policies and programmes can improve breastfeeding (BF) outcomes. Furthermore, considerable interest exists in learning from relatively recent successful efforts that can inform further scaling up, with appropriate adaptations, across countries. The purpose of this four-country case studies analysis was to examine why and how improvements in BF practices occurred across four contrasting countries; Burkina Faso, the Philippines, Mexico and the United States of America. Literature reviews and key informant interviews were conducted to document BF trends over time, in addition to why and how BF protection, promotion and support policies and programmes were implemented at a national level. A qualitative thematic analysis was conducted. The 'Breastfeeding Gear Model' and RE-AIM (Reach; Effectiveness; Adoption; Implementation; and Maintenance) frameworks were used to understand and map the factors facilitating or hindering the scale up of the national programmes and corresponding improvements in BF practices. Each of the studied countries had different processes and timing to implement and scale up programmes to promote, protect and support breastfeeding. However, in all four countries, evidence-based advocacy, multisectoral political will, financing, research and evaluation, and coordination were key to fostering an enabling environment for BF. Furthermore, in all countries, lack of adequate maternity protection and the aggressive marketing of the breast-milk substitutes industry remains a strong source of negative feedback loops that are undermining investments in BF programmes. Country-specific best practices included innovative legislative measures (Philippines), monitoring and evaluation systems (United States of America), engagement of civil society (Mexico) and behavior change communication BF promotion (Burkina Faso) initiatives. There is an urgent need to improve maternity protection and to strongly enforce the WHO Code of Marketing of Breast-Milk Substitutes.

Follow-up and growing-up formula promotion among Mexican pregnant women and mothers of children under 18 months old.

Milk formula sales have grown globally, particularly through follow-up formulas (FUF) and growing-up milks (GUM). Marketing strategies and weak regulatory and institutional arrangements are important contributors to caregivers' decisions about child feeding choices. This study describes maternal awareness, beliefs, and normative referents of FUFs and GUMs among Mexican pregnant women and mothers of children 0-18 months (n = 1044) through the lens of the theory of reasoned action (TRA). A cross-sectional survey was undertaken in two large metropolitan areas of Mexico. Descriptive analyses were conducted following the constructs of the TRA. One-third of the participants had heard about FUFs, mainly through health professionals (51.1%) and family (22.2%). Once they had heard about FUFs, the majority (80%) believed older infants needed this product due to its benefits (hunger satisfaction, brain development, and allergy management). One quarter of the participants were already using or intended to use FUFs; the majority had received this recommendation from doctors (74.6%) and mothers/mothers-in-law (25%). Similarly, 19% of the women had heard about GUMs. The pattern for the rest of TRA constructs for GUMs was similar to FUFs. Mexican women are exposed to FUFs and GUMs, once women know about them, the majority believe older infant and young children need these products, stating perceived benefits that match the poorly substantiated marketing claims of breast-milk substitutes. Health professionals, particularly doctors, act as marketing channels for FUFs and GUMs. Marketing of FUFs and GUMs represents a threat to breastfeeding in Mexico and a more protective regulatory and institutional environment is needed.

Breastfeeding at the workplace: a systematic review of interventions to improve workplace environments to facilitate breastfeeding among working women.

BACKGROUND: Breastfeeding can be affected by maternal employment. This is important considering that in 2019, 47.1% of women globally participated in the labor force. The aim of this study was to review workplace interventions to promote, protect and support breastfeeding practices among working mothers globally. METHODS: A systematic review was conducted following the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Observational, experimental and qualitative peer-reviewed studies in English and Spanish, published between 2008 and 2019 were included. The review focused on working women who were pregnant, breastfeeding or who recently had a child, and women's working environments. The outcomes of interest included breastfeeding intentions, initiation, exclusivity and duration, confidence in breastfeeding or breastmilk extraction, and perceived support at workplace. Quality was assessed according to National Institute for Health and Care Excellence (NICE) checklist for systematic reviews. It was registered on PROSPERO (#140624). RESULTS: Data was extracted from 28 quantitative and 9 qualitative studies. The most common interventions were designated spaces for breastfeeding or breastmilk extraction (n = 24), and the support from co-workers (n = 20). The least common interventions were providing breast pumps (n = 4) and giving mothers the flexibility to work from home (n = 3). Studies explored how interventions affected different breastfeeding outcomes including breastfeeding duration, breastfeeding exclusivity, confidence in breastmilk expression, and breastfeeding support. The evidence suggests that workplace interventions help increase the duration of breastfeeding and prevent early introduction of breastmilk substitutes. Having a lactation space, breastmilk extraction breaks, and organizational policies are key strategies. However, to achieve equitable working conditions for breastfeeding mothers, organizational and interpersonal changes need to occur as well. CONCLUSIONS: The systematic review revealed that interventions at the workplace are important in protecting, promoting and supporting breastfeeding among working mothers. To achieve equitable work environments and fair nutritional opportunities for infants of working mothers, interventions should focus at the three ecological layers - individual, interpersonal, and organizational. The quality of studies can be improved. There is a need for studies assessing impacts of workplace interventions on infant feeding practices, mothers' self-esteem and outcomes such productivity and abstentionism.

Marketing of breast milk substitutes on the internet and television in Mexico.

AIM: We aimed to examine the advertising and marketing of breast milk substitutes (BMS) through the internet, social media and television in Mexico. METHODS: We recorded the programming of four main TV channels at peak times to identify BMS advertisements. In addition, we identified the main BMS products and companies present on the internet, as well as related home pages and social networks (Facebook, Twitter and YouTube). After that, we examined current BMS' marketing practices using the International Code of Marketing of Breast-milk Substitutes ('the Code') as a framework for ethical marketing. Qualitative and statistical analyses are presented. RESULTS: BMS manufacturers have a presence on television, social media and the internet. Violations of the Code, as well as promotional practices unforeseen by the Code, were identified in all the studied media. These include text and images idealising the use of BMS, as well as mechanisms for boosting sales and making contact with consumers. CONCLUSIONS: The Mexican population is exposed to BMS advertisements that breach the Code on the internet, on social networks and on television. Emerging challenges related to the use of electronic means to market BMS may call for new strategies for monitoring and enforcing the Code through local regulations.

[Risk factors associated with overweight and obesity among female Mexican teenagers]. / Factores de riesgo asociados con sobrepeso y obesidad en adolescentes mexicanas.

OBJECTIVE: To analyze risk factors associated with overweight and obesity (OW+O) among female Mexican teenagers (12 to 19 years old). MATERIALS AND METHODS: Secondary analysis of 1 072 teenagers from the Halfway National Survey of Health and Nutrition (Ensanut MC, 2016). Ordinal logistic regression models were used to estimate the association between OW+O and screen time, living with adults with OW+O, marital union, and dietary patterns, among others. RESULTS: OW+O in adolescents was higher when living with overweighed and obese adults (OR= 2.13), >2 hours of screen time (OR= 2.5), discretionary food consumption pattern (OR= 1.81), living in marital union (OR = 2.13), classified in the highest tertile of household wealth index (OR= 1.86), work and doing housework (OR= 5.4). CONCLUSIONS: The most important risk factors associated with OW+O in Mexican teenagers were related to family factors and lifestyles.

OBJETIVO: Analizar factores de riesgo asociados con sobrepeso y obesidad (SP+O) en adolescentes mexicanas (12 a 19 años). MATERIAL Y MÉTODOS: Análisis secundario de 1 072 adolescentes de la Encuesta Nacional de Salud y Nutrición de Medio Camino 2016. Mediante modelos de regresión logística ordinal se estimó la asociación entre SP+O y tiempo frente a pantalla, convivir con adultos con SP+O, cohabitar con pareja, patrones dietarios, entre otros. RESULTADOS: El SP+O en adolescentes se asoció con convivir con adultos con SP+O (RM=2.13), >2 horas frente a pantalla (RM=2.5), patrón de consumo de alimentos discrecionales (RM=1.81), cohabitar con pareja (RM=2.13), índice de condición de bienestar alto (RM=1.86) y dedicarse al hogar y trabajar (RM=5.4). CONCLUSIONES: Los factores de riesgo más importantes asociados con el SP+O en adolescentes mexicanas se relacionan con factores de convivencia familiar y de estilos de vida.

Violations of the International Code of Marketing of Breast-milk Substitutes in Mexico.

This study estimated the prevalence of violations of the International Code of Marketing of Breast-milk Substitutes (BMS) and subsequent resolutions of the World Health Assembly (Code) at health facilities, points of sale (POS), and on BMS labelling and media in Mexico. We carried out a cross-sectional survey among 693 mothers with children aged less than 24 months and 48 health providers at public and private health facilities in two states of Mexico. Observational assessment at 20 POS and the health facilities was conducted as well as an analysis of labels on BMS products for sale. Women attending public and private health facilities reported receiving free BMS samples in the previous 6 months (11.1%), and about 80% reported seeing BMS promotion in the mass media. Health providers reported contact with BMS manufacturer representatives in the previous 6 months (15.5%), and only 41.6% of the health providers had knowledge of the Code. BMS promotions were identified at nearly all POS. Analysis of 190 BMS labels showed that 30% included pictures/text idealizing the use of BMS, and all labels incorporated health and nutrition claims. Violations of the Code are prevalent within the health services, POS, and labelling of BMS products. The high percentage of health providers with no knowledge of the Code calls for action at national level to better disseminate and comply with the Code. A transparent, free from commercial influence, and continual monitoring system for Code compliance is needed, including a follow-up component on sanctions for contraventions of the Code.

[Dietary patterns and metabolic syndrome components in women with excess weight 18 to 45 years old]. / Patrones dietéticos y síndrome metabólico en mujeres con exceso de peso de 18 a 45 años de edad.

OBJECTIVE: To analyze the association between dietary patterns and metabolic syndrome (MS) components in adult women with excess weight. MATERIAL AND METHODS: Cross-sectional study with anthropometric, dietary, biochemical and blood pressure data. Dietary patterns were identified by factor analysis and multiple logistic regression models were used to analyze associations. RESULTS: The prevalence of altered glucose was 14.6%, of hypertriglyceridemia 40.4%, of altered concentration of high density lipoprotein cholesterol(HDLc) 45.0%, hypertension 4.6% and MS 30%. The pattern with high consumption of corn tortillas, meats and legumes, was associated with less possibility of hyperglycemia (OR= 0.62; 95%CI 0.39-0.98). The pattern with high consumption of sweet and salty snacks, milk, rice, soaps and pasta, was inversely associated with the possibility of low HDLc concentration (OR= 0.76; 95%CI 0.60-0.97). CONCLUSIONS: A dietary pattern with greater consumption of legumes, meats and corn tortillas was associated with less possibility of having hyperglycemia.

OBJETIVO: Analizar la asociación de patrones dietéticos y componentes del síndrome metabólico (SM) en mujeres adultas con exceso de peso. MATERIAL Y MÉTODOS: Estudio transversal que incluye datos antropométricos, dietéticos, bioquímicos y de presión arterial. Se identificaron patrones dietéticos mediante análisis de factores y se emplearon modelos de regresión logística múltiple, para analizar asociaciones. RESULTADOS: Las prevalencias fueron: glucosa alterada 14.6%, hipertrigliceridemía 40.4%, lipoproteínas de alta densidad (HDLc) bajas 45.0%, hipertensión 4.6% y SM de 30%. El patrón con alto consumo de tortilla de maíz, carnes y leguminosas se asoció con menor posibilidad de hiperglucemia (OR= 0.62; IC95% 0.39-0.98). El patrón con alto consumo de botanas dulces y saladas, leche, arroz, sopas y pastas, se asoció inversamente con la posibilidad de baja concentración de HDLc (OR= 0.76; IC95% 0.60-0.97). CONCLUSIONES: Un patrón dietético con mayor consumo de leguminosas, carne y tortilla de maíz se asoció con menor posibilidad de tener hiperglucemia.

[Trends of malnutrition in Mexican children under five years from 1988 to 2016: Analysis of five national surveys]. / Tendencias de la mala nutrición en menores de cinco años en México, 1988-2016: análisis de cinco encuestas nacionales.

OBJECTIVE: To study the magnitude, distribution and trends of undernutrition and overweight in Mexican children un¬der five years between 1988 and 2016. MATERIALS AND METHODS: Underweight, wasting, stunting and overweight prevalences were calculated, at national, regional and rural/ urban locality levels in children under five years from the 1988, 1999, 2006, 2012 and 2016 national probabilistic surveys. RESULTS: Currently 3.9% suffer underweight, 1.9% wasting and 10% stunting. There was an decrease in stunting from 1988 to 2016 (26.9 vs 10.0%), in rural (43.1 vs 12.6%) and urban (22.5 vs 9.1%) localities and in South (38.6 vs 13.4%), Center (29.2 vs 8.4%) and Mexico City (13.6 vs 4.7%). In the North region the decrease was smaller (13.3 vs 11.4%). Overweight diminished from 9.7% to 5.8, mainly between 2012-2016. CONCLUSIONS: Stunting has continued its decline in Mexico, but high prevalences persist in some vulnerable groups. Overweight had an unexpected decline between 2012-2016.

OBJETIVO: Estudiar la magnitud, distribución y tendencias de la desnutrición y el peso excesivo en menores de cinco años entre 1988 y 2016. MATERIAL Y MÉTODOS: Se calcularon prevalencias de bajo peso, emaciación, desnutrición crónica y sobrepeso, en el ámbito nacional, en cuatro regiones y locali­dades urbanas/rurales, en menores de cinco años obtenidas en encuestas nacionales probabilísticas en 1988, 1999, 2006, 2012 y 2016. RESULTADOS: Actualmente 3.9% de la muestra tiene bajo peso, 1.9% emaciación y 10% desnutrición crónica. Hubo un descenso en la desnutrición crónica de 1988 a 2016 (26.9 vs 10.0%), en localidades rurales (43.1 vs 12.6%) y urbanas (22.5 vs 9.1%) y en el sur (38.6 vs 13.4%), centro (29.2 vs 8.4%) y Ciudad de México (13.6 vs 4.7%). En el Norte el descenso fue menor (13.3 vs 11.4%). El sobrepeso disminuyó de 9.7% a 5.8%, entre 2012-2016. CONCLUSIONES: La desnutrición crónica continúa a la baja en México, pero persisten preva­lencias elevadas en grupos vulnerables. El sobrepeso presentó una disminución inesperada entre 2012-2016.

[Recommendations for a multisectorial national policy to promote breastfeeding in Mexico: position of the National Academy of Medicine]. / Recomendaciones para una política nacional de promoción de la lactancia materna en México: postura de la Academia Nacional de Medicina.

Evidence strongly supports that to improve breastfeeding practices it is needed to strengthen actions of promotion, protection and support. To achieve this goal, it is necessary to establish a multisectoral national policy that includes elements such as design, implementation, monitoring and evaluation of programs and policies, funding research, advocacy to develop political willingness, and the promotion of breastfeeding from the national to municipal level, all coordinated by a central level. It is until now that Mexico has initiated a reform process to the establish a National Strategy for Breastfeeding Action. This strategy, is the result not only of the consistent scientific evidence on clear and strong benefits of breastfeeding on population health and the development of human capital, but also for the alarming data of deterioration of breastfeeding practices in the country. The comprehensive implementation of the National Strategy for Breastfeeding Action that includes the establishment of a national committee, intra- and inter-sectoral coordination of actions, setting clear goals and monitoring the International Code of Marketing of Breast-Milk Substitutes, is the awaiting responsibility of the public health agenda of the country.

The Associations of Maternal Weight Change with Breastfeeding, Diet and Physical Activity During the Postpartum Period.

OBJECTIVE: To determine the association between breastfeeding practices, diet and physical activity and maternal postpartum weight. METHODS: This was a secondary data analysis of a randomized community trial on beneficiaries of the Programa de Desarrollo Humano Oportunidades, recently renamed Prospera (n = 314 pregnant women), without any diseases that could affect body weight. Generalized estimating equations were used to determine the association between postpartum weight change and changes in diet, physical activity and type of breastfeeding. RESULTS: The mean postpartum weight change from the first to the third month was 0.6 ± 2.2 kg. Women who breastfed exclusively for 3 months had a 4.1 (SE = 1.9) kg weight reduction in comparison with women who did not provide exclusive breastfeeding or who discontinued breastfeeding before 3 months (p = 0.04). There was no association between postpartum weight change and physical activity (p = 0.24) or energy intake (p = 0.06). CONCLUSIONS: Exclusive breastfeeding was associated with maternal postpartum weight reduction. These results reinforce the World Health Organization recommendation of exclusive breastfeeding during the first 6 months of life in order to reduce the risk of weight retention or weight gain in postpartum women. It has been well established that exclusive breastfeeding is beneficial for both infants and mothers, but promoting breastfeeding as a strategy to promote postpartum weight loss is of paramount importance, especially in countries like Mexico where excessive weight in women of reproductive age is a public health problem.

A Water and Education Provision Intervention Modifies the Diet in Overweight Mexican Women in a Randomized Controlled Trial.

BACKGROUND: There is minimal information on the impact of replacing sugar-sweetened beverage (SSB) consumption with water on diet quality from randomized controlled trials. OBJECTIVE: We evaluated the effect of a water intake intervention on diet quality in overweight Mexican women. METHODS: Women with a body mass index ≥25 and <39, 18-45 y old, and a self-reported high intake of SSBs (≥250 kcal/d) were randomly allocated to either the water and education provision (WEP) group (n = 120) or the education provision (EP) only group (n = 120). Each group received monthly nutrition counseling, and the WEP group received biweekly water deliveries for 9 mo. Three 24-h recalls, anthropometry, and demographic information were collected at baseline, and 3, 6, and 9 mo. Energy, macronutrient, sugar, SSB, fruit and vegetable, salty snack, cake and cookie, and fast food intakes were assessed in study completers (n = 189) classified by intervention assignment and by actual water intake at every time point (low <1200 vs. high ≥1200 mL/d). RESULTS: The WEP group reported greater decreases in SSB intake than the EP group (from 20.9% to 10.3% of energy/d vs. from 20.1% to 17.8%). Thirty-eight percent of the EP group and 84.3% of the WEP group reported attaining a water intake ≥1200 mL/d. Reductions in energy intake and food groups were similar across intervention groups. However, the high actual water intake group reported greater increases vs. the lower intake group in intake of fruits and vegetables (117 vs. 47 g/d), as well as larger reductions in salty snacks (4.6 vs. 0.7 g/d) and cakes and cookies (31.7 vs. 14.7 g/d). CONCLUSIONS: Other than SSBs, improvements in food group intake did not differ by intervention group in overweight Mexican women. However, post hoc analyses suggested that achieving a high actual water intake was associated with additional beneficial changes in food group intake. This trial was registered at clinicaltrials.gov as NCT01245010.

Impact of a Water Intervention on Sugar-Sweetened Beverage Intake Substitution by Water: A Clinical Trial in Overweight and Obese Mexican Women.

BACKGROUND/AIMS: Intense marketing for sugar-sweetened beverages (SSB) along with the human innate preference for sweet taste contributes to the increase in consumption of SSB. It is important to understand the intricacies of dietary intake and global changes to the food supply to understand the complexities facing any intervention promoting water intake. We describe challenges to promote and achieve an increase in water intake and present key findings from a clinical trial examining the effects of substituting water for SSB on triglyceride levels, weight and other cardiometabolic factors in overweight/obese Mexican women. METHODS: A randomized trial was conducted in Cuernavaca, Mexico selecting overweight/obese (BMI ≥25 and <39 kg/m(2)) women (18-45 years old), reporting an intake of SSB of at least 250 kcal/day. Women were randomly allocated to the water and education provision (WEP) group (n = 120) or to the education provision (EP) group (n = 120). Repeated 24 h dietary recall questionnaires, anthropometry, and fasting blood levels were collected at baseline and 3, 6, and 9 months following the intervention. RESULTS: There was no effect of the intervention on triglyceride concentration or on any of the studied outcomes. Post-hoc analyses according to weight at baseline show that triglyceride concentration decreased in obese women. Prevalence of metabolic syndrome after the intervention was lower in obese women from the WEP group. CONCLUSION: Water intake was increased but insufficient to achieve complete substitution of SSB, without effects on triglyceride concentration. Post-hoc analyses suggested that interventions lowered triglyceride concentration. Further studies are needed.

Comparing a 7-day diary vs. 24 h-recall for estimating fluid consumption in overweight and obese Mexican women.

BACKGROUND: High intake of sugar-sweetened beverages (SSB) is linked to increased weight, energy intake, and diabetes. Even though the increasing interest on beverages and water intake, there are few dietary tools carefully validated. The purpose of this paper is to compare a fluid intake 7-day diary against a 24-h recall questionnaire to estimate the fluid consumption in overweight and obese women participating in a randomized controlled trial in Mexico. METHODS: This cross-sectional study explored the correlation of reported fluid consumption between two methods: 3-day 24-hr recalls and 7-day diary beverage registry in overweight and obese Mexican women aged 18-45 y (n = 190). RESULTS: There was no difference on median estimated volume (mL/d), nor the median estimated energy (kcal/d) from total beverage consumption registered by the two dietary tools. The crude and rank correlation among the two dietary instruments was high for total fluid consumption in mL/d r = 0.7, p < 0.001 (crude and rank correlation) and for fluid consumption measured as energy intake: r = 0.7; p < 0.001 crude, and r = 0.5; p < 0.001 rank correlation. By type of beverage, the more meaningful rank correlations were for fluid intake in: mL/d, water, alcohol beverages, and SSB; and in kcal/d, alcohol beverages and SSBs (rank correlation ≥ 0.6). CONCLUSIONS: Overall, the 7-day diary showed high and strong rank correlations with that reported in the 24-h recall, suggesting that the diary method is a valid dietary tool to evaluate total fluid, water and SSB intake in this population.

Substituting water for sugar-sweetened beverages reduces circulating triglycerides and the prevalence of metabolic syndrome in obese but not in overweight Mexican women in a randomized controlled trial.

BACKGROUND: Mexico's sugar-sweetened beverage (SSB) intake is among the highest globally. Although evidence shows that increases in SSB intake are linked with increased energy intake, weight gain, and cardiometabolic risks, few randomized clinical trials have been conducted in adults. OBJECTIVE: The aim of this study was to determine if replacing SSBs with water affects plasma triglycerides (TGs) (primary outcome), weight, and other cardiometabolic factors. METHODS: We selected overweight/obese (BMI ≥ 25 and <39 kg/m(2)) women (18-45 y old) reporting an SSB intake of at least 250 kcal/d living in Cuernavaca, Mexico. Women were randomly allocated to the water and education provision (WEP) group (n = 120) or the education provision (EP)-only group (n = 120). The WEP group received biweekly water deliveries, and both groups received equal monthly nutrition counseling. During nutrition counseling, the WEP group sessions included activities to encourage increased water intake, reduced SSB intake, and substitution of water for SSBs. Repeated 24-h dietary recalls, anthropometric measurements, and fasting blood samples were collected at baseline and at 3, 6, and 9 mo. The Markov-Monte Carlo method was used for multiple imputation; separate mixed-effects models tested each outcome. RESULTS: An intent-to-treat (ITT) analysis indicated that the WEP group increased water intake and decreased SSB intake significantly over time, but there were no differences in plasma TG concentrations between groups at the end of the intervention (WEP at baseline: 155 ± 2.10 mg/dL; WEP at 9 mo: 149 ± 2.80 mg/dL; EP at baseline: 150 ± 1.90 mg/dL; EP at 9 mo: 161 ± 2.70 mg/dL; P for mean comparisons at 9 mo = 0.10). Secondary analyses showed significant effects on plasma TGs (change from baseline to 9 mo: WEP, -28.9 ± 7.7 mg/dL; EP, 8.5 ± 10.9 mg/dL; P = 0.03) and metabolic syndrome (MetS) prevalence at 9 mo (WEP: 18.1%; EP: 37.7%; P = 0.02) among obese participants. CONCLUSIONS: Providing water and nutritional counseling was effective in increasing water intake and in partially decreasing SSB intake. We found no effect on plasma TGs, weight, and other cardiometabolic risks in the ITT analysis, although the intervention lowered plasma TGs and MetS prevalence among obese participants. Further studies are warranted. This trial was registered at http://www.clinicaltrials.gov as NCT01245010.