Equitability of Individual and Population Interventions to Reduce Obesity: A Modeling Study in Mexico.

INTRODUCTION: Modeling studies have estimated the potential impact and cost effectiveness of interventions to reduce obesity; few have focused on their equity across socioeconomic groups. This study aims to compare the equitability of individual- and population-level interventions to reduce obesity in Mexico. METHODS: Mathematical models were implemented to estimate the expected effect of 2 sugar-sweetened beverage tax scenarios (10% and 20%) and bariatric surgery, pharmacotherapy, and dietary advice as individual interventions to reduce body weight. Individual interventions were modeled using meta-analytical weight change, inclusion and exclusion criteria, and the probability of access to healthcare services. For the tax, investigators obtained the baseline consumption of sugar-sweetened beverages from the National Health Survey 2012 and applied the reduction in sales observed in 2016 to estimate the caloric change and weight reduction. Implementation costs and cost per person, per kilogram, and equity were calculated for all interventions over a 1-year timeframe. RESULTS: The 20% tax produced the largest estimated increase (4.50%) in normal BMI prevalence, was the most cost effective, and had the largest and most equitable decrease in obesity across socioeconomic categories. Pharmacotherapy and bariatric surgery produced sizable decreases in obesity prevalence (3.68% and 1.18%), particularly among the middle and high socioeconomic groups, whereas dietary advice had the lowest impact on normal and obese categories. CONCLUSIONS: Individual interventions were effective in reducing obesity; yet, they were more expensive and less equitable than population interventions. Obesity in Mexico affects all socioeconomic groups; available interventions need to be carefully analyzed to tailor a national strategy that is both effective and equitable.

Educational inequalities in obesity: a multilevel analysis of survey data from cities in Latin America.

OBJECTIVE: Using newly harmonised individual-level data on health and socio-economic environments in Latin American cities (from the Salud Urbana en América Latina (SALURBAL) study), we assessed the association between obesity and education levels and explored potential effect modification of this association by city-level socio-economic development. DESIGN: This cross-sectional study used survey data collected between 2002 and 2017. Absolute and relative educational inequalities in obesity (BMI ≥ 30 kg/m2, derived from measured weight and height) were calculated first. Then, a two-level mixed-effects logistic regression was run to test for effect modification of the education-obesity association by city-level socio-economic development. All analyses were stratified by sex. SETTING: One hundred seventy-six Latin American cities within eight countries (Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico and Peru). PARTICIPANTS: 53 186 adults aged >18 years old. RESULTS: Among women, 25 % were living with obesity and obesity was negatively associated with educational level (higher education-lower obesity) and this pattern was consistent across city-level socio-economic development. Among men, 18 % were living with obesity and there was a positive association between education and obesity (higher education-higher obesity) for men living in cities with lower levels of development, whereas for those living in cities with higher levels of development, the pattern was inverted and university education was protective of obesity. CONCLUSIONS: Among women, education was protective of obesity regardless, whereas among men, it was only protective in cities with higher levels of development. These divergent results suggest the need for sex- and city-specific interventions to reduce obesity prevalence and inequalities.

Mortality attributable to sugar sweetened beverages consumption in Mexico: an update.

BACKGROUND: In 2010, sugar sweetened beverages (SSBs) were estimated to cause 12% of all diabetes, cardiovascular disease (CVD) and obesity-related cancer deaths in Mexico. Using new risk estimates for SSBs consumption, we aimed to update the fraction of Mexican mortality attributable to SSBs, and provide subnational estimates by region, age, and sex. METHODS: We used an established comparative risk assessment framework. All-cause mortality estimates were calculated from a recent pooled cohort analysis. Age- and sex-specific relative risks for SSBs-disease relationships were obtained from updated meta-analyses. Demographics and nationally representative estimates of SSBs intake were derived from the National Health and Nutrition Survey 2012; and mortality rates, from the National Institute of Statistics and Geography. Attributable mortality was calculated by estimating the population attributable fraction of each disease, with uncertainty in data inputs propagated through Monte Carlo probabilistic sensitivity analyses. RESULTS: In Mexican adults 20 years and older, 6.9% (95%UI: 5.4-8.5) of all cause-mortality was attributable to SSBs, representing 40,842 excess deaths/year (95%UI: 31,950-50,138). Furthermore, 19% of diabetes, CVD and obesity-related cancer mortality was attributable to SSBs (95%UI: 11.0-26.5), representing 37,000 excess deaths/year (95%UI 21,240-51,045). Of these, 35.6% were diabetes-related (95%UI 16.4-52.0). Proportional burden was highest in the South (22.8%), followed by the Center (18.0%) and North (17.4%). Men aged 45-64-years in the Center region had highest proportional mortality (37.2%), followed by 20-44-year-old men living in the South (35.7%) and both men and women aged 20-44 living in the Center (34.4%). CONCLUSIONS: Utilizing current evidence linking SSBs to cardiometabolic disease and obesity-related cancers, earlier estimates of Mexican mortality attributable to SSBs could have been underestimated. Mexico urgently needs stronger policies to reduce SSBs consumption and reduce these burdens.

Concentrations of nicotine, nitrosamines, and humectants in legal and illegal cigarettes in Mexico.

BACKGROUND: Article 10 of the World Health Organization Framework Convention on Tobacco Control states the need for industry disclosure of tobacco contents and emissions. Currently, the profiles of key tobacco compounds in legal and illegal cigarettes are largely unknown. We aimed to analyze and compare concentrations of nicotine, nitrosamines, and humectants in legal and illegal cigarettes collected from a representative sample of smokers. METHODS: Participants of the International Tobacco Control cohort provided a cigarette pack of the brand they smoked during the 2014 wave. Brands were classified as legal or illegal according to the Mexican legislation. Nicotine, nitrosamines, glycerol, propylene glycol, and pH were quantified in seven randomly selected packs of each brand. All analyses were done blinded to legality status. Average concentrations per brand and global averages for legal and illegal brands were calculated. Comparisons between legal and illegal brands were conducted using t tests. RESULTS: Participants provided 76 different brands, from which 6.8% were illegal. Legal brands had higher nicotine (15.05 ± 1.89 mg/g vs 12.09 ± 2.69 mg/g; p < 0001), glycerol (12.98 ± 8.03 vs 2.93 ± 1.96 mg/g; p < 0.001), and N-nitrosanatabine (NAT) (1087.5 ± 127.0 vs 738.5 ± 338 ng/g; p = 0.006) concentrations compared to illegal brands. For all other compounds, legal and illegal brands had similar concentrations. CONCLUSION: Compared to illegal cigarettes, legal brands seem to have higher concentrations of nicotine, NAT, and glycerol. Efforts must be made to implement and enforce Article 10 of the Framework Convention on Tobacco Control to provide transparent information to consumers, regulators, and policy-makers; and to limit cigarette engineering from the tobacco industry.

Antecedentes maternos prenatales y riesgo de complicaciones neonatales en productos de término de bajo peso para edad gestacional / Maternal prenatal history and neonatal risk complications for low-weight for gestacional age term newborns

Resumen Introducción: El bajo peso neonatal (< 2.5 kg o < percentil 10) se atribuye a causas constitucionales (pequeño para la edad gestacional [PEG]) o a la restricción en el crecimiento intrauterino (RCIU), con riesgos posnatales diferentes. En ausencia de una valoración fetal-placentaria prenatal adecuada, resulta difícil establecerlo. El conocer los antecedentes maternos de enfermedades gestacionales (AMEG): hipertensión arterial (HTA), hipotiroidismo, Diabetes Mellitus (DM) gestacional y otra; pudiera orientar a la diferenciación y el manejo. El objetivo de este trabajo fue determinar si la presencia de AMEG se asocia a complicaciones neonatales en productos de bajo peso neonatal. Métodos: Se realizó un estudio de cohorte retrospectivo en un grupo de 349 recién nacidos vivos de término (≥ 37 semanas de edad gestacional [SEG]), PEG, en cunero fisiológico y agrupados según los AMEG. Se determinó la frecuencia de dificultad respiratoria (DR), hipoglucemia (HG) e hiperbilirrubinemia (HBr). Resultados: El 16.6% (58/349) presentó AMEG (58.6% HTA y 41.3% hipotiroidismo, solos o combinados). Los neonatos con AMEG fueron más limítrofes (37 SEG, 55.2% vs. 35.1%; p = 0.037). Los de 37 SEG con menor peso (diferencia de ≈100 g; p = 0.028), más riesgo de HG (13.6%; intervalo de confianza al 95% [IC 95%]: −4.08-31.2) pero menos DR (diferencia de −4.7%; IC 95%: −20.6-11.05). La HG en los de 39 SEG solo se presentó en neonatos sin AMEG (diferencia 12.7%; IC 95%: 3.9 a 31.5) igual que la HBr (tres casos). Conclusiones: Indagar sobre los AMEG en un producto PEG parece ser útil en la inferencia de RCIU. Sin embargo, es insuficiente, por lo que en conjunto con otras herramientas nos ayuda a estimar posibles complicaciones y acciones preventivas.

Abstract Background: Low-birth-weight (LWB < 2.5 kg or <10 percentile) could be caused by constitutional matters or by intrauterine growth restriction (IUGR), both with different neonatal complications. Without an adequate prenatal evaluation is hard to stablish those conditions. Knowing the maternal history for gestational diseases (MHGD) such as hypertension (HTA), hypothyroidism or diabetes, among others could help clarify that difference. The aim of this work was to determine if having a MHGD is associated to neonatal complications in newborns with LWB. Methods: Retrospective cohort study, which included 349 with LWB at term (≥ 37 weeks of gestation [WG]) grouped into those with or without MHGD at a hospital nursery. The frequency of respiratory distress, hypoglycemia, and hyperbilirubinemia was determined. Results: 16.6% (58/349) had MHGD (58.6% for HTA and 41.3% hypothyroidism alone or combined). The neonate with MHGD were more borderline term (37 WGA, 55.2% vs. 35.1%; p = 0.037), and had lower weight (difference of ≈100 g; p = 0.028), had more cases with hypoglycemia (13.6%; CI 95%: −4.08 to 31.2%) but developed less respiratory distress (RD) (difference of −4.7%; CI 95%: −20.6 to 11.05%). Hypoglycemia in 39 WGA was only seen among neonates without MHGD (difference 12.7%; CI95%: 3.9 to 31.5%) just as for the hyperbilirubinemia cases (three). Conclusions: Inquiring about the MHGD on LBW term babies could be useful in the inference of IUGR, although we need other tools so that altogether can help to predict possible complications and to plan preventive actions.

Environmental Tobacco Exposure and Urinary Cotinine Levels in Smoking and Nonsmoking Adolescents.

Objective: We aimed to evaluate the association between environmental tobacco smoke (ETS) exposure and urinary cotinine levels in current adolescent smokers and nonsmokers. The secondary objective was to explore the association between ETS exposure and nicotine dependence in adolescent smokers. Methods: Using the results from a validation study for the 2012 Global Youth Tobacco Survey in Mexico, we quantified urinary cotinine levels in adolescent smokers and nonsmokers. We fitted a multivariate regression model to assess the association between household exposure to ETS and cotinine levels in adolescent smokers and nonsmokers. In addition, using the questionnaire's answers for morning cravings, we fitted a multivariate Poisson regression model to explore the association between household ETS exposure and nicotine dependence in adolescent smokers. Results: For each day of household ETS exposure, cotinine levels increase by 5% in adolescent smokers compared to a 2% increase in nonsmokers, adjusting for the number of cigarettes smoked per week, age and sex (exp(ß) 1.05; 95% confidence interval [CI] [1.00, 1.10]; p = .041). Morning cravings increase 11% for each day of household ETS exposure adjusting for the number of cigarettes smoked per week, age and sex (prevalence ratio [PR] 1.11; 95% CI [0.99, 1.25]; p = .064). Conclusions: There is an association between ETS exposure and cotinine levels, and ETS may contribute to nicotine dependence in adolescent smokers. If confirmed, avoiding ETS exposure could prove helpful for addiction control and quitting in adolescents. Implications: Evidence suggests that ETS increases cotinine levels in nonsmokers and adult smokers. However, no study has explored the association between ETS exposure and cotinine levels and addiction in adolescent smokers. This paper provides evidence of an association between ETS exposure and cotinine levels in adolescent smokers: each day of environmental tobacco smoke exposure at home increased cotinine levels by 5% among smokers. In addition, morning cravings in adolescent smokers increased 11% for every day of ETS exposure. ETS exposure is a significant source of nicotine for adolescent smokers and could play an important role in addiction.

Population profiles associated with severe functional difficulties and disability among 5-17 years-old children in México / Perfiles poblacionales asociados con dificultades funcionales y discapacidad severa en niños de 5-17 años en México

Abstract: Objectives: To report the prevalence of severe functional difficulties and disability (SFD) in a nationally representative sample of children ages 5 to 17 in Mexico, to identify factors associated with SFD, and population profiles predictive of SFD. Materials and methods: Using data from the National Survey on Children and Women we estimated prevalence and 95% confidence intervals of SFD and risk factors. We fitted bivariate and multivariate logistic regression models. We then examined which combinations of the sociodemographic factors best predicted SFD. Results: The prevalence of SFD was 11.2%. The most prevalent SFD were on the socioemotional dimension (8.3%). The associated risk factors in the three dimensions were: living in a poor household, being a boy, having a mother with basic education or less, and non-indigenous background or living in an urban area. Conclusions: Identifying groups of the population at higher risk for SFD provides useful information for targeted intervention implementation.

Resumen: Objetivos: Reportar la prevalencia de dificultades funcionales y discapacidad severa (SFD) en una muestra nacional representativa de niños de 5 a 17 años en México; identificar los factores asociados con SFD; documentar los perfiles poblacionales que predicen SFD. Material y métodos: Se utilizaron los datos de la Encuesta Nacional de Niñas, Niños y Mujeres en México; se estimaron prevalencias e intervalos de confianza al 95%. Se ajustaron modelos bivariados y multivariados. Se examinaron las combinaciones de factores sociodemográficos que mejor predecían la SFD. Resultados: La prevalencia de SFD fue de 11.2%. Las SFD más prevalentes fueron en la dimensión socioemocional (8.3%). Los factores de riesgo asociados en las tres dimensiones fueron pobreza, ser hombre, tener una madre con educación primaria o menor, no ser indígena o vivir en zonas urbanas. Conclusiones: Identificar a los grupos con mayor riesgo de SFD dentro de la población proporciona información útil para el desarrollo de intervenciones.

Educación sexual integral: cobertura, homogeneidad, integralidad y continuidad en escuelas de México / Comprehensive sexual education in Mexico: an analysis of coverage, comprehensiveness and continuity of contents in Mexican public and private schools

Resumen: Objetivo: Analizar la cobertura de la educación sexual integral (ESI) en México y describir su integralidad, homogeneidad y continuidad en cuanto a contenidos sobre salud sexual y reproductiva, autoeficacia, derechos y relaciones. Material y métodos: En una encuesta probabilística transversal con muestreo estratificado y por conglomerados, se aplicó un cuestionario sobre ESI a una muestra representativa a nivel nacional de 3 824 adolescentes de 45 escuelas de educación media superior públicas y privadas, en localidades urbanas y rurales. Resultados: El porcentaje de adolescentes que reportan recibir educación sexual integral varía dependiendo de los temas y nivel escolar. Los temas más frecuentes están relacionados con salud sexual y reproductiva; los menos tratados con derechos y relaciones. Los contenidos de educación sexual se trasmiten mayoritariamente durante la escuela secundaria. Conclusiones: Se requiere garantizar la integralidad, homogeneidad y continuidad de los contenidos de la ESI, asegurando que se imparta la totalidad de los temas planteados en recomendaciones nacionales e internacionales.

Abstract Objective: To analyze coverage of comprehensive sex education (CSE) in high schools in Mexico and describe whether it is comprehensive, homogeneous and has continuity based on student reports of exposure to topics in three dimensions: reproductive and sexual health, self-efficacy and rights and relations. Materials and methods: Within a probabilistic, cross-sectional survey with stratified, cluster sampling, a nationally representative sample of 3 824 adolescents attending 45 public and private high-schools in urban and rural areas completed questionnaires on CSE. Results: The proportion of adolescents reporting having received sex education from school personnel varies depending on topics and grade level. Topics most frequently covered are those related to sexual and reproductive health while rights and relations are least frequently dealt with. Most sex education topics are covered during junior high school and much less frequently in elementary or high school. Conclusions: CSE needs to be comprehensive and homogenous in terms of content, ensure inclusion of priority topics, meet national and international recommendations, ensure continuity and adapt contents to student age through all education levels.

[Neonatal morbidity and hospital mortality of preterm triplets.] / Morbilidad y mortalidad neonatal intrahospitalaria en trillizos pretérmino.

Background: multiple gestations have caused an increase in vulnerable preterm births. Our objective was to analyze neonatal morbidity and mortality in preterm triplets. Methods: we analyzed a cohort of 30 triplets in an obstetrics and gynecology hospital. Data were obtained during pregnancy, childbirth and neonatal period: birth order, sex, weight, height, malformations, advanced resuscitation, assisted ventilation, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pulmonary hypertension, bronchopulmonary dysplasia, days of hospitalization, and death. Results: 90 infants were analyzed. There was an omphalopagus con-joined twins case; 42 (70 %) had between 30-33 weeks and six between 24-29; 19 (21 %) had low weight for gestational age, and 18 (30 %) had a major malformation; 27 % required ventilatory support, 33 % sepsis, 32 % necrotizing enterocolitis, 21 % pulmonary hypertension, 14 % bronchopulmonary dysplasia and 2 % intraventricular hemorrhage, without statistically significant differences related to the order, presentation at birth, sex and number of placentas and amniotic sacs. Eight 24-week triplets died, four over 28 weeks, and a siamese (p = 38). There was no difference in hospital days between triplets. Conclusions: the triplets mortality is low and mainly associated with extreme prematurity, intrauterine growth restriction and sepsis.

Introducción: las gestaciones múltiples favorecen el nacimiento de niños prematuros vulnerables. El objetivo de esta investigación fue analizar la morbilidad y la mortalidad neonatal en trillizos pretérmino. Métodos: se estudiaron 30 grupos de trillizos. Se obtuvieron datos del embarazo, parto y neonatales: orden al nacimiento, sexo, peso, talla, malformaciones, reanimación, asistencia ventilatoria, comorbilidad, días de estancia hospitalaria y muerte. Resultados: se analizaron 90 neonatos. Hubo un embarazo con siameses onfalópagos, 42 (70 %) tuvieron entre 30 y 33 semanas de gestación y seis entre 24 y 29, 19 (21 %) bajo peso y 18 (30 %), alguna malformación mayor; 25 (27 %) requirieron asistencia ventilatoria, 30 (33 %) presentaron sepsis, 29 (32 %) enterocolitis necrosante, 19 (21 %) hipertensión pulmonar, 13 (14 %) broncodisplasia pulmonar y dos (2 %), hemorragia intraventricular. No hubo diferencias significativas respecto al orden, presentación al nacimiento, sexo, número de placentas y sacos amnióticos y días de hospitalización. Murieron ocho trillizos (8.8 %) de 24 semanas de gestación, cuatro mayores de 28 semanas y un siamés (p = 0.38). Conclusiones: la mortalidad en trillizos es baja y relacionada con la premadurez extrema, la restricción del crecimiento intrauterino y la sepsis. Las secuelas son pocas.