Gender and non-communicable diseases in Mexico: a political mapping and stakeholder analysis.

BACKGROUND: Mexico and other low- and middle-income countries (LMICs) present a growing burden of non-communicable diseases (NCDs), with gender-differentiated risk factors and access to prevention, diagnosis and care. However, the political agenda in LMICs as it relates to health and gender is primarily focused on sexual and reproductive health rights and preventing violence against women. This research article analyses public policies related to gender and NCDs, identifying political challenges in the current response to women's health needs, and opportunities to promote interventions that recognize the role of gender in NCDs and NCD care in Mexico. METHODS: We carried out a political mapping and stakeholder analysis during July-October of 2022, based on structured desk research and interviews with eighteen key stakeholders related to healthcare, gender and NCDs in Mexico. We used the PolicyMaker V5 software to identify obstacles and opportunities to promote interventions that recognize the role of gender in NCDs and NCD care, from the perspective of the political stakeholders interviewed. RESULTS: We found as a political obstacle that policies and stakeholders addressing NCDs do not take a gender perspective, while policies and stakeholders addressing gender equality do not adequately consider NCDs. The gendered social and economic aspects of the NCD burden are not widely understood, and the multi-sectoral approach needed to address these aspects is lacking. Economic obstacles show that budget cuts exacerbated by the pandemic are a significant obstacle to social protection mechanisms to support those caring for people living with NCDs. CONCLUSIONS: Moving towards an effective, equity-promoting health and social protection system requires the government to adopt an intersectoral, gender-based approach to the prevention and control of NCDs and the burden of NCD care. Despite significant resource constraints, policy innovation may be possible given the willingness among some stakeholders to collaborate, particularly in the labour and legal sectors. However, care will be needed to ensure the implementation of new policies has a positive impact on both gender equity and health outcomes. Research on successful approaches in other contexts can help to identify relevant learnings for Mexico.

Density of alcohol-selling outlets and prices are associated with frequent binge drinking in Mexico.

Despite the increase in the prevalence of binge drinking in Mexico studies focus on sociodemographic factors and little attention is paid on contextual factors. We estimated the association between density of alcohol outlets, price of alcoholic beverages, and binge drinking in Mexico among the population aged 12 to 65 years old who consumed alcohol during the last 12 months. Data come from different sources for alcohol consumption; availability of bar, nightclubs, saloons and stores that sell alcohol and prices of alcoholic beverages. We estimated generalized linear models for binary outcomes for the relationship between density of alcohol outlets and prices of alcoholic beverages with binge drinking at least once per year, at least once per month, and at least once per week controlling for sex, age, religion, household income and municipality size. Living in areas with a high density of alcohol-selling outlets was associated with a higher risk of binge drinking, at least once a year (RR 1.0, 95% CI: 1.0,1.1) at least once a month (RR 1.3, 95% CI: 1.2, 1.4) and weekly (RR 1.9, 95% CI: 1.6, 2.2). Living in States with lower alcohol prices was marginally associated to binge drinking at least once a year (RR 1.0, 95% CI: 1.0, 1.1) but more strongly associated to monthly (RR 1.2, 95% CI: 1.2, 1.4) and weekly binge drinking (RR 1.4, 95% CI: 1.3, 1.6). Along with strong fiscal policies, the implementation of spatial restrictions to the number of alcohol-selling outlets could help decrease binge drinking.

Productivity loss associated with the consumption of sugar-sweetened beverages in Mexico.

The objective of the study was to estimate the productivity loss by premature death, absenteeism and presenteeism attributable to sugar sweetened beverage (SSB) consumption in Mexico in 2014. We used population attributable fractions due to SSBs for diabetes, cardiovascular diseases and cancers. We gathered information from a variety of publicly available sources: mortality data from the National Institute of Statistics and Geography; hospital discharges and outpatient visits from the Health Ministry; and productivity (measured in wages earned) from the National Occupation and Employment Survey. We estimated a total productivity loss of 1426.6 million USD attributable to SSB consumption. 56.9% of the attributable productivity loss was due to premature mortality and 41.1% was reduced productivity through presenteeism. Diabetes was the main cause of productivity loss (92.1% of premature death-related productivity loss and 99.8% from presenteeism). SSB consumption leads to a considerable loss of productivity in Mexico. Findings emphasize the need to strengthen fiscal policies to reduce or eliminate these indirect costs associated with SSB consumption.

After Mexico Implemented a Tax, Purchases of Sugar-Sweetened Beverages Decreased and Water Increased: Difference by Place of Residence, Household Composition, and Income Level.

Background: In January 2014, Mexico implemented a tax on sugar-sweetened beverage (SSB) purchases of 1 peso/L.Objective: We examined the heterogeneity of changes in nonalcoholic beverage (SSB and bottled water) purchases after the tax was implemented by household income, urban and rural strata, and household composition.Methods: We used 4 rounds of the National Income and Expenditure Surveys: 2008, 2010, 2012, and 2014. Changes in purchases in per capita liters per week were estimated with the use of 2-part models to adjust for nonpurchases. We compared absolute and relative differences between adjusted changes in observed purchases in 2014 with expected purchases in 2014 based on prior trends (2008-2012). The models were adjusted for sociodemographic characteristics of the households, place of residence, and lagged gross domestic product per capita.Results: We found a 6.3% reduction in the observed purchases of SSBs in 2014 compared with the expected purchases in that same year based on trends from 2008 to 2012. These reductions were higher among lower-income households, residents living in urban areas, and households with children. We also found a 16.2% increase in water purchases that was higher in low- and middle-income households, in urban areas, and among households with adults only.Conclusions: SSB purchases decreased and water purchases increased after an SSB tax was imposed in Mexico. The magnitude of these changes was greater in lower-income and urban households.

Employment changes associated with the introduction of taxes on sugar-sweetened beverages and nonessential energy-dense food in Mexico.

We assessed changes in employment in the manufacturing industry, the commercial sector and national unemployment rates, associated with the fiscal policies implemented in 2014 in Mexico: a 1 peso per liter excise tax to sugar-sweetened beverages (SSB) and an 8% tax on nonessential energy-dense food. We used data from three nationally representative surveys. Controlling for contextual variables, we used interrupted time series analyses to model changes in number of employees in the SSB and nonessential energy-dense food industry, in commercial establishments selling beverages and food and changes in national unemployment rates. Our results show that there were no significant changes in employment associated with the taxes in the manufacturing industries (for beverages and nonessential energy-dense food). We found a very small increasing trend in the post-tax period for employment in commercial stores and a decreasing trend in the unemployment rate. However, these changes are negligible and unlikely to be caused by the implementation of the taxes. In conclusion, there were no employment reductions associated with the fiscal policies implemented in Mexico in 2014 on SSB and nonessential energy-dense food.

Price elasticity of the demand for soft drinks, other sugar-sweetened beverages and energy dense food in Chile.

BACKGROUND: Chile is the second world's largest per capita consumer of caloric beverages. Caloric beverages are associated with overweight, obesity and other chronic diseases. The objective of this study is to estimate the price elasticity of demand for soft drinks, other sugar-sweetened beverages and high-energy dense foods in urban areas in Chile in order to evaluate the potential response of households' consumption to changes in prices. METHODS: We used microdata from the VII Family Budget Survey 2012-2013, which collects information on expenditures made by Chilean urban households on items such as beverages and foods. We estimated a Linear Approximation of an Almost Ideal Demand System Model to derive own and cross price elasticities of milk, coffee, tea and other infusions, plain water, soft drinks, other flavored beverages, sweet snacks, sugar and honey, and desserts. We considered the censored nature of the data and included the Inverse Mills Ratio in each equation of the demand system. We estimated a Quadratic Almost Ideal Demand System and a two-part model as sensitivity analysis. RESULTS: We found an own price-elasticity of -1.37 for soft drinks. This implies that a price increase of 10% is associated with a reduction in consumption of 13.7%. We found that the rest of food and beverages included in the demand system behave as substitutes for soft drinks. For instance, plain water showed a cross-price elasticity of 0.63: a 10% increase in price of soft drinks could lead to an increase of 6.3% of plain water. Own and cross price elasticities were similar between models. CONCLUSIONS: The demand of soft drinks is price sensitive among Chilean households. An incentive system such as subsidies to non-sweetened beverages and tax to soft drinks could lead to increases in the substitutions for other healthier beverages.

Gender disparities in lost productivity resulting from non-communicable diseases in Mexico, 2005-2021.

Background: Non-communicable diseases (NCDs) cause long-term impacts on health and can substantially affect people's ability to work. Little is known about how such impacts vary by gender, particularly in low- and middle-income countries (LMICs), where productivity losses may affect economic development. This study assessed the long-term productivity loss caused by major NCDs among adult women and men (20-76 years) in Mexico because of premature death and hospitalisations, between 2005 and 2021. Methods: We conducted an economic valuation based on the Human Capital Approach. We obtained population-based data from the National Employment Survey from 2005 to 2021 to estimate the expected productivity according to age and gender using a two-part model. We utilised expected productivity based on wage rates to calculate the productivity loss, employing Mexican official mortality registries and hospital discharge microdata for the same period. To assess the variability in our estimations, we performed sensitivity analyses under two different scenarios. Results: Premature mortality by cancers, diabetes, chronic cardiovascular diseases (CVD), chronic respiratory diseases (CRD) and chronic kidney disease (CKD) caused a productivity loss of 102.6 billion international US dollars (Intl. USD) from 2.8 million premature deaths. Seventy-three percent of this productivity loss was observed among men. Cancers caused 38.3% of the productivity loss (mainly among women), diabetes 38.1, CVD 15.1, CRD 3.2, and CKD 5.3%. Regarding hospitalisations, the estimated productivity loss was 729.7 million Intl. USD from 54.2 million days of hospitalisation. Men faced 65.4 and women 34.6% of these costs. Cancers caused 41.3% of the productivity loss mainly by women, followed by diabetes (22.1%), CKD (20.4%), CVD (13.6%) and CRD (2.6%). Conclusions: Major NCDs impose substantial costs from lost productivity in Mexico and these tend to be higher amongst men, while for some diseases the economic burden is higher for women. This should be considered to inform policymakers to design effective gender-sensitive health and social protection interventions to tackle the burden of NCDs.

Burden of non-communicable diseases and behavioural risk factors in Mexico: Trends and gender observational analysis.

Background: There is scarce gender-disaggregated evidence on the burden of disease (BD) worldwide and this is particularly prominent in low- and middle-income countries. The objective of this study is to compare the BD caused by non-communicable diseases (NCDs) and related risk factors by gender in Mexican adults. Methods: We retrieved disability-adjusted life years (DALYs) estimates for diabetes, cancers and neoplasms, chronic cardiovascular diseases (CVDs), chronic respiratory diseases (CRDs), and chronic kidney disease (CKD) from the Global Burden of Disease (GBD) Study from 1990-2019. Age-standardized death rates were calculated using official mortality microdata from 2000 to 2020. Then, we analysed national health surveys to depict tobacco and alcohol use and physical inactivity from 2000-2018. Women-to-men DALYs and mortality rates and prevalence ratios (WMR) were calculated as a measure of gender gap. Findings: Regarding DALYs, WMR was >1 for diabetes, cancers, and CKD in 1990, indicating a higher burden in women. WMR decreased over time in all NCDs, except for CRDs, which increased to 0.78. However, WMR was <1 for all in 2019. The mortality-WMR was >1 for diabetes and cardiovascular diseases in 2000 and <1 for the rest of the conditions. The WMR decreased in all cases, except for CRDs, which was <1 in 2020. The WMR for tobacco and alcohol use remained under 1. For physical inactivity, it was >1 and increasing. Conclusions: The gender gap has changed for selected NCDs in favour of women, except for CRDs. Women face a lower BD and are less affected by tobacco and alcohol use but face a higher risk of physical inactivity. Policymakers should consider a gendered approach for designing effective policies to reduce the burden of NCDs and health inequities.

A Gender-Based and Quasi-Experimental Study of the Catastrophic and Impoverishing Health-Care Expenditures in Mexican Households with Elderly Members, 2000-2020.

Latin America has experienced a rise in noncommunicable diseases (NCDs) which is having repercussions on the structuring of healthcare delivery and social protection for vulnerable populations. We examined catastrophic (CHE) and excessive (EHE, impoverishing and/or catastrophic) health care expenditures in Mexican households with and without elderly members (≥65 years), by gender of head of the households, during 2000-2020. We analyzed pooled cross-sectional data for 380,509 households from eleven rounds of the National Household Income and Expenditure Survey. Male- and female-headed households (MHHs and FHHs) were matched using propensity scores to control for gender bias in systematic differences regarding care-seeking (demand for healthcare) preferences. Adjusted probabilities of positive health expenditures, CHE and EHE were estimated using probit and two-stage probit models, respectively. Quintiles of EHE by state among FHHs with elderly members were also mapped. CHE and EHE were greater among FHHs than among MHHs (4.7% vs 3.9% and 5.5% vs 4.6%), and greater in FHHs with elderly members (5.8% vs 4.9% and 6.9% vs 5.8%). EHE in FHHs with elderly members varied geographically from 3.9% to 9.1%, being greater in less developed eastern, north-central and southeastern states. Compared with MHHs, FHHs face greater risks of CHE and EHE. This vulnerability is exacerbated in FHHs with elderly members, because of gender intersectional vulnerability. The present context, marked by a growing burden of NCDs and inequities amplified by COVID-19, makes key interlinkages across multiple Sustainable Development Goals (SDGs) apparent, and calls for urgent measures that strengthen social protection in health.

Is store density associated with sugar-sweetened beverages consumption and overweight or obesity in Mexican adolescents?

BACKGROUND: The consumption of sugar-sweetened beverages (SSBs) is a risk factor for obesity. In Mexico, SSBs are widely available and consumed daily by adolescents. OBJECTIVES: The purpose of this study was to estimate the indirect association between store density (including grocery, convenience, non-alcoholic beverage stores and supermarkets) and overweight or obesity (OW/O) among Mexican adolescents, using SSB consumption as a mediator. METHODS: We used cross-sectional data on adolescent SSB consumption, weight status (body mass index for age [BMI for age]), physical activity, screen time and sociodemographic factors from the 2016 Mexican Midway National Health and Nutrition Survey (ENSANUT MC 2016). The National Statistical Directory of Economic Units provided information on stores selling SSBs. We estimated structural equations models to test associations between store density and OW/O, using SSB consumption as a mediator. RESULTS: We found a direct positive association between store density and SSB intake in adolescents (ß =1.229), including density of supermarkets (ß = 132.07), grocery stores (ß = 1.170) and non-alcoholic beverage stores (ß = 1.537). No significant association was observed for convenience stores. Direct association between store density and OW/O was strongest for supermarket density (ß = 0.426). In addition, SSB intake was significantly associated with OW/O (p = 0.033). No significant indirect association between density of any store and OW/O was found. CONCLUSIONS: Store density was directly associated with SSB consumption but not indirectly associated with OW/O mediated by SSB. Further research on food environment is required in order to design evidence-based strategies aimed at reducing SSB intake and OW/O in adolescents.

Municipality-Level Predictors of COVID-19 Mortality in Mexico: A Cautionary Tale.

OBJECTIVE: Local characteristics of populations have been associated with coronavirus disease 2019 (COVID-19) outcomes. We analyze the municipality-level factors associated with a high COVID-19 mortality rate (MR) of in Mexico. METHODS: We retrieved information from cumulative confirmed symptomatic cases and deaths from COVID-19 as of June 20, 2020, and data from most recent census and surveys of Mexico. A negative binomial regression model was adjusted, the dependent variable was the number of COVID-19 deaths, and the independent variables were the quintiles of the distribution of sociodemographic and health characteristics among the 2457 municipalities of Mexico. RESULTS: Factors associated with high MRs from COVID-19, relative to quintile 1, were diabetes and obesity prevalence, diabetes mortality rate, indigenous population, economically active population, density of economic units that operate essential activities, and population density. Among factors inversely associated with lower MRs from COVID-19 were high hypertension prevalence and houses without sewage drainage. We identified 1351 municipalities without confirmed COVID-19 deaths, of which, 202 had high and 82 very high expected COVID-19 mortality (mean = 8 and 13.8 deaths per 100,000, respectively). CONCLUSION: This study identified municipalities of Mexico that could lead to a high mortality scenario later in the epidemic and warns against premature easing of mobility restrictions and to reinforce strategies of prevention and control of outbreaks in communities vulnerable to COVID-19.

Affordability of Food and Beverages in Mexico between 1994 and 2016.

We estimated the affordability of food and beverages by energy density and nutrient quality in Mexico and tested for differential trends in affordability over time and by income quintile. We used the National Income and Expenditures Survey from 1994 to 2016, and information on the caloric and nutrient content of food and beverages from Mexican food composition tables. We estimated food energy density (kcal/kg) and nutrient quality of food and beverages using the nutrient-rich food index (NRFI). Affordability of food and beverages was defined as household monthly income needed to purchase 1000 kcal. The affordability index was expressed by quintiles of energy density and quintiles of the NRFI and by income quintile over time. We found that more energy-dense foods and food and beverages with lower nutrient quality were more affordable compared to healthier food and beverages. Food categories with lower energy density and a higher NRFI became less affordable over time for most income groups, but the burden was higher for lower-income households. A comprehensive national strategy should be implemented to make healthier options more affordable and discretional foods and beverages with lower nutrient quality less affordable.