versión impresa ISSN 1665-1146
Bol. Med. Hosp. Infant. Mex. v.63 n.6 México nov./dic. 2006
Mortgaging the future: the failure to address nutrition deficiencies and obesity
Gerardo Maupomé, PhD
Indiana University/Purdue University at Indianapolis, The Regenstrief Institute, Inc., Indianapolis, Indiana, EUA.
Five years after the 1999 National Nutrition Survey (NNS) in Mexico, and after several analyses addressing the major issues that have arisen since the NNS have been published, nutrition problems and their differential impact along the socioeconomic gradient remain at the forefront of the public health agenda. Federal programs have enjoyed a measure of improvement, following efforts to collect representative data and undertake cogent analyses to elucidate the meaning of current nutritional status at the national level.1 Such policies and programs have been limited by a lack of funding, and federal programs are still no closer to a comprehensive, nationallevel food policy. Excess weight has become a public health problem2,3 and together with hunger (and, more broadly, food insecurity), micronutrient deficiencies, anemia, and inadequate vitamin in take,47 constitute a public health crisis as they pose a sizeable threat to the future health of the country.
Even as studies have linked malnutrition and food insecurity to hunger, hunger itself has received surprisingly little attention in the context of the 1999 NNS. Common sense suggests that hunger and food insecurity are more likely to affect poor people because they have fewer resources with which to buy food but we do not fully understand what hunger and food insecurity mean in the social contexts of Mexico as most investigations address trends in "hard" epidemiological data, confirming the socioeconomic divide in the disease burden affecting poorer households.8,9 Food insecurity occurs whenever the availability of safe, nutritionally adequate food, or the ability to acquire acceptable foods in socially acceptable ways, is limited. Why excess weight is becoming increasingly common in most age and population groups, against a background of malnutrition and food insecurity, deserves further investigation. To say that excess weight results from an imbalance of energy intake and expenditure provides little insight into important social and environmental causes of higher energy consumption and lower energy expenditure. While the more obvious causes include energyrich foods, larger portion sizes, and lower physical activity levels,10 these causes fail to illustrate how lifestyle options induce excess weight linked to food insecurity, lack of exercise and leisure facilities (mostly), nonregulated advertising in the mass media, and even the reduced variety of comfort foods and comfort beverage options to choose from in everyday life.
While the Mexican population is gaining weight across all population groups investigated in the 1999 NNS,2,11 comparing teenage and adult women from different regions, ruralurban areas, and socioeconomic statuses reveals that marginal groups are increasingly relying on the consumption of inexpensive, energydense foods and beverages. In addition to the social and environmental causes of higher energy consumption and lower energy expenditures, these marginal households face the added burden of low income just as it has been documented in the United States.12 Food insecurity occurs when people, due to economic constraints, do not have enough food to meet their basic needs. Motivated by the fear of running out of food, they reduce the quality of their diets and/or adjust the quantity of food. Food insecurity is not limited to those who always have inadequate energy supplies, which helps explain why those who are insecure about food can also be overweight.
Data from the United States suggest that four factors interact when an inadequate food supply leads to weight gain. 1) The need to make best use of caloric intake. Poor families must maximize the number of available calories to avoid suffering frequent, and often painful, hunger. This strategy undermines a healthy balance of nutritious foods.13 The greater the economic constraints, the harder it becomes for poor families to select nutritious foods.14 2) The tradeoff between food quantity and quality. In foodinsecure households, food quality is generally affected before food quantity. Households reduce food spending by changing food quality instead of food quantity.15 As a result, while families may get enough food to avoid feeling hungry, they could also be malnourished. 3) Overeating when food is available. Chronic fluctuations in food availability can cause people to eat more than normal when food is available. Over time, this cycle causes weight gain.16 4) Physiologic changes associated with discontinuous food availability. Physiologic changes may occur to help the body conserve energy when diets are often inadequate. The body compensates for periodic food shortages by becoming more efficient at storing calories.17
Hunger, food insecurity, and obesity have costly direct and indirect consequences. Obesity is a risk factor for heart disease, diabetes, several types of cancer, and other nutritionrelated chronic diseases (NRCD).1 Although we still do not have an actual quantification of excess weight's impact on NRCD in Mexico, excess weight and NRCD have been linked with premature death and disability, increased health care costs, and lost productivity.1820 Hunger and food insecurity impair health status, making illness more likely. Hunger not only reduces a child's ability to learn, but it also negatively affects behavior, increasing the need for mental health and special education services.21 While this scenario is distressing, considering the significant nutritional problems the 1999 NNS identified such as 20 to 25% of children and women of the entire country being anemic, or 26% of children and 60% of women of the entire country having excess weight the conclusion that we lack appropriate solutions to these problems is unavoidable.
It could be, however, that the scale of the solutions has not yet matched the magnitude of the problems. Again citing American data, federal nutrition programs the Food Stamp Program, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and child nutrition programs like school lunch and school breakfast have protected the people most vulnerable to hunger and malnutrition. Perhaps more importantly, the programs help families fortify stronger food security and enhance household nutrition. The fact that each dollar in food stamps increases a household's Healthy Eating Index score (an indicator of overall dietary quality) is an example of these achievements.22 WIC has been shown to improve the dietary intake of pregnant and postpartum women and young children23 results replicated in other programs with similar philosophies.24 Furthermore, children who participate in school lunch and breakfast programs, compared with students who participate in neither program, consume more than twice as many servings of milk and fruits and vegetables, and onequarter the number of servings of soda and fruitflavored drinks.25
A cursory look at the Mexican data and the federal policy modifications implemented in response to the impacts identified in the 1999 NNS1 indicate that such programs are restricted to people in extreme poverty, effectively leaving without assistance a large segment of the population that is not terribly poor, but nevertheless struggles with food insecurity, moderatetosevere malnutrition, and excess weight. The magnitude of micronutrient and macronutrient deficiencies, and the constantly rising epidemic of excess weight, suggests that public health and food policy initiatives have been too timid to effectively meet these challenges.
A fundamental goal of health research and epidemiological information is to influence change. Thus, epidemiological data that do not lead to change are of little use. To protect and promote health and wellbeing, a strong governmental public health infrastructure should lead the way in affecting change.26 An example of such major change in the philosophy and the systems used to provide health care at a national level has been recently attained in Thailand, where research informed policy development and implementation.27 Improving the nutrition of every household in the country through food policies informed by research, and sufficiently funded by reorienting public spending, will advance the health and security of millions of Mexicans, today and in the future.
This report is part of the research outfit BiNational/CrossCultural Health Enhancement Center.
1. Rivera JA, Sepúlveda AJ. Conclusions from the Mexican National Nutrition Survey 1999: Translating results into nutrition policy. Salud Publica Mex. 2003; 45 Supl 4: 56575.
2. Barquera S, Rivera JA, Safdie M, Flores M, CamposNonato I, Campirano F. Energy and nutrient intake in preschool and school age Mexican children: National Nutrition Survey 1999. Salud Publica Mex. 2003; 45 Supl 4: 54050.
3. Hernández B, CuevasNasu L, ShamahLevy T, Monterrubio EA, RamírezSilva Cl, GarcíaFeregrino R, et al. Factors associated with overweight and obesity in Mexican schoolage children: results from the National Nutrition Survey 1999. Salud Publica Mex. 2003; 45 Supl 4: 5517.
4. Villalpando S, ShamahLevy T, RamírezSilva Cl, MejíaRodríguez F, Rivera JA. Prevalence of anemia in children 1 to 1 2 years of age. Results from a nationwide probabilistic survey in Mexico. Salud Publica Mex. 2003; 45 Supl 4: 4908.
5. Villalpando S, MontalvoVelarde I, Zambrano N, GarcíaGuerra A, RamírezSilva Cl, ShamahLevy T, et al. Vitamins A, and C and folate status in Mexican children under 12 years and women 1249 years: a probabilistic national survey. Salud Publica Mex. 2003; 45 Supl 4: 50819.
6. Villalpando S, GarcíaGuerra A, RamírezSilva Cl, MejíaRodríguez F, Matute G, ShamahLevy T, et al. Iron, zinc and iodide status in Mexican children under 12 years and women 1249 years of age. A probabilistic national survey. Salud Publica Mex. 2003; 45 Supl 4: 5209.
7. ShamahLevy T, Villalpando S, Rivera JA, MejíaRodríguez F, CamachoCisneros M, Monterrubio EA. Anemia in Mexican women: A public health problem. Salud Publica Mex. 2003; 45 Supl 4: 499507.
8. Frank R, Finch BK. Los Años de la Crisis: An examination of change in differential infant mortality risk within Mexico. Soc Sci Med. 2004; 59: 82535.
9. Martínez SC, Leal FG. Epidemiological transition: Model or illusion? A look at the problem of health in Mexico. Soc Sci Med. 2003; 57: 53950.
10. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: Prevalence and trends, 19601994. Int J Obes Relat Metab Disord. 1998; 22: 3947.
11. Barquera S, Rivera JA, EspinosaMontero J, Safdie M, Campirano F, Monterrubio EA. Energy and nutrient consumption in Mexican women 1249 years of age: Analysis of the National Nutrition Survey 1999. Salud Publica Mex. 2003; 45 Supl 4: 5309.
12. Pamuk E, Makue D, Heck K, Reuben C, Lochner K. Socioeconomic status and health chartbook. Hyattsville: NCHS;1998.
13. Haldeman VA. Validity of the selfreported food sufficiency status item in the US. En: Haldeman VA, editor. Department of Agriculture's food consumption surveys. Columbia, MO: American Council on Consumer Interests; 1992.
14. Darmon N, Ferguson EL, Briend A. A cost constraint alone has adverse effects on food selection and nutrient density: An analysis of human diets by linear programming. J Nutr. 2002; 132: 376471.
15. Radimer KL, Olson CM, Greene JC, Campbell CC, Habicht J. Understanding hunger and developing indicators to assess it in women and children. J Nutr Educ. 1992; 24: 36s45.
16. Townsend MS, Peerson J, Love B, Achterberg C, Murphy SP. Food insecurity is positively related to overweight in women. J Nutr. 2001; 131: 173845.
17. Wardlaw GM, Insel PM. Perspectives in Nutrition. Third ed. New York: WCB/McGrawHill; 1996.
18. Eriksson JG, Forsen T, Tuomilehto J, Osmond C, Barker DJ. Early adiposity rebound in childhood and risk of type 2 diabetes in adult life. Diabetologia. 2003; 46: 1904.
19. Bhargava SK, Sachdev HS, Fall CH, Osmond C, Lakshmy R, Barker DJ, et al. Relation of serial changes in childhood bodymass index to impaired glucose tolerance in young adulthood. N Engl J Med. 2004; 350: 86575.
20. US. Department of Health and Human Services. The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001.
21. Center on Hunger and Poverty. The consequences of hunger and food insecurity for children. Heller School for Social Policy and Management, Brandéis University; 2002.
22. Basiotis PP, KramerLeBlanc CS, Kennedy ET. Maintaining nutrition security and diet quality: The role of the Food Stamp Program and WIC. Fam Econ Nutr Rev. 1998; 11: 416.
23. Rush D. The national WIC evaluation: An evaluation of the special supplemental food program for women, infants and children. Research Triangle Park: Research Triangle Institute; 1988.
24. Bruening KS, Gilbride JA, Passannante MR, McClowry S. Dietary intake and health outcomes among young children attending 2 urban daycare centers. J Am Diet Assoc. 1999; 99: 152935.
25. Gleason P, Suitor C. Children's diets in the mid1990s: Dietary intake and its relationship with school meal participation. Alexandria: US Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation; 2001.
26. Institute of Medicine. The future of the public's health in the 21st century. Washington: National Academics Press; 2002.
27. Tangchareonsathien V, Wibulpholprasert S, Nitayaramphong S. Knowledgebased changes to health systems: the Thai experience in policy development. Bull World Health Organ. 2004; 82: 7506.