Teresa González de Cossío

Cash and In-Kind Transfers in Poor Rural Communities in Mexico Increase Household Fruit, Vegetable, and Micronutrient Consumption but Also Lead to Excess Energy Consumption

Conditional transfer programs are increasingly popular, but the impact on household nutrient consumption has not been studied. We evaluated the impact of the Programa de Apoyo Alimentario (PAL), a cash and in-kind transfer program, on the energy and nutrient consumption of poor rural households in Mexico. The program has been shown to reduce poverty. Beneficiary households received either a food basket (including micronutrient-fortified milk) or cash. A random sample of 206 rural communities in Southern Mexico was randomly assigned to 1 of 4 groups: a monthly food basket with or without health and nutrition education, a cash transfer with a cost to the government equivalent to the food basket (14 USD/mo) with education, or control. The impact after 14 mo of exposure was estimated in a panel of 5823 households using a double difference regression model with household fixed effects. PAL was associated with increases (P < 0.01) in the consumption of total energy (5-9%), energy from fruits and vegetables (24-28%), and energy from animal source foods (24-39%). It also affected iron, zinc, and vitamin A and C consumption (P < 0.05). The consumption of energy and all nutrients was greater in the food basket group (P < 0.05). Cash and in-kind transfers in populations that are not energy-deficient should be carefully redesigned to ensure that pulling poor families out of poverty leads to improved micronutrient intake but not to increased energy consumption.

Cash and in-Kind Transfers Lead to Excess Weight Gain in a Population of Women with a High Prevalence of Overweight in Rural Mexico

There is a growing concern that food or cash transfer programs may contribute to overweight and obesity in adults. We studied the impact of Mexicos Programa de Apoyo Alimentario (PAL), which provided very poor rural households with cash or in-kind transfers, on womens body weight. A random sample of 208 rural communities in southern Mexico was randomly assigned to 1 of 4 groups: food basket with or without health and nutrition education, cash with education, or control. The impact on womens weight was estimated in a cohort of 3010 women using a difference-in-difference model. We compared the impact between the food basket and cash groups and evaluated whether the impact was modified by womens BMI status at baseline. With respect to the control group, the program increased womens weight in the food basket (550 ± 210 g; P = 0.004) and the cash group (420 ± 230 g; P = 0.032); this was equivalent to 70 and 53% increases in weight gain, respectively, over that observed in the control group in a 23-mo time period. The greatest impact was found in already obese women: 980 ± 290 g in the food basket group (P = 0.001) and 670 ± 320 g in the cash group (P = 0.019). Impact was marginally significant in women with a preprogram BMI between 25 and 30 kg/m2: 490 ± 310 g (P = 0.055) and 540 ± 360 g (P = 0.067), respectively. No program impact was found in women with a BMI <25 kg/m2. Providing households with a considerable amount of unrestricted resources led to excess weight gain in an already overweight population. Research is needed to develop cost-effective behavior change communication strategies to complement cash and in-kind transfer programs such as PAL and to help beneficiaries choose healthy diets that improve the nutritional status of all family members.

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

Abstract Background: Mexicos 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/m2) 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.

Child malnutrition in Mexico in the last two decades: prevalence using the new WHO 2006 growth standards

OBJECTIVE To describe preschool malnutrition prevalence and trends in Mexican children for the 1988, 1999 and 2006 Mexican National Nutrition Surveys using WHO-2006 standards and National Center for Health Statistics/WHO (NCHS/WHO) references. MATERIAL AND METHODS Prevalence of undernutrition (< minus 2 z-score for weight/age, height/age and weight/height) and overweight (> plus 2 z-score for weight/height) were calculated. RESULTS Height/age and weight/height have increased over time (p< 0.05). Using WHO-2006 standards, stunting in children less than 5 years years old was 26.9%, 21.5% and 15.5% in 1988, 1999 and 2006, respectively; values for wasting were 6.2%, 2.1% and 2.0%, respectively. Wasting in the very young (< 6 mo) in 2006 is high (4.9%). Overweight increased from 1988 to 1999 (6.1% to 7.5%) and stabilized in 2006 (7.6%). Gaps among ethnic and socioeconomic groups have decreased over time. CONCLUSIONS Stunting has decreased markedly but continues to be the main malnutrition problem. Overweight has emerged as a public health problem in the young. Lower NCHS/WHO estimates previously published underestimated true prevalence. Length deviations in attained height after 12 months indicate poor infant feeding practices, probably coupled with early infections. Results reinforce the need to improve the quality of nutrition programs and to promote adequate lactation and infant feeding practices in Mexico.

Scripted Messages Delivered by Nurses and Radio Changed Beliefs, Attitudes, Intentions, and Behaviors Regarding Infant and Young Child Feeding in Mexico

Scalable interventions are needed to improve infant and young child feeding (IYCF). We evaluated whether an IYCF nutrition communication strategy using radio and nurses changed beliefs, attitudes, social norms, intentions, and behaviors related to breastfeeding (BF), dietary diversity, and food consistency. Women with children 6-24 mo were randomly selected from 6 semi-urban, low-income communities in the Mexican state of Morelos (intervention, n = 266) and from 3 comparable communities in Puebla (control, n = 201). Nurses delivered only once 5 scripted messages: BF, food consistency, flesh-food and vegetable consumption, and feed again if food was rejected; these same messages aired 7 times each day on 3 radio stations for 21 d. The control communities were not exposed to scripted messages via nurse and radio. We used a pre-/post-test design to evaluate changes in beliefs, attitudes, norms, and intentions as well as change in behavior with 7-d food frequency questions. Mixed models were used to examine intervention-control differences in pre-/post changes. Coverage was 87% for the nurse component and 34% for radio. Beliefs, attitudes, and intention, but not social norms, about IYCF significantly improved in the intervention communities compared with control. Significant pre-/post changes in the intervention communities compared with control were reported for BF frequency (3.7 ± 0.6 times/d), and consumption of vegetables (0.6 ± 0.2 d) and beef (0.2 ± 0.1 d) and thicker consistency of chicken (0.6 ± 0.2 d) and vegetable broths (0.8 ± 0.4 d). This study provides evidence that a targeted communication strategy using a scalable model significantly improves IYCF.

Maternal Education Mitigates the Negative Effects of Higher Income on the Double Burden of Child Stunting and Maternal Overweight in Rural Mexico

Globally, the rate at which maternal overweight and obesity increase with rising wealth is higher than the accompanying decline in the prevalence of child stunting, resulting in the double burden of malnutrition. The positive association between household wealth and child linear growth is larger in households with a more educated mother. However, whether a similar positive and synergistic association between maternal education and household wealth is observed for maternal body weight is unknown. Our objective was to assess the potential protective role of maternal education in the etiology of the double burden of malnutrition (stunted child with an overweight mother). We used data on 1547 nonpregnant mothers (aged 18-49 y) and their children (aged 0-5 y) collected in a cross-sectional survey in 235 rural communities in southern Mexico. Child height-for-age Z-score and maternal body weight were regressed on household wealth, womens schooling, and the interaction between both, controlling for relevant covariates. A similar model was used for the prevalence of double-burden pairs (stunted child with an overweight mother). In mothers with less than primary school, a doubling in wealth was not associated with improved childs height but was associated with an increase in mothers weight (3.7%, P < 0.01). In mothers who had completed primary school, the reverse was found: a doubling in wealth score was associated with improved child height-for-age Z-score (0.32 SD, P < 0.01) but not with mothers weight. As a result, a 100% increase in wealth among households with less schooled mothers was associated with a 4.5 percentage point increase (P < 0.05) in double-burden pairs; in households with mothers with primary schooling or more, it was not associated with the occurrence of double-burden pairs. Maternal schooling effectively mitigated the negative effects of household wealth on the prevalence of double-burden households in rural Mexico. Where maternal schooling is low, poverty reduction must be accompanied by effective behavior change communication to prevent child stunting and to protect women from unhealthy weight gain.

Energy and nutrient intake in Mexican adolescents: analysis of the Mexican National Health and Nutrition Survey 2006

OBJECTIVE To describe energy and nutrient intake and adequacy percentages in Mexican adolescents included in the Mexican National Health and Nutrition Survey 2006 (ENSANUT 2006) as well as the proportion of population at risk of dietary inadequacy. MATERIAL AND METHODS Data were analyzed from 7-day food-frequency questionnaires for 8442 male and female adolescents 12-19 years old. Energy and nutrient adequacies as percentage of the Estimated Average Requirement were calculated and comparisons were done by region, residence area, and socioeconomic status (SES). RESULTS Energy intake was 1903 kcal [adequacy percentage (AP=75%)] in boys, and 1 571 kcal (AP=79.2%) in girls. Intake of most nutrients (zinc, iron, vitamin C and A) was lower in subjects of low SES, living in the southern region and in rural areas. CONCLUSIONS The rural area, the southern region, and the lower socioeconomic status show the lowest intakes and percentages of nutrient adequacy for both male and female adolescents, in particular vitamin A, folates, heme iron, zinc, and calcium.