Open Journal Systems

SOCIAL MEDICINE

Received: September 2^nd 2014

Accepted: November 10^th 2014

Obesity in México

Javier Dávila-Torres,^a José de Jesús González-Izquierdo,^b Antonio Barrera-Cruz^c

^aTitular de la Dirección de Prestaciones Médicas

^bMédico Especialista en Cirugía General, Maestro en Ciencias Médicas,

Titular de la Unidad de Atención Médica

^cMédico Especialista en Medicina Interna y Reumatología, Doctor en Ciencias Médicas, Coordinador de Programas Médicos en la Coordinación

Técnica de Excelencia Clínica, Encargado del Programa de Cirugía Bariátrica

Instituto Mexicano del Seguro Social, Distrito Federal, México

Communication with: Javier Dávila-Torres

Email: javier.davilat@imss.gob.mx

Excess body weight (overweight and obesity) is currently recognized as one of the most important challenges of public health in the world, given its size, speed of growth and the negative effect it has on the health of the population that suffers. Overweight and obesity significantly increases the risk of chronic noncommunicable diseases, premature mortality and the social cost of health. An estimated 90 % of cases of type 2 diabetes mellitus attributable to overweight and obesity. Today, Mexico is second global prevalence of obesity in the adult population, which is ten times higher than that of countries like Japan and Korea. With regard to children, Mexico ranks fourth worldwide obesity prevalence, behind Greece, USA and Italy. In our country, over 70 % of the adult population, between 30 and 60 years are overweight. The prevalence of overweight is higher in men than females, while the prevalence of obesity is higher in women than men. Until 2012, 26 million Mexican adults are overweight and 22 million obese, which represents a major challenge for the health sector in terms of promoting healthy lifestyles in the population and development of public policies to reverse this scenario epidemiology. Mexico needs to plan and implement strategies and action cost effective for the prevention and control of obesity of children, adolescents and adults. Global experience shows that proper care of obesity and overweight, required to formulate and coordinate multisectoral strategies and efficient for enhancing protective factors to health, particularly to modify individual behavior, family and community.

Keywords: Obesity; Public health; Epidemiology; Prevention & control; Mexico

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Excess body weight (overweight and obesity) is now recognized as one of the most important public health challenges in the world because of its size, the speed of the increase, and the negative effect it has on the health of the population suffering from it. Overweight and obesity significantly increases the risk of chronic non-communicable diseases (NCDs), premature mortality, the social cost of healthcare, and reduces quality of life.¹ It is estimated that 90% of cases of type 2 diabetes mellitus are attributable to overweight and obesity. Other obesity-related NCDs are hypertension, dyslipidemia, coronary heart disease, sleep apnea, cerebral vascular disease, osteoarthritis, and some cancers (breast, esophagus, colon, endometrium, and kidney, among others).²

Obesity (BMI ≥ 30 kg/m²) is a multi-causal, systemic, chronic disease, not exclusive of economically developed countries, involving all age groups, different ethnic groups, and all social classes (Table I). The disease has reached epidemic proportions globally, which is why the World Health Organization (WHO) calls obesity as the epidemic of the century. In fact, excess body weight is the sixth leading risk factor for death in the world. Each year about 3.4 million adults die as a result of being overweight or obese. In addition, 44% of the burden of diabetes, 23% of the burden of ischemic heart disease, and between 7% and 41% of the burden of some cancers are attributable to overweight and obesity (Figure 1).³

Excessive weight gain is a gradual process that usually begins in childhood and adolescence, based on an imbalance between energy intake and energy expenditure; its origin involves genetic and environmental factors that determine a metabolic disorder that leads to an excessive accumulation of body fat beyond the expected value according to gender, height, and age.² As for its magnitude, WHO estimates that by 2015, there will be approximately 2 million 300 thousand overweight adults, more than 700 million obese, and more than 42 million overweight children under five years.³ According to projections by the Organization for Economic Co-operation and Development (OECD), it is estimated that more than two thirds of the world population will be overweight or obese by the year 2020.⁴

A recent analysis of the epidemiological transition in Mexico found that NCDs caused 75% of all deaths and 68% of the years of potential life lost.⁵ In Latin America, the overall prevalence of the metabolic syndrome is 24.9% (range 18.8-43.3%), and it is slightly more common in women (25.3%) than men (23.2%), the over-50 age group having the highest prevalence. The parallel increase in the prevalence of obesity and metabolic syndrome is a global phenomenon and Mexico is no exception.^6,7 This epidemiological scenario allows us to determine the gravity of obesity in Mexico and calls for the management of profitable and successful programs and projects to solve this health problem.

Definition

Overweight and obesity are defined as abnormal or excessive accumulation of fat.⁸

Body mass index (BMI) is a simple indicator of the relationship between weight and height that is commonly used to identify overweight and obesity in adults. It is calculated by dividing a person's weight in kilos by the square of their height in meters (kg/m²).

The WHO definition is as follows:

• A BMI equal to or greater than 25 defines overweight.
• A BMI equal to or greater than 30 defines obesity.

BMI provides the most useful measure for the diagnosis of overweight and obesity in the population, since it is the same for both sexes and for adults of all ages.

Objectives of the study

1. Describe the epidemiological picture of overweight and obesity in Mexico.
2. Specify the negative health impact of overweight and obesity.
3. Highlight the strategies and lines of action for the prevention and control of overweight and obesity.

Epidemiology of obesity

National and international level

At present, Mexico and the United States are leading worldwide prevalence of obesity in the adult population (30%), which is ten times greater than that of countries like Japan and Korea (4%) (Figure 2). With regard to children, Mexico ranks fourth for worldwide prevalence of obesity, approximately 28.1% in boy and 29% in girls, surpassed only by Greece, the US and Italy.4,8 In our country, trends in overweight and obesity in different national surveys show steady increase in prevalence over time. From 1980 to date, the prevalence of obesity and overweight in Mexico has tripled, reaching alarming proportions.⁹

According to data from the International Association for the Study of Obesity it is estimated that currently about one billion adults are overweight and 475 million are obese. The largest prevalence of overweight and obesity was recorded in the Americas region (overweight: 62% in both sexes; obesity: 26%) and the lowest in the South East Asia (overweight: 14% in both sexes; obesity: 3%).^3,10

Major national surveys

In 1993, the results of the Encuesta Nacional de Enfermedades Crónicas (ENEC) showed that the prevalence of obesity among adults was 21.5%, whereas data from the Encuesta Nacional de Salud 2000 found that 24% of adults in our country suffer from it, and, more recently, measurements obtained by the Encuesta Nacional de Salud y Nutrición (ENSANUT 2006) found that about 30% of the population over 20 years (women 34.5%, men 24.2%) are obese.¹¹ In 2006, over 70% of the adult population (women 71.9%, men 66.7%) between 30 and 60 years was overweight. The prevalence of overweight was higher in men (42.5%) than females (37.4%), while the prevalence of obesity was higher in women (34.5%) than in men (24.2%).11 One factor associated with this gender difference is that obesity is more common in people with low income and low educational level.^12,13 In several OECD countries, women with low educational background are two to three times more likely to be overweight than women with higher educational background; children with at least one obese parent are 3-4 times more likely to be obese also. It is well documented that overweight and obesity during childhood and adolescence increases the risk of being overweight or obese in adulthood. This is not only genetic, because children generally share the poor diets and sedentary lifestyles of their parents, a relevant social aspect in the spread of obesity.^14-17 This scenario threatens the sustainability of the health system, increasing the risk of death and the development of other chronic noncommunicable diseases associated with obesity, such as diabetes mellitus, cardiovascular disease, and cancer.

The Instituto Mexicano del Seguro Social (IMSS), with the objective of assessing the progress of preventive health programs for children, adolescents, and adults, through the measurement of program coverage and other health indicators, were conducted in 2003, 2004, and 2005 probabilistic population surveys with national and municipal (state) representation, with IMSS enrollees (ENCOPREVENIMSS 2003, 2004 and 2005); specifically in the ENCOPREVENIMSS 2003 survey, in the areas relating to prevalence of underweight, overweight, general obesity, and central obesity (which included 16,325 individuals), it was observed that the prevalence of overweight and obesity increased progressively in both men and women since the first decade of life, reaching more than 80% in men and women in the fifth and sixth decade of life. It is also documented that the risk of central obesity (waist circumference greater than 88 cm) was very high in women over 20 years in every decade of life (36.6 to 74.2%).¹⁵

According to findings from the Encuesta Nacional de Salud y Nutrición (ENSANUT 2012), the prevalence of overweight and obesity in children under five registered a slight increase over time, almost 2 percentage points (pp) from 1988 to 2012 (from 7.8 to 9.7% respectively), mainly in the northern region of the country, reaching a prevalence of 12% in 2012. Regarding the population of school age (5 to 11 years old), national prevalence of combined overweight and obesity in 2012, using the WHO criteria, was 34.4% (19.8 and 14.6%, respectively). For girls, this figure is 32% (20.2 and 11.8%, respectively) and for boys it is almost 5 pp higher at 36.9% (19.5 and 17.4%, respectively). These prevalences in school-age children account for about 5,664,870 children with overweight and obesity nationwide. With regard to the adolescent population, more than a third of overweight (35%), representing about 6,325,131 individuals between 12 and 19 years of age, i.e., more than one in five adolescents is overweight and one in ten is obese. Moreover, the combined prevalence of overweight and obesity in adults was 71.28% (representing 48.6 million people), according to the cutoff points of body mass index (BMI) (kg/m²) proposed by WHO. The prevalence of obesity (BMI ≥ 30 kg/m²) in adults was 32.4% and overweight 38.8%. Obesity was higher among females (37.5%) than males (26.8%), while overweight was higher in males (42.5%) compared to females (35.9%).¹⁷ In fact, from 1988 to 2012, overweight women aged 20 to 49 years of age increased from 25 to 35.3% and obesity from 9.5 to 35.2%. The prevalence of obesity shows differences by socioeconomic status (SES), region, and locality (p < 0.05); the prevalence of obesity is higher in high SES than in low, similarly in urban areas compared to rural, and the North of the country compared with the South and the center (Figure 3 and 4). These figures clearly indicate a major challenge for the health sector in terms of promoting healthy lifestyles in the population and the development of public policies to reverse the obesogenic environment.¹⁸

In Mexico clear differences were found between dietary patterns and the risk of overweight and obesity in different subpopulations, by socioeconomic status, rural or urban area, and by region.¹⁹ Using the classification of the International Obesity Task Force (IOTF ) to consistently define overweight and obesity in school-aged children, it is observed that the states of Oaxaca and Chiapas were those with the lowest prevalence of overweight in children (15.75%) while the states of Baja California Norte and Baja California Sur were those with the highest prevalence of overweight (41.7 and 45.5%, respectively). For adolescents and adults, southern states like Oaxaca and Guerrero showed the lowest prevalence of overweight compared to those in the north, such as Baja California Sur and Durango.²⁰

Impact of obesity

Causes and consequences of overweight and obesity

Obesity has a multifactorial origin involving genetic susceptibility, lifestyle, and environmental characteristics, influenced by various underlying determinants such as globalization, culture, economic status, education, urbanization, and political and social environment. Individual behavior, as well as family, community, and the social environment have a predominant role in this phenomenon.^21,22

The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and expended. Worldwide, there is an overwhelming increase in the intake of energy-dense foods that are high in fat, salt, and sugars but low in vitamins, minerals, and other micronutrients, as well as a decrease in physical activity as a result of the increasingly sedentary nature of many forms of work, new ways of transport, and growing urbanization.³

The nutrition transition experienced by the country has the characteristics of the Westernization of diet, specifically:

1. Increasing availability of low-cost processed foods with high amounts of added fat, sugar, and salt.
2. Increased consumption of fast food.
3. Decreased time available for food preparation at home.
4. Significantly increased exposure to advertising and supply of processed foods, and 5) significant decrease in population physical activity.²³

There is evidence that a high BMI is an important risk factor for noncommunicable diseases, such as cardiovascular disease (mainly heart disease and stroke), diabetes, musculoskeletal disorders (especially osteoarthritis), and some cancers (endometrial, breast, and colon) (Table II). Childhood obesity is associated with a higher likelihood of obesity, premature death, and disability in adulthood. Depending on age and ethnicity, obesity is associated with a decrease in life expectancy of 6-20 years, and severely obese people die 8-10 years earlier than those of normal weight, like smokers. It is estimated that every additional 15 kilograms increases the risk of early death approximately 30%.^8,24

Estimating the economic and social costs

It is estimated that obesity accounts for 1 to 3% of total healthcare spending in most countries (5-10% in the United States) and that costs will increase rapidly in the coming years due to obesity related diseases. In Latin America, specifically in Brazil, it is estimated that the total annual cost of all diseases related to overweight and obesity amounted to $2.1 billion dollars, of this $1.4 billion dollars (68.4% of total costs) are used hospitalizations and $679 million dollars in outpatient procedures.²⁵

In Mexico, it is estimated that the care of diseases caused by obesity and overweight, has an approximate annual cost of 3 thousand 500 million dollars. The estimated direct cost is that medical care for illnesses attributable to overweight and obesity (cardiovascular and cerebrovascular diseases, hypertension, some cancers, diabetes mellitus type 2) increased by 61% in the period 2000-2008 (present value), going from 26,283 million pesos to at least 42,246 million pesos. By 2017 it is estimated that such spending will reach 77,919 million (in 2008 pesos).²⁶

The indirect cost of lost productivity due to premature death attributable to overweight and obesity has increased from 9146 million in 2000 (present value) to 25,099 million pesos in 2008. This implies an annual average growth rate of 13.51%. The total cost of overweight and obesity (sum of direct and indirect costs) has increased (in 2008 pesos) from 35,429 million pesos in 2000 to an estimated 67,345 million in 2008. For 2017, the total estimated cost amounts to 150,860 million pesos.^23,26

Overweight and obesity are a cause of impoverishment because of lower work productivity and astronomical costs in health-related chronic diseases. For example, currently 12% of the population living in poverty has diabetes and 90% of these cases can be attributed to overweight and obesity.23,26
Based on the OECD’s estimates, an effective prevention strategy each year would prevent 155,000 deaths from chronic diseases in Japan, 75,000 in Italy, 70,000 in England, 55,000 in Mexico and 40,000 in Canada. The annual cost of this strategy would be $12 USD per capita in Mexico, $19 USD in Japan and England, $22 USD in Italy, and $32 USD in Canada.⁸

Strategies for comprehensive care of overweight and obesity

Comprehensive care of NCDs requires high impact interventions that can be applied by a primary care approach to strengthen early detection and timely treatment. For maximum effect, it is necessary to formulate healthy public policies that promote the prevention and control of NCDs and reorient health systems to meet the needs of people suffering from excess body weight.²⁷ The current situation of overweight and obesity in Mexico calls for implementing a comprehensive, multi-sectoral policy with effective coordination, to achieve changes in eating patterns and physical activity to allow the prevention of chronic diseases and reducing the prevalence of overweight and obesity.^20,28,29

In response to this growing epidemic, the WHO promoted the Global Strategy on Diet, Physical Activity, and Health for the prevention of chronic diseases, which Mexico joined in 2004. In 2010, our country updated the Norma Oficial Mexicana (NOM-008-SSA3-2010),³⁰ which established health criteria to regulate the comprehensive treatment of overweight and obesity, particularly the provisions for medical, surgical, and nutritional management.

The Action Plan 2008-2013 of the Global Strategy for the prevention and control of noncommunicable diseases at WHO, has as one of its objectives to promote interventions to reduce the main modifiable risk factors for noncommunicable diseases, including tobacco consumption, unhealthy diets, physical inactivity, and harmful use of alcohol.³¹

In our country, the strategy against overweight and obesity described in the Acuerdo Nacional para la Salud Alimentaria^23,26 sets out 10 priority objectives:

1. Encourage physical activity in the population in school, work, community, and recreational environments in collaboration with public, private, and social sectors.
2. Increase the availability, accessibility, and consumption of plain drinking water.
3. Decrease consumption of sugar and fat in beverages.
4. Increase daily intake of fruits and vegetables, legumes, whole grain cereals, and fiber in the diet, increasing its availability and accessibility and promoting its consumption.
5. Improve population ability to make informed decisions about proper diet through labeling that is useful, easy to understand, and promotes nutrition and health literacy.
6. Promote and protect exclusive breastfeeding until six months of age, and encourage appropriate complementary feeding after 6 months of age.
7. Decrease consumption of added sugars and other caloric sweeteners in food.
8. Decrease daily consumption of saturated fats in the diet and minimize trans-fat from industrial sources.
9. Provide guidance to the public about the control of recommended portion sizes in home food preparation, making accessible and available processed foods that are allowed, and including smaller portions sizes in restaurants and food outlets,. 
10. Reduce daily sodium intake and increase the availability and accessibility of products with low or no sodium.

The first six goals depend primarily on individual will and the existence of conditions and adequate supply allowing, for example, increasing physical activity and consuming drinking water, fruits, and vegetables. The other four objectives require major involvement of the government, social sectors, and the food and restaurant industry to reduce the amount of sodium and sugars added to foods, minimize trans-fat from industrial sources, guide the consumer in home food preparation and foster attention to portion size.

The Agreement provides four horizontal actions always considered as a fundamental requirement to achieve mainstreaming each of the 10 agreed-upon targets.³²

• Information, education and communication: promoting access to information and making educated decisions based on population evidence to improve the quality of their diet, increase physical activity, and, in general, promote healthy lifestyles.
• Advocacy, co-regulation, and regulation: with the participation of authorities, civil society, and industry, promote proper nutrition and increased physical activity.
• Monitoring and evaluation: monitoring and evaluation of each objective and actions are needed to identify opportunities for improvement, ensure compliance with the actions, and correct any faults.
• Research: There is an agenda of basic, clinical, epidemiological, and health systems research to support decision-making on obesity and chronic disease prevention.

The prevention of obesity in infants and young children should be considered a matter of the highest priority. For these groups, the main prevention strategies are:

• Romote exclusive breastfeeding.
• Avoid adding sugars and starches to bottle milk.
• Teach mothers to accept their child's ability to regulate caloric intake rather than feeding them until the plate is finished.
• Ensure micronutrient intake needed to promote optimal linear growth.

In the case of children and adolescents, preventing obesity means:

• Promote an active lifestyle.
• Limit television viewing.
• Promote the consumption of fruits and vegetables.
• Restrict the intake of foods high in calories and poor in micronutrients (e.g. packaged snacks).
• Restrict the intake of sugary soft drinks.

Among additional measures, we must change the environment to increase physical activity in schools and communities, create more opportunities to develop family relationships, limit the exposure of young children to heavy marketing of foods high in calories and low in micronutrients, and provide information and tools necessary to make correct choices regarding diet.²¹

Finally, the Estrategia Nacional para la Prevención y el Control del Sobrepeso, la Obesidad y la Diabetes of the current administration (2013-2018) promotes the construction of a national public policy to generate healthy food consumption habits and perform physical activity in the population, involving the public and private sectors and civil society.³³

The overall objective of the strategy is to improve the levels of welfare and contribute to the sustainability of national development by slowing the increase in the prevalence of overweight and obesity in Mexicans, to reverse the epidemic of noncommunicable diseases, particularly type 2 diabetes mellitus, through public health interventions, a comprehensive model of care, and interdisciplinary public policies. Moreover, the actions to be taken for the prevention and control of overweight, obesity and diabetes involve different frameworks of actions for health, specifically:

• Health promotion: actions for the development of personal skills for health (promotion of proper nutrition), development of healthy environments (schools and workplaces), community actions (activities in public spaces), and promotion of healthy public policies.
• Disease prevention: actions for early detection of noncommunicable diseases, as well as a monitoring system that provides health information and regularly collects data on risk factors.
• Healthcare: for healthcare services to have increased effectiveness it is necessary to strengthen the training of human resources; for this reason, among the actions to follow is incorporating prevention and control of noncommunicable diseases in the training of all health workers, including health workers in communities and social agents, professional or not (technical and/or medium level), with emphasis on primary healthcare.
• Sanitary regulation and fiscal policy: surveillance activities focused on food and beverages and the advertising of these products in the mass media. Specifically, this seeks to establish a clear front labeling that provides useful information for the consumer to have enough elements to make decisions about their caloric intake. Similarly, the implementation of fiscal measures is suggested in order to reduce the consumption of high-calorie and low nutritional value foods.

It is worth mentioning that it is unlikely that a single intervention can alter the incidence or natural history of overweight and obesity, so it is necessary to plan and implement multisectoral interventions oriented to our national context.^34-36 International experience, from the National Institutes Health of the United States and the Canadian Working Group on Preventive Health recommend, for weight loss and maintenance, implementing multiple actions, including include a low-calorie diet and increased physical activity and behavioral therapy.

Conclusions

In Mexico, overweight and obesity are a serious public health problem that affect 7 out of 10 adults from different regions, towns, and socio-economic levels. This means that efforts to prevent this problem should be a national priority, while making it necessary to plan and implement strategies and lines of cost-effective action for the prevention and control of obesity of children, adolescents, and adults. Global experience indicates that proper care of obesity and overweight requires formulating and coordinating comprehensive and efficient multisectoral strategies with social participation for control, to enhance health protective factors, particularly for individual, family, and community behavior change.

The use of indicators like BMI and measure waist circumference represent clinical detection strategies that allow us a proper classification of the severity of the disease and the risk associated with it, in order to establish prevention or management of both obesity and its associated illnesses, especially in genetically susceptible populations. Moreover, the promotion of moderate or vigorous physical activity and decreased sedentary lifestyles, together with the promotion of a healthy diet, are essential actions for the prevention and control of overweight and obesity in childhood and adolescence, the risk of chronic diseases in youth and adulthood.

Given this situation, IMSS develops programs and projects of social interest, to provide quality comprehensive care to beneficiaries who are overweight and obese, in order to limit the metabolic consequences of the disease, improve quality of life, and achieve more efficient use of resources.

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