obesity reviews doi: 10.1111/obr.12096 Latin America Mexico attempts to tackle obesity: the process, results, push backs and future challenges S. Barquera, I. Campos and J. A. Rivera Centro de Investigación en Nutrición y Salud, Summary Instituto Nacional de Salud Pública, Mexico’s obesity prevalence is one of the world’s highest. In 2006, academics, and Cuernavaca Morelos, México federal and state government agencies initiated efforts to design a national policy for obesity prevention. The Ministry of Health (MOH) established an expert Received 13 August 2013; accepted 14 panel to develop recommendations on beverage intake for a healthy life in 2008. August 2013 Subsequently, the MOH, with support from academia, initiated the development of the National Agreement for Healthy Nutrition (ANSA). ANSA was signed by Address for correspondence: Dr JA Rivera, all relevant sectoral actors in 2010 and led to initiatives banning sodas and Av. Universidad no. 655. Col. Sta. Ma. regulating unhealthy food in schools and the design of other yet to be imple- Ahuacatitlan, Cuernavaca, Mor., Mexico CP. mented initiatives, such as a front-of-package labeling system. A main challenge of 62100, México. the ANSA has been the lack of harmonization between industry interests and E-mail: [email protected] public health objectives and effective accountability and monitoring mechanisms to assess implementation across government sectors. Bold strategies currently under consideration include taxation of sugar-sweetened beverages, improvement of norms for healthy food in schools, regulation of food and beverage marketing to children and implementation of a national front-of-pack labeling system. Strong civil society organizations have embraced the prevention of obesity as their goal and have used evidence from academia to position obesity prevention in the public debate and in the government agenda. Keywords: Health policy, Mexico, national programmes, obesity. obesity reviews (2013) 14 (Suppl. 2), 69–78 Public Health (INSP). Varying age–gender groupings were Introduction collected in the 1988, 1999, 2000, 2006 and 2012 national An estimated 75% of all deaths in Mexico are caused surveys. We combined these surveys to present an overall by noncommunicable diseases (NCDs), and obesity and picture of trends in overweight plus obesity (OW + O) unhealthy diet were among the six main risk factors for across time and the various age–gender groupings. We used mortality in 2010 (1). Projected healthcare costs of 13 the World Health Organization (WHO) definitions for obesity-related diseases in 2013 were estimated at US$880 risk of OW + O in children under 5 years (y) and OW + O million, with alarming projections for the next few years. in children 5 years and older and adolescents (>1 standard According to this study, if an effective policy does not deviation [SD] of the body mass index [BMI] 2006 WHO control this trend, in only 7 years, direct healthcare costs growth standards) (3) and the conventional cutoff point of will rise above US$1 billion (2). BMI ≥ 25 for adults. We use a common indicator, shifts in The prevalence of obesity in Mexico has been estimated the percentage points annualized (population prevalence from a number of national surveys implemented by the change per year). The prevalence of OW + O among Ministry of Health (MOH) and the National Institute of children under 5 years increased from 26.6% to 33.6% © 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd 69 on behalf of the International Association for the Study of Obesity. 14 (Suppl. 2), 69–78, November 2013 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. 70 Obesity prevention policies in Mexico S. Barquera et al. obesity reviews Figure 1 Prevalence of overweight and obesity in children <5 years, children 5–11 years, adolescents (12–19 years), women (20–49 years) and adults (≥20 years), 1988–2012. between 1988 and 2012 (0.3 percentage point per year), lescents (12–19 years) the combined OW + O prevalence that among children 5–11 years increased from 28.2% to was 35.8% in women and 34.1% in men. Among adults 20 36.9% between 1999 and 2012 (0.7 percentage point per years and older, the prevalence of OW + O was 73.0% in year), and that among girls 5–11 years increased from women and 69.4% in men. The prevalence of abdominal 25.5% to 32.0% between 1999 and 2012 (0.5 percentage obesity (waist circumference ≥ 90 cm in men and ≥80 cm in point per year). Among female adolescents (12–19 years), women) (7) was 82.8% in women and 64.5% in men. the combined OW + O grew from 11.1% to 35.8% With these surveys we have been able to identify the between 1988 and 2012 (1.0 percentage point increase per regional distribution of obesity and the association with year), and among male adolescents (12–19 years) the com- other risk factors, sex, age group and socioeconomic status. bined OW + O grew from 33.0% to 34.1% between 2006 Some of the main conclusions of these studies are summa- and 2012 (0.2 percentage point increase per year). Among rized in Table 1A. adult women (20–49 years) it increased from 34.5% to To understand the environmental drivers of the increase 70.6% between 1988 and 2012 (1.5 percentage points per in the prevalence of obesity and mortality attributed to year), and among adult men (≥20 years) it increased from NCDs in Mexico, the INSP analysed national income and 60.7% to 69.4% between 2000 and 2012 (0.7 percentage expenditure surveys and other databases to explore trends point per year) (4–6). and patterns in food expenditure, transportation, leisure While no decline has been observed in spite of some time activities, and other factors associated with obesity attempts to control the problem, the rate of increase has and NCDs. One of the first findings (2002) was a dramatic dropped among adults in recent years, with an annual rise in consumption of sugar-sweetened beverages (SSBs). increase of 0.2% per year in women and 0.5 in men for the Between 1984 and 1998 we found significant decreases 2006–2012 period, in contrast to 1.2% per year in women in expenditures on some food groups, such as fruits and for the 1999–2006 period and 1.0% per year in men for the vegetables (−29.3%), dairy products (−26.7%), and meats 2000–2006 period. However, the prevalence has positioned (−18.8%), and an increase in expenditures on refined car- Mexico among the countries with the highest obesity rates bohydrates and sugars (6.3%) together with a very high (Fig. 1). increase in expenditures on SSBs (37.2%) (8). These studies According to the latest national health and nutrition identified important changes associated with the nutrition survey (ENSANUT 2012), the prevalence of OW + O transition that are summarized in Table 1B. (BMI >+2 SD) in Mexico among children under 5 years In this context researchers from the MOH identified the was 9.7% in 2012. Among the school-age population (chil- urgent need to develop and implement programmes to dren 5–11 years) the combined OW + O prevalence was control the increase in the prevalence of OW + O. In con- 34.4% (19.8% overweight and 14.6% obese). Among ado- trast with the comprehensive undernutrition, vaccination © 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd 14 (Suppl. 2), 69–78, November 2013 on behalf of the International Association for the Study of Obesity obesity reviews Obesity prevention policies in Mexico S. Barquera et al. 71 Table 1 The obesity problem in Mexico, nutrition transition–related factors, and opportunities for action A. Characteristics of obesity in Mexico identified from surveys and mortality registries 1. Obesity is a highly prevalent health problem in all regions, age groups, and genders in Mexico (31). 2. The increasing obesity prevalence trends in 1999–2006 were among the highest documented in the world (32). However, between 2006 and 2012, this trend increased at a lower rate, probably because of a saturation of susceptible population effect (33). 3. Obesity’s prevalence is increasing at more alarming rates in the most vulnerable populations, such as those living in poverty and children (34). 4. Mortality associated with obesity is a significant percentage of the total national mortality (12.2%) (35). 5. The generalized obesity problem appeared in Mexico before the undernutrition problem was solved, and they still coexist. Undernutrition still affects important sectors of the country (36). 6. Obesity coexists with undernutrition within the most vulnerable communities of the country, within households, within families, and even within individuals (e.g. obesity with iron deficiency) (37). 7. Health expenditure is increasing at a significant rate because of obesity, and even small reductions in the prevalence of this condition would mean notable savings to the country (38). B. Changes in the Mexican diet associated to the nutrition transition 1. Increase in the availability of low-cost processed foods with high quantities of sugar, fat and sodium (8). 2. Increase in fast food consumption and food consumption outside the home for a growing sector of the population (39). 3. Decrease in available time for food preparation (8). 4. Significant increase in exposure to food and beverage marketing and to technology that decreases physical activity (40). 5. Increase in per capita income (38). 6. Increase in the availability and supply of ready-to-eat foods and processed foods in general (41).