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Food and nutrition programmes in Mexico

Social policy in Mexico has included diverse food aid programmes designed to improve nutritional status in the country. Since the 1990s, the government has changed its food policy substantially, moving from generalized to selective targeting programmes, which have been demonstrated to be a more effective strategy for transferring resources and inputs to the poor. Among current programmes are ones for food distribution, micronutrient supplementation and fortification. Most of these include health and nutrition education components. The two most important national poverty alleviation integrated nutrition programmes are Oportunidades and Liconsa. In addition, the government has national food fortification and food coupon programmes directed to vulnerable populations. Several other initiatives are being implemented to address the double burden of disease: the Mexican Institute of Social Security’s Preven-IMSS is an integrated health programme with an important nutrition and physical activity component; and the Ministry of Health has a programme for adults and elderly people that emphasizes prevention of non-communicable chronic diseases as one of its objectives.

The Oportunidades programme

The current comprehensive national programme for human development - Oportunidades - has three main components: nutrition, education and health. Among its diverse inputs are cash transfers, food coupons, food supplements for preschool children and pregnant women, and medical services (Barquera, Rivera-Dommarco and Gasca-Garcia, 2001). This programme has the general objective of supporting families that are suffering from extreme poverty by increasing the capacities of their members and increasing their education, health care and food options (Ministry of Social Development, 2000). In addition, it acts as a link to new services and development programmes to improve socio-economic conditions and quality of life.

The education component supports the registration and regular assistance of participating children through scholarships and school materials support. The health component has four specific strategies: delivering free health care services; preventing child undernutrition at the pre-gestational age through the delivery of food supplements; promoting and improving self-sufficiency through education; and improving families’ health care and nutrition status. The food component provides direct cash transfer supports to beneficiary families in order to improve dietary quantity, quality and diversity with the aim of improving nutritional status. Supplement delivery and nutrition education are designed to reinforce adequate nutrition among infants and women.

In 2004, the programme had an annual budget of about US$2 273 million, and covered 5 million families in rural and urban areas in more than 70 000 locations of Mexico’s 31 states. In order to measure the programme’s impact on beneficiary families, external academic institutions designed evaluations (Bautista et al., 2003; Behrman and Hoddinott, 2000; Parker, 2004; Rivera et al., 2004b). Among the impacts observed during these evaluations are: a 12 percent reduction in the prevalence of disease in children under five years of age; an 8 percent increase in pregnant women’s attendance at health care centres; a 59 percent increase in attendance at health care centres among the programme’s beneficiaries; a 19 percent reduction in the number of days of morbidity among adults; a height increase in children under three years of age; and a 23.9 percent decrease in anaemia prevalence in children under two years of age.

The Liconsa programme

Iron deficiency anaemia (IDA) is a public health problem in Mexican children. Among children aged 12 to 23 months, MNS-2 (1999) found prevalence of anaemia of 49 percent, with iron deficiency (percentage transferrin saturation < 16) at 66 percent. Thus, approximately two-thirds of anaemic children were iron-deficient (Shamah-Levy et al., 2003). Although total dietary iron intake in Mexican children is high relative to recommendations, the intake of haem iron is low, while the consumption of foods that inhibit iron absorption - such as phytates - is high.

Since 1944, a Federal Government programme - Liconsa - has been distributing low-cost milk to low-income families with children aged one to 11 years (Barquera, Rivera Dommarco and Gasca-Garcia, 2001). Since 1970, the milk distributed by this programme has been fortified with vitamins A and D according to sanitary norms. No further nutritional improvements were introduced until 2002, when in response to the high prevalence of IDA and its detrimental effects the government decided to fortify further the milk that Liconsa was distributing to about 5 million children. Every 400 ml daily ration of milk now contains 6.6 mg of iron (as gluconate), 6.6 mg of zinc (as oxide), 60 mg of vitamin C, 40.2 mcg of folic acid, and 0.55 mcg of vitamin B12.

The effectiveness and efficacy of the new fortified milk was assessed in 2003 among children aged 12 to 30 months at baseline by the National Institute of Public Health (Rivera et al., 2005; Villalpando et al., 2005). A double blind effectiveness trial was carried out at 17 milk distribution centres located in four states in Central Mexico. Baseline prevalence of anaemia fell in both the non-fortified (from 43.9 to 23.9 percent) and fortified (from 47.6 to 17.8 percent) groups by 20.0 and 29.8 percentage points, respectively. Thus, 33 percent of the reduction in the group receiving the fortified milk was attributable to the programme. The programme was effective in reducing the prevalence of anaemia in 12 to 30-month-old children over a six-month period. Extrapolating these results to all the children who were exposed to the programme during the course of the study, it is estimated that more than 50 000 cases of anaemia were prevented during the six-month period. A far larger number of older children (ages not evaluated) probably also benefited as a result of the programme. Based on these results, the National Institute of Public Health recommended that distribution of fortified milk be continued and incorporated into other food assistance programmes that distribute milk.

The Preven-IMSS programme

The Mexican Institute for Social Security (MISS) provides health services to approximately 50 percent of the population. As part of recent efforts to improve these services, MISS designed and implemented an integrated strategy for health programmes called Preven-IMSS, which focuses on a portfolio of preventive actions aimed at improving the health status of target populations. This is the first massive prevention programme to be launched by MISS. Starting in 2002, actions were organized for different age groups and vulnerable populations: children up to ten years of age; adolescents aged ten to 19 years; women aged 20 to 59 years; men aged 20 to 59 years; and elderly adults over 60 years of age. Activities include major food and nutrition, physical activity and health education components (MISS, 2005).

The main preventive actions among children focus on health promotion; nutrition education; disease control and prevention; early identification of diseases; oral health; vaccination; and miscellaneous issues such as personal hygiene, breastfeeding issues and fever control. For adolescents activities include physical activity; prevention of accidents, violence and addiction; oral health; sexual health and education; nutrition education; overweight and obesity detection and control; parasite treatment; vaccination; condom use; prevention of human immunodeficiency virus (HIV) and sexually transmitted diseases (STD); visual, auditory and postural defects; and reproductive health.

Activities directed to women, include health care education; physical activity; oral health; sexual education; prevention of addiction, accidents and family violence; nutrition education; detection and control of overweight and obesity; detection of anaemia; prevention of HIV and STD; prevention of tuberculosis; mammary cancer; cervical and uterine cancer; diabetes mellitus; high blood pressure; reproductive health; post-pregnancy care; climaterium attention and prevention of menopause complications; and vaccination. Activities for men focus on health care education; nutrition education; physical activity; diabetes mellitus; high blood pressure; obesity; prevention of accidents and violence; prevention of HIV and STD; prevention of tuberculosis; oral health; sexual education; and vaccination.

Among older adults the main preventive actions focus on health care education; physical activity; oral health; prevention of accidents and family violence; sexual education; prostate disease; detection and control of undernutrition, overweight and obesity; vaccination; prevention of tuberculosis; post-menopause care; mammary, cervical and uterine cancer; diabetes mellitus; and high blood pressure.

For each preventive action there is a set of activities and objectives designed for each age group. As part of the promotion strategy, this programme produces a magazine with health care information related to its activities, which is sold at newspaper shops nationwide. In addition, television advertisements are broadcast every day, focusing on lifestyles, nutrition and obesity, and promoting the magazine to the general public.

Ministry of Health programmes for non-communicable chronic diseases

The Ministry of Health has a number of programmes that include prevention as a component. Rather than being integrated health or nutrition programmes, these focus on the most relevant public health problems such as obesity, diabetes mellitus, high blood pressure and cancer. For each of these diseases there is a programme providing general management and prevention guidelines for government health service providers to follow.


At present, as in the past, there are many clear differences in dietary patterns and disease risk among different subpopulations of Mexico, including among different socio-economic groups, between rural and urban locations and among regions. As this case study makes clear, trends or rates of change in dietary patterns and disease risk over the last decade and a half also differ along the same lines. Many trends in dietary intake, food expenditure and health status are very clearly differentiated according to socio-economic status or income level, suggesting that poverty continues to play an important role in dietary patterns - perhaps more so than cultural differences by region or locality.

The case study found that total energy consumption dropped by about 9 percent between 1988 and 1999, but there is clear indication that underreporting was greater in 1999 than in 1988. Given the increases in per capita GNP, food availability and the prevalence of obesity observed in the country, the case study team consider that total energy intake is not decreasing in Mexico. Furthermore, the increase in total fat intake observed over the period is very likely to be underestimated, given the issues described earlier. Despite the marked underreporting of intakes in MNS-2, both fat intake and percentage of energy derived from fat had increased since MNS-1, 11 years earlier. This implies that the overall energy density of the diet also increased, which is consistent with the important shift in BMI distribution towards overweight and obesity. There is also consistency in the time-based trends observed: among women, the increase in percentage of energy intake from fat that occurred between MNS-1 and MNS-2 was greater among women of higher socio-economic status, as was the increase in prevalence of overweight and obesity that was determined from the same surveys. Nonetheless, in the absence of comparative data on physical activity, the relative contribution to weight gain of increased energy intake and decreased energy expenditure in the population cannot be assessed adequately. In order more fully to understand the contribution of dietary changes in this phenomenon, it is necessary to collect reliable information on physical activity and related lifestyle factors.

Vegetable fat was the greatest source of dietary fat in both rural and urban populations, with the second most important sources being milk in urban and maize products in rural areas. As the purchase of milk products continues to rise, a good public health measure to help reduce fat intake may be to promote greater availability of reduced-fat milk and milk products. Although maize is not likely to be an important source of fat per se, maize products are often prepared with fat (e.g., tortillas are fried in vegetable oil and tamales are prepared with lard). Education campaigns are the only way of achieving changes in such food preparation or selection practices.

While there is much concern about sugar intake and its likely contributions to obesity and chronic diseases, there is no satisfactory way of quantifying total sugar intake in Mexico. Dietary intake data derived from national surveys and food expenditure data are largely confined to capturing the intake of sugar added at the table or to dishes prepared at home, thereby omitting sugar derived from industrialized foods (e.g., sweet drinks, cookies, cakes), which may often be consumed outside the home. Soda may well be a sentinel food for total sugar intake, but other sources may be important contributors. In order adequately to quantify and monitor the intakes and specific food sources of sugar, it is necessary to include sugar in the food composition database used for dietary intake assessment in the future.

The gap that remains between lower- and upper-income quintiles in the purchase of micronutrient-rich foods (meats, milk and dairy products, vegetables and fruit) suggests that there will also remain inequalities in the micronutrient adequacy of the diet among socio-economic status groups. When expressed as percentage adequacy of intakes there was a clear trend of greater adequacies at higher socio-economic levels for vitamins A, D and B12, while the adequacies of iron, zinc, folate and calcium showed no apparent trend with socio-economic level. This can be explained by the fact that the foods that contribute most to intakes of vitamins A, D and B12 are also those for which the greatest intake and purchase discrepancies occur (i.e., meat, dairy products and vegetables). On the other hand, the foods that contribute most to intakes of calcium, iron, zinc and folate come from food groups with similar intakes or purchase distributions among different socio-economic or income groups (i.e., maize products, legumes). Biochemical indicators for micronutrient status determined in MNS-2 conform with the dietary data. Most notable is the apparent increase in the prevalence of anaemia with an apparent decrease in the adequacy of iron intakes among women.

While the adequacy of intakes of vitamins A and B12 and folate has improved substantially, iron adequacy decreased by about 30 percent. (Although the iron adequacy estimate according to United States dietary recommendations was > 100 percent, the case study team considers this to be an overestimate of the true adequacy because the bioavailability of iron from the Mexican diet - about 7.5 percent [Rivera et al., 2005] - is far lower than the 18 percent assumed for the United States population [Institute of Medicine, 2001].) Tortillas and beans have high contents of phytic acid and other food components that inhibit iron absorption, so percentage iron adequacies are not useful predictors of iron intakes without accounting for bioavailability.

Owing to the underreporting of intakes in MNS-2, it is likely that the changes in nutrient intakes and adequacy were underestimated. The case study team therefore thought that expressing nutrient intakes as density (nutrient/100 kcal) may be more indicative of the quality of the diet. It was found that the density of iron was also lower in MNS-2 than in MNS-1, which could be attributable either to differences in the iron content of some key foods in the food composition tables used in each of the surveys, or to the increased energy density of the diet, as suggested by the greater percentage of energy derived from fats in MNS-2. Vitamin A and folate showed large increases in total intake, and higher densities of these nutrients were also found in MNS-2, despite the underreporting and the increased energy density of the diet. Interestingly, the trend was reversed for the folate densities recorded in MNS-1 and MNS-2; while folate densities were higher in higher socio-economic levels and urban areas in MNS-1, the opposite was true in MNS-2. This is difficult to interpret, as biochemical data for overt folate deficiency do not suggest that such a trend exists (Shamah-Levy et al., 2003).

Although large quantities of resources are being directed to programmes to prevent micronutrient deficiencies among the poorest populations (e.g., Oportunidades and Liconsa), certain micronutrient deficiencies - such as those of iron, zinc and folate - still persist in populations of moderate to high socio-economic status levels. The fortification of maize flour with iron and folate is mandatory in Mexico, but only about half the population consumes maize products made from flour. The other half derives maize products from a nixtamalized maize dough, which is currently not fortified because of technological and logistic difficulties. One possible public health measure would be to encourage industry to fortify additional basic foods with micronutrients in order to reach the entire population.

Prevalence of child stunting, which is a result of chronic undernutrition early in life, showed a substantial decrease (23 percent) between the two surveys. This change was not homogeneous, however, and prevalence was as high as 38 percent in the South region, 40.1 percent in rural locations and 40.8 percent in the lowest socio-economic quintile. Stunting therefore continues to be a main public health and nutrition challenge. Mexico has a higher prevalence of stunting than the average for Latin American countries (Rivera et al., 2004a). This problem coexists with another common form of malnutrition - overweight and obesity, which is present in high prevalence in not only developed regions but also in rural locations and the South. Overall, 62.3 percent of men and 67.6 percent of women over 20 years of age are overweight or obese. This represents relative increases of 19.8 and 13.6 percent, respectively, in only seven years. Diabetes mellitus, which is commonly associated with overweight and obesity, has also doubled in recent years (Barquera, Rivera Dommarco and Gasca-Garcia, 2001).

Although the collection and interpretation of data on nutritional and health status may have become more standardized, there is a great need to adapt and improve methods of data collection on dietary habits. The important impact of underreporting on the interpretation of dietary intake data is of concern, and efforts should be made to develop innovative methods of quantifying food consumption, both inside and outside the home. This is of great concern because underreporting appears to be intimately linked with degree of overweight. Trends in the quality of food consumed outside the home may be of special concern, but these cannot be assessed with the data that are available at present; food consumption outside the home may be underestimated in the food intake surveys, and the types of foods consumed outside the home are not captured by food expenditure studies. Although food expenditure data may reflect consumption in urban areas fairly accurately, they are less reliable among rural populations, where domestic agricultural production contributes more to total intakes. Surveys combining food intake data for both inside and outside the home, expenditure data and food production data would be useful for monitoring dietary trends and informing the design of dietary and food policy interventions.


Although this analysis used cross-sectional surveys that lack the conditions necessary to establish causal relationships, the information obtained can be used to identify opportunities for action and research aimed at reducing and controlling nutrition-related diseases. The double burden of disease related to under- and overnutrition represents one of Mexico’s most challenging public health problems (Ministry of Health, 2001). Anaemia and other micronutrient deficiencies coexist with rising levels of obesity, type-2 diabetes, high blood pressure and dislipidaemias. Clearly, nutritional recommendations must be developed to avoid collateral negative effects, but this is not a simple task. For example, there is a need for interventions that promote higher energy intakes, particularly among schoolchildren from marginal communities and among vulnerable groups. This situation needs to be addressed through targeted interventions with educational messages promoting adequate calorie intakes that include the consumption of a variety of fruits and vegetables, and not only energy-dense foods as these can be a factor in the development of future nutrition-related chronic diseases. Funds for the prevention and control of obesity in children and adults should become a health expenditure priority in order to avoid the higher costs generated by cardiovascular risk factors associated with excess body fat and adiposity.

In Mexico, the diet is changing rapidly and becoming more homogeneous across regions, locations and socio-economic groups. The same is happening with morbidity and mortality patterns. Increasing urbanization and modernization could reduce, for better or worse, the polarization currently observed in the country. The national food fortification policy (i.e., folate, zinc, iron) and the distribution of micronutrient supplements to vulnerable groups are playing a key role in reducing the prevalence of stunting and micronutrient deficiencies. The importance of MNS-2’s recommendation to improve the targeting of nutrition inputs to the most vulnerable populations has been recognized, as has the importance of evaluating the impact of food and nutrition programmes in order to distribute scarce resources more efficiently.

Overweight, obesity and other diet-related non-communicable diseases are currently the main nutrition and public health problem. The success of focusing health policy on preventing infectious diseases, improving reproductive health and preventing some micronutrient deficiencies has modified the shape of Mexico’s population pyramid. It is now necessary to adapt the health systems to face a relatively new type of disease, which can only be prevented and controlled by organized responses involving not only policy planners, but also communities, families and people interacting with the health and education sectors to regulate, promote and inform about diseases. The coexistence of obesity and undernutrition has been documented in diverse Latin American countries (Garret and Ruel, 2003; Popkin, Richards and Montiero, 1996; Sawaya et al., 2003).

In Mexico, an estimated 6.1 percent of overweight mothers have a stunted child under five years of age (Barquera, 2005). This fact, together with the high prevalence of obesity in adults, suggests that programmes aimed at improving nutrition should always consider the high risk of obesity. Thus, nutrition programmes must address the double burden of disease, and focus on comprehensive integrated approaches - including the promotion of adequate nutrition through education and environmental changes - rather than trying to solve the problem though one-dimensional interventions such as the use of supplements or food coupons. The health sector, which for a long time was concerned exclusively with infections and other acute health problems, must now pay attention to nutrition-related chronic diseases, which are a very different type of health problem. Thus, health professionals require training so that they can encourage appropriate behavioural change in the population (WHO, 2002).

Among the topics that should be addressed through integrated nutrition programmes are general education on health and nutrition in order to foster a culture where healthy eating practices are promoted, increasing the consumption of fruits and vegetables, and implementing regulatory measures focused on food and nutrition in public schools (Kennedy, Nantel and Shetty, 2004). Studies need to be carried out in order to identify cost-effective policies aimed at preventing, reducing and controlling nutrition-related diseases, including behavioural change and environmental modifications. Such interventions could use the experiences and data from previous studies (mostly conducted in developed countries) as a reference. However, given the unique characteristics of Mexico - in terms of heterogeneous socio-economic development, infrastructure and cultural background - it will be necessary to evaluate the feasibility and impact of these. Improved methods of data collection for evaluation and monitoring purposes should also be emphasized.

Various institutions, universities and government bodies are implementing a wide range of research projects in Mexico to improve the understanding of and to prevent nutrition-related and other emerging diseases. The results of these studies will contribute to ameliorating and controlling these health challenges (Fernald, Gertler and Olaiz, 2005; Fernald et al., 2004; Rivera et al., 2005; 2004b).


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