Letter to the editor: will it be possible to achieve the global nutrition targets in Mexico by 2030?

In May 2012, the 65th World Health Assembly (WHA) approved six global nutrition targets by 2025 aimed to reduce stunting in children under five by 40%, maintain childhood wasting below 5%, halt obesity, cut anemia in women by 50%, lower low birth weight prevalence by 30%, and increase exclusive breastfeeding (EBF) within the first 6 months to 50%. These targets were extended to 2030, with all of them remaining as originally planned, but the EBF one (increased to 70%), wasting and overweight (both objectives set to eliminate them to negligible concern). Mexico is projected to achieve only one of the six nutrition targets (wasting) by 2025, falling far short of the stunting, low birth weight, anemia, and exclusive breastfeeding for the updated goals by 2030. This letter to the editor describes the most recent prevalence of malnutrition among mothers and children in Mexico. It discusses the challenges pregnant women and children under five years of age face exercising their right to good food, nutrition, and development. The authors reflect on the urgent need to make structural changes to achieve the global nutrition targets by 2030, highlighting the paramount importance of addressing the profound structural obstacles in Mexico and how Mexico's government must prioritize poverty reduction, reduce the marked inequalities, enhance the quality of nutritional care and healthcare infrastructure, and implement climate-resilient agricultural practices to address this pressing issue.

Barriers to promoting breastfeeding in primary health care in Mexico: a qualitative perspective

Objective

This article aimed to identify the main barriers related to promoting and counseling breastfeeding (BF) at the Primary Health Care (PHC) in Mexico.

Methodology

A qualitative study with a phenomenological approach was carried out in 88 health centers of the Ministry of Health in the states of Chihuahua, Oaxaca, Chiapas, Veracruz, Mexico, and Yucatan. From September to November 2021, we interviewed 88 key health professionals (HPs) (physicians, nurses, nutritionists, and others) from the PHC of the Ministry of Health in Mexico and 80 parents of children under 5 years old. In addition, nine focus groups were conducted with parents and caregivers. The data obtained were triangulated with information from focus groups and semi-structured interviews.

Results

Of the total interviews, 43.2% (n = 38) were nurses, 29.5% (n = 26) were physicians, 19.3% (n = 17) were nutritionists, and the rest were other health professionals. In the group of users, 97.6% (n = 121) were women. We identified contextual barriers, such as the lack of well-trained health professionals and the scarcest nutrition professionals, as material resources in the health units, without mentioning the low user attendance at their control consultations. Furthermore, we identified barriers related to the orientation and promotion of breastfeeding in health units, including a lack of specific strategies, ineffective communication, and the recommendations of commercial milk formulas.

Conclusion

The results presented reflect the reality of Mexico in relation to BF, making it urgent to take immediate action to improve the quality of nutritional care related to the promotion and orientation of BF at the PHC.

A scoping review and critical evaluation of the methodological quality of clinical practice guidelines on nutrition in the preconception

Introduction

Clinical practice guidelines (CPGs) contain recommendations for specific clinical circumstances, including maternal malnutrition. This study aimed to identify the CPGs that provide recommendations for preventing, diagnosing, and treating women's malnutrition. Additionally, we sought to assess the methodological quality using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

Methods

An online search for CPGs was performed, looking for those that contained lifestyle and nutritional recommendations to prevent, diagnose and treat malnutrition in women during the preconception period using PubMed and different websites. The reviewers utilized the AGREE II instrument to appraise the quality of the CPGs. We defined high-quality guidelines with a final score of > 70%.

Results

The titles and abstracts from 30 guidelines were screened for inclusion, of which 20 guidelines were fully reviewed for quality assessment. The overall quality assessment of CPGs was 73%, and only 55% reached a high-quality classification. The domains in the guidelines classified as high-quality had the highest scores in "Scope and Purpose" and "Clarity of Presentation" with a median of 98.5 and 93%, respectively.

Discussion

Further assessment is needed to improve the quality of the guidelines, which is an opportunity to strengthen them, especially in the domains with the lowest scores.

Association of pre-pregnancy body mass index and rate of weight gain during pregnancy with maternal indicators of cardiometabolic risk

BACKGROUND/OBJECTIVE

Changes in metabolism and extensive hemodynamic adjustments occur during normal pregnancy. The presence of maternal obesity imposes an overload to these physiological adaptations that may result in increased risk for the development of cardiometabolic complications during and after pregnancy. The aim of this study is to describe total cholesterol (TC), triglycerides (TG), glucose, and arterial blood pressure (BP) trajectories and to analyze the association of these cardiometabolic risk indicators during pregnancy with pre-pregnancy body mass index (pBMI) and monthly gestational weight gain (MGWG).

SUBJECTS/METHODS

A prospective cohort study of pregnant women was conducted in Mexico City. Monthly samples of blood were taken during clinical follow-up and biochemical and blood pressure were measured during each visit. Adjusted linear mixed-effect regression models were fit to describe the trajectories of these biomarkers during pregnancy and to analyze the association with pBMI and MGWG.

RESULTS

Seven hundred and twenty women were included of which 16.6% had pre-gestational obesity, 33.2% had pre-gestational overweight, 45.8% had normal pBMI and 4.4% had pre-gestational underweight. Women with pre-gestational obesity had higher lipids concentrations in the beginning of pregnancy (TC: [Formula: see text] = 33.08, p = 0.010; TG: [Formula: see text] = 31.29, p = <0.001) but the concentrations increased less than in women with normal pBMI (TC: [Formula: see text] = -14.18, p = 0.001; TG: [Formula: see text] = -5.42, p < 0.001). By the end of pregnancy, women with pre-gestational obesity had lower concentrations of lipids than women with normal pBMI. By contrast, women with pre-gestational obesity had higher glucose concentrations and higher BP levels than women with normal pBMI over pregnancy.

CONCLUSIONS

pBMI is differentially associated with longitudinal trajectories of maternal biochemical markers of cardiometabolic risk. MGWG did not significantly affect the biochemical indicators or BP trajectories. Our results suggest that pBMI is more relevant to predicting adverse cardiometabolic markers trajectories during pregnancy than MGWG.

Incidence of low birth weight in Mexico: A descriptive retrospective study from 2008-2017

According to the WHO, low birth weight (LBW) affects 15-20% of newborns worldwide. In Mexico, there are no national, state, nor municipal estimates that inform the country's situation over time. The purpose of this study was to estimate the incidence of LBW at the national, state, and municipal levels from 2008 to 2017, and to estimate the LBW incidence based on maternal sociodemographic characteristics, prenatal care and marginalization indexes at the national level using open national data. We used spatial data analysis to georeferenced LBW incidence at the three levels of geographical disaggregation studied. At the national level, the incidence of LBW increased progressively from 6.2% (2008) to 7.1% (2017), and the country's capital represented the area with the highest incidence. Southeastern and central states reported the highest LBW regional incidence. At the municipal level, the number of municipalities with an incidence of LBW ≥8% increased in both male and female newborns. The incidence of LBW was higher as the marginalization indexes increases. The results from this study may assist in the identification of vulnerable groups and the development of public health programs and policies with an intersectoral approach that improves maternal and child nutrition.

Breastfeeding at the workplace: a systematic review of interventions to improve workplace environments to facilitate breastfeeding among working women

Background

Breastfeeding can be affected by maternal employment. This is important considering that in 2019, 47.1% of women globally participated in the labor force. The aim of this study was to review workplace interventions to promote, protect and support breastfeeding practices among working mothers globally.

Methods

A systematic review was conducted following the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Observational, experimental and qualitative peer-reviewed studies in English and Spanish, published between 2008 and 2019 were included. The review focused on working women who were pregnant, breastfeeding or who recently had a child, and women’s working environments. The outcomes of interest included breastfeeding intentions, initiation, exclusivity and duration, confidence in breastfeeding or breastmilk extraction, and perceived support at workplace. Quality was assessed according to National Institute for Health and Care Excellence (NICE) checklist for systematic reviews. It was registered on PROSPERO (#140624).

Results

Data was extracted from 28 quantitative and 9 qualitative studies. The most common interventions were designated spaces for breastfeeding or breastmilk extraction (n = 24), and the support from co-workers (n = 20). The least common interventions were providing breast pumps (n = 4) and giving mothers the flexibility to work from home (n = 3). Studies explored how interventions affected different breastfeeding outcomes including breastfeeding duration, breastfeeding exclusivity, confidence in breastmilk expression, and breastfeeding support. The evidence suggests that workplace interventions help increase the duration of breastfeeding and prevent early introduction of breastmilk substitutes. Having a lactation space, breastmilk extraction breaks, and organizational policies are key strategies. However, to achieve equitable working conditions for breastfeeding mothers, organizational and interpersonal changes need to occur as well.

Conclusions

The systematic review revealed that interventions at the workplace are important in protecting, promoting and supporting breastfeeding among working mothers. To achieve equitable work environments and fair nutritional opportunities for infants of working mothers, interventions should focus at the three ecological layers – individual, interpersonal, and organizational. The quality of studies can be improved. There is a need for studies assessing impacts of workplace interventions on infant feeding practices, mothers’ self-esteem and outcomes such productivity and abstentionism.

[Scope of Mendelian randomization to control for unobserved confounding in epidemiology]

The Mendelian randomization is an epidemiologic method proposed to control for spurious associations in observational studies. These associations are commonly caused by confusion derived from social, environmental, and behavioral factors, which can be difficult to measure. Mendelian randomization is based on the selection of genetic variants that are used as instrumental variables that influence exposure patterns or are associated with an intermediate phenotype of the disease. The present work aims to discuss how to select the appropriate genetic variants as instrumental variables and to present methodological tools to deal with the limitations of this epidemiological method. The use of instrumental variables for modifiable exposures has the potential to mitigate the effects of common limitations, such as confusion, when robust genetic variants are chosen as instrumental variables.

Simultaneous evaluation of metabolomic and inflammatory biomarkers in children with different body mass index (BMI) and waist-to-height ratio (WHtR)

Metabolic disturbances and systemic pro-inflammatory changes have been reported in children with obesity. However, it is unclear the time-sequence of metabolic or inflammatory modifications during children obesity evolution. Our study aimed to quantify simultaneously metabolomic and inflammatory biomarkers in serum from children with different levels of adiposity. For this purpose, a cross-sectional study was used to perform targeted metabolomics and inflammatory cytokines measurements. Serum samples from children between six to ten years old were analyzed using either body mass index (BMI) or waist-to-height ratio (WHtR) classifications. One hundred and sixty-eight school-aged children were included. BMI classification in children with overweight or obesity showed altered concentrations of glucose and amino acids (glycine and tyrosine). Children classified by WHtR exhibited imbalances in amino acids (glycine, valine, and tyrosine) and lipids (triacyl glycerides and low-density lipoprotein) compared to control group. No differences in systemic inflammation biomarkers or in the prevalence of other results were found in these children. Abnormal arterial blood pressure was found in 32% of children with increased adiposity. In conclusion, obesity in school-aged children is characterized by significant metabolic modifications that are not accompanied by major disturbances in circulating concentrations of inflammatory biomarkers.

An intervention to promote physical activity in Mexican elementary school students: building public policy to prevent noncommunicable diseases

Physical activity is an important component of strategies for health promotion and prevention of noncommunicable diseases. It is also associated with decreased risk for cardiovascular disease in overweight and obese adults and children. This article addresses the initial description of a physical activity intervention for children attending public elementary schools in Mexico. The objective was to develop a replicable model based on a strategic public, private, academic, and social partnership that would have a short-term impact on the metabolic health of children and be useful for building effective public policy. Forty-nine schools (20 000 students) participated, and 5 schools were selected for evaluation. The intervention included a 30-minute supervised middle-effort interchangeable routine, 5 days a week for a complete school year, adapted for different school conditions and students of different ages. Evaluation included anthropometric measurements and biochemical markers. Actual prevalence of combined overweight and obesity in these children was 31.9%. The intervention was successfully implemented in all schools. No change in body mass index, waist circumference, or other anthropometric indicators was found. However, changes in biochemical markers showed a significant decrease in blood glucose, total cholesterol, and cholesterol-low-density lipoproteins, reflecting a positive effect on cardiovascular health indicators.