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Community and International Nutrition

A More Diversified Diet among Mexican Men May Also Be More Atherogenic^1,2

³ WHO Collaborating Centre on Nutrition Changes and Development, Department of Nutrition, Faculty of Medicine, Université de Montréal, Montreal, Canada and ⁴ Hospital General de Zona No.1, Instituto Mexicano del Seguro Social, Oaxaca, México

^* To whom correspondence should be addressed. E-mail: helene.delisle{at}umontreal.ca.

	ABSTRACT

TOP ABSTRACT Introduction Materials and Methods Results Discussion LITERATURE CITED

 
The objective of this study was to assess the nutritional quality of Mexican men's diet and its relation to socio-economic status (SES) and BMI. A random sample of 325 Mexican men, aged 35–65 y and stratified by SES and urban or rural residence, took part in the study. Two nonconsecutive 24-h dietary recalls were conducted in person. Dietary diversity was based on the consumption of 24 food groups. The micronutrient adequacy score that was used as a cut off was 75% of the U.S. RDA (Institute of Medicine) for 13 vitamins and minerals. A prevention score assessed subjects' adherence to 8 WHO dietary recommendations for the prevention of chronic diseases. Dietary diversity and micronutrient adequacy increased with SES status of urban subjects; these indices were also significantly higher among urban poor than among rural poor. In contrast, the prevention score tended to be higher among the poorer urban and rural respondents. Dietary diversity was significantly higher but the preventive score was significantly lower in obese subjects than in normal BMI subjects. There was a positive correlation between diet diversity and micronutrient adequacy (r = 0.34, P < 0.01), whereas dietary diversity and the prevention score were inversely correlated (r = –0.21, P < 0.01). The inverse association of dietary diversity and the prevention score was stronger in rural than in urban subjects. Dietary diversity was positively and significantly correlated with fruit and vegetable intake (r = 0.295, P < 0.001). It was, however, also positively correlated with the percent of energy from total and saturated fat, and cholesterol intake. Therefore, in some settings, higher food diversity may not predict a healthier diet from the standpoint of the prevention of chronic diseases.

	Introduction

TOP ABSTRACT Introduction Materials and Methods Results Discussion LITERATURE CITED

In 1960, the most common causes of death in Mexico were related to infection. However, in the last decade, the principal causes of death in the Mexican population were those related to noncommunicable chronic diseases (NCCD) such as cardiovascular disease (CVD),⁵ cancer, and diabetes (6). Concurrent changes in dietary patterns in Mexico are higher intakes of fat and refined carbohydrates (7,8). Recent research also indicates that overweight, obesity, and NCCD increase as socio-economic conditions improve in developing countries (9).

The importance of overall diet quality for health is well established. Indices based on nutrients (10), foods (11), and on both nutrients and foods (12,13) have been developed to evaluate diet quality. Dietary guidelines usually recommend increasing the diversity of foods across and within foods groups (14–16) to ensure micronutrient adequacy. Accordingly, dietary variety or diversity and various indices of micronutrient adequacy have been used to reflect dietary quality (17–20). Diet quality can also be assessed based on compliance with dietary guidelines or recommendations for health, such as those formulated by WHO for the prevention of diet-related chronic diseases (21,22). As suggested by Kim et al. (23), the assessment of diet quality in populations at different stages of nutrition transition is an important source of information for dietary issues related to that transition.

The purpose of this study was to examine the relation between socio-economic and anthropometric status of Mexican men and the nutritional quality of their diet. We used 3 diet-quality indices: dietary diversity, micronutrient adequacy, and adherence to WHO recommendations for the prevention of CVD. Our hypothesis was that urban subjects enjoying a higher socio-economic status (SES) would have a more diversified and adequate diet but also a more atherogenic diet, whereas the rural group would have a low-diversity diet and possibly micronutrient inadequacies.

	Materials and Methods

TOP ABSTRACT Introduction Materials and Methods Results Discussion LITERATURE CITED

 
Subjects and study design

As part of a larger research project on nutrition transition and CVD risk, this cross-sectional study was conducted in Oaxaca, one of the poorer states of Mexico with marked socio-economic disparities. A total of 325 Mexican men, 35–65 y of age and apparently in good health, were randomly selected after stratification for residential area (n = 76 in rural, n = 249 in urban poor, middle, or well-off neighborhoods). We included only men because they appear more susceptible to CVD and because of the confounding effect of menopause in women. The 35–65 y-old age range includes the age strata where CVD risks are increased. All subjects with a medical diagnosis of diabetes, hypertension, or CVD were excluded, as well as severely ill or incapacitated subjects, insofar as these conditions might modify lifestyle and therefore alter the results. Full-blood aboriginals were also excluded because they can have a higher genetic predisposition to the metabolic syndrome and diabetes (24). Studies also suggest that a lower resting metabolic rate can contribute to a higher risk of excess weight or obesity in Indians compared with non-Indians (25). Sample size was based on an estimated prevalence of 15% of the metabolic syndrome (26) and a precision of 4%, with a confidence level of 95%.

The rural area was comprised of 3 randomly selected towns in the central valley of Oaxaca with a population <2500 (27). Rich farm proprietors were excluded, so that overall, the whole rural group could be considered poor.

This study was approved by the Committee of Investigation and Ethics of the Oaxaca Delegation of the Mexican Institute of the Social Security (IMSS) and by the Hospital Center of the Université de Montréal (CHUM). After participants were given an explanation of the nature of the study, informed consent was obtained in writing.

Data collection

A questionnaire was administered, in person, to urban subjects to obtain demographic information and to confirm SES based on area of residence. A SES score was built and education level, occupational status, and type of health services were used as indicators. A score of 0 was given if the subject had no schooling, 1 if he had reached the primary level, 2 for the secondary level, 3 for achieving a technical education, and 4 for university level. For occupational status, 1 point was given for a manual job, 2 and 3 for a service and technical job, respectively, and 4 for a professional job (Table 1). Regarding health services, a 1-point score was given if the participant used the free public medical services, 2 if he used the employer's insurance program, and 3 if he used private health services. After summing the points, the 3 SES levels were confirmed in the urban sample: low for a score 3, middle for a score ranging between 4 and 8, and high for scores 9.

Dietary intakes were assessed from 2 nonconsecutive 24-h dietary recalls conducted by a trained research assistant. The interval between the first and the second 24-h recall was 14 d. Cups, spoons, plates, and glasses were used to help respondents estimate the size of servings. Nutrient intakes were computed using the food composition table for Mexico from the World Food Dietary Assessments Systems (29). The Table of Mexican Nutritional Values of Food (30) was used for food items not found in WorldFood. We calculated mean daily intakes of energy, macronutrients, and 13 micronutrients.

Diet quality scores

    Dietary diversity. In this study, 24 food groups were identified on the basis of local dietary habits and subjects' food consumption patterns (Supplemental Table 1). Dietary diversity was defined as the total number of different food groups consumed over the 2 food-recall days (20,31). Dietary diversity was divided into quartiles for analyses (scores 1–4).

    Micronutrient adequacy score. The micronutrient adequacy score was computed based on 75% of the U. S. recommended dietary allowances (RDA) (32–34) for the 13 micronutrients (Table 2). The selected micronutrients were those that could be in short supply or that showed high variability among socio-economic groups. For -tocopherol, values of the WorldFood table, given in tocopherol equivalents, were multiplied by 0.80 as recommended (32). If a subject met 75% of the dietary reference intake (DRI), 1 point was given, and 0 if he did not, for a possible maximum score of 13.

Nutrient intake data were adjusted for the day of the dietary recall (week-day or weekend day), and for the time interval between the first and second recalls, to reduce the day-to-day within-person variation of intake (35), using SIDE software (Iowa State University, 2002). Urban subjects were compared according to SES level. The rural poor group was compared only with the poorer urban group. For continuous variables, differences between the urban poor and the rural poor were analyzed using Student's t test. Differences between urban SES groups and between BMI categories were analyzed using 1-way ANOVA with Bonferroni post-hoc test. The ² test was used to compare proportions of subjects. Pearson's correlation coefficient tested the relation among diet-quality indices according to SES and area of residence. The level of significance was set at P < 0.05 in all analyses. We used SPSS for Windows, version 11.0 (36) for data processing and analysis.

	Results

TOP ABSTRACT Introduction Materials and Methods Results Discussion LITERATURE CITED

 
    Subject characteristics. Age did not differ among urban SES groups (P = 0.81) or between urban and rural poor subjects (P = 0.50). The lower SES urban group had a higher proportion of subjects with manual work and limited formal education than the other urban groups (P < 0.001). In the rural group, nearly all subjects had a manual job and only 6.5% had reached secondary school (Table 1).

The proportion of overweight and obese subjects was 71.5% among urban subjects and this proportion did not differ due to SES (P = 0.18). The proportion of obese and overweight subjects was higher among urban poor (61.5%) than rural poor (46.1%, P = 0.01). Only 4 subjects were underweight (3 in the rural group) (Fig. 1A).

View larger version (23K): [in this window] [in a new window]   Figure 1  BMI (A), and dietary diversity score (B) in Mexican men according to SES and residence area, n = 68 (High SES urban), 118 (Middle SES urban), 63 (low SES urban), and 76 (rural poor). Underweight: BMI <18.5; normal weight: BMI 18.5–24.9; overweight: BMI: 25–29.9; obese: BMI 30. Dietary diversity quartile 1: 11 different food groups consumed; quartile 2: 12 food groups; quartile 3: 13–14 food groups; quartile 4: 15 food groups.

    Prevention score. Among urban subjects, compliance with the recommended level of consumption of fruits and vegetables was overall low (<40%), and there was a progressive decline from the urban rich to the urban poor (P = 0.02) and to the rural poor (P = 0.02). Less than 25% of the urban poor and <10% of the rural poor ate at least 400 grams of fruits and vegetables per day. Compliance was also low for the percentage of energy from total fat (<35%), saturated fat (55%), and polyunsaturated fat (<65%), and for cholesterol (<30%). There was no difference among the urban SES groups, except that compliance with the consumption of limited saturated fatty acids tended to be better in the lower SES group (P = 0.05). A higher proportion of rural than urban poor complied with the recommendation for total fat (58% vs. 40%; P = 0.03). The rural poor diets also tended to be more consistent than the urban poor diets with the cholesterol (P = 0.05) and sucrose recommendations (P = 0.08). Diets of nearly all subjects met the protein recommendation. Compliance for sucrose was >80% in all groups and that for fiber, >90% (Table 3).

    Quality of the diet according to SES, residence area, and BMI status. DDS decreased from the upper to the lower SES urban group and to the rural poor (P < 0.001). Micronutrient adequacy score showed the same pattern, although the only difference was between the urban and rural poor (P = 0.04). The rural group tended to have a more preventive diet than the urban poor (P = 0.06) (Table 4). Whereas micronutrient adequacy and DDSs increased from underweight (P < 0.001) to obese (P = 0.007), the prevention score was higher in normal weight than in obese subjects (P = 0.009) (Table 5). Total (P = 0.01) and saturated fat (P = 0.007) as a percentage of total energy intake increased with BMI, and so did cholesterol intake (P < 0.001) (data not shown). However, the variance of BMI explained by diet quality scores was low, ranging from 3% for the micronutrient adequacy score (P = 0.001), to 4% for the prevention score (P < 0.001), and 6% for the DDS (P < 0.001).

	Discussion

TOP ABSTRACT Introduction Materials and Methods Results Discussion LITERATURE CITED

Dietary diversity appears strongly related to household socio-economic characteristics (31,38) in both urban and rural areas (39). As income increases, people tend to diversify their diet so that dietary diversity may be a useful indicator of household food security (40). They increase their consumption of highly desirable foods that are primarily high in fat, cholesterol, and sugar, and low in fiber (8,41). This could explain the negative association found between dietary diversity and the prevention score: a more diversified diet was associated with a significantly higher percentage of total energy from fat and saturated fat and with a higher intake of cholesterol, particularly among rural poor subjects. Therefore, highly diversified diets were less in accordance with the recommendations for the prevention of chronic diseases. The negative association between diet diversity and the preventive score was stronger in rural than urban subjects, which suggests that rural people may be more vulnerable to the improvement of SES, as dietary diversification would mean a less healthy diet. Our results are similar to observations made in China (42), which showed that improvement of income leads to more detrimental effects on diet and body composition in the poorest groups.

We found a significantly higher rate of overweight and obesity in the upper SES urban group, who had a more diversified diet and tended to have a less preventive diet. Furthermore, overweight or obese subjects had a higher intake of total fat and saturated fat (as percentage of total energy), as well as a higher intake of cholesterol, compared with normal weight or underweight subjects. The low variance of BMI explained by diet quality, however, indicates that other determinants of obesity play an important role. The inverse relation between physical activity and obesity has been amply emphasized (43). Whereas physical activity was significantly higher in rural than urban subjects it did not vary significantly according to SES level in the city, however (unpublished data).

The prevention score included foods and nutrients related to CVD risk (44,45) as well as to the nutrition transition (46). The prevention score may therefore give an idea of the dietary transition stage, with declining values associated with urbanization and growing income. In developing countries such as Mexico, it appears that the last stage of dietary transition, that is, shifting to more prudent and therefore healthier diets is not attained as yet, at least in poorer states such as Oaxaca. The higher SES group did not have a more preventive diet than the other groups.

Kim et al. (23) developed a tool to compare diet quality across countries at different stages of nutrition transition, known as the Diet Quality Index-International (DQI-I), which includes dietary diversity, adequacy, moderation, and balance. Although we recognized the value of the DQI-I, we did not use it primarily because it is totally based on U.S. guidelines, and our aim was to design a more international instrument. For instance, in the DQI-I, dietary diversity is based on the 5 food groups of the U.S. food pyramid and on variety of protein sources, whereas we used 24 food groups based on the Mexican food culture. As a basis for the micronutrient adequacy score, we used the U.S. DRI because these are also used in Mexico, but we referred to the WHO recommendations to build the prevention score.

Dietary diversity is a key requirement for healthy diets (31) and, historically, it has referred to nutrient adequacy (47). In the realm of nutrition transition in developing countries, dietary quality also has to encompass prudence and moderation, with the limited consumption of fat, salt, and refined sugars (48). Our results showed that both dietary diversity and micronutrient adequacy increased with SES and BMI, as other studies have found (49,50). However, we observed that a more diversified diet may also be less healthy from the standpoint of CVD. We therefore conclude that the concept of diet quality has to take into account the epidemiological and nutritional context, and that dietary diversity cannot be equated with dietary quality, particularly in nutrition-transitioning populations.

	ACKNOWLEDGMENTS

 
The authors thank Nora Cruz Fernandez for assistance with dietary interviews and Marguerite Desaulniers for assistance with WorldFood management and data processing.

	FOOTNOTES

 
¹ Supported by TRANSNUT, WHO Collaborating Centre on Nutrition Changes and Development, Department of Nutrition, Université de Montréal, Canada, and Instituto Mexicano del Seguro Social, Oaxaca, Mexico.

² Supplemental Table 1 is available with the online posting of this paper at jn.nutrition.org.

⁵ Abbreviations used: CVD, cardiovascular diseases; DDS, dietary diversity score; DRI, dietary reference intake; SES, socio-economic status; RDA, recommended dietary allowances.

Manuscript received 12 May 2006. Initial review completed 13 June 2006. Revision accepted 14 August 2006.

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