Women and Health Learning Package Developed by The Network: TUFH Women and Health Taskforce Second edition, September 2006 docx

Women and Health Learning Package: Nutrition and Women’s Health
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NUTRITION AND WOMEN’S HEALTH


Women and Health Learning Package
Developed by The Network: TUFH Women and Health Taskforce
Second edition, September 2006


Support for the production of the Women and Health Learning Package (WHLP) has been provided
by The Network: Towards Unity for Health (The Network: TUFH), Global Health through Education,
Training and Service (GHETS), and the Global Knowledge Partnership. Copies of this and other
WHLP modules and related materials are available on The Network: TUFH website at
or by contacting GHETS
by email at , or by fax at +1 (508) 448-8346.


About the authors

Pilar Torre Medina-Mora, MPH
Full Professor, Department of Health Care, Division of Biological and Health Sciences
Universidad Autónoma Metropolitana-Xochimilco
Mexico City, Mexico

Pilar Torre, a nutritionist, graduated from the Faculty of Nutrition, Ibero-American
University, Mexico, and holds a masters degree from the National Institute of Public Health,
Cuernavaca, Mexico. She began work at the Metropolitan Autonomous University,
Xochimilco Campus (UAM-X) in 1992, and has been a full professor since 2000. Before
entering the UAM, she worked at the Ministry of Health and at the National Institute of

Nutrition, Mexico. Her academic interests include infant and child nutrition, breastfeeding
practices, and women’s health and nutrition. She was the coordinator of the Research Unit on
Health and Society, and she teaches subjects related to infant and maternal health and
nutrition. She also collaborated in the design of a new curriculum proposal to train nutrition
professionals at the UAM-X. Pilar Torre served as an external advisor to UNICEF, from 1982
to 1986, and to the High Commissioner of United Nations for Refugees from 1989 to1992, in
the implementation of emergency programs for Guatemalan refugees in the south-eastern
region of Mexico. She collaborates with a Mexican NGO dedicated to the improvement of
the nutritional status of indigenous children and women, in the state of Chiapas, Mexico,
since 1994. She has been a member of The Network: TUFH Taskforce on Women and Health
since 2004. E-mail:


Deyanira González de León Aguirre, MD, MPH
Full Professor, Department of Health Care, Division of Biological and Health Sciences
Universidad Autónoma Metropolitana-Xochimilco
Mexico City, Mexico

Deyanira González de León graduated from the Faculty of Medicine, National Autonomous
University of Mexico, and holds a master’s degree from the Institute of Health Development,
Havana, Cuba. She began work at the Metropolitan Autonomous University, Xochimilco
Campus (UAM-X) in 1981, and has been a full professor since 1992. Her academic interests
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include health promotion and education, gender studies, and women’s sexual and
reproductive health. She was the coordinator of the Research Unit on Education and Health,
and is currently responsible for the project “Abortion Care in Mexico: Physicians’ Attitudes
towards Abortion”. She also conducted a project on women and medicine in Mexico, and has
collaborated in other research projects at the UAM-X. She teaches subjects related to

women’s sexual and reproductive health in both undergraduate and graduate university
programs, and collaborated in the design of a new curriculum proposal to train nutrition
professionals at the UAM-X. Deyanira González de León served as an external advisor from
2001-2002 to Ipas Mexico, a non-profit agency working to improve women’s lives by
focusing on reproductive health. She has been a member of The Network: TUFH Women and
Health Taskforce since 2002, and previously served on the Taskforce Management
Committee (2004-2005). E-mail: and


Fernando Mora Carrasco, MD, PhD
Full Professor, Department of Health Care, Division of Biological and Health Sciences
Universidad Autónoma Metropolitana-Xochimilco
Mexico City, Mexico

After studying medicine at the University of Chile and Microbiology at the University of
Illinois (1952-1962) Fernando Mora moved to Cuba, where he collaborated until 1969 in the
development of medical education and biomedical research. From 1969 until 1974 he was
professor at the Faculty of Medicine of the National Autonomous University of Mexico.
Since 1974 he has been a full professor at the Metropolitan Autonomous University,
Xochimilco Campus, where he has been Director of the Division of Biological and Health
Sciences and Coordinator of the Program in Medicine, among other responsibilities. He has
been an invited professor at the medical schools of Brown University and University of
California at San Francisco, in the USA, and the University of Helsinki, in Denmark. He has
collaborated with the WHO and PAHO as a temporary advisor on different aspects of health
sciences education, and helped in the creation of medical schools in Georgetown, Guyana,
and Managua, Nicaragua. He has participated in The Network: TUFH since its beginning in
1979, and with GHETS also from its conception in 2002. He has been chairman of the
Network: TUFH, and is currently vice-president of the GHETS Board of Directors. E-mail:
and
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NUTRITION AND WOMEN’S HEALTH

Global Overview

Today it is well recognised that in developing countries, women are one of the most
vulnerable population groups in terms of their health and nutritional status. Different
socioeconomic and cultural factors generate unfavourable nutritional outcomes for many
women, and this may in turn seriously affect their health and overall quality of life.

Women’s nutritional conditions differ widely among and within countries. Such conditions
are worst in the less-developed regions and countries of the world, where poverty, social
disparities, discrimination, and different kinds of malnutrition affect large populations. The
nutritional and health status of women may be severely impaired in societies where the
political and cultural context allows extreme conditions of subordination, as well as in those
countries where the threat of hunger persists because of political conflicts, migration,
environmental degradation, or natural disasters. On the other hand, not all women who live in
developing countries experience nutritional problems in the same way, and such problems do
not have the same impact on all women. Economic and social inequalities have a strong
correlation with the differences in the nutritional status among women in these countries.
Poor women in general, with limited or no access to nutritious food, education, employment
or adequate health care, are more vulnerable to nutritional deficiencies. In developed
countries, women in lower income groups may also be affected by nutritional deficiencies
because of economic disparities and lack of social protection.

During the last decades, global organizations and women’s rights advocates have called on
governments to recognise the multiple determinants of women’s health, and there has been a
growing consensus about the need to integrate and widen health services to respond to a
broad variety of problems affecting them. Nutrition is a fundamental pillar of women’s well-

being, and women’s right to full and equal access to health care, including adequate nutrition
during pregnancy and lactation, has been recognised at many international conferences,
including the 1979 Convention on the Elimination of All Forms of Discrimination against
Women, the 1987 International Conference on Safe Motherhood, the 1990 World Summit for
Children, the 1994 International Conference on Population and Development, the 1995
Fourth World Conference on Women, and the 2000 Millennium Goals Declaration, to name
just a few.

Experts have made recommendations to incorporate nutrition as an essential component of
primary health care, stressing that programs to deal with women’s nutritional problems must
be based on a life cycle approach. The nutritional needs of women substantially change
during the different stages of their lives. A life cycle approach allows a better recognition of
specific nutritional needs at every stage of women’s lives, as well as a more comprehensive
understanding of the cumulative effects of poor nutrition on women’s health.

In many countries, the nutritional deficiencies that affect thousands of women are still
neglected. Most of the strategies to respond to women’s nutritional needs—such as
micronutrient dietary supplementation programs, health education activities, and delivery of
medical services—have been mainly focused on pregnant and lactating women, giving little
or no attention to women in other moments of their lives.

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There is no doubt that the protection of women during pregnancy and lactation must be one
of the major priorities of health systems and social policies. The effect of women’s nutritional
status on pregnancy outcomes is particularly strong, and adequate maternal nutrition is
closely related to the survival and well-being of babies and children. However, not all women
are mothers, and their nutritional and health needs go far beyond motherhood and
reproduction.

Women of all ages in developing countries face elevated risks of nutritional deficiencies.
Therefore much more attention should be paid to the nutritional needs of girls, adolescents
and young women, in order to strengthen their overall health, protect them from the
cumulative effects of poor nutrition, and prevent problems later in life. In fact, the health
problems of many women in late adulthood and old age are mostly chronic and often
associated with previous nutritional deficiencies.

Research has suggested a link between nutritional deficiencies in early (including prenatal)
life, and the development of chronic diseases—cardiovascular disease, diabetes mellitus,
hypertension, stroke, cancer, and osteoporosis, among others—some decades later (World
Health Organization 2000a, 2000b; Jacoby 2004). A possible link between early nutritional
deficiencies and obesity has also been suggested, and it remains an area of ongoing research
(Pan American Health Organization 2003). These associations are especially relevant for
women, since they generally live longer than men, and therefore the complications and
disabilities that result from these kinds of diseases are much more common among elderly
women.

Undernutrition affects large populations of boys and girls in developing countries. Its major
determinant is poverty, which usually combines with other important factors like poor
breastfeeding practices and inadequate complementary foods for babies, as well as lack of
basic health care, safe water and sanitation. Globally, about 150 million children under five
years are undernourished, which comprises 27% of the world’s population in this age group.
Twelve million of these children die every year, and protein-energy malnutrition is
implicated in more than 55% of all these deaths. Undernourished children are much more
likely to get sick and die from common infectious diseases. Chronic protein-energy
malnutrition leads to growth retardation and stunting and may severely impair mental and
cognitive abilities. Undernutrition and a variety of micronutrient deficiencies—iron, calcium,
iodine, and vitamins A and D, for example—often start before birth and may continue
throughout life (United Nations Children’s Fund 1998; World Health Organization 2000a).

The impact of undernutrition on young girls has received special attention. In many parts of
the world, poverty often interacts with sociocultural factors that make girls and adult women
less favoured than men. Female infants and children commonly receive less medical care and
also less and lower-quality food than male children. In a number of countries in the
developing world, these discriminatory attitudes result not only in higher rates of protein-
energy malnutrition among girls but also in an excess of mortality among them (Gómez 1993;
United Nations Children’s Fund 1998, 1999).

Undernourished girls are likely to reach adolescence in disadvantaged physical conditions,
and this may in turn have severe implications for their overall health, in particular when they
experience early pregnancies. Stunted and/or anaemic adolescent mothers are more likely to
have complications during childbirth and the postpartum period, as well as to give birth to
premature and low-weight babies. Closely-spaced pregnancies and repeated childbearing,
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along with heavy physical work, poor diets, discrimination and inadequate health care, may
severely undermine the nutritional status of many women, with consequences for both them
and for the health and nutrition of the next generation (World Health Organization 1997,
2000a; United Nations Population Fund 1997, 2000). Global data indicate that at the end of
the 20th century, an estimated 450 million adult women in developing countries were stunted
as a result of chronic protein-energy malnutrition during infancy and childhood (The World
Bank 1997).

Nutritional deficiencies during pregnancy usually lead to intrauterine growth retardation,
which is one of the main causes of foetal and infant undernutrition in developing countries.
Every year, 30 million newborns, or 23% of 126 million births per year, are affected by
intrauterine growth retardation; by contrast, in developed countries the rate is only about 2%
(World Health Organization 2000a). A significant proportion of infant mortality, in particular

within the first month of life, is also attributable to poor maternal health and nutrition during
pregnancy and the immediate postpartum period (United Nations Children’s Fund 1999).

Specific micronutrient deficiencies may affect maternal and foetal health. Iodine deficiency
during pregnancy may cause foetal brain damage and mental retardation in infants. Vitamin
A deficiency increases the risk in pregnant women of infection and anaemia, may cause
blindness during pregnancy and early lactation, and has been associated to an elevated risk of
HIV mother-to-child transmission. Folate deficiency may cause severe foetal neural tube
defects like anencephaly and spina bifida. Iron deficiency weakens the maternal body,
impairs intrauterine growth and increases the risk of both maternal and foetal morbidity and
mortality (World Health Organization 2000a).

Anaemia is one of the most common nutritional problems affecting women in developing
countries, where iron deficiency usually combines with other micronutrient deficiencies such
as folate and vitamin B. In addition, the diet of the poorest populations is often monotonous
and mainly based on staple foods, which are low in iron and contain absorption inhibitors.
Other important factors involved in the occurrence of anaemia include malaria and
hookworm infestations, chronic infections such as HIV, and congenital conditions like sickle
cell disease, among others. Available data indicate that in developing countries the
prevalence rates of anaemia among women of reproductive age are extremely elevated (see
table 1). In pregnant women the rates vary from 40-60%, and among other women from 20-
40%. In developed countries, many women are also affected by anaemia, but the prevalence
rates are lower (World Health Organization 1992, 2000a; Rush 2000).

The poor nutritional status of women in developing countries has been associated with
maternal mortality. Maternal deaths do not result from malnutrition alone, however, but
mainly from a lack of access to obstetric care and from previous conditions that may be
aggravated by poor nutrition. For example, maternal deaths caused by obstructed labour are
more common in malnourished adolescents and young women with a short stature and small
pelvic size; and deaths resulting from haemorrhage during childbirth and the immediate

postpartum period may be associated with severe anaemia (Rush 2000).

Obesity and overweight are also among the most relevant nutritional problems of women
worldwide. The obesity epidemic has rapidly been increasing around the world over recent
decades, affecting virtually all social and age groups in both developed and developing
countries. An estimated 200 million adults worldwide were obese in 1995, a number which
had risen to 300 million by 2000. In addition, more than 17 million children under five years
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were overweight (World Health Organization 2000a, 2000b). Child obesity is associated with
many health problems, and it has been observed that the most important long-term
consequence of childhood and adolescent obesity is its persistence into adulthood (Pan
American Health Organization 2003).

In a number of developing countries, obesity currently affects all income groups of adult men
and women, but it is rapidly increasing among poor urban populations. The increase in
obesity in these countries is attributed to the conjunction of complex societal factors, such as
urbanization, economic growth and modernization, globalisation of food markets, and
changes in diet and physical activity patterns. In many cities of the developing world, diet has
become higher in fats, refined sugars and processed foods, and the consumption of relatively
cheaper but higher-calorie, lower-nutrient foods has been progressively adopted by poor
populations. These changes in diet patterns combine with a more sedentary life and a marked
decreased of physical activity among urban populations (Pan American Health Organization
2003; Jacoby 2004).

Obesity is a chronic disease, and its consequences include an elevated risk of premature death
and a variety of serious health problems such as heart disease, hypertension and stroke,
diabetes, cancer, osteoarthritis, and accidents, among others (World Health Organization
1997, 2000a). An estimated 35 million deaths from chronic diseases were expected to occur

worldwide in 2005, with 80% of them in low-income and middle-income developing
countries. Along with tobacco smoking and physical inactivity, obesity is responsible for
many of these deaths among adults aged 30-69 years (Strong et al. 2005). Obesity is also
associated with nonfatal but debilitating conditions like sleep apnoea, low back pain, skin
diseases, and infertility, which reduce the overall quality of life in overweight and obese
persons and are often the primary reason for consultation with health services (World Health
Organization 1997, 2000a). In addition, obesity may seriously impair mental health by
causing anxiety, depression or eating disorders; obese persons are often stigmatised as weak-
willed, lazy and unhygienic in their personal habits, because of generalised negative attitudes
towards obesity and dominant perceptions about body image (Pan American Health
Organization 2003).

Surveys from both developed and developing countries have shown that obesity rates are in
general higher in women, although overweight is more frequent in men (see table 2). Obesity
presents a major risk for the health and well-being of women. Currently, all health
consequences of obesity described above affect many women in both developed and
developing countries, but obesity may also have specific negative effects on reproductive
health.

It has been documented, for example, that high maternal pre-pregnancy weight and excessive
weight gain during pregnancy are often associated with adverse pregnancy outcomes,
including greater risks of gestational diabetes, childbirth complications, caesarean sections,
hypertension and pre-eclampsia, and post-partum obesity. Women with severe (morbid)
obesity are more likely to experience even poorer outcomes such as stillbirths or neonatal
deaths. Studies have shown that obesity is frequently associated with hormonal and menstrual
disorders, as well as with polycystic ovary syndrome, infertility, and higher risks of
endometrial, ovarian, cervical, and breast cancer. It has also been reported that obesity may
reduce the effectiveness of some hormonal contraceptives, and implies technical difficulties
for inserting intrauterine devices and for performing surgical sterilisation or abortions (World
Health Organization 1997; Lederman 2001; Grims & Shields 2005).

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In many countries, professional education for physicians and nurses has little emphasis on
nutrition. It is common that when nutritional topics are presented to students the problems
and solutions show serious restrictions. In the particular case of women, curricular contents
are usually selected from a narrow perspective about their health and nutritional needs.
Currently, the nutritional problems affecting women in the developing world present
important challenges for health systems and social policies and should receive more attention
in university programs.


Regional Overview: Mexico

The current nutritional and health profiles of the Mexican population reflect notable failures
in the field of social policies. Protein-energy malnutrition and infectious diseases are still
relevant public health matters among poor rural and urban populations, and they remain
common causes of death during infancy and childhood, and even later in life. By contrast,
overweight and obesity affect a large proportion of the adult urban population and are rapidly
increasing among young children and lower income groups; over the last decades, the high
prevalence rates of obesity have been a major factor in the increase of chronic diseases,
which today constitute the leading causes of general mortality in the country.

A general profile of the Mexican population is presented in Table 3. It is important to note
that the information contained in this table, as well as in this section, may not give an
adequate overview of the social reality prevailing in the country, since average data cannot
reflect extensive social inequalities and a wide dispersion of income and ethnicity.

Available information shows that the nutritional status of Mexican women differs widely

within the country, according to geographical regions, urban and rural areas, and income
groups. Nutritional deficiencies, anaemia and stunting, for example, are more common in
poor women who live in the less-developed regions of the country, in rural and indigenous
communities or in marginal urban areas. On the other hand, overweight and obesity currently
affect women of all income groups, but rates are higher in the more economically advanced
regions and big cities. Available information also shows that women’s nutritional needs seem
to remain far too low on the national agenda of health priorities.

The prevalence rates of anaemia among pregnant and nonpregnant women increased between
1988 and 1999 (table 4). In 1999, an estimated 21% of all women aged 12-49 were anaemic
(27.8% of pregnant women and 20.8% for nonpregnant women). Among all nonpregnant
women, the rate of anaemia was higher (about 25%) in indigenous minorities. (Shamah et al.
2003). As a result of the cumulative effects of undernutrition, many adult women had short
statures, with an average height of 1.52m for those in reproductive age. Specific
micronutrient deficiencies affected many women; 40% of nonpregnant women had iron and
vitamin C deficiencies, and 5% were deficient in vitamin A and folate (Rivera & Sepúlveda
2003).

According to information about the nutritional status of children under five years, collected in
1999 at the national level, the percentages of boys and girls affected by undernutrition were
very similar. For example, 8% of boys and 7% of girls had low weight according to their age,
and the prevalence of stunting was of 18% and 17%, respectively (Instituto Nacional de
Salud Pública 2001). Mortality statistics indicate that deaths attributed to protein-energy
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malnutrition and other nutritional deficiencies decreased between 1990 and 2003. However,
data presented in Table 5 show that the percentages of deaths because of this cause are
slightly higher in women during childhood, early adolescence and even old age (Instituto
Nacional de Estadística, Geografía e Informática 2003). In addition, protein-energy

malnutrition and nutritional anaemia were among the twenty primary causes of general
mortality in women in 2003 (Secretaría de Salud 2005).

Overweight and obesity among women have been dramatically increasing over the last
decades (Table 6). At the national level, more than 56% of women of reproductive age were
overweight or obese in 1999 (Rivera and Sepúlveda 2003). In Mexico City, where more than
one fifth of the country’s total population is concentrated, the prevalence rates of overweight
and obesity among low-income adults—both men and women—sharply increased within the
period 1995-2002 (table 7); more than 65% of women and 52% of men were overweight or
obese in 2002, and the prevalence rates of obesity were higher in women than men (Instituto
Nacional de Nutrición 1995, 2003).

Four diet-related chronic diseases—diabetes, heart disease, stroke and hypertension—were
the leading causes of general mortality among women in 2003, accounting for more than 36%
of total female deaths (Secretaría de Salud 2005). Breast cancer, which is strongly associated
with overweight and obesity, is also a frequent cause of death among Mexican women. This
kind of cancer has had a marked ascending trend during the last decades; an estimated 706
women died because of breast cancer in 1970, while in 2002 the number of annual deaths had
increased to 3860. On the other hand, diet-related chronic diseases are clearly associated with
premature deaths among women. In 2002, diabetes, breast cancer, stroke, and heart disease
accounted for more than one-fifth of the total deaths in women of reproductive age
(Secretaría de Salud 2004).

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APPENDIX

Table 1: Estimated prevalence of anaemia in women by region, around 1988*

Region


Pregnant
women
(%)

Non pregnant
women
(%)

All
women
(%)


World

51

35

37

Developing countries 56 43 44
Developed countries 18 12 13

Africa

52

42

44

Eastern 47 41 42
Middle 54 43 45
Northern 53 43 45
Southern 35 30 30
Western 56 47 48

Asia**

60

44

45

Eastern** 37 33 33
South-eastern 63 49 50
Southern 75 58 60
Western 50 36 38

Latin America

39

30

31

Caribbean 52 36 37
Central 42 39 39
South 37 25 26

Northern America

17

10

11

Europe

17

10

11

Oceania**

71

66

67

USSR***

15

12

12


Source: World Health Organization, 1992. The prevalence of anaemia in women: a tabulation of
available information. Geneva: WHO (WHO/MCH/MSM/92.2).
*Figures may not add up exactly to total due to rounding.
** Japan, Australia and New Zealand were excluded from the regional estimates but are
included in the total for developed countries.
*** Data collected before political changes. USSR: former Union of Soviet Socialist Republics.


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Table 2: Prevalence of obesity among women and men in selected countries, 1989-1996



Countries


Year

Age
(years)

Men
(%)

Women
(%)


Australia

1989

25-64

11.5

13.2

Bahrain

1992

20-65

6.5

11.2

Brazil

1989

25-64

6

13

Canada

1991

18-74

15

15

China

1992

20-45

1.2

1.6

Czech Republic

1988

20-65

16

20

England

1995

16-64

15

16.5

Finland

1993

20-75

14

11

Islamic Republic of Iran

1994

20-74

2.5

7.7

Japan

1993

20+

1.7

2.7

Netherlands

1995

20-59

8

8

New Zealand

1989

18-64

10

13

Peru*

1996

adults

13.8

26.5

Saudi Arabia

1993

15+

12

18

South Africa**

1990

15-64

8

44

Tanzania

1989

35-64

0.6

3.6

United States of America

1994

20-74

20.0

25.0

Source: World Health Organization, 1998. Obesity: preventing and managing the global
epidemic. Geneva: WHO. Pan American Health Organization, 2003. Obesity in the Americas: the
challenge to promote healthy nutrition and active living. Washington, DC: PAHO.
* Low socio-economic level.
** Black population, Cape Peninsula.

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Table 3: General profile of the Mexican population, around 2004


Total population (millions), 2004

Projected population 2050
Average population growth rate (%), 2000-2005
Urban population (%), 2003
Urban growth rate, 2000-2005
Total fertility rate, 2000-2005

Life expectancy of women, 2001
Life expectancy of men, 2001

Births per 1,000 women aged 15-19
Births with skilled attendants (%)

Contraceptive prevalence
All methods

Modern methods

Maternal mortality ratio per 100,000 live births
Infant mortality rate per 1,000 live births

Under-five years mortality
Boys
Girls

HIV prevalence rate (%, 15-49)
Men
Women

Primary enrolment (gross)
Males
Females
% of males and females reaching grade 5
Males
Females
Secondary enrolment (gross)
Males
Females
% of illiterate (aged 15 and over)
Males
Females

GNI per capita, 2002
Public health expenditures (% of GDP)
Primary education expenditures (% of GDP per capita)
Energy consumption (per capita)

% of population with access to safe water


104.9

140.2
1.5
76
1.8
2.50

76.4
70.4

64
86


67
58

83
28


50
40


0.3

0.2


111
110

90
91

73
78

7
11

US$8,540
2.7
11.8
1,532
88

Source: United Nations Population Fund, 2004. State of world population 2004.
The Cairo consensus at ten: Population, reproductive health and the global
effort to end poverty. New York: UNFPA.

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Table 4: Prevalence of anaemia among Mexican women of reproductive age (12-49
years), 1988 and 1999.

Description

1988
(%)

1999
(%)


Pregnant women

18.2

27.8

Non pregnant women

ND

20.8

All women

15.4

21.1

Source: Shamah, T. et al., 2003. Anemia en mujeres mexicanas: un problema de salud
pública. Salud Pública de México, Vol. 45, suplemento 4.


Table 5: Percentage of direct deaths attributed to protein-energy malnutrition and
other nutritional deficiencies, by sex and selected age groups, Mexico 2003



Age groups


Total
deaths (all
causes)

% of total
deaths due to
nutritional
deficiencies



Males

%


Females

%


0-12 months

33 355

2.2

2.3

2.2

1-4 years

6 700

5.0

4.4

5.7

5-14 years

6 957

2.1

1.7

2.4

65 years and over

224 068

2.8

2.6

3.0


Source: Instituto Nacional de Estadística, Geografía e Informática, 2003. Estadísticas de mortalidad.
México: INEGI.



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Table 6: Prevalence of overweight and obesity among Mexican women of reproductive
age (12-49 years), 1988 and 1999



Description

1988
(%)

1999
(%)


Overweight

24.0

35.2


Obesity

10.2

21.2


Overweight + Obesity

34.2


56.4


Source: Rivera, Juan; Sepúlveda, Jaime, 2003. Conclusiones de la Encuesta Nacional de Nutrición.

Salud Pública de México, Vol. 45, suplemento 4


Table 7: Nutritional status* among low income adult men and women in Mexico City,
1995 and 2002.


Men (%)

Women (%)




Nutritional Status

1995

2002

1995

2002


Underweight

5.5

4.5

7.3

2.1

Normal

48.6

43.5

36.6

31.7

Overweight

36.1

32.5

33.6

36.5

Obesity

9.8

19.5

22.5

29.7


* According to Body Mass Index (BMI).
Source: Instituto Nacional de la Nutrición, 1995. Encuesta Urbana de Alimentación en la Zona
Metropolitana de la Ciudad de México 1995. México: INNSZ. Instituto Nacional de Nutrición,
2003. Encuesta Urbana de Alimentación en la Zona Metropolitana de la Ciudad de México
2002. México: INCMNSZ.


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REFERENCES

Gómez, Elsa, 1993. Sex discrimination and excess female mortality in childhood. In: Gómez,
Elsa (editor): Gender, women and health in the Americas. Washington: Pan American Health
Organization, Scientific Publication 541, pp. 43-61.

Grimes, David; Shields, Wayne, 2005 (editorial). Family planning for obese women:
challenges and opportunities. Contraception, Vol. 72, pp. 1.4.

Instituto Nacional de la Nutrición, 1995. Encuesta Urbana de Alimentación en la Zona
Metropolitana de la Ciudad de México 1995. México: INNSZ.

Instituto Nacional de la Nutrición, 2003. Encuesta Urbana de Alimentación en la Zona

Metropolitana de la Ciudad de México 2002. México: INCMNSZ.

Instituto Nacional de Estadística, Geografía e Informática, 2003. Estadísticas de mortalidad.
México: INEGI (www.inegi.gob.mx).

Instituto Nacional de Salud Pública, 2001. Encuesta Nacional de Nutrición 1999. Cuernavaca
(México): INSP.

Jacoby, Enrique, 2004. The obesity epidemic in the Americas: making healthy choices the
easiest choices. Pan American Journal of Public Health, Vol. 15, No. 4, pp. 278-284.

Lederman, Sally A., 2001. Pregnancy weight gain and postpartum loss: avoiding obesity
while optimizing the growth and development of the fetus. Journal of the American Medical
Women’s Association, Vol. 56, No. 2, pp. 53-58.

Pan American Health Organization, 2003. Obesity in the Americas: the challenge to promote
healthy nutrition and active living. 132nd Session of the Executive Committee. Washington,
DC: PAHO (CE132/21).

Rivera, Juan; Sepúlveda, Jaime, 2003. Conclusiones de la Encuesta Nacional de Nutrición.
Salud Pública de México, Vol. 45, suplemento 4.

Rush, David, 2000. Nutrition and maternal mortality in the developing world. American
Journal of Clinical Nutrition, Vol. 72, No. 1 (Supplement), pp.212-240.

Secretaría de Salud, 2004. Estadísticas de mortalidad relacionada con la salud reproductiva.
México 2002. Salud Pública de México, Vol. 46, no. 1, pp. 75-84.

Secretaría de Salud, 2005. Estadísticas de mortalidad en México: muertes registradas en el
año 2003. Salud Pública de México, Vol. 47, no. 2, pp. 171-187.

Shamah, Teresa; Villalpando, Salvador; Rivera, Juan; Mejía, Faviola; Camacho, Martha;
Monterrubio, Eric, 2003. Anemia en mujeres mexicanas: un problema de salud pública. Salud
Pública de México, Vol. 45, suplemento 4.

Women and Health Learning Package: Nutrition and Women’s Health
www.the-network.tufh.org
15
Strong, Kathleen; Mathers, Colin; Leeder, Stephen; Beaglehole, Robert, 2005. preventing
chronic diseases: how many lives can we save? The Lancet, published online October 5, 2005
(DOI:10.1016/50140-6736(05)67341-2).

The World Bank, 1997. A new agenda for women’s health and nutrition. Washington, DC:
The International Bank for Reconstruction and Development / The World Bank.

United Nations Children’s Fund, 1998. The state of of world’s children 1998. Nutrition. New
York: UNICEF / Oxford University Press.

United Nations Children’s Fund, 1999. Human rights for children and women; how UNICEF
helps make them a reality. New York: UNICEF.

United Nations Population Fund, 1997. State of world population 1997. The right to choose:
reproductive rights and reproductive health. New York: UNFPA.

United Nations Population Fund, 2000. Women’s empowerment and reproductive health.
Links throughout the life cycle. New York: UNFPA / Pacific Institute for Women’s Health.

World Health Organization, 1992. The prevalence of anemia in women: a tabulation of
available information. Geneva: WHO (WHO/MCH/MSM/92.2).

World Health Organization, 1997. Food aid for health and development. Geneva:
WHO/FSF/FAP/97.2

World Health Organization, 1998. Obesity: preventing and managing the global epidemic.
Geneva: WHO / NUT / NCD / 98.1.

World Health Organization, 2000a. Nutrition for health and development. A global agenda
for combating malnutrition. Geneva: WHO/NHD/00.6.

World Health Organization, 2000b. Turning the tide of malnutrition. Responding to the
challenge of the 21st century. Geneva: WHO/NHD/00.7


Women and Health Learning Package: Nutrition and Women’s Health
www.the-network.tufh.org
16
SUGGESTED READING

Blocker, Deborah, Freudenberg, Nicholas, 2001. Developing comprehensive approaches to
prevention and control of obesity among low-income, urban, African-American women.
Journal of the American Medical Women’s Association, Vol. 56, No. 2, pp. 59-64.

Burke, Anne; Shileds, Wayne, 2005 (editorial). Millennium development goals: slow
movement threatens women’s health in developing countries. Contraception, Vol. 72, pp.
247-49.

Huffman, Sandra; Baker, Jean; Shumann, Jill; Zehner, Elizabeth, 1998. The case for
promoting multiple vitamin / mineral supplements for women of reproductive age in
developing countries. Washington, DC: The Linkages Project.

Nestle, Marion, 2001. Nutrition and women’s health: the politics of dietary advice. Journal of
the American Medical Women’s Association, Vol. 56, No. 2, pp. 42-43.

Safe Motherhood Inter-Agency Group, 1997. The safe motherhood action agenda: priorities
for the next decade. New York: Family Care International.

Smith, Lisa C; Ramakrishan, Usha; Ndiaye, Aida; Hadad, Lawrence; Martorell, Reynaldo,
2003. The importance of women’s status for child nutrition in developing countries.
Washington, DC: International Food Policy Research Institute.

Teutsch, Carol, 2001. How can clinicians approach nutrition? Journal of the American
Medical Women’s Association, Vol. 56, No. 2, pp.75-76.

United Nations Population Fund, 2002. State of world population 2002. People, poverty and
possibilities: making development work for the poor. New York: UNFPA.

United Nations Population Fund, 2003. State of world population 2003. Investing in
adolescents’ health and rights. New York: UNFPA.

United Nations Population Fund, 2004. State of world population 2004. The Cairo Consensus
at ten: population, reproductive health and the global effort to end poverty. New York:
UNFPA.

World Health Organization, 2003. Obesity and overweight. Global strategy on diet, physical
activity and health. Geneva: WHO.



RECOMMENDED WEBSITES

American Medical Women’s Association


Association of Reproductive Health Professionals


Women and Health Learning Package: Nutrition and Women’s Health
www.the-network.tufh.org
17
Engender Health


Family Care International
http:/www.fci.org

International Centre for Research on Women


International Food Policy Research Institute
www.ifpri.org

International Planned Parenthood Federation
http:/ipph.org

International Women’s Health Coalition


National Association of Nurse Practitioners in Women’s Health

National Association of Social Workers


Pan American Health Organization


Population Council
http:/www.popcouncil.org

Safe Motherhood Initiative


The Linkages Project


The World Bank


United Nations Population Fund


Women Watch (United Nations)




Women and Health Learning Package: Nutrition and Women’s Health Case Study: Chiapas
www.the-network.tufh.org
Case Study: Nutrition and Reproductive Profile of Indigenous Women in Chiapas,
México

Introduction

We have taken this community case from our experience working in a Nutritional Assistance
Program, oriented to children and pregnant or lactating women, performed in 1994 in five
indigenous communities in Chiapas, México.

Data are from a group of 227 women with at least one child of five years or less, interviewed
in 1994. Since the general social and economic conditions have not changed much since then,
we believe that the information presented here is still in existence. Moreover, the conditions
of poverty, cultural isolation and political adversity observed have not substantially changed
for indigenous communities in the last centuries. Some of the data presented here has been
already published, and we have used selected items that are relevant or pertinent to the case
under discussion.

Location and background

The State of Chiapas is one of the poorest in Mexico, especially among indigenous groups,
which have high indexes of marginality and poverty. The region of the Lacandon forest,
tropical and humid, bordering Guatemala, is inhabited by Tzeltal and Tojolabal indigenous
groups, in small, disperse communities of less than 500 inhabitants each. The region is rich in
natural resources and biodiversity, contrasting with the poverty of its inhabitants.

In 1994, many of the indigenous peoples of Chiapas started an open and armed rebellion
against the state and national government—the Zapatista rebellion—and the resulting conflict
has worsened their living conditions, mainly affecting the health and nutritional status of the
population. This situation has called for intervention of what is called “civil society”, in order
to contain and perhaps improve this situation. In particular a strategy for nutritional assistance
was developed, focused in areas with high prevalence of maternal and infant malnutrition.
This program has collected information with different methods, but for the purpose of the

present case study the most important is in the form of a clinical record for each individual.

We present here the reproductive profile of indigenous women in the south of Mexico,
showing dynamic reproductive practices under conditions of extreme poverty and chronic
and transgenerational malnutrition, and compelled to perform continuous work. Since 1994,
forced relocation has created a group of internal refugees (that is, within the country and the
state limits) at the very limits of survival. We believe that from a humane perspective the
reality shown here could be useful for action in similar circumstances (nutritional
emergencies) elsewhere in the world.

Maternal Clinical Record (MCR)

The following variables were taken into account to describe the reproductive profile of
women:

1. Reproductive status at the time of the visit, with four categories:

a) Not pregnant, not lactating (NPNL)
Women and Health Learning Package: Nutrition and Women’s Health Case Study: Chiapas
www.the-network.tufh.org
b) Pregnant (P)
c) Lactating (L)
d) Pregnant and lactating (PL)

2. Total number of pregnancies, by age group and live births per woman.

3. Age of women at first birth, calculated by age of mother less the age of the eldest
child.

4. Rate of infant mortality: number of deceased of children of less than a year of age

among all live births of the 225 women, times 1,000.

5. Rate of child mortality: number of deaths of children of 5 years or less, among all live
births of the 225 women, times 1,000.

6. Intervals between deliveries, obtained from women with more than one child less than
five years of age. An average is constructed with the age differences of all the
children delivered. The time interval is expressed in months.

7. Duration of breastfeeding:

a) Age of child at weaning
b) Age of child if lactating at present

It is not possible to be absolutely sure of the data obtained, since there may be lapses in the
memories of individuals. But this imprecision can be minimized with proper training of
health personnel and by using, if available, cross-references to sustain the data presented by
the people. In any case, what is presented here does not attempt to replace national or
international data.

As Annex I we presented the structure of the MCR that we have used since 1994. We hope
that we have constructed a useful clinical and epidemiological instrument for health and
nutritional assistance of this population group.

Reproductive profile of indigenous women in Chiapas

Two hundred ninety-five women of reproductive age (15-49 years old) were studied in the
five communities. Out of these, 243 (82%) were either pregnant or had at least one child less
than five years old. The remaining 18% were either single or their children were older than 5
years. We present here data from 227 clinical records, mainly because they were completed.

Women and Health Learning Package: Nutrition and Women’s Health Case Study: Chiapas
www.the-network.tufh.org
Table 1: Distribution by age group
________________________________________________________________________
Age Number %
_________________________________________________________________________

20 years or less 50 22.0
21-30 95 41.9
>30 82 36.1
_________________________________________________________________________
Total 227 100.0




Table 2: Reproductive situation
______________________________________________________________________
Situation* Number %
_________________________________________________________________________

npnl 38 16.7
p 23 10.1
l 152 67.0
pl 14 6.2
Total 227 100.0
_____________________________________________________________________
*npnl: nonpregnant, nonlactating, p: pregnant, l: lactating, pl: pregnant and lactating.

Table 3: Selected data for reproductive profile, Chiapas, 1994
_________________________________________________________________________
Variable Average SD Min. Max.
_________________________________________________________________________

Age* 27.0 7.5 15 48
Age at first birth* 18.2 3.1 15 28
Time between deliveries 26.7 8.0 10 49
Breastfeeding duration** 17.5 7.5 0 42
Time lactating** 14.1 8.4 1 53
_________________________________________________________________________
* years and decimals
** months and decimals
Breastfeeding duration refers to women who have ended lactation
Time lactating refers to women still lactating

Women and Health Learning Package: Nutrition and Women’s Health Case Study: Chiapas
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Table 4: Deliveries
_________________________________________________________________________
Live births Number %
________________________________________________________________________

1 36 16.3
2 - 3 60 26.4
4 - 6 62 27.8
7 - 10 51 22.5
more than 10 16 7.0
_________________________________________________________________________

Total 225 100




Table 5: Deliveries by age
_________________________________________________________________________
Age, years Number Live births
_________________________________________________________________________

17 years or less 11 0.8
18-20 39 1.5
21-25 54 2.8
26-30 41 4.9
31-35 43 6.9
36 years or more 39 9.1
_________________________________________________________________________
Total 227 4.7



Table 6: Age at first birth
_________________________________________________________________________
Age (years) Number %
_________________________________________________________________________
Less than 17 36 27.8
17-20 118 52.0
21-25 43 18.9
Older than 25 3 1.3
_________________________________________________________________________

Total 227 100.0

Women and Health Learning Package: Nutrition and Women’s Health Case Study: Chiapas
www.the-network.tufh.org
Table 7: Age at weaning
_________________________________________________________________________
Age (months) Number %
_________________________________________________________________________
0 9 4.1
1-3 3 1.4
4-6 11 5.0
7-12 71 32.6
13-18 42 19.3
19-24 70 32.1
> 24 12 5.5
_________________________________________________________________________
Total 218 100.0



Table 8: Selected data for reproductive health: national data, indigenous communities
and the group of women from Chiapas, México, 1994
_________________________________________________________________________
Data National Indigenous communities Chiapas

_________________________________________________________________________

Live births
1
2.2 2.9 4.7

High-fertility women
2
15.3% 18.1% 55.5%
Deceased descendants/all births
3
4.7% 8.5% 12.0%
Infant mortality
4
1.3 57.9 94.7
Child mortality
5
36.9 — 117.1
1) Average of live births per woman
2) Percentage of women with 5 or more live births
3) Percentage of deceased descendants over all live births
4) Deaths of children under 12 months of age over 1,000 live births
5) Deaths of children under 5 years of age over 1,000 live births


Table 9: Anthropometric variables of women in Chiapas (n =225)

Variable Mean SD Mín. Max.
Published
data
(Ref.*)
Age (years) 27,8 7,5 15.0 48,0 18
Weight (Kg) 49,4 6,7 35,0 80,0 56,9
Stature (cm) 146,7 5,5 121,0 161,0 160,6
BMI (Kg/m
2

) 22,9 2,7 16,0 34,7 22,1
MAC (cm) 25,0 2,4 19,4 35,2 24,5
* Ramos-Galván R. (1975).
8

Source: Encuesta nutricional en la zona de conflicto. Chiapas, 1994.


Women and Health Learning Package: Nutrition and Women’s Health Case Study: Chiapas
www.the-network.tufh.org
Table 10: BMI of women in Chiapas according to FAO classification


Nutritional status * Number %

Severe undernutrition 3 1.3
Moderate undernutrition 4 1,8
Normal thin 19 8.4
Normal 161 70.9
Overweight 40 17.6
Total 227 100
*FAO criteria classification of BMI, 1995:
Severe undernutrition less than 17.0
Moderate undernutrition 17.0-18.4
Normal thin 18.5-19.9
Normal 20.0-24.9
Overweight 25.0-29.9
Obesity 30.0 or more

Table 11: Anthropometric data and reproductive situation (mean and standard deviation)

Situation


Age
(years)
Weight
(kg)
Stature
(cm)
BMI
(kg/m
2
)
MAC
(cm)
n


npnl 34.8 (6.2) 50.4 (8.7) 147.4 (6.1) 23.1 (3.3) 26. 3 (3.0) 38
p 25.6 (6.4) 52.7 (6.3) 147.1 (5.3) 24.4 (2.9) 25.1 (2.3) 23
l 26.6 (7.1) 48.8 (6.2) 146.7 (5.3) 22.6 (2.5) 24.9 (2.2) 149
pl 26.1 (7.1) 48.6 (6.0) 145.3 (6.1) 23.0 (2.5) 23.8 (1.7) 17
Global 27.8 (7.5) 49.4 (6.7) 146.7 (5.5) 22.9 (2.7) 25.0 (2.4) 225
*npnl: nonpregnant, nonlactating, p: pregnant, l: lactating, pl: pregnant and lactating.
Source: Encuesta nutricional en la zona de conflicto. Chiapas, 1994

Women and Health Learning Package: Nutrition and Women’s Health Case Study: Chiapas
www.the-network.tufh.org
Questions for students

1. Analyze the reproductive profile of women included in the case scenario (including
their age at first birth; intervals between deliveries; total number of pregnancies, by
age group and live births per woman). What similarities do you observe between this
particular profile and the reality of women in those communities where you have
served as a student?

2. How do you evaluate the breastfeeding practices (duration of breastfeeding; age of
infant/child at weaning, and age of infant/child if lactating at present) presented in
the case? What connections do you find between recommendations of international
agencies and these breastfeeding practices?

3. How do socioeconomic inequalities affect the reproductive profile of women who
were included in the case?

4. How do gender-based inequities affect the nutritional status of girls and women who
live under conditions of extreme poverty? How do these inequities affect, for
example, women’s access to education, employment and health care?

5. What measures can be taken to improve the health and nutritional status of girls and
women who live under conditions of extreme poverty?

6. What role can health services play to improve women’s nutritional conditions during
pregnancy and lactation?

7. What resources and facilities are available in the communities you serve to assist

women in poor health and nutritional status?


Women and Health Learning Package: Nutrition and Women’s Health Case Study: Chiapas – Tutor’s Notes
www.the-network.tufh.org
Case Study: Chiapas – Tutor’s Notes

The community case study presented in this module is based on the experience of faculty
members training nutrition professionals at the Metropolitan Autonomous University,
Campus Xochimilco (UAM-X), in Mexico City, since 1982.

The case was designed to help students develop their analytical and problem-solving skills, as
well as to allow them to put the concepts presented during the workshop into use. This case
includes details of a community situation that students may face in practice.

The exercise must be carried out with students working together in small groups. The results
of each one of the small groups will be shared and discussed in a general session conducted
by one or more tutors. Students have to play an active role in presenting and discussing the
case, so tutors must intervene as little as possible in order to allow the students to take the
leading role in the general session. However, tutors must be sure to motivate quiet and shy
students to share their views and queries on the case.

Tutors should guide students to focus the discussion on the most relevant elements of the
case. Please keep in mind that the main objective of the session is to help students to
understand the underlying socio-economic and gender-based cultural issues involved in
women’s nutritional conditions.

Suggestions to the tutor(s) for the discussion of this case:

1. Identify the characteristics (data, categories, variables) that were used to describe the

reproductive and anthropometric profiles of women.

2. Analyze with the team the relevance of the maternal clinical record (MCR).

3. Analyze with the team the characteristics of the reproductive and anthropometric
profile of the women under study. Compare these data with that of other women
around the world.

4. Analyze how gender inequities and socio-economic inequalities influence women’s
social status, as well as their health and nutritional conditions.

5. Stress on the need for analyzing women’s health and nutritional conditions from a
life cycle approach.

6. Analyze the connections between women’s reproductive health and the nutritional
risks associated to pregnancy and lactation.

7. Discuss alternative ways to face and solve these kinds of problems, according to
social realities in different parts of the world.