Regional-level estimation of expected years of life lost attributable to overweight and obesity among Mexican adults

ORIGINAL ARTICLE

Regional-level estimation of expected years of life lost attributable to overweight and obesity among Mexican adults

Efrén Murillo-Zamora1, Raúl García-Ceballos2, Iván Delgado-Enciso3,4, Raquel Garza-Guajardo5, Oralia Barboza-Quintana5, Irám P. Rodríguez-Sánchez6 and Oliver Mendoza-Cano7,8*

1Unidad de Medicina Familiar No. 19, Instituto Mexicano del Seguro Social, Colima, México; 2Coordinación de Vigilancia Epidemiológica, Servicios de Salud del Estado de Colima, Colima, México; 3Facultad de Medicina, Universidad de Colima, Colima, México; 4Instituto Estatal de Cancerología, Servicios de Salud del Estado de Colima, Colima, México; 5Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario “José Eleuterio González”, Servicio de Anatomía Patológica y Citopatología, Monterrey, Nuevo León, México; 6 Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario “José Eleuterio González”, Departamento de Genética, Monterrey, Nuevo León, México; 7Facultad de Ingeniería Civil, Universidad de Colima, Colima, México; 8Center for Health and the Global Environment, Harvard T.H. Chan School of Public Health, Boston, MA, USA

Abstract

Background: Excess body weight has become a major public health problem worldwide, and the burden of overweight and obesity was calculated in this work from a health economics perspective.

Objective: To estimate the burden of disease attributable to overweight and obesity among males and females aged 20 years and older using years of life lost (YLL) and age-standardized YLL rates (ASYLL), and to rank the leading causes of premature death.

Design: A cross-sectional study took place (2010–2014) and 6,054 deaths were analyzed. Thirteen basic causes of death associated with overweight or obesity were included. The population attributable fraction (PAF), YLL, and ASYLL were calculated.

Results: The overall burden attributable to overweight and obesity was 36,087 YLL, and the estimated ASYLL per 10,000 persons was 1,098 and 1,029 in males and females, respectively. Type 2 diabetes mellitus was the main cause of premature death (males, 968 ASYLL; females, 772 ASYLL).

Conclusions: Overweight and obesity are major risk factors of chronic diseases that are main causes of premature death in the study population. Strategies for preventing overweight and obesity may decrease the incidence and mortality associated with these non-communicable diseases. ASYLL seems to be an indicator that is particularly well adapted to decision-making in public health.

Keywords: obesity; overweight; risk factor; mortality

Citation: Glob Health Action 2016, 9: 31642 - http://dx.doi.org/10.3402/gha.v9.31642

Responsible Editor: Peter Byass, Umeå University, Sweden.

Copyright: © 2016 Efrén Murillo-Zamora et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

Received: 16 March 2016; Revised: 7 July 2016; Accepted: 15 July 2016; Published: 6 September 2016

Competing interests and funding: All authors declare no conflict of interest.

*Correspondence to: Oliver Mendoza-Cano, Center for Health and the Global Environment, Harvard T.H. Chan School of Public Health, 401 Park Drive, 4th Floor West, Suite 415, PO Box 15677, Boston, MA 02215, USA, Email: omendoza@hsph.harvard.edu; Facultad de Ingeniería Civil, Universidad de Colima, Km. 9 Carretera Colima – Coquimatlán, Coquimatlán, CP 28400 Colima, México, Email: oliver@ucol.mx

Introduction

Overweight (body mass index, BMI, 25–29.9 kg/m2) and obesity (BMI ≥30 kg/m2) are public health problems because of the substantial burden they represent for health systems in terms of health care and related costs (1, 2). In Mexico, among adults aged 20 years and older, the prevalence of overweight and obesity is 32.4 and 38.8%, respectively (3, 4). Between 1988 and 2006, an average annual increase of 2% in the prevalence of individuals with BMI ≥30 has been documented in Mexican adults, and this increase is the highest recorded worldwide (5).

A high BMI is a major risk factor for type 2 diabetes mellitus, cardiovascular diseases, and other chronic non-communicable diseases associated with a high mortality and disability (2). The excess body weight is also associated with an increased risk of malignant tumors (6).

Worldwide, according to the Global Burden of Diseases (GBD) study, in 2010 exposure to overweight and obesity was estimated to cause 3.4 million deaths and 4% of overall years of life lost (YLL) (7). The GBD methodology has been used at country-level to obtain local measurements of interest (8). In our knowledge, there are not published studies regarding regional (i.e. at state-level) estimation of burden of disease attributable to overweight or obesity in Mexico. From a public health perspective, and in order to minimize the impact of overweight and obesity-related mortality through the implementation of health policies, the accurate measurement of the burden of disease is fundamental (8).

The age-standardized expected YLL rates (ASYLL) are a useful analytical tool to identify and prioritize causes of premature death (9). In comparison with potential YLL (PYLL), which result from the arithmetic subtraction of age at death to a determined cut-off (10), ASYLL incorporate strategies used in cost-effectiveness analysis and are particularly important from a public health perspective because they measure potentially preventable deaths (11). The state of Colima, located on the western coast of Mexico (Fig. 1), has demographic and epidemiological information systems that make viable the computing of ASYLL attributable to overweight and obesity.

Fig 1

Fig. 1.   Map of Mexico showing the location of Colima State.

The aim of this study was to estimate, by means of YLL and ASYLL, the burden of overweight and obesity among adults aged 20 years and older living in the state of Colima (Mexico). In addition, the leading causes of premature death were ranked and gender differences were evaluated.

Methods

Study design

A cross-sectional study took place from October 2015 to January 2016 using data from the Statistical and Epidemiological Death Registration System from the state of Colima. This surveillance system integrates data from issued death certificates, and its function is regulated by specific governmental normative lineaments (12). The events (deaths) that occurred between January 2010 and December 2014 were analyzed.

Study population

Individuals aged 20 years and older at death with a registered basic cause of death of interest were enrolled. Thirteen underlying causes of death (International Classification of Diseases – 10th revision, ICD-10) were included: type 2 diabetes mellitus (E11.0–E11.9), arterial hypertension (I10), congestive heart failure (I50.0–I50.9), pulmonary embolism (I26.0 and I26.9), acute myocardial infarction (I21.0–I21.9), and malignant tumors (breast among postmenopausal women, C50.0–C50.9; colorectal, C18.0–C18.9; endometrial, C54.0–C54.9; esophageal, C15.0–C15.9; renal, C64; ovarian, C56; pancreatic, C25.0–C25.9; prostatic, C61). Because increased body weight is inversely associated with breast cancer risk before menopause (13), only deaths secondary to malignant tumors from the breast among postmenopausal women were analyzed. Females aged 48.1 years and older at death were considered as postmenopausal according to the mean age of menopause among Mexican women (14).

Relative risks

In this study, the relative risks (RRs), sex-stratified, estimated by a previously published meta-analysis were used; this meta-analysis evaluated the association of overweight and obesity with the events of interest (15).

Statistical analysis

Next, we calculated the burden of disease attributable to overweight and obesity. First, the population attributable fraction (PAF) (16) was estimated for each event as a function of the corresponding RR, and the prevalence of exposure among Mexican adults (≥20 years old) residing in the state of Colima evidenced by the Health and Nutrition National Survey 2012 (males, overweight 37.0%, obesity 30.5%; females, overweight 29.4%, obesity 42.7%). The PAF quantifies the proportional reduction in mortality that would potentially be observed with risk factor (overweight or obesity) reduction. Second, total age and cause-specific YLL were estimated following the GBD (Global Burden of Diseases, Injuries, and Risk Factors Study) procedure (17); standard life expectancy by each interval () was obtained from the Tables of Life 2013 (Global Health Observatory) corresponding to Mexico (18). The arithmetic mean of age at death at each interval (nax) was calculated using the whole registers from the analyzed database. The next parameters were fixed: discount rate (r)=0.03, age-weighting (β)=0.04, adjustment constant for age weights (C)=0.1658, and age-weighting modulation (K)=0. Templates (Microsoft® Excel®) from the GBD study were used to compute the YLL, and the summary statistics were estimated using Stata® MP 13.0 (StataCorp LP). Finally, the ASYLL rates per 10,000 inhabitants were estimated using the World Standard Population (2000–2025) (19).

Ethical considerations

This study was approved by the Local Research and Ethics on Health Research Committee. Data regarding identification of individuals included in the study sample were omitted in order to preserve their anonymity.

Results

Underlying causes of death of interest were registered on death certificates from 13,960 individuals. Data from 6,054 participants, for which death was attributable to overweight or obesity, were analyzed. Table 1 shows the number of deaths attributable to overweight or obesity by sex and age interval. Female proportion in the study sample was 46.6% (n=2,824), and the mean age at death was 55.1±21.3 years in both males and females.


Table 1.  Population and study sample, Mexico 2010–2014
  Males Females
Age nNx nDx nax nNx nDx nax
20–24 29,487 59.5 18 22.3 30,583 54.4 2 22.0
25–29 25,994 54.6 24 27.2 27,142 49.9 3 27.2
30–34 24,590 49.8 30 32.4 25,931 45.4 12 32.2
35–39 23,868 45.0 58 37.6 24,995 41.0 16 37.5
40–44 20,101 40.2 82 42.0 21,331 36.7 42 42.3
45–49 17,505 35.5 114 47.8 18,307 32.3 85 47.7
50–54 15,247 31.0 184 52.3 15,670 28.1 152 52.5
55–59 11,581 26.6 272 57.6 11,720 24.0 171 57.5
60–64 8,939 22.5 327 62.5 9,416 20.2 246 62.5
65–69 6,765 18.7 367 67.6 7,041 16.6 307 67.6
70–74 4,918 15.1 393 72.4 5,321 13.4 367 72.7
75–79 3,375 11.9 399 77.6 3,601 10.6 333 77.5
80–84 2,050 9.1 320 82.0 2,515 8.3 305 82.0
≥85 2,176 6.8 642 90.1 2,611 6.3 783 90.3
Total 196,596   3,230   206,184   2,824  
Symbols and sources: nNx, population within each age group in the state of Colima, Mexico (Census of Population and Housing 2010, National Institute of Statistics and Geography); , standard life expectancy at each age interval (Tables of Life 2013: Mexico, Global Health Observatory); nDx, number of deaths secondary to specific causes of interest (Statistical and Epidemiological Death Registration System 2010–2014, Health Secretariat); nax, arithmetic mean of age at death by age interval (Statistical and Epidemiological Death Registration System 2010–2014, Health Secretariat).

The overall burden of disease attributable to overweight and obesity was 36,086.9 YLL (Table 2). Among males, the estimated YLL due to overweight and obesity were 6,756.4 and 11,259.3, respectively. The number of YLL, among females, attributable to overweight and obesity were 6,756.4 and 11,259.3, respectively. In age-stratified analyses, YLL rate per 10,000 persons was higher in males than in females (overweight, 345.3 vs. 308.2 per 10,000 persons; obesity, 571.0 vs. 568.2 per 10,000 persons).


Table 2.  YLL lost attributable to overweight and obesity and rate per 10,000 persons, Mexico 2010–2014
  Overweight Obesity Overall
Age YLL/rate YLL/rate YLL/rate
Males            
20–24 0.0 0.0 32.9 11.2 32.9 11.2
25–29 53.7 20.7 80.6 31.0 134.3 51.7
30–34 103.4 42.1 181.0 73.6 284.4 115.6
35–39 177.4 74.3 297.3 124.6 474.7 198.9
40–44 259.1 128.9 444.2 221.0 703.3 349.9
45–49 421.1 240.6 722.2 412.5 1,143.3 653.1
50–54 592.8 388.8 990.6 649.7 1,583.4 1,038.4
55–59 893.2 771.3 1,579.0 1,363.5 2,472.2 2,134.8
60–64 1,004.2 1,123.3 1,752.0 1,960.0 2,756.2 3,083.3
65–69 1,002.1 1,481.4 1,735.0 2,564.7 2,737.1 4,046.0
70–74 844.6 1,717.4 1,470.8 2,990.6 2,315.4 4,708.0
75–79 614.4 1,820.4 994.8 2,944.7 1,609.2 4,765.1
80–84 346.9 1,692.0 494.7 2,413.3 841.6 4,105.3
≥85 443.5 2,038.3 484.2 2,225.4 927.7 4,263.7
Total 6,756.4 345.3 11,259.3 571.0 18,015.7 916.3
Females            
20–24 0.0 0.0 26.8 8.8 26.8 8.8
25–29 0.0 0.0 25.9 9.5 25.9 9.5
30–34 49.6 19.1 99.2 38.2 148.8 57.4
35–39 55.0 22.0 92.8 37.1 147.8 59.1
40–44 181.7 85.2 366.4 171.7 548.1 256.9
45–49 315.4 172.3 647.1 353.5 962.5 525.8
50–54 558.4 356.4 975.0 622.3 1,533.4 978.7
55–59 661.4 564.4 1,167.4 996.0 1,828.8 1,560.4
60–64 922.7 980.0 1,577.8 1,675.6 2,500.5 2,655.6
65–69 947.9 1,346.3 1,675.7 2,379.9 2,623.6 3,726.2
70–74 912.1 1,714.1 1,686.5 3,169.5 2,598.6 4,883.6
75–79 655.9 1,821.5 1,188.2 3,299.8 1,844.1 5,121.3
80–84 470.2 1,869.5 862.5 3,429.3 1,332.7 5,298.7
≥85 625.0 2,393.8 1,324.6 5,073.2 1,949.6 7,467.0
Total 6,355.3 308.2 11,715.9 568.2 18,071.2 876.5
YLL, years of life lost.

The leading causes of premature death are presented in Table 3. Type 2 diabetes mellitus represented the main cause of premature death (968.0 and 771.7 ASYLL per 10,000 persons in males and females, respectively) followed by acute myocardial infarction (males, 53.3 ASYLL; females, 84.3 ASYLL) and arterial hypertension (males, 20.1 ASYLL; females, 77.6 ASYLL). The overall estimated burden secondary to malignant tumors was 27.1 ASYLL and 66.2 ASYLL in males and females, respectively. Colorectal cancer had the highest site-specific burden, mainly in females (15.9 vs. 11.9 ASYLL in males).


Table 3.  ASYLL by cause of death, Mexico 2010–2014
    YLL  
Event n % Ratea ASYLLb
Males        
1 Type 2 diabetes mellitus 15,815.3 87.8 804.5 968.0
2 Acute myocardial infarction 1,245.1 6.9 63.3 53.5
  All cancersc 443.1 2.5 22.5 27.1
3 Arterial hypertension 332.0 1.8 16.9 20.1
4 Colorectal cancer 186.8 1.0 9.5 11.9
5 Congestive heart failure 128.1 0.7 6.5 7.4
6 Prostatic cancer 103.4 0.6 5.3 6.4
7 Pancreatic cancer 94.0 0.5 4.8 6.1
8 Pulmonary embolism 52.1 0.3 2.7 3.1
9 Renal cancer 46.8 0.3 2.4 2.6
10 Esophageal cancer 12.1 0.1 0.6 0.8
  Total 18,015.7   916.3 1,098.4
Females          
1 Type 2 diabetes mellitus 13,302.2 73.6 645.2 771.7
2 Acute myocardial infarction 1,584.7 8.8 76.9 84.3
3 Arterial hypertension 1,481.0 8.2 71.8 77.6
  All cancersc 1,141.2 6.3 55.3 66.2
4 Congestive heart failure 419.7 2.3 20.4 21.9
5 Colorectal cancer 275.9 1.5 13.4 15.9
6 Endometrial cancer 183.6 1.0 8.9 10.9
7 Ovarian cancer 187.2 1.0 9.1 10.2
8 Breast cancer 173.4 1.0 8.4 9.9
9 Renal cancer 160.8 0.9 7.8 9.4
10 Pancreatic cancer 154.6 0.9 7.5 8.8
11 Pulmonary embolism 142.4 0.8 6.9 7.7
12 Esophageal cancer 5.7 0.03 0.3 0.2
  Total 18,071.2   876.5 1,028.5
YLL, years of life lost; ASYLL, age-standardized expected YLL.
aPer 10,000 inhabitants; bRates per 10,000 inhabitants were estimated using the World Standard Population (2000–2025); cIncludes breast cancer among postmenopausal women and colorectal, endometrial, esophageal, renal, ovarian, pancreatic, and prostatic cancer.

Discussion

Our findings suggest that, in the state of Colima (Mexico) from 2010 to 2014 and measuring 13 specific causes of death, the attributable burden of overweight and obesity was 18,015.7 and 18,071.2 YLL in adult males and females, respectively. The YLL for all deaths in the study period are 148,573.8 in males and 87,615.3 in females. The overall proportion of YLL attributable to the exposure to overweight and obesity is 12.1 and 20.6% in males and females, respectively. Therefore, among adults ≥20 years old, an average of 7,200 YLL may be prevented annually by the implementation of health policies focusing on the reduction of exposure to overweight and obesity.

Chronic degenerative diseases were the main cause of premature death; the aggregated mortality of type 2 diabetes mellitus (29,117.5 YLL), acute myocardial infarction (2,829.8 YLL), and arterial hypertension (1,813.0 YLL) represents more than 93% of total YLL from the study sample. Overweight and obesity are major risk factors for these diseases (15).

The World Health Organization (WHO) definition of premature death includes deaths under 70 years old (20). In this study, the standard life expectancy by age interval was used and enabled us to estimate the YLL and other parameters of interest among individuals aged 70 years and older at death.

Type 2 diabetes mellitus was the non-communicable disease with the highest burden; in both sexes, more than 70% of ASYLL were secondary to this metabolic disease. Similar findings were previously observed in other populations (8). Epidemic characteristics of type 2 diabetes mellitus have been observed in Mexico; according to the Health and Nutrition National Survey 2012, its prevalence among adults aged 20 years and older is 9.2%. The estimated prevalence in the state of Colima is 9.1 and 9.9% in males and females, respectively (21).

The burden of type 2 diabetes mellitus is increased by the substantial costs of medical attention of these patients. A recently published analysis evidenced that the annual cost per diabetic patient ranges from US$699 to US$748 (22). Direct costs of this chronic disease represent approximately 14% of total health spending (23) and, since 2000, diabetes mellitus is the leading cause of death in Mexico (13.8% of deaths) (5).

Worldwide, ischemic heart disease, as acute myocardial infarction, is the principal cause of death (24). However, deaths attributable to cardiovascular diseases may be underestimated by the use of ‘garbage’ codes in death certificates that do not correctly identify the main cause of death (25).

In addition to overweight and obesity, a high prevalence of other known cardiovascular risk factors such as tobacco use (31.9%) and hypercholesterolemia (13.8%) have been documented in the Mexican adult population (26); type 2 diabetes mellitus is also associated with an increased risk of cardiovascular diseases (27). Age-adjusted incidence of myocardial infarction in this population is 6.6 and 4.8 per 1,000 person-years (28).

A high proportion (31.5%) of Mexican adults have arterial hypertension and almost half of them (47.3%) are unaware of their disease (29). Only 56.8% of hypertension patients have a good control of blood pressure levels (<140/90 mmHg) (30).

Chronic non-communicable disease associated with overweight and obesity represents a major challenge for health systems. Body weight reduction reverses the excess risk of type 2 diabetes mellitus (31, 32) and cardiovascular diseases (33). The promotion of healthy lifestyles including a balanced diet, restricted caloric intake, and regular physical activity is priority in order to prevent these events (34). In addition, steady preventive actions at cluster and individual level are needed because frequent body weight fluctuations have been associated with an increased risk of chronic diseases and mortality rate (35, 36).

Despite the efforts in prevention, early detection, and opportune and accurate medical treatment, cancer morbidity and mortality have increased because of population aging and high prevalence of known major risk factors such as smoking and obesity (37). Malignant tumors are an important cause of premature death in adults residing in the state of Colima; in the study period, the overall burden estimate secondary to malignant neoplasms was 11,184.0 YLL. The excess risk fraction attributable to overweight and obesity was 14.2% (1,584.3 YLL).

Malignant neoplasms are among the top five causes of disease burden in Mexico, mainly secondary to tumors from breast, prostate, respiratory tract (trachea, bronchi and lung), gastrointestinal track (stomach and colorectal), and leukemia (38). Overweight and obesity are associated with increased risk of breast, prostate, and colorectal cancer and were analyzed in this study (3941).

Our findings suggest that, among malignant tumors, colorectal cancer has the highest burden. The attributable fraction of overweight and obesity was also high in males (52.5%) and females (31.2%). This finding correlates with a previously published study that documented an increasing incidence of colorectal cancer and related mortality among Mexican individuals (42).

In females, the overall burden of disease of postmenopausal breast cancer and ovarian cancer was the highest in the study period (ovarian, 187.2 YLL; breast, 173.4 YLL), but only 6.1 and 13.6% of risk excess were attributable to a high BMI. Therefore, research regarding modifiable risk factors such as physical activity is needed in order to reduce cancer-related mortality (4345).

Regarding malignant prostate tumors, the disease burden in the study period was 2,006.0 YLL, and 103.4 YLL (5.1%) were attributable to a high BMI. In Mexico, 80% of prostate malignant tumors are diagnosed in advanced clinical stages and have a poor prognosis (46).

The mechanisms of obesity-induced cancer risk increase are not completely understood (47). Recently, a role of increased levels of placental growth factor in obesity-induced tumor progression has been suggested (6). Targeting overweight and obesity may improve cancer prevention and outcomes after diagnosis (48). Therefore, a cancer burden reduction may be potentially observed.

YLL and years lived with disability (YLD), combined, inform disability-adjusted life-years (DALY). However, data regarding YLD are not collected systematically by the surveillance system (12). The computing of YLD is not useful for relatively small regions, and ASYLL represent a good analytical tool to measure the burden of disease (11).

Reliability of causes of death registered on death certificates is a fundamental aspect of this research. According to estimates, the Mexican system of death registration is one of the best worldwide in terms of quality and integrity of data (49). Concordance between the causes of death in medical death certificates issued in Mexico, when compared versus the gold standard, is 66.5% among adults. The accuracy of registered underlying cause of death in this age group is 0.780 (50).

Conclusion

Our findings provide quantitative evidence at regional level of burden of disease attributable to overweight and obesity among a Mexican adult population. Overweight and obesity are major and potentially modifiable risk factors for type 2 diabetes mellitus and cardiovascular diseases that are main causes of premature death in the study population.

This work exposes the attributable fraction of obesity. The number of healthy (disability-free) ASYLL is an alternative that could be developed and used by policymakers and health professionals to highlight the total risk of obesity. Computing disability-adjusted life-years needs more information than calculating YLL, because subjective decisions would be required to determine what constitutes a disability and to develop severity-of-disability ratings. However, the YLL metric provides a useful strategy to illustrate the most tangible cost of obesity and overweight.

Authors’ contributions

EM-Z designed the study, performed data collection and analysis, and wrote the manuscript. RG-C designed the study and performed data collection. ID-E performed data collection and analysis. RG-G performed data analysis. OB-Q analyzed data. IPR-S analyzed data. OM-C analyzed data and wrote the manuscript.

Paper context

The exposure to overweight and obesity is a major risk factor for non-communicable diseases associated with a high mortality among adult individuals. The contribution of both exposures to premature death, at regional-level, was quantified in this study. Strategies for preventing overweight and obesity may decrease the incidence and mortality associated with these diseases.

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About The Authors

Efrén Murillo-Zamora
http://www.imss.gob.mx
Mexican Institute of Social Security Department of Epidemiology
Mexico

Raúl García-Ceballos
http://www.saludcolima.gob.mx
State Health Ministry of Colima, México.
Mexico

 

 

Iván Delgado-Enciso
http://www.saludcolima.gob.mx
State Health Ministry of Colima, México.

Raquel Garza-Guajardo

Oralia Barboza-Quintana

Irám P. Rodríguez-Sánchez

Oliver Mendoza-Cano
http://www.chgeharvard.org
Center for Health and the Global Environment. Harvard TH Chan School of Public Health
United States

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