Table S5. Risk factors considered in this analysis, their exposure variables, theoretical-minimum-risk exposure distributions, disease
outcomes, and data sources for relative risks and exposure.
TheoreticalSources for
Sources for
minimum-risk
Risk Factor
Exposure variable
Disease outcomes a
relative risks
exposure data
exposure
distribution
Childhood and maternal undernutrition
Childhood
and maternal
underweight
Iron
deficiency
anemia
Re-analysis of 10
cohort studies for
mortality to obtain
hazard in 1 SD
increments, and
systematic review
and new metaanalysis of
existing cohort
studies for
morbidity [1]
Systematic review
and new metaanalysis of cohort
studies [2]
Children <-1
standard deviation
weight-for-age
compared to the
international
reference group in 1
SD increments
Hemoglobin
concentrations
ENSANut 2006
Same proportion of
children below -1
standard deviation
weight-for-age as
the international
reference group
Mortality and acute
morbidity from
diarrhea; malaria;
pneumonia; selected
other communicable
diseases; long term
risks of under nutrition
ENSANut 2006
Hemoglobin
distributions that
reduce anemia
prevalence to
9.1%, based on
Mexican clinical
trials b
Anemia and its
sequelae (including
cognitive impairment);
maternal and perinatal
mortality as a result of
exposure among
pregnant women
1
Risk Factor
Sources for
relative risks
Exposure variable
Vitamin A
deficiency
Prevalence of low
serum retinol
concentrations
(<0.70 µmol/L)
Systematic review
among children 0-4
and meta-analysis
years and among
as well as repregnant women.
analysis of
Data were adjusted
randomized trials
for supplementation
for childhood and
in the Oportunidades
maternal outcomes
program using data
[3]
from a prospective
evaluation of the
program's
effectiveness.
Zinc
deficiency
Systematic review
and new metaanalysis as well as
re-analysis of
randomized trials
[4]
Prevalence of low
zinc serum
concentration (<65
mg/dL)
Sources for
exposure data
ENN 1999;
prevalence
adjusted by
estimates of
coverage in
supplementation
programs (e.g.
Oportunidades)
ENN 1999
Theoreticalminimum-risk
exposure
distribution
No vitamin A
deficiency
No zinc deficiency
Disease outcomes a
Mortality from
diarrhea; malaria;
miscellaneous
infectious causes of
disease (children < 5);
morbidity due to
malaria (children< 5);
maternal mortality
(pregnant women);
vitamin A deficiency
and its sequelae (all age
groups); maternal
morbidity, low birth
weight and other
perinatal conditions
Diarrhea; pneumonia;
malaria; adult and
pregnancy outcomes
2
Risk Factor
High blood
pressure
High blood
cholesterol
Sources for
relative risks
Meta-analysis of
61 cohort studies
with 1,000,000
North American
and European
participants [5]
Meta-analysis of
10 cohorts with
490,000 North
American and
European
participants, 29
cohorts with
350,000
participants from
the Asia Pacific
region, and 49
trials of
cholesterol
lowering [6]
Theoreticalminimum-risk
Exposure variable
exposure
distribution
Other nutrition-related risk factors and physical inactivity
Sources for
exposure data
Disease outcomes a
Usual level of
systolic blood
pressure
ENSANut 2006
Ischemic heart disease
(IHD); stroke;
hypertensive
disease; other
cardiovascular diseases;
renal failure
Usual level of total
blood cholesterol
ENSANut 2006
115 SD 6 mmHg
3.8 SD 0.6 mmol/l
IHD; stroke; other
cardiovascular diseases
3
Risk Factor
High blood
glucose
Overweight
and obesity
(high body
mass index)
Sources for
relative risks
Meta-analysis of
19 cohorts with
237,000
participants for
ischemic heart
disease and stroke;
Mexico burden of
disease estimates
for micro-vascular
outcomes [7]
Meta-analysis of
33 cohorts with
310,000
participants for
vascular risks, 27
cohorts for cancer
risks [8] and
review of one
cohort for diabetes
risks [9]
Exposure variable
Sources for
exposure data
Theoreticalminimum-risk
exposure
distribution
Disease outcomes a
Fasting blood
glucose
ENSA 2000; only
fasting sample
was used together
with statistical
methods to
account for the
sociodemographic
characteristics of
those who had
fasted
4.9 SD 0.3 mmol/l
IHD; stroke; diabetes
diseases and its microvascular sequelae
Body mass index
(BMI)
ENSANut 2006
21 SD 1 kg/m2
IHD; stroke;
hypertensive disease;
diabetes; osteoarthritis;
endometrial and colon
cancers; postmenopausal breast
cancer; gallbladder
cancer, kidney cancer,
breathlessness, back
pain, dermatitis,
menstrual disorders
and infertility,
gallstones,
psychological effects
4
Risk Factor
Sources for
relative risks
Low fruit and
vegetable
consumption
Systematic review
and new metaanalysis of
published cohort
studies [10]
Physical
inactivity
Systematic review
of published
literature and new
meta-analysis of
cohort studies [11]
Exposure variable
Sources for
exposure data
Theoreticalminimum-risk
exposure
distribution
Fruit and vegetable
intake per day
ENSANut 2006
600 SD 50 g intake
per day for adults
ENSANut 2006
3 or more days of
vigorous intensity
activity (minimum
1500 met-minutes
per week), or daily
physical activity of
any intensity
(minimum 3000
met-minutes per
week)
Three categories,
low, medium and
high levels of
physical activity
Disease outcomes a
IHD; stroke; colorectal
cancer; gastric cancer;
lung cancer; esophageal
cancer
IHD; breast cancer;
colon cancer; diabetes;
falls and osteoporosis,
osteoarthritis, lower
back pain, prostate and
rectal cancer
5
Risk Factor
Sources for
relative risks
Exposure variable
Sources for
exposure data
Theoreticalminimum-risk
exposure
distribution
Disease outcomes a
No unsafe sex
HIV/AIDS; sexually
transmitted infections
Sexual and reproductive health
Unsafe sex
By definition,
100% of STIs
other than
HIV/AIDS are
attributable to this
risk factor [12].
For HIV/AIDS,
National Registry
of HIV/AIDS
estimate of
attributable
fraction was used.
Sex with an infected
partner without any
measures to prevent
infection
N/A; PAF directly
from registries
Addictive substances
6
Risk Factor
Tobacco
smoking
Sources for
relative risks
Exposure variable
American Cancer
Society Cancer
Current levels of
Preventions Study, smoking impact ratio
Phase II, a
(indirect indicator of
prospective study
accumulated
of risk factors for
smoking risk based
mortality in more
on excess lung
than one million
cancer mortality)
subjects [13,14]
[15]
Sources for
exposure data
Lung cancer
mortality from
adjusted vital
registration
Theoreticalminimum-risk
exposure
distribution
Disease outcomes a
No smoking
Lung cancer; upper
aero-digestive cancer;
all other cancers;
chronic obstructive
pulmonary disease
(COPD); other
respiratory diseases; all
cardiovascular diseases;
selected other medical
causes in adults > 30
years;
fire injuries, maternal
outcomes and perinatal
conditions
7
Risk Factor
Alcohol use
Sources for
relative risks
Published
systematic reviews
and meta-analyses
of health effects;
modeling for role
of patterns on
coronary heart
disease [16];
systematic review
of studies of
Mexican
emergency room
and highway
studies for injuries
[17-26]c
Exposure variable
Current alcohol
consumption
volumes and
patterns; prevalence
of alcohol use
among emergency
room patients
Sources for
exposure data
ENA 2002,
Sistema de
Vigilancia
Epidemiológica
de las Adicciones
(SISVEA) 20032004, and
Emergency Room
Collaborative
Alcohol Analysis
Project
(ERCAAP)
Theoreticalminimum-risk
exposure
distribution
Disease outcomes a
No alcohol used
IHD; stroke;
hypertensive disease;
diabetes; liver cancer;
mouth and oropharynx
cancer; breast cancer;
esophageal cancer;
other cancers; liver
cirrhosis; epilepsy;
alcohol use disorders;
depression; intentional
and unintentional
injuries; selected other
cardiovascular diseases
and cancers, social
consequences
Access to piped
water and a flush
toilet in the home
Diarrhea
Environmental risk factors
Unsafe water
and sanitation
Systematic
reviews of multicountry
randomized
controlled trials
and observational
studies [27]
Four scenarios,
ranging from
regulated water and
sanitation to no
improved sanitation
ENSANut 2006,
Conteo 2005
8
Risk Factor
Sources for
relative risks
Urban air
pollution
Systematic review
of published
cohort studies [28]
Indoor air
pollution from
solid fuels
Systematic review
and new metaanalysis of crosssectional, cohort
and case-control
studies [29]
Exposure variable
Measured and
modeled average
concentration of
particulate matter
Household use of
solid fuels and
ventilation
Sources for
exposure data
Theoreticalminimum-risk
exposure
distribution
Disease outcomes a
Annual average
Red de Monitoreo PM10 concentration
Ambiental, Global of 15 μg/m3 and
Modal of Ambient
PM2.5
particulates
concentration of
7.5 μg/m3
Acute lower respiratory
infections in children
<5; lung cancer,
cardiopulmonary
morbidity, and
mortality in adults
No household solid
fuel use
Acute lower respiratory
infections in children <
5; chronic obstructive
pulmonary disease; low
birth weight, cataracts,
tuberculosis, asthma,
lung cancer from
Biomass
ENSANut 2006
a
Outcomes in italics are those that are likely to be causal but not quantified due to lack of sufficient evidence on prevalence and/or
hazard size.
b
Clinical trials indicate that approximately 50% of anemia cases among non-pregnant Mexican women could be eliminated by iron
supplements [30,31]. Given that the prevalence of anemia among non-pregnant women aged 15 to 44 is 18.2% [32], adequate dietary
iron would result in an anemia prevalence of 9.1%.
c
A number of emergency room studies in Mexico have collected data on alcohol consumption among injury patients. Injuries that
occur among patients who had consumed alcohol prior to their injury were classified as “alcohol-related” injuries. Because some of
these injuries would have occurred in the absence of alcohol, not all are caused by alcohol; in other words, the proportion of alcohol-
9
attributable injuries is lower than that of alcohol-related injuries. Emergency room studies as well as highway studies in Mexico have
also quantified the odds ratios for injuries among individuals who have consumed alcohol relative to those who have not. Ideally, odds
ratios would be used in conjunction with data on population prevalence of intoxication to calculate PAF. Because intoxication data are
not easily available, we used a slightly modified equation to calculate PAF using odds ratios from emergency room studies and data on
alcohol-related injuries:
 OR  1 
PAF  P

 OR 
where P is the percent of alcohol-related injuries, or injuries in which the subject reported consuming alcohol in the 6 hours prior to
the injury. All analyses were done by injury type (road traffic, falls, etc.).
d
Theoretical-minimum-risk exposure for alcohol is set to zero, the level which minimizes total health hazards. Specific sub-groups
may have a non-zero theoretical minimum based on moderate drinking patterns, high risk of cardiovascular diseases, and low risk of
injuries.
Table Abbreviations:
ENA
ENN
ENSA
ENSANut
INE
INP
INSP
SSA
WHO
Encuesta Nacional de Adicciones
Encuesta Nacional de Nutrición
Encuesta Nacional de Salud
Encuesta Nacional de Salud y Nutrición
Instituto Nacional de Ecologia
Instituto Nacional de Psiquiatría, Ramón de la Fuente Muñiz
Instituto Nacional de Salud Pública
Secretaría de Salud
World Health Organization
10
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