Asociación de la calidad de la

dieta y el índice de masa corporal

en adultos mexicanos: un análisis
de pseudopanel

Association of diet quality and

body mass index in Mexican
adults: a pseudo-panel analysis

10.20960/nh.04974

04/12/2024
OR 4974

Association of diet quality and body mass index in Mexican

adults: a pseudo-panel analysis

Asociación de la calidad de la dieta y el índice de masa corporal en

adultos mexicanos: un análisis de pseudopanel

Sandra Pérez-Tepayo1, Sonia Rodríguez-Ramírez1, Mishel Unar-Munguía1,

Teresa Shamah-Levy2

Centro de Investigación en Nutrición y Salud y 2Centro de Investigación

1

en Evaluación y Encuestas. Instituto Nacional de Salud Pública.

Cuernavaca, Morelos. Mexico

Received: 29/09/2023
Accepted: 30/01/2024
Correspondence: Sonia Rodríguez-Ramírez. Centro de Investigación en
Nutrición y Salud, Instituto Nacional de Salud Pública. Av. Universidad,
655; Col. Santa Maria Ahuacatitlan. 62100 Cuernavaca, Morelos. Mexico
e-mail: [email protected]

Acknowledgements: we are grateful for the support received from the

National Council of Science and Technology in Mexico (CONACYT by its
acronym in Spanish).

Conflicts of interest: the authors declare that they have no conflicts of

interest.

1
Artificial intelligence: the authors declare not to have used artificial
intelligence (AI) or any AI-assisted technologies in the elaboration of the
article.

ABSTRACT
Introduction: most studies that analyze the relationship between diet
quality and obesity have a cross-sectional design; an alternative whit
repeated cross-sectional data is a pseudo-panel design.
Objective: to estimate the association between trends in dietary
patterns, defined by a diet quality index, and body mass index (BMI) of
Mexican adults between 2006 and 2016.
Methodology: a pseudo-panel analysis was performed using data from
cross-sectional surveys: National Health and Nutrition Surveys of México
(ENSANUTs) 2006 and 2012 and the Midway National Health and
Nutrition Survey 2016 (ENSANUTMC). Cohorts (n = 108) were
constructed by grouping adults 20-59 years old by sex (men n = 6,081
and women n = 11,404), education level, and year of birth. The
association between diet quality (defined with the Healthy Eating Index-
2015) and BMI was estimated using a fixed effects model, adjusting for
sociodemographic characteristics.
Results: a one-point increase in the proportion of women with high diet
quality was associated with 4.1 points lower BMI ( p = 0.014) compared
with women with low diet quality when excluding sub-reporters of
energy, the same association is observed when physical activity is
included in the model. No association was found between diet quality
and BMI in men, possibly because of the existence of latent classes
within sociodemographic strata, which does that the quality of the diet is
inversely associated with the BMI, only in some categories of the strata.
Conclusions: these results contribute to the evidence in the
longitudinal analysis between diet and BMI, highlighting the importance
of differentiating the population by sex and sociodemographic

2
characteristics. These results are input for public policy creation that
promotes improving the quality of the population's diet as part of
multisectoral strategies to reduce overweight and obesity in Mexican
adults.

Keywords: Diet quality. Body mass index. Pseudo-panel. Mexican

adults.

RESUMEN
Introducción: muchos estudios que analizan la relación entre calidad
de la dieta y obesidad son transversales; una alternativa con datos
transversales repetidos es el diseño de pseudopanel.
Objetivo: estimar la asociación entre patrones alimentarios definidos
mediante un índice de calidad de la dieta y el índice de masa corporal
(IMC) en adultos mexicanos entre 2006 y 2016.
Metodología: se realizó un análisis de pseudopanel utilizando datos de
las Encuestas Nacionales de Salud y Nutrición de México (ENSANU´s) de
2006 y 2012 y la Encuesta Nacional de Salud y Nutrición de medio
camino de 2016 (ENSANUTMC). Se construyeron cohortes ( n = 108)
agrupando datos de adultos entre 20 y 59 años, por sexo (hombres n =
6,081, mujeres n = 11,404), nivel de escolaridad y año de nacimiento.
La asociación entre calidad de la dieta (definida mediante el Índice de
Calidad de la Dieta 2015) y el IMC se estimó con un modelo de efectos
fijos, ajustado por características sociodemográficas.
Resultados: un aumento de 1 punto en la proporción de mujeres con
calidad de dieta alta se asoció con 4,1 puntos menos de IMC ( p = 0,014)
comparado con las mujeres con calidad de dieta baja; al excluir a las
subreportadoras de energía, la misma asociación se observó incluyendo
la actividad física al modelo. No se encontró asociación entre calidad de
dieta e IMC en los hombres, posiblemente debido a la existencia de

3
subgrupos dentro de los estratos sociodemográficos, lo cual hace que la
calidad de la dieta esté inversamente asociada al IMC solo en algunas
categorías de los estratos.
Conclusiones: estos resultados contribuyen a la evidencia longitudinal
entre dieta e IMC, destacando la importancia de estratificar por sexo y
características sociodemográficas. Los resultados son un ínsumo para
crear políticas públicas que promuevan mejorar la calidad de la dieta
como parte de estrategias multisectoriales para disminuir el sobrepeso y
la obesidad en los adultos mexicanos.

Palabras clave: Calidad de la dieta. Índice de masa corporal.

Pseudopanel. Adultos mexicanos.

INTRODUCTION
The prevalence of overweight and obesity has increased globally in all
regions and age groups of the population (1). In 2022, a combined
prevalence of overweight and obesity of 75.2 % in adults was higher in
women than in men, 76.8 % vs 73.5 %, respectively (2).
Among the proximal factors associated with the increase in this
prevalence, high-energy dietary patterns have been identified,
characterized by excessive intake of certain food groups such as fats,
sugars, and salt, as well as decreased physical activity, as determinants
of a positive energy balance that give rise to the appearance of obesity
(3). However, these elements do not completely predict the
phenomenon, since they are permeated by multiple factors specific to
the individual, both of a socioeconomic, political, and demographic
nature, climate change, as well as biological and cultural aspects that
contribute to the development of environments that promote obesity (4).

4
The quality of the population's diet has also been evaluated, giving a
score to nutrients and food groups according to adherence to a greater
or lesser extent to dietary patterns considered optimal based on
nutritional recommendations and food guides from different countries
(5). Different indices have been proposed to estimate the diet quality.
One is the Dietary Quality Index developed to important nutrients fiber
and vitamin C (6), other are the Dietary Quality Index-International,
which was designed to explore diet quality in all countries (7), and the
Healthy Eating Index (HEI), validated in different age groups including
adults, which has been used to relate diet quality to health outcomes,
including obesity (8). In Mexico, it has been demonstrated that the diet
quality has been more deficient in men with high socioeconomic status,
urban areas, the northern region, young adults (20-39 years old) (9) and
low education level (10).
Although the evidence about the influence of obesity on health is strong
(11), the results about the association between diet quality and BMI
have been inconsistent (5). To our knowledge in Mexico and other
countries, most studies that analyze the relationship between diet
quality and obesity have a cross-sectional design. This type of study
does not allow causality to be established, nor does it allow control by
variables fixed over time, often unobserved, such as culture, food and
environment, among other characteristics that could influence exposure
and outcome. Therefore, longitudinal or panel designs that follow up the
same individuals and allow controlling for unobserved characteristics
that are invariant over time would be very useful. However, worldwide
there are few longitudinal studies with diet and anthropometry data in
representative samples, so an alternative when repeated cross-sectional
data are available is a pseudo-panel design.
Based on the above, the objective of this study was to estimate the
association between trends in diet quality and BMI of Mexican adults in

5
the years 2006, 2012, and 2016, through pseudo-panels, using national
cross-sectional surveys.

METHODOLOGY
An analysis of pseudo-panels was carried out, built with data on adults
20-59 years old from the National Surveys of Health and Nutrition of
Mexico (ENSANUT) 2006 and 2012 and the Midway National Survey of
Health and Nutrition 2016 (ENSANUTMC), the details of the methodology
of these surveys have been described in other documents (12-14). The
ENSANUT have similar designs that allow them to be comparable. They
collect health, diet, anthropometry, and sociodemographic data
periodically in a different cross-sectional sample on each occasion, so it
is not possible to carry out a panel study. However, all the ENSANUT
have the same type of probabilistic, multi-stage, and cluster sampling,
which allows representativeness to be maintained at the national level
and in urban and rural areas. In this way, individuals sharing similar
characteristics can be grouped and followed up at different points in
time, if the grouping characteristics remain constant (15). Pseudo-panel
models make it possible to follow cohorts over time in repeated cross-
sections, generating time series for the means of the subgroups to be
estimated, which can be analyzed as panel data (16). The main
difference with a panel design is that we do not work with individuals but
with groups of individuals or synthetic cohorts that share common and
invariant characteristics over time (15). We grouped the participants by
sex, year of birth, and education level to form these cohorts, which
constitute the unit of analysis in this study.

Study population
After a cleaning process in the diet databases, we obtained a sample
with valid data from 21,796 adults 20-59 years old ( n = 14,040 in 2006;

6
n = 2,027 in 2012 and n = 5,729 in the year 2016), the details of the
cleaning process are described in another document (9).
In the resulting sample (n = 21,796), a second cleaning process was
carried out, in which those who did not have complete variables to form
the cohorts (n = 73 without schooling data) or the main analysis
variables were excluded (n = 68 without weight or height data). Those
who were not born between 1957 and 1986 ( n = 4,170) were excluded,
because they did not have the age for the analysis (20-59 years) in the
three years of the survey and following the recommendation that
cohorts must be maintained and analyzed at least three at points in time
to have sufficient variation (17). The final sample for the formation of the
cohorts and statistical analyzes was 17,485 individuals, a sensitivity
analysis was performed excluding 253 (1.44 %) participants without
physical activity data (Fig. 1).
The observations of the final sample (n = 17,485) were grouped into
five-year birth periods (1957-1961, 1962-1966, 1967-1971, 1972-1976,
1977-1981, 1982-1986) and schooling was categorized into low,
medium, and high education level, this to have the largest possible
number of observations in each cohort and have better precision in the
estimates (18). We obtained 108 cohorts: 6 birth categories, 2 sex
categories (men and women), and 3 education level categories in the 3
years of analysis (2006, 2012, and 2016).
A sub-sample was also determined in which data with energy under-
reporting were excluded. First, the estimated energy requirement (EER)
was calculated using the formulas for adults aged ≥ 19, proposed by the
Institute of Medicine of the United States, considering the nutritional
status of the population (19), and the factors of physical activity for
people with low physical activity in men and women, respectively, this
according to the level of physical activity of this population, found in
other studies (20). Subsequently, the Energy Intake (EI) ratio was
estimated about the EER, dividing the reported EI by the EER, multiplied

7
by 100 (EI / EER x 100). Next, the distribution and standard deviation
(SD) of these variables were estimated, and finally, data below -1 SD for
each sex and age group were defined as under-reports (21).

Diet quality
The independent variable was the diet quality, which was obtained
through an adaptation of the Healthy Eating Index 2015 (HEI-2015), the
details to calculate it are described in another document (6). Briefly, the
diet data analyzed were obtained by the ENSANUT through a semi-
quantitative food frequency questionnaire, from seven days before the
interview, this instrument has been previously validated and described
(22). The HEI-2015 was obtained by the sum of 13 components of the
diet, nine are food groups or nutrients that are recommended to be
maintained or adjusted in the diet, called adequacy components (total
fruits, whole fruits, total vegetables, green vegetables and legumes,
whole grains, dairy, total protein, seafood and plant protein and fatty
acids). The four remaining components are foods groups or nutrients
that are recommended to moderate in the diet, called moderation
components (refined grains, sodium, added sugar, and saturated fat).
Each component is scored on a scale of 0-5 or 0-10, according to the
consumption of established portions (23), the cut-off points for sodium,
saturated fat, and added sugar were adapted, according to the
recommendations of the World Health Organization (WHO) (24). Finally,
the sum of 13 components was performed and a score between 0 and
100 was obtained, where 100 represents a better diet quality (23).
In the HEI-2015 per se, the energy consumed by each participant
(including alcohol intake) is considered, so from the determination of the
diet quality, an adjustment is made for energy intake. We worked with
the index score continuously (from 0 to 100) and dichotomously,
classifying the participants into low and high diet quality (below and
above the mean diet quality in men and women respectively).

8
Body mass index
Weight and height were measured by trained and standardized
personnel using electronic scales, with a precision of 0.1 kg, and
stadiometers with a precision of 0.1 cm, with these variables, the body
mass index (BMI) was determined.
The dependent variable was the BMI, which was obtained by dividing the
weight in kilograms by the square of the height in meters (BMI = weight
(kg) / [height (m)]2). BMI data were considered valid between 10 and 58
kg/m2, according to the criteria that have been used in official studies of
the ENSANUT (12).

Sociodemographic variables
Sex
Sex information female/male was considered.

Age
Age was considered continuously (in years) and in two categories (20-39
and 40-59 years), because it has been described that both diet and BMI
are different at different ages (25).

Education level
It was asked the highest educational level and grade achieved, which
was categorized into low (primary or less), medium (secondary), and
high (from high school or equivalent studies) education level.

Socioeconomic status (SES)

It was determined in the ENSANUT as an index of household welfare
conditions, which is constructed through principal component analysis

9
with variables that represent the characteristics of the dwelling and the
possession of household goods. The complete methodology is described
on another side (26). We categorized the index into SES tertiles (low,
medium, and high).

Area and region of residence

The area was classified according to the number of inhabitants, ≥ 2,500
for urban and < 2,500 for rural.
The 32 states of Mexico were categorized into 4 regions: North, Center,
Mexico City, and metropolitan areas, and South, according to their
geographic location (27).

Marital status
The participants were asked about their marital status. Three categories
were made: a) single; b) married or partnered (living as a couple with or
without children); and c) separated, divorced, or widowed.

Employment
Through a questionnaire, the participants were asked about their paid
work activity in the last seven days, the answers were categorized into
two categories: if they worked and if they did not work.

Physical activity
Through the short version of the International Physical Activity
Questionnaire (IPAQ-short) used in ENSANUT asked about activities in
the last seven days, participants were categorized as active (> 300
minutes of moderate to vigorous activity per week) inactive (< 50
minutes per week) and moderately active (150-300 minutes per week).
This variable was used in the sensitivity analysis, since physical activity
data was available in 17,253 (98.6 %).

10
Statistical analysis
Descriptive analyses were carried out to characterize the cohorts; for
each variable of interest the average per cohort was estimated in the
case of continuous variables and the average proportions for categorical
variables. A t-test was performed to compare the means of diet quality,
BMI, and sociodemographic characteristics between the male/female
cohorts.
The association between diet quality and BMI was analyzed in the
cohorts stratified by sex, keeping sociodemographic characteristics
constant (area, region, SES, marital status, and employment), and an
interaction effect with area and year of birth following the exploration of
the behavior of the variables.
As the main model, a fixed effects model (model a) was used, with which
it is assumed that the unobservable characteristics of the cohorts that
explain the variation between them do not change over time.

(a)

BMI cest= β0 + β 1 HEI Highcest + β 2 AREA cest + β 3 REGION Center cest + β 4 REGION Mexico city .cest + β5 REGION

Where c = year of birth (1957-1961, 1962-1966, 1967-1971, 1972-1976,

1977-1981, 1982-1986), e = education level (low, medium, high), s =
sex (men, women) and t = survey year (2006, 2012, 2016).
The dependent variable is the average body mass index ( BMI cest ) of the
participants in the five-year birth cohort c, with education level e, with
sex s, and survey year t.
And the exposure variable is the average of the diet quality index (
HEI cest ) or the average proportion of participants with a high diet quality
index. The adjustment variables are the average proportion of
participants from the urban area ( AREA cest ), and the average proportion
of participants from each region ( REGION cest ), compared with the

11
northern region as a reference. The average proportion of participants
with medium and high socioeconomic status ( SES cest ) compared to low.
The average proportion of participants married or separated (
MARITAL STATUS cest ¿ ¿ compared to singles. The average proportion of
participants with paid work ( EMPLOYMENT cest ) compared to those who
did not have paid work. The dummy variables of education level (
2 5

∑ D ⎼ EDUCATION e ¿, year of birth (∑ γ i D ⎼ BIRTH c ¿ , and survey year (

i=1 i=1

∑ ∂ j D ⎼ SURVEY YEAR t) represent the fixed effects of the cohorts. The

j=1

interaction between area and years of birth ( AREA cest∗BIRTH c ¿. Finally,

the error term ε cest represents the unobserved characteristics fixed in
time (28).
Sensitivity analyses were performed to assess the inclusion of physical
activity in the model, as well as to assess the relationship between diet
quality and BMI in the sub-sample excluding sub-reporters of energy
intake.
For all analyses, a p-value < 0.05 was set to detect significant
differences, and the SVY module of STATA statistical software version
13.0 was used to account for survey design.

RESULTS
Within the analysis cohorts, a larger sample size was observed for
women than for men, as well as a larger sample size with low education
level in the 2006 survey (Table I).
The mean age was 38 years in men and women; BMI and diet quality
means were higher in women than in men; the proportion of active men
(69 %) was higher than that of women (56 %). A 13 % under-reporting of
energy was identified in men and women (Table II).

12
Association of diet quality and BMI by sex in the complete
sample
Among men, a one-point increase in the proportion living in urban areas
in the 1957-1961 birth cohort was associated with 7.3 points lower BMI
(kg/m2) on average (p < 0.001) compared to men from rural areas. A
one-point increase in the proportion of men in medium and high SES was
associated with 5.3 points higher BMI (p = 0.008) and 2.9 points higher
BMI (p = 0.039), respectively, compared with low SES men. A one-point
increase in the proportion of married men was associated with a 4.2-
point higher BMI (p < 0.001) and a one-point increase in the proportion
of separated men with a 5.1-point higher BMI ( p = 0.005), compared
with singles. While an increase of one point in the proportion of men with
medium and high education level was associated with 1.0 points and 1.9
points (p < 0.05) higher BMI than those with low education level,
respectively (Table III).
Regarding women, an increase of one point in the proportion of those
living in the center region of the country was associated with 3.8 points
(p = 0.02) less BMI compared to women in the north region. And a one-
point increase in the proportion of married women was associated with a
4.1-point higher BMI (p = 0.04) compared with single women (Table III).

Interaction between area and year of birth in the complete

sample
In rural men, most of the birth cohorts (except 1977-1981) had lower
mean BMI (p < 0.05) compared to the oldest cohort (1957-1961). In
women the relationship was the opposite; in the cohorts born in 1962-
1966 and 1972-1976, they had a higher average BMI ( p < 0.05),
compared with the older cohort. In the urban area, the relationship is
significantly opposite to that observed in the rural area, except in the
1977-1981 cohort for both men and women. The same trend was
observed in the sub-sample (Table III).

13
Association of diet quality and BMI in men and women in the
sub-sample of plausible energy reporters
In the men of the sub-sample, no significant association was observed
between BMI and diet quality, while in women was observed that an
increase in the proportion of the high diet quality category was
significantly associated with 4.1 BMI points less ( p = 0.014) compared to
low diet quality (Table III). In addition, increasing the proportion living in
urban areas by one point in the 1957-1961 birth cohort was associated
with 6.4 points more BMI (kg/m 2) on average (p = 0.002) compared to
women in the rural area.
When the physical activity was included as a covariate in the fixed
effects model, adjusting for sociodemographic variables and the
interaction between area and year of birth, no statistically significant
association was found between diet quality and BMI in the male and
female cohorts, a one-point increase in the proportion of men with
moderately physical activity and inactive was associated with 5.2 points
higher BMI (p = 0.001) compared with active men in the complete
sample. In the sub-sample, it was observed that a one-point increase in
the proportion of women with a high diet quality index was associated
with 4.3 points lower BMI (p = 0.007) compared to women in the low diet
quality index category and a one-point increase in the proportion of men
with moderately physical activity was associated with 4.6 points higher
BMI (p = 0.001) compared with active men (Table IV).

DISCUSSION
In this study we analyzed the association of diet quality with body mass
index (BMI) in the adult population, using a pseudo-panel approach. We
found that, in women with plausible energy reporting, an increased
proportion of women with high diet quality was associated with lower
BMI, compared with women with low diet quality. This result is consistent

14
with other studies that have described a negative association between
diet quality and BMI in women (29,30). It is possible that no association
was found in the complete sample because there is a high prevalence of
those who under-report energy intake (26 %), which does not allow for
estimating the real association of diet quality with BMI (31,32). Few
studies have analyzed the association between diet quality and BMI
using pseudo-panels and stratifying by sex, so it is not easy to compare
our results. In a study similar to ours, a direct association was found
between high-energy diet patterns and a higher BMI (33). Similarly, the
authors suggest that dietary components, in addition to energy, play an
important role in the increase of BMI.
Contrary to what has been described in some studies that found a
negative association between diet quality and BMI in men and not in
women (34,35) in our study we obtained this result only in women, even
when physical activity was added. These differences could be due to the
use of different methodologies to obtain dietary patterns (36). It is also
possible that, in men, some components of the HEI-2015 are associated
to a greater extent with BMI or attenuate the association, as has been
seen with other health outcomes, such as type-2 diabetes, when
excluding some components of indices of diet quality, the association
was magnified or became non-significant (37). Another possibility is that
within the sociodemographic strata there are latent classes, that is, the
quality of the diet is inversely associated with the BMI, only in some
categories of the strata, as was observed in a study Mexican adults, in
which, inverse association was found only in men with a low educational
level (10) or in another study that found an inverse association between
the quality of the diet and BMI only when it was categorized into high
and low BMI (29).
We found disagreement regarding BMI by area of residence since in men
was observed that living in urban areas was significantly associated with
a lower BMI compared to rural areas, contrary to what has been

15
described at the national level (25). The fact that this opposite trend has
been observed only in men also emphasizes the importance of analyzing
men and women separately.
Among the limitations of this study, the fact that we did not include
more years of the survey stands out, because the method of collecting
diet in the National Surveys of Health and Nutrition (ENSANUT for its
initials in Spanish) was not the same before 2006, so it was not was able
to use a dynamic model with lags as recommended in pseudo-panel
analysis (16); however, the model we used is a valid alternative when
there are few points in time but sufficient units of analysis (38).
Another limitation is that the method of obtaining physical activity data
is considered partially valid (39), so the role of this variable in the
relationship between diet quality and BMI cannot be safely inferred.
Possibly with the fixed effects model, the variable is not fully controlled
since physical activity can change over time. However, in our study,
when this variable was included in the main model, the association did
not change, which could be a reflection that the relationship between
diet quality and BMI is significant, even when it cannot be controlled by
complete physical activity.
One of the strengths of this study is that the diet, anthropometry, and
sociodemographic data were obtained by trained, standardized
personnel and through validated instruments. Similarly, the diet quality
index we used was validated in adults to explore diet quality about
dietary recommendations and for analysis of health outcomes including
obesity (23). Another strength is that the design of the surveys was
considered, so the results can be considered representative of the
population at the national level, and based on their design, they are
comparable surveys.
Finally, the main strength of the pseudo-panel design concerning a linear
regression model is that it reduces the possibility of bias due to the

16
omission of variables that are fixed, since this methodology controls for
unobservable heterogeneity invariant over time (28).

CONCLUSION
The increase in the quality of the diet was associated with a decrease in
the BMI in women when energy sub-reporters are excluded. To our
knowledge, this is one of the first national studies to analyze the
association of diet quality with BMI in nationally representative samples,
using the pseudo-panel approach. Further studies could analyze the
association between diet quality and BMI in specific strata such as area
of residence, as well as analyze the relationship with the components of
HEI-2015. The results of this study can serve as a reference for future
analyzes between diet and BMI, highlighting the importance of
stratifying the population by sex and sociodemographic characteristics,
and as an input for the creation of public policies that promote
improving diet quality to reduce overweight and obesity in Mexican adult
men and women.

REFERENCES
1. Alfaris N, Alqahtani AM, Alamuddin N, Rigas G. Global Impact of
Obesity. Gastroenterol Clin North Am 2023;52(2):277-93. DOI:
10.1016/J.GTC.2023.03.002
2. Campos-Nonato I, Galván-Valencia Ó, Hernández-Barrera L,
Oviedo-Solís C, Barquera S. Prevalencia de obesidad y factores de
riesgo asociados en adultos mexicanos: resultados de la Ensanut
2022. Salud Publica Mex 2023;65:s238-47. DOI: 10.21149/14809
3. Romieu I, Dossus L, Barquera S, Blottière HM, Franks PW, Gunter
M, et al. Energy balance and obesity: what are the main drivers?
Cancer Causes Control 2017;28(3):247-58. DOI: 10.1007/s10552-
017-0869-z

17
4. Swinburn BA, Kraak VI, Allender S, et al. The Global Syndemic of
Obesity, Undernutrition, and Climate Change: The Lancet
Commission report. Lancet 2019;393(10173):791-846. DOI:
10.1016/S0140-6736(18)32822-8
5. Asghari G, Mirmiran P, Yuzbashian E, Azizi F. A systematic review
of diet quality indices in relation to obesity. Br J Nutr
2017;117(8):1055-65. DOI: 10.1017/S0007114517000915
6. Patterson RE, Haines PS, Popkin BM. Diet quality index: Capturing
a multidimensional behavior. J Am Diet Assoc 1994;94(1):57-64.
DOI: 10.1016/0002-8223(94)92042-7
7. Kim S, Haines PS, Maria Siega-Riz A, Popkin BM. The Diet Quality
Index-International (DQI-I) Provides an Effective Tool for Cross-
National Comparison of Diet Quality as Illustrated by China and the
United States 1,2. J Nutr 2003;133:3476-84. DOI:
10.1093/jn/133.11.3476
8. Krebs-Smith SM, Pannucci TE, Subar AF, et al. Update of the
Healthy Eating Index: HEI-2015. J Acad Nutr Diet 2018;118:1591-
602. DOI: 10.1016/j.jand.2018.05.021
9. Pérez-Tepayo S, Rodríguez-Ramírez S, Unar-Munguía M, Shamah-
Levy T. Trends in the dietary patterns of Mexican adults by
sociodemographic characteristics. Nutr J 2020;19(1):51. DOI:
10.1186/s12937-020-00568-2
10. López-Olmedo N, Popkin BM, Mendez MA, Taillie LS. The
association of overall diet quality with BMI and waist
circumference by education level in Mexican men and women.
Public Health Nutr 2019;22(15):2777-92. DOI:
10.1017/S136898001900065X
11. Afshin A, Forouzanfar MH, Reitsma MB, Sur P, Estep K, Lee A,
et al. Health effects of overweight and obesity in 195 countries
over 25 years. N Engl J Med 2017;377(1):13-27. DOI:
10.1056/NEJMoa1614362.

18
12. Shamah Levy T, Cuevas-Nasu L, Rivera-Dommarco J,
Hernández Ávila M. Encuesta Nacional de Salud y Nutrición de
Medio Camino 2016 (ENSANUT MC2016).; 2016. Informe final de
resultados. Cuernavaca (MX); 2016. Available from:
https://www.gob.mx/cms/uploads/attachment/file/209093/ENSANU
T.pdf
13. Olaiz-Fernández G, Rivera-Dommarco J, Shamah-Levy T,
Rojas R, Villalpando-Hernández S, Hernández-Avila M, Sepúlveda-
Amor J. Encuesta Nacional de Salud y Nutrición 2006. Cuernavaca,
México: Instituto Nacional de Salud Pública; 2006. Available from:
https://www.insp.mx/images/stories/ENSANUT/Docs/Ensanut2006.p
df
14. Gutierrez J, Rivera-Dommarco JA, Shama-Levy T, Villalpando-
Hernández S, Franco A, Cuevas-Nasu L et al. Encuesta Nacional de
Salud y Nutrición, Ensanut 2012. Resultados Nacionales 2a ed..
Instituto Nacional de Salud Pública. Cuernavaca, México; 2013.
Available from: http://ensanut.insp.mx/informes/ENSANUT2012
ResultadosNacionales.pdf
15. Deaton A. Panel data from time series of cross-sections. J
Econom 1985;30(1-2):109-26. DOI: 10.1016/0304-4076(85)90134-
4
16. Verbeek M, Vella F. Estimating dynamic models from
repeated cross-sections. J Econom 2005;127(1):83-102. DOI:
10.1016/j.jeconom.2004.06.004
17. Verbeek M, Nijman T. Can cohort data be treated as genuine
panel data? Empir Econ 1992;17(1):9-23. DOI:
10.1007/BF01192471
18. Gam I, Ben Rejeb J. Micro-economic analysis of domestic
water demand: application of the pseudo-panel approach. Environ
Challenges 2021;4:100118. DOI: 10.1016/J.ENVC.2021.100118
19. Institute of Medicine of the National Academies. Dietary

19
 Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty
Acids, Cholesterol, Protein, and Amino Acids. Washington, D.C.;
2005;185:202-3. Available from:
http://www.nap.edu/catalog/10490
20. Hernández B, De Haene J, Barquera S, Monterrubio E, Rivera
J, Shamah T, et al. Factores asociados con la actividad física en
mujeres Mexicanas en edad reproductiva. 2003;14(4):235-45.
Available from: http://www.scielosp.org/scielo.php?
script=sci_arttext&pid=S1020-
49892003000900004&lng=es&nrm=iso&tlng=es
21. Mccrory MA, Hajduk CL, Roberts SB. Procedures for screening
out inaccurate reports of dietary energy intake. Public Health Nutr
2002;5(6a):873-82. DOI: 10.1079/phn2002387
22. Denova-Gutiérrez E, Ramírez-Silva I, Rodríguez-Ramírez S,
Jiménez-Aguilar A, Shamah-Levy T, Rivera-Dommarco JA, et al.
Validity of a food frequency questionnaire to assess food intake in
Mexican adolescent and adult population. Salud Publica Mex
2016;58:617. DOI: 10.21149/spm.v58i6.7862
23. Reedy J, Lerman JL, Krebs-Smith SM, Kirkpatrick SI, Pannucci
TE, Wilson MM, et al. Evaluation of the Healthy Eating Index-2015.
J Acad Nutr Diet 2018;118(9):1622-33. DOI:
10.1016/j.jand.2018.05.019
24. WHO. Diet, nutrition and prevention of chronic deseases.
Geneva; 2003. Available from:
https://www.who.int/nutrition/publications/obesity/WHO_TRS_916_s
pa.pdf
25. Barquera S, Campos-Nonato I, Hernández-Barrera L, Rivera-
Dommarco JÁ. Prevalencia de obesidad en adultos mexicanos,
2000-2012. Salud Publica Mex 2013;55(supl.2):s154. Available
from: http://www.scielo.org.mx/scielo.php?
script=sci_arttext&pid=S0036-36342013000800012

20
26. Gutiérrez JP. Clasificación socioeconómica de los hogares en
la ENSANUT 2012. Salud Publica Mex 2013;55:S341-6. Available
from: http://www.scielo.org.mx/scielo.php?pid=S0036-
36342013000800034&script=sci_arttext
27. Tamayo Chuc DU, Hernández Chávez L. Distribución
geográfica de Ias mexicanas con carrera de Nutrición y estado
nutricio infantil ENSANUT 2012, ¿Hay correlación? Rev Salud
Pública y Nutr 2016;15(4):0-4. Available from:
https://respyn.uanl.mx/index.php/respyn/article/view/22
28. Russell JE, Fraas JW. An application of panel regression to
pseudo panel data. Mult Linear Regres Viewpoints 2005;31(1):1-
15. Available from: http://mlrv.ua.edu/2005/Russell-Fraas-3.pdf
29. Sundararajan K, Campbell MK, Choi YH, Sarma S. The
Relationship Between Diet Quality and Adult Obesity: Evidence
from Canada. J Am Coll Nutr 2014;33(1):1-17. DOI:
10.1080/07315724.2013.848157
30. Jessri M, Ng AP, L’Abbé MR. Adapting the Healthy Eating
Index 2010 for the Canadian Population: Evidence from the
Canadian National Nutrition Survey. Nutrients 2017;9(8). DOI:
10.3390/nu9080910
31. Zulfarina MS, Sharif R, Mohd Sharkawi A, et al. Quality of
energy intake in Malaysian adolescents: prevalence,
characteristics, determinants and impact of implausible reporters.
Public Health Nutr 2023;26(1):122-31. DOI:
10.1017/S1368980022000726
32. Jessri M, Lou WY, L’Abbé MR. Evaluation of different methods
to handle misreporting in obesity research: Evidence from the
Canadian national nutrition survey. British Journal of Nutrition
2016;115:147-59. DOI: 10.1017/S0007114515004237
33. Kwock CK, Park J. Dietary patterns and body mass indices
among adults in Korea: Evidence from pseudo panel data. Agric

21
 Econ (United Kingdom). 2015;46(2):163–72. DOI:
10.1111/agec.12148
34. Drewnowski A, Fiddler EC, Dauchet L, Galan P, Hercberg S.
Diet quality measures and cardiovascular risk factors in france:
Applying the healthy eating index to the su.vi.max study. J Am Coll
Nutr 2009;28(1):22-9. DOI: 10.1080/07315724.2009.10719757
35. Drenowatz C, Shook RP, Hand GA, Hébert JR, Blair SN. The
independent association between diet quality and body
composition. Sci Rep 2014;4(1):1-6. DOI: 10.1038/srep04928
36. Rodríguez-Ramírez S, Martinez-Tapia B, González-Castell D,
Cuevas-Nasu L, Shamah-Levy T. Westernized and Diverse Dietary
Patterns Are Associated With Overweight-Obesity and Abdominal
Obesity in Mexican Adult Men. Front Nutr 2022;9(June):1-10. DOI:
10.3389/fnut.2022.891609
37. Jacobs S, Harmon BE, Boushey CJ, Morimoto Y, Wilkens LR, Le
Marchand L, et al. A priori-defined diet quality indexes and risk of
type 2 diabetes: the Multiethnic Cohort. Diabetologia
2015;58(1):98-112. DOI: 10.1007/s00125-014-3404-8
Devereux PJ. Small-sample bias in synthetic cohort models of labor
supply. J Appl Econom 2007;22(4):839-48. DOI: 10.1002/jae.938
38. Medina C, Barquera S, Janssen I. Validity and reliability of the
International Physical Activity Questionarie among adults in
Mexico. Rev Panam Salud Pública 2013;34(1):21-8. Available from:
https://www.scielosp.org/scielo.php?
script=sci_arttext&pid=S1020-
49892013000700003&lng=en&nrm=iso&tlng=en

22
Table I. Number of participants by birth cohort, sex, and education level
by survey year (n = 108)
MALES (n = 6 081)
Low education Medium education High education
level level level
n = 2 800 n = 1 923 n = 1 358
Survey year Survey year Survey year
Birth 200 201 201 201 201 201
cohort 6 2 6 2006 2 6 2006 2 2016 Total
1957-1961 378 60 138 113 13 51 106 16 31 906
1962-1966 470 50 128 192 24 57 160 26 48 1155
1967-1971 362 36 121 285 47 73 156 32 51 1163
1972-1976 326 38 106 262 45 113 141 29 48 1108
1977-1981 224 35 112 196 40 118 147 26 57 955
1982-1986 122 32 62 186 34 74 188 21 75 794
FEMALES (n = 11 404)
Low education Medium education High education
level level level
n = 5 864 n = 3 796 n = 1 744
Survey year Survey year Survey year
Birth 200 201 201 201 201 201
cohort 6 2 6 2006 2 6 2006 2 2016 Total
1957-1961 756 73 246 139 26 88 81 20 43 1472
1962-1966 873 93 233 328 36 115 159 21 67 1925
1967-1971 937 81 231 541 57 174 164 28 74 2287
1972-1976 818 83 191 557 80 258 195 44 90 2316
1977-1981 525 64 215 445 60 250 200 39 112 1910
1982-1986 235 42 168 313 61 268 221 42 144 1494

23
Table II. Sociodemographic characteristics of the cohorts by sex
Males Females
n = 54 cohorts n = 54 cohorts
Characteristics Mean or Mean or
proporti SD 95 % CI proporti SD 95 % CI
on on

Age (years) ǂ 38.81 0.2 38.3, 38.20 0.19 37.8,

3 39.2 38.5*
Body mass index 27.94 0.1 27.6, 29.04 0.13 28.7,

(kg/m2)ǂ 4 28.2 29.3*

Diet Quality (score)ǂ 43.97 0.3 43.2, 46.63 0.34 46.2,

4 44.6 47.2*
Under-reporting of 0.13 0.0 0.11, 0.13 0.00 0.12, 0.14
energy 1 0.15
Area
Urban 0.77 0.0 0.75, 0.77 0.00 0.75, 0.79
1 0.79
Rural 0.23 0.0 0.20, 0.23 0.00 0.20, 0.24
1 0.24
Region
North 0.23 0.0 0.20, 0.22 0.01 0.19, 0.24
1 0.25
Center 0.30 0.0 0.27, 0.30 0.01 0.27, 0.32
1 0.32
Mexico city 0.18 0.0 0.15, 0.18 0.01 0.15, 0.20
1 0.20
South 0.29 0.0 0.26, 0.30 0.01 0.27, 0.32
1 0.31
Socioeconomic
status1
Low 0.27 0.0 0.24, 0.26 0.00 0.24, 0.27
1 0.29
Medium 0.31 0.0 0.28, 0.33 0.01 0.30, 0.34
1 0.33
High 0.42 0.0 0.38, 0.41 0.01 0.38, 0.44
1 0.44

24
Marital status
Single 0.18 0.0 0.15, 0.15 0.00 0.13,
1 0.19 0.17*
Married/partnered 0.77 0.0 0.75, 0.72 0.01 0.69,
1 0.79 0.73*
Separated/ 0.05 0.0 0.03, 0.13 0.00 0.11,
widowed 0 0.06 0.14*
Employment2
Yes 0.86 0.0 0.84, 0.38 0.01 0.36,
0 0.88 0.40*
No 0.14 0.0 0.11, 0.62 0.01 0.59,
0 0.15 0.63*
Education3
Low 0.35 0.0 0.32, 0.41 0.01 0.38,
1 0.37 0.43*
Medium 0.35 0.0 0.32, 0.33 0.01 0.31,
1 0.37 0.35*
High 0.30 0.0 0.27, 0.25 0.01 0.23,
1 0.32 0.27*
Survey year
2006 0.30 0.0 0.27, 0.36 0.01 0.33,0.37*
1 0.31
2012 0.37 0.0 0.33, 0.34 0.01 0.31.0.36*
1 0.39
2016 0.33 0.0 0.30, 0.30 0.01 0.28,0.33*
1 0.36
Birth cohort
1957-1961 0.14 0.0 0.12, 0.13 0.00 0.11,0.13
0 0.15
1962-1966 0.16 0.0 0.14, 0.18 0.00 0.16,0.19
0 0.18
1967-1971 0.17 0.0 0.15, 0.17 0.00 0.15,0.18
0 0.19
1972-1976 0.19 0.0 0.17, 0.18 0.00 0.16,0.20
1 0.21
1977-1981 0.18 0.0 0.15, 0.15 0.00 0.14,0.16

25
 1 0.20
1982-1986 0.16 0.0 0.14, 0.19 0.00 0.16,0.20
0 0.18
Physical activity4
Active 0.69 0.0 0.66, 0.56 0.01 0.54, 0.58
Moderarely 0.05 1 0.72 0.08 * 0.06, 0.09
active 0.0 0.04, 0.00
Inactive 0.25 0 0.06 0.35 0.22, 0.27
0.01
0.0 0.22, *
1 0.27

Means.
ǂ 1
Tertiles of the principal component of household welfare
conditions index. 2Paid work activity in the last 7 days. 3Schooling low:
primary or less; medium: secondary; high: from high school or
equivalent studies. 4
Active: > 300 minutes of moderate to vigorous
activity per week; inactive: < 50 minutes per week; moderately active:
150-300 minutes per week, including 98.6 % of the population with
physical activity data. *p-value < 0.05.

26
Table III. Association of diet quality and sociodemographic characteristics with body mass index (BMI)
Complete sample Sub-sample of plausible energy reporters

Males Females Males Females

n = 54 (cohorts) n = 54 (cohorts) n = 54 (cohorts) n = 54 (cohorts)
Variables 2 N = 707 025 N = 561 929 N = 703 342 N = 575 260

β 95 % CI p- β 95 % CI p- β 95 % CI p- β 95 % CI p-
BMI value BMI value BMI value BMI value

Diet quality
Low Reference Reference Reference Reference

High -1.22 -4.0,1.5 0.38 -0.53 -4.1,3.1 0.77 -1.60 -4.0, 0.7 0.18 -4.10 -7.3,-0.8 0.014
Area
Rural Reference Reference Reference Reference

Urban -7.39 -9.6,-5.1 < -0.50 -6.5,5.5 0.86 -8.03 -10.8,-5.2 < 6.40 2.4,10.3 0.002
0.001 0.001
Region
North Reference Reference Reference Reference

Center -0.09 -1.9,1.7 0.92 -3.84 -6.2,-0.4 0.02 -0.84 -2.3,0.6 0.27 0.23 -2.6,3.1 0.86

Mexico city 2.24 -0.9,5.4 0.16 -1.47 -8.9,5.9 0.69 1.12 -2.0,4.3 0.47 -9.33 -14.9,-3.6 0.002
South 2.01 -1.7,5.8 0.29 -4.0 -9.0,0.8 0.10 0.53 -1.9,3.05 0.67 -6.27 -9.6,-2.9 <
0.001
Socioeconomic status
Low Reference Reference Reference Reference

Medium 5.32 1.4,9.2 0.008 3.35 -2.4,9.1 0.25 4.27 1.4,7.1 0.014 -3.92 -7.3,0.4 0.027
High 2.94 0.1,5.7 0.039 -0.63 -4.9,3.6 0.76 2.62 0.8,3.2 0.002 -4.45 -9.0,0.1 0.059

Marital status
Single Reference Reference Reference Reference

Married/partnered 4.23 1.9,6.4 < 4.13 0.1,8.2 0.04 3.83 2.2,5.4 < 1.99 -0.6,4.6 0.13
0.001 0.001
Separated/widowed 5.18 1.6,8.7 0.005 1.04 -3.6,5.7 0.65 4.02 0.9,7.0 0.011 2.13 -1.3,5.6 0.23

27
Employment
Yes Reference Reference Reference Reference

No -1.14 -3.7,1.5 0.39 -1.51 -4.9,1.8 0.37 -1.29 -3.3,0.7 0.22 1.95 -1.4,5.3 0.28

Education
Low Reference Reference Reference Reference

Medium 1.03 0.1,1.9 0.027 -0.12 -0.9,0.7 0.76 0.82 0.1,1.4 0.014 -0.35 -1.3,0.6 0.46

High 1.97 0.5,3.4 0.009 1.26 -1.4,3.9 0.35 2.05 0.8,3.2 0.002 0.73 -1.2,2.7 0.46

Survey year
2006 Reference Reference Reference Reference

2012 0.83 0.2,1.4 0.006 1.53 0.9,2.1 < 0.71 0.1.1.2 0.012 1.50 0.8,2.1 <
0.001 0.001
2016 0.27 -0.4,1.0 0.47 0.83 -0.3,1.9 0.15 0.38 -0.3,1.1 0.30 2.91 1.6,4.1 <
0.001
Birth cohort
1957-1961 Reference Reference Reference Reference

1962-1966 -3.21 -4.9,-1.5 < 3.47 1.1,5.7 0.004 -4.11 -6.3,-1.8 0.001 3.67 1.5,5.8 0.001
0.001
1967-1971 -2.81 -4.3,-1.3 < 1.38 -0.9,2.8 0.066 -3.82 -6.0,-1.5 0.001 2.56 1.0,4.0 0.001
0.001
1972-1976 -3.21 -5.0,-1.3 0.001 3.32 1.3,5.3 0.001 -3.61 -5.9,-1.2 0.004 4.42 2.4,6.4 <
0.001
1977-1981 -1.22 -2.9,0.4 0.15 0.72 -1.4,2.8 0.50 -1.62 -3.7,0.5 0.13 1.68 0.1,3.2 0.031
1982-1986 -3.23 -5.0,-1.4 0.001 1.68 -0.5,3.9 0.13 -3.74 -5.8,-1.6 0.001 2.61 0.3,5.0 0.028
Birth cohort * Area
1957-1961 Reference Reference Reference Reference

4.76 2.0,7.3 < -5.13 -8.2,-2.0 0.002 5.93 2.8,8.9 < -5.2 -7.9,-2.4 <
1962-1966 0.001 0.001 0.001
4.47 1.7,7.3 < -3.29 -5.3,-1.2 0.002 5.59 2.4,8.7 0.001 -4.6 -6.6,-2.5 <
1967-1971 0.002 0.001
1972-1976 5.97 3.3,9.1 < -5.55 -8.2,-2.8 < 6.08 2.4,9.7 0.001 -7.0 -9.6,-4.3 <

28
 0.001 0.001 0.001
2.17 -0.9,5.0 0.093 -2.96 -6.2,0.3 0.075 2.12 -1.0,5.2 0.18 -4.7 -7.0,-2.3 <
1977-1981 0.001
4.58 1.2,7.7 0.003 -7.04 -10.4,-3.6 < 4.90 1.5,8.2 0.005 -9.1 -12.3,-6.0 <
1982-1986 0.001 0.001
24.73 21.3,28.0 < 28.97 20.4,37.4 < 27.08 23.9,30.2 < 28.60 22.2,34.9 <
Intercept 0.001 0.001 0.001 0.001
0.87 < 0.90 < 0.90 < 0.93 <
R2 0.001 0.001 0.001 0.001

Model adjusted for sociodemographic characteristics (area, region, marital status, socioeconomic
status, employment, education, survey year, birth cohort) and area * birth cohort interaction. Score of
body mass index = kg/m2.

29
Table IV. Association of diet quality and body mass index (BMI) adjusting for physical activity
Complete sample Sub-sample of plausible energy reporters
Males Females Males Females
n = 54 (cohorts) n = 54 (cohorts) n = 54 (cohorts) n = 54 (cohorts)
Variables N = 707 025 N = 561 929 N = 703 342 N = 575 260

β 95 % CI p- β 95 % CI p- β 95 % CI p- β 95 % CI p-
BMI value BMI value BMI value BMI value

Diet quality
Low Reference Reference Reference Reference
High -0.48 -3.1, 2.1 0.713 -2.05 -5.82,1.71 0.27 -1.72 -3.72.,0.27 0.090 -4.30 -7.40,-1.20 0.007
Area
Rural Reference Reference Reference Reference
Urban -7.07 -9.4, -4.6 < 1.39 -4.5,8.3 0.54 -7.28 -9.73,-4.83 < 8.22 4.0,12.4 <
0.001 0.001 0.001
Region
North Reference Reference Reference Reference
Center -1.45 -3.0, 0.1 0.074 -1.39 -4.5,1.73 0.37 -2.66 -4.1,-1.2 0.001 1.67 -1.3,4.7 0.272
Mexico city 1.09 -1.3,3.5 0.377 -7.03 -16.7,2.6 0.15 -0.58 -3.2,2.0 0.660 -13.8 -20.6,-7.11 <0.001
South 0.80 -2.8,4.4 0.661 -4.57 -9.3,0.15 0.05 -1.39 -3.7,0.9 0.234 -6.38 -9.4,-3.3 <0.001
Socioeconomic status
Low Reference Reference Reference Reference
Medium 5.06 1.8,8.2 0.003 0.67 -5.6, 6.9 0.83 3.27 1.1,5.4 0.003 -5.75 -9.0, -2.4 0.001
High 1.08 1.0,5.8 0.006 -0.49 -4.2,3.2 0.79 1.63 -0.5,3.8 0.137 -5.03 -8.9, -1.0 0.013
Marital status
Single Reference Reference Reference Reference
Married/partnered 4.41 2.3,6.4 < 3.49 -0.7,7.7 0.102 4.44 1.1,5.4 < 1.51 -1.0,4.0 0.240
0.001 0.001
Separated/widowed 6.21 2.4,9.9 0.001 1.15 -4.1,6.4 0.665 4.79 -0.5,3.8 < 2.15 -1.6,5.9 0.261
0.001
Employment

30
 Yes Reference Reference Reference Reference
No -0.99 -3.4,1.4 0.418 -0.99 -4.8,2.8 0.603 -0.23 -2.0, 1.5 0.798 2.48 -1.0,5.9 0.161
Education
Low Reference Reference Reference Reference
Medium 0.70 -0.2,1.6 0.153 -0.25 -1.1,0.6 -0.56 0.39 -0.1,0.9 0.157 -0.12 -1.1,0.8 0.813
High 1.08 -0.5,2.7 0.197 0.33 -3.0,3.7 0.84 1.39 0.1, 2.5 0.024 0.80 -1.3,2.9 0.459
Survey year
2006 Reference Reference Reference Reference
2012 0.61 -0.6,1.9 0.346 -0.33 -2.1, 1.5 0.721 1.10 0.2.1.9 0.011 0.32 -0.7,1.4 0.549
2016 0.18 -1.5,1.9 0.831 0.01 -1.1,1.2 0.974 1.13 0.1,2.0 0.020 2.41 1.1,3.7 <
0.001
Birth cohort
1957-1961 Reference Reference Reference Reference
1962-1966 -3.11 -4.9,-1.2 0.002 3.10 0.9,5.3 0.007 -4.52 -6.6,-2.4 < 3.55 1.3,5.8 0.003
0.001
1967-1971 -2.51 -4.1,-0.8 0.004 1.46 0.0,2.9 0.046 -3.29 -5.2,-1.3 0.001 2.35 0.6,4.0 0.008
1972-1976 -2.66 -4.6,-0.6 0.009 3.59 1.4,5.7 0.001 -3.23 -5.4,-1.0 0.005 4.53 2.6,6.4 <
0.001
1977-1981 -0.75 -2.5,0.9 0.390 1.05 -0.9,3.0 0.287 -1.00 -3.0,1.0 0.319 1.63 -0.1,3.4 0.078
1982-1986 -2.67 -4.4,-0.8 0.004 1.25 -0.8,3.3 0.242 -2.96 -4.8,-1.9 0.002 2.06 -0.2,4.3 0.082
Birth cohort * Area
1957-1961 Reference Reference Reference Reference
5.01 2.3,7.7 < -7.34 -7.3,-1.4 0.004 7.06 4.1,9.9 < -5.0 -8.1,-2.0 0.002
1962-1966 0.001 0.001
4.62 1.8,7.3 0.001 -5.33 -5.3,-1.4 0.001 5.51 2.5,8.4 < -4.4 -7.0,-1.9 0.001
1967-1971 0.001
5.57 2.5,8.5 < -8.40 -8.4,-2.9 < 5.87 2.4,9.3 0.001 -7.2 -9.9,-4.5 <
1972-1976 0.001 0.001 0.001
1977-1981 2.20 -0.4,4.8 0.105 -6.31 -6.3,-0.5 0.020 1.78 -1.2,4.8 0.246 -4.8 -7.6,-2.0 0.001
1982-1986 4.71 1.7,7.7 0.003 -9.34 -9.3,-3.0 < 4.48 1.3,7.5 0.006 -8.5 -11.6,-5.4 <

31
 0.001 0.001

Physical activity Reference Reference Reference Reference

Active 5.26 -3.1, 6.1 0.001 -2.79 -5.6,0.0 0.056 2.5,6.7 0.021 -1.78 -4.7, 0.9 0.004
4.64
Moderarely active 1.53 2.2, 8.2 0.509 1.63 -3.5,6.7 0.526 0.5,5.8 < -2.85 -6.4, 2.8 0.447
3.16
Inactive 0.001
24.30 20.5,28.0 < 31.04 22.2,39.8 < 26.6 24.0,29.2 < 29.98 23.9,36.0 <
Intercept 0.001 0.001 0.001 0.001
0.89 < 0.91 < 0.92 < 0.93 <
R2
0.001 0.001 0.001 0.001

Model including 98.6 % of the population with physical activity data, adjusted for sociodemographic
characteristics (area, region, marital status, socioeconomic status, employment, education, survey
year, birth cohort), physical activity, and area * birth cohort interaction.

32
 ENSANUT 2006 ENSANUT 2012 ENSANUTMC 2016
n= 14 040 n= 2 027 n= 5 729

n = 21 796 Incomplete data

n= 68 (0.3%), without
weight and height data
n= 73 (0.3%), without
schooling data
n = 21 655

Out of analysis age

range
n = 4 170 (19.2 %)

Sensitivity analysis
Final sample, born
in
between 1957 and 1986 n = 17, 253 (98.6 %)
n = 17 485 with physical activity
data

Figure 1. Identification of the adult population sample for analysis.

33