Dear editor: Diabetes mellitus (DM) has been the first cause of death in females and the second cause in males since 2003 in Mexicans aged 20 to 79.¹1. Instituto Nacional de Estadística Geografía. Principales causas de mortalidad por residencia habitual, grupos de edad y sexo del fallecido [web site] INEGI 2016 [cited 2016 Nov 7]. Available from: http://www.inegi.org.mx/est/contenidos/proyectos/registros/vitales/mortalidad/tabulados/PC.asp?t=14&c=11817
http://www.inegi.org.mx/est/contenidos/p... A study from 1980 to 1999 showed that the age-standardized mortality rate of DM (ASMR) in Mexico increased dramatically parallel to rates of obesity.²2. Rivera JA, Barquera S, Campirano F, Campos I, Safdie M, Tovar V. Epidemiological and nutritional transition in Mexico: rapid increase of non-communicable chronic diseases and obesity. Public Health Nutr 2002;5:113-122. https://doi.org/10.1079/PHN2001282
https://doi.org/10.1079/PHN2001282... In 2004, half of Mexicans had no health insurance and the Popular Health Insurance or “Seguro Popular” (SP) was introduced ³3. King G, Gakidou E, Imai K, Lakin J, Moore RT, Nall C, et al. Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme. Lancet 2009;373:1447-1454. https://doi.org/10.1016/S0140-6736(09)60239-7
https://doi.org/10.1016/S0140-6736(09)60... extending health insurance nationwide mainly for the poor. Among other diseases, SP covers free diagnostics, hospitalization and medical treatment for DM. By 2015, 57.1 million people in the country were enrolled in SP.⁴4. Comisión Nacional de Protección Social en Salud. Personas Afiliadas al Seguro Popular [web site ] Seguro Popular. México: Secretaría de Salud, 2017 [cited 2016 Dec 15 ]. Available from:http://www.seguro-popular.gob.mx/index.php/transparencia/iii-transparencia-focalizada?layout=edit&id=568
http://www.seguro-popular.gob.mx/index.p... In this letter we report the annual percent change (APC) of DM’s ASMR from 1999 to 2014 in Mexicans aged 20 to 79 to determine whether the introduction of SP in 2004 has impacted DM mortality.

De-identified DM mortality and population growth data were obtained from official websites.⁵5. Dirección General de Información en Salud. Bases de datos sobre defunciones [web site]. Secretaría de Salud 2017 [ cited 2016 Nov 7 ]. Available in:http://www.dgis.salud.gob.mx/contenidos/basesdedatos/std_defunciones_gobmx.html
http://www.dgis.salud.gob.mx/contenidos/... ^,66. Secretaría de Gobernación (Segob). Datos de Proyecciones de la población [web site] Consejo Nacional de Población (Conapo) 2015 [ cited 2016 Nov 7 ]. Available in:http://www.conapo.gob.mx/es/CONAPO/Proyecciones_Datos
http://www.conapo.gob.mx/es/CONAPO/Proye... ASMR were calculated according to the World (WHO 2000-2025) Standard population⁷7. World Health Organization. World Standard Population 2000-2025 [web site ] WHO 2001 [ cited 2016 Nov 7] Available in:http://seer.cancer.gov/stdpopulations/world.who.html
http://seer.cancer.gov/stdpopulations/wo... and joinpoint regression analysis⁸8. National Cancer Institute. Joinpoint Trend analysis Software [web site] Division of Cancer Control and Population Sciences 2016 [ cited 2016 Nov 7 ]. Available in:https://surveillance.cancer.gov/joinpoint
https://surveillance.cancer.gov/joinpoin... was used to determine national trends of DM’s ASMR.

From 1999 to 2014 a total of 882 968 DM deaths were reported, all estimates shown in table I increased during this period. From 1999 to 2005 the crude rate and ASMR were higher in females than males but from 2006 to 2014 both were higher in males. From 1999 to 2005, the ASMR’s APC statistically increased in the whole sample, in females (3.3 and 2.5, respectively), and in males (3.9) from 1999 to 2006. However, a decreased trend was seen in females (APC:-0.9) from 2005-2014 with a diminished increase in males (APC: 0.8) from 2006 to 2014 (figure 1). This favorable trend in females and diminished increase in males after 2004 was likely associated with the introduction of SP and may be partially explained by the higher number of females enrolled in SP.⁴4. Comisión Nacional de Protección Social en Salud. Personas Afiliadas al Seguro Popular [web site ] Seguro Popular. México: Secretaría de Salud, 2017 [cited 2016 Dec 15 ]. Available from:http://www.seguro-popular.gob.mx/index.php/transparencia/iii-transparencia-focalizada?layout=edit&id=568
http://www.seguro-popular.gob.mx/index.p... Other potential reasons for the favorable trend in females might include a better blood sugar control, compliance to healthy diet and/or DM treatment all of which deserves further investigation.

Unfortunately SP does not cover dialysis expenses in patients with renal failure secondary to DM nephropathy which is more frequent in males and a frequent cause of death. Mexico is among the countries with the highest prevalence of obesity and DM ⁹9. World Health Organization. Global database on body mass index [web site] World Health Organization 2006 [ cited 2016 Dec 8] Available in:http://apps.who.int/bmi/index.jsp
http://apps.who.int/bmi/index.jsp... ^,1010. International Diabetes Federation. IFD Diabetes atlas. 7th ed. [web site] IDF 2015 [ cited 2016 Dec 8] Available in:http://www.diabetesatlas.org/
http://www.diabetesatlas.org/... and even though lifestyle changes have been noted such as slight reduction of sugary drinks consumption,¹¹11. Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ 2016;352: h6704. https://doi.org//10.1136/bmj.h6704
https://doi.org/10.1136/bmj.h6704... more has to be done. Motivation for more male enrollment in SP, along with preventive and educational material on risk factors of obesity and DM should be reinforced at each SP consultation. These alone with adequate DM treatment and compliance will likely translate into ideal body weight and glycemic control resulting in a decrease of DM complications and mortality at a higher pace for females and promotion of a favorable trend for males. Future studies will determine the impact of SP on DM mortality in specific Mexican States.

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