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‘Vida Saludable’: Healthy living is on the school curriculum in Mexico

Read a Spanish version of the article here

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By Angélica Hernández, Gabriela Tamez Hidalgo and Anabel Fiorella Espinosa

Angélica Hernández is a former consultant at UNICEF Mexico. She supported the Ministry of Education in the development of Healthy Living content.

Gabriela Tamez Hidalgo is the former Director of Curricular Strengthening in Basic Education at the Ministry of Public Education, Mexico.

Fiorella Espinosa is a Nutrition Officer at UNICEF Mexico. She is a public health nutritionist and her main role at UNICEF is to promote the modification of the food environment to improve the nutrition of children and adolescents.

Location: Mexico

What this article is about: This article outlines the development of a new subject – ‘Vida Saludable’ or ‘Healthy Living’ – which is featured in the Mexican national school curriculum. The subject aims to educate schoolchildren whilst tackling the wider nutritional challenges facing Mexico’s youth.

Key messages:

  • Vida Saludable is the latest in a growing body of nutrition-focused initiatives that the Mexican government has introduced in recent years with the objective of curbing the national obesity epidemic in the context of the COVID-19 pandemic.
  • This comprehensive initiative highlights the value of collaboration between government departments and organisations with the formation of the new subject showcasing the government’s ability to develop a novel, evidence-based, child and adolescent-focused intervention.
  • Despite successes, remaining challenges revolve around implementing a robust monitoring and evaluation system, as well as formally incorporating the subject into the national curriculum and resolving the associated timetabling issues.

 Background

Since the turn of the century, Mexico has made steady progress across a number of nutrition indicators (Global Nutrition Report, 2021). Child and adolescent (5-19 years) underweight prevalence, now at 8.8% and 9.7% for girls and boys respectively, has decreased year on year, exclusive breastfeeding in children under six months increased from 14.4% in 2012 to 28.6% in 2018 and the dietary intake of adults older than 25 years of fruits, legumes, wholegrains, fibre and polyunsaturated fat all fall above the global average with sodium consumption falling below. For more than a decade, the government has also proactively pursued favourable public health nutrition policies such as salt iodisation, sodium reduction, sugar-sweetened beverage taxation, , introducing food warning labels and restricting the marketing of ultra-processed foods towards children. The country therefore appears to be ‘on course’ towards meeting global nutrition targets.

However, progress in Mexico is a tale of two sides. As the burden of undernutrition has fallen, overnutrition has risen. In 2020, the combined prevalence of overweight and obesity amongst the school-aged population (5-11 years) was 38.2% with the prevalence rising to 43.8% in adolescents and up to 44.6% in adolescent women specifically (Shamah-Levy et al, 2021). Vegetables, nuts and seeds and omega-3 consumption are all under the global average, with red and processed meat and sugar-sweetened beverage consumption higher compared to the global average (Global Nutrition Report, 2021). Moreover, the emergence of the COVID-19 pandemic has reaffirmed overweight and obesity as a public health priority in Mexico due to the links with increased susceptibility to COVID-19 (UNICEF, 2021).

In response to the nutritional challenges facing Mexico’s youth, the Ministry of Health (MoH) and the Ministry of Education (MoE), with the support of UNICEF, launched a new subject for the school curriculum, ‘Vida Saludable’ (healthy living) (Government of Mexico, 2020). The project aims to help children to develop healthy habits through long-term behaviour change. The original idea for Vida Saludable was driven by the government of Mexico with President Andres Manuel Lopez Obrador introducing the idea to provide a unified response to the public health problems faced by the country’s youth. This vision was in place before the COVID-19 pandemic but the arrival of the virus in Mexico, along with the evidence that obesity and diabetes influenced intensive care admittance rates (Cai et al, 2020), reinforced the need for the programme. This paved the way for the MoH, MoE and UNICEF to unite and deliver the initiative. The design of the programme was finalised in June 2020 and the programme was rolled out from July, although it remains unpublished to date.

The Vida Saludable initiative

Background research and development

Although nutrition partially featured on the existing national curriculum in the form of civic studies, science and physical education, the Vida Saludable vision is to formally incorporate nutrition, physical education and hygiene into the learning roster to combat the emergence of obesity, diabetes and sedentary lifestyle behaviours. Like many other public health endeavours of such magnitude, Vida Saludable was informed by other current public health projects. Approaches such as the labelling of ultra-processed foods, sugar-sweetened beverage taxation and increased access to water fountains in schools –  all part of a collective effort to dissuade the youth from consuming sugar-laden, fizzy drinks –  attempt to facilitate healthier lifestyle behaviours in children and adolescents. Each of these initiatives is linked to the Mexican government’s wider policy objective of combating obesity with the Vida Saludable initiative designed to build upon these policies, specifically targeting the youth population who are particularly susceptible to the obesogenic environment.

Although the project has its origins in Mexico, evidence was taken from a number of global sources with the UNESCO and World Health Organization’s (WHO) Global Standards for Health Promoting Schools (WHO, 2018) informing best practice and the UNICEF transferable skills framework (UNICEF, 2019) used to build the intervention. Before Vida Saludable, there was a precursor programme, ‘Scholar Health’, which was run by various government entities related to health, education and social protection and in collaboration with the National Institute of Public Health, UNICEF and the Pan American Health Organisation (PAHO). Vida Saludable therefore relied on the work of this same consolidated group of individual entities who, after the arrival of the COVID-19 pandemic, were commissioned to carry out a one-month review to appraise empirical evidence pertinent to the Vida Saludable initiative. The review was initially carried out by the health sector before being transferred to the MoE who applied expertise from the education system. Over 200 international documents and reports were reviewed to guide the initiative, with the formation of the programme representing a collective effort featuring a large workforce of professionals operating in various roles across the aforementioned institutions.

Vida Saludable Diploma

To ensure quality across schools, the General Directorate of Continuous Training for Teachers and Managers, housed within the MoE, introduced a Vida Saludable Diploma for teachers. The creation of a formal diploma encouraged teachers to complete this training before delivering the subject to students although the course was not compulsory. Various materials were developed for teachers which were divided into five modules: 1) comprehensive human development and health care, 2) mental health, 3) healthy and sustainable food, 4) physical activity and sleep habits and 5) personal hygiene and cleanliness of environments. Teachers could complete the diploma independently by downloading a study guide and an activity booklet for each module as well as a general introductory guide. UNICEF contributed to the development of the healthy and sustainable eating resources, based on the study guide developed by the National Institute of Public Health (INSP), with an approach focused on optimal communication for behaviour change.

Implementation and the COVID-19 pandemic

Vida Saludable learning began in July 2020 with the ‘learn at home’ platform aimed at preschool through to high school students across the country via television, radio and the internet. The intervention was shared in a novel format through interactive games. However, once the government acknowledged that the pandemic was likely to be protracted, this platform became the long-term strategy for delivering the initiative in the 2020-2021 school year.

To build upon remote education, food diaries were provided to the students with each participant expected to reflect on their food and drink consumption which was then followed up by teachers. This made the students aware of any entrenched suboptimal dietary habits such as excess salt or added sugar consumption. The primary goal of this multi-platform approach was to reinforce healthy habits, allowing students to become more autonomous in their lifestyle behaviours, irrespective of the wider obesogenic environment they found themselves in.

Funding

Funding efforts for Vida Saludable were initially coordinated by the Secretary of Education. As much of the programme was, and still is, delivered via television, radio and the internet, Mexican state television helped to finance the programme. Alongside state resources, other partners, including the Danish toy manufacturer LEGO®, were brought on board to help to fund delivery.

Results

The Vida Saludable initiative has now been fully implemented into the national curriculum in all 32 states in Mexico, targeting children aged 6-15 years, despite the initiative not yet being officially enshrined in national policy. Testimonies from the participants involved so far speaks to the popularity of the initiative amongst children.

However, no quantifiable results are available for the programme as yet. Changes in federal administration, specifically within the MoE, and subsequent changes in the education system have made it difficult to determine to date how to quantify success and how success will be measured moving forwards. UNICEF and INSP are currently aiming to support government efforts by conducting a study to analyse the design, implementation and specific outcomes of the initiative through a non-representative sample from three states, to inform future improvements to the initiative. In the middle of the 2021-2022 school year, the short-term results of the implementation of this initiative will be analysed through quantitative and qualitative methods, including interviews with teachers and focus groups with students.

Lessons learned and next steps

The Vida Saludable initiative is an example of how large-scale, seemingly insurmountable challenges such as the national obesity epidemic can be broken down into smaller objectives and tackled using a combination of unified and targeted interventions. Previous nutrition-focused policies have had mixed success in Mexico although progress has been made on some nutrition indicators over recent years. However, collectively, such policies have laid the foundations for Vida Saludable to be successful and this example highlights how a proactive government approach to a public health crisis has the potential for impact. The introduction of Vida Saludable to the national curriculum would have been a greater challenge had previous iterations of the scheme, such as ‘Scholar Health’, not been in place. Such leadership from the government must be commended.

One of the success stories of Vida Saludable is the coordination of different inter- and intra-governmental actors during the development phase. Firstly, the unified approach from the MoE and MoH highlights a level of coordination that, up until now, has not always been apparent at this level of government in Mexico. On a practical level, the consolidation of over 200 international documents and reports to guide the initiative, along with the coordination of the large workforce required to do this, shows promise for the future of Vida Saludable and subsequent programmes that the government prioritises to implement. This process also highlights the government’s commitment to evidence-based programming as well as a willingness to recruit external agencies, namely UNICEF, to provide technical expertise in the interest of delivering a successful intervention.

A paucity of data demonstrating progress, success and impact represents the biggest challenge of the Vida Saludable initiative so far. This is especially pertinent given the scale of the project, with national rollout susceptible to diminishing returns as some regions may perform worse than others, highlighting the need for detailed subnational data. The construction and subsequent implementation of a monitoring system designed by the government, based on the findings from the UNICEF and INSP study, is a necessary addition to the programme that will provide both short- and medium-term results. The provision of this evaluation can therefore offer a valuable opportunity to incorporate lessons learned moving forwards.

The lack of usable data has been mostly attributed to challenges at the policy level. Changes in personnel within the government have hindered the implementation of a workable monitoring and evaluation strategy. These same changes have also made it difficult for Vida Saludable to be integrated into national policy as, long term, there is uncertainty regarding the most effective way to fit the subject into the national curriculum. The impact on timetabling and the knock-on effect that introduction would have on other subjects are key questions for the initiative moving forwards.

In addition to these broader challenges, changing the ingrained habits found within the Mexican lifestyle has been problematic for the programme so far. For example, questions have arisen about how best to reach wider family members within the household. This is the main driver of a move away from ultra-processed foods toward the purchase of food from local markets which in turn is an important aim for Vida Saludable. For this reason, the social determinants of health are being included in lessons so that children can critically engage with the subject matter and work with their parents to overcome the obstacles of behaviour change.

However, linked to the wider determinants of health, there is an acknowledgement that this programme may only go so far in delivering change. For example, promoting behaviour change models in isolation is unlikely to confer significant gains for families who live in conditions not conducive to healthy living. The hygiene arm of Vida Saludable will not change the lives of those who have limited access to appropriate water, sanitation and hygiene facilities, for example. Nutrition education can increase agency and improve dietary decision-making but it will not be able to overcome the proliferation of ultra-processed foods, sugar-sweetened beverages and a lack of access to fresh produce that constitutes the food environment found in some districts.

Therefore, a multi-sector approach to address income generation, poverty alleviation, suboptimal food systems and making healthy choices accessible to young people is required to create an enabling environment, ensuring the long-term success of Vida Saludable. Nevertheless, the introduction of Vida Saludable holds promise, as wider policies are already in place which point to the government’s willingness to implement a multi-sector approach. Since 2010, and then updated in 2014, guidelines have been published that prohibit the sale and distribution of foods that do not meet specific nutritional criteria between Mondays and Thursdays. There is also a law that mandates the installation of drinking fountains in all schools although this ambition is yet to be fully realised. With the return of pupils to classes after the initial impact of the COVID-19 pandemic, the dialogue between the MoE and MoH is being resumed to push forward with these regulations to facilitate healthier school environments.

Conclusion

Vida Saludable is the most recent in a growing body of nutrition-focused initiatives that the Mexican government has introduced in recent years. Obesity amongst children and adolescents is a public health priority and the government has responded proportionately with this curriculum-based initiative which it hopes can stem the tide of unhealthy lifestyle habits that have crept into daily life. However, although promising steps have been taken, a paucity of data prevents any conclusive evaluation of the programme so far. The next steps for Vida Saludable will be to officially incorporate the subject into the national curriculum which will give the initiative more visibility as well as contribute to the broader strategy of healthier living in Mexico. Above all, implementing an effective monitoring and evaluation strategy, with the support of UNICEF and INSP, is integral to documenting the success of the initiative and determining whether Vida Saludable is a worthwhile endeavour.

For further information, please contact Fiorella Espinosa at aespinosa@unicef.org 

Furthermore, to see an example of Vida Saludable in action, visit here

Read the Spanish version here

References 

Cai, Q, Chen, F, Wang, T, Luo, F, Liu, X, Wu, Q et al (2020) Obesity and Covid-19 Severity in A Designated Hospital in Shenzhen, China. Diabetes Care. 43(1), 1392-1398. Available At: https://care.diabetesjournals.org/content/diacare/43/7/1392.full.pdf 

Global Nutrition Report (2021) Country Nutrition Profiles: Mexico. https://globalnutritionreport.org/resources/nutrition-profiles/latin-america-and-caribbean/central-america/mexico/ 

Government of Mexico (2020) “Healthy Living”, A New Subject in Study Plans. Available At: https://www.insp.mx/avisos/vida-saludable-nueva-materia-en-planes-de-estudio 

Shameh-Levy, T, Romero-Martinez, M, Barrientos-Gutierrez, T, Cuevas-Nasu, L, Bautista-Arredondo, S, Colchero, M et al (2021) Encuesta Nacional de Salud y Nutricion 2020 Sobre Covid-19. Resultados Nationales. Cuernavaca, Mexico: Instituto Nacional de Salud Publica. https://ensanut.insp.mx/encuestas/ensanutcontinua2020/doctos/informes/ensanutCovid19ResultadosNacionales.pdf 

UNICEF (2019) Global Framework on Transferable Skills. Available at: https://www.unicef.org/reports/global-framework-transferable-skills 

UNICEF (2021) Country Office Annual Report 2020: Mexico. Available at: https://www.unicef.org/media/100406/file/Mexico-2020-COAR.pdf

WHO (2018) Global Standards for Health Promoting Schools. Available at: https://www.who.int/publications/i/item/global-standards-for-health-promoting-schools

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Angélica Hernández, Gabriela Tamez Hidalgo and Anabel Fiorella Espinosa (). ‘Vida Saludable’: Healthy living is on the school curriculum in Mexico. Field Exchange 66, November 2021. p44. www.ennonline.net/fex/66/healthylivingschoolcurriculum

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