Multidimensional Intervention to Improve Healthy Lifestyle Practices and Nutrition and Health Status in Mexican Schoolchildren: Development of an Intervention Platform, Randomized Clinical Trial and Scaling Proposal
Phase: NA
Conditions: Childhood Obesity, Pediatric Obesity, Childhood Overweight
Sponsor: Mexican National Institute of Public Health

 
1  
  
  
      
      
 
 
 
  
  
Multidimensional intervention to improve healthy lifestyle practices , nutritional 
status and health in Mexican schoolchildren: Development of an intervention 
platform, randomized clinical trial and escalation proposal. 
  
 
 
 
 
 
Juan Rivera Dommarco 1 , David Kershenobich 2 , María Elena Medina Mora 3 , Simón 
Barquera 1 , Carlos Aguilar-Salinas 2 , Teresa Shamah 1 , Nalú Navarro 2 , Sonia Hernández 
Cordero 4, Anabelle Bonvecchio 1 , Lucía Hernández 1 , Ana Carolina Ariza 1 , Lizbeth 
Tolentino Mayo 1 , Alejandra Jauregui 1 , Claudia Unikel 3 , Edgar Denova Gutiérrez 1 . 
  
  
  
  
  
  
  
 
1 National Institute of Public Health, 2 Salvador Zubirán National Institute of Medical 
Sciences Nutrition, 3 Ramón de la Fuente Muñiz National Institute of Psychiatry , 4 Ibero-
American University. 
  

 
2  
  
  
      
      
INTERVENTION TO IMPROVE HEALTHY LIFESTYLE PRACTICES AND NUTRITION AND HEALTH 
STATUS IN MEXICAN SCHOOLCHILDREN: DEVELOPMENT OF AN INTERVENTION PLATFORM, 
RANDOMIZED TRIAL AND SCALING PROPOSAL. 
 
 
TABLE OF CONTENTS 
Summary.  .........................................................................................................................................5 
Introduction  ....................................................................................................................................7 
National policies developed to prevent overweight and obesity in the population  ......8 
Proposal for a multidimensional intervention  ............................................................................9 
Boarding  .....................................................................................................................................................9 
Theoretical Framework  ........................................................................................................... 10 
Ecological model  ................................................................................................................................... 10 
Theory of planned behavior (Ajzen)  .............................................................................................................................. 11 
General objective  ........................................................................................................................ 14 
Specific objectives  ...................................................................................................................... 14 
Research Questions  ................................................................................................................... 14 
Methodology  ................................................................................................................................ 15 
Selection of the sample of schools and children  ............................................................... 17 
School selection criteria  .................................................................................................................... 17 
1.  Stage 1. Situational diagnosis  ........................................................................................ 20 
Generalities of stage 1  ........................................................................................................................ 20 
1.1.  Systematic literature review  ...................................................................................... 22 
1.2.  Focused formative research  ....................................................................................... 23 
1.3.  Review and analysis of the political and structural environment for the 
implementation of multidimensional intervention  ........................................................ 32 
1.4.  Instrument validation  .................................................................................................. 32 
1.4.1  
Logistics diagnostic stage  ................................................................................................ 33 
1.5.  Analysis of information from the 2005-2017 birth cohort  ............................... 34 
Ethical considerations of stage 1  .................................................................................................... 34 
Generalities of the results of stage 1  ............................................................................................. 35 
Progress of the analysis of the birth cohort  ................................................................................. 36 

 
3  
  
  
      
      
2.  Stage 2. Design and development of the multidimensional intervention and 
evaluation instruments.  ........................................................................................................... 37 
Generalities of stage 2  ........................................................................................................................ 37 
Stage 2 objectives  ................................................................................................................................. 37 
Study design for stage 2  ..................................................................................................................... 37 
1) Healthy and sustainable diet (ASS) ........................................................................................................................... 37 
2) Movement behaviors (CM)  ........................................................................................................................................... 38 
3) Psychosocial component (PC)  ..................................................................................................................................... 38 
Multidimensional intervention design  ................................................................................ 39 
2.1 Feasibility study and validation/pilot test of the intervention materials.  .............. 39 
Feasibility study methodology  ........................................................................................................ 39 
2.2 Feedback and modification of the activities and communication materials of the 
initial IM proposal on healthy and sustainable eating, movement behaviors and 
psychosocial determinants based on the results of the field work.  .................................. 40 
2.3 Implementation logistics. ........................................................................................................... 40 
Description of the intervention by axis  ........................................................................................ 40 
AXIS 1. HEALTHY AND SUSTAINABLE DIET .............................................................................................................. 41 
AXIS 2. MOVEMENT BEHAVIORS  .................................................................................................................................... 46 
AXIS 3. PSYCHOSOCIAL COMPONENT  .......................................................................................................................... 47 
Generalities of the results of stage 2  ............................................................................................. 50 
3.  Stage 3. Implementation, monitoring and evaluation of the multidimensional 
intervention.  ................................................................................................................................ 51 
3.1.  Basal Measurement  ....................................................................................................... 51 
3.2.  Implementation of the intervention  ......................................................................... 51 
3.3.  Intervention monitoring  .............................................................................................. 67 
Qualitative monitoring indicators  ................................................................................................. 68 
Quantitative monitoring indicators  .............................................................................................. 69 
Logistics of monitoring information collection  ........................................................................ 74 
Evaluation of the multidimensional intervention .................................................................... 74 
Community essay  .................................................................................................................................. 74 
Clinical trial  ............................................................................................................................................ 75 
Statistical analysis  ................................................................................................................................ 84 
Information analysis  ........................................................................................................................... 85 
Schedule of activities for the implementation of the intervention  ............................. 86 

 
4  
  
  
      
      
4.  Stage 4. Institutionalization of the intervention  ....................................................123 
Ethical and biosafety aspects  ........................................................................................................ 123 
Problems and limitations  ............................................................................................................... 123 
Mechanisms for transferring results and their feasibility  ................................................. 123 
References  ............................................................................................................................................ 124 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
5  
  
  
      
      
Summary.  
  
Obesity in Mexico has experienced an increase in the last three decades in both adults 
and children and adolescents. This epidemic has been documented through the 
different National Health and Nutrition Surveys. Currently more than 7 out of every 10 
adults and approximately 4 out of every 10 girls, boys and adolescents live with 
overweight or obesity. For this reason, for several years, the National Institute of Public 
Health (INSP, for its Spanish acronym), the Salvador Zubirán National Institute of 
Medical Sciences and Nutrition (INCMNSZ for its Spanish acronym) and the Ramón de 
la Fuente Muñiz National Institute of Psychiatry (INPRFM for its Spanish acronym) have 
developed, independently, studies and interventions to generate proposals that 
contribute to the solution of this problem. 
The experience of the three National Institutes of Health (INSalud for its Spanish 
acronym), in the study of various dimensions of the problem of overweight and obesity, 
including individual aspects (such as psychological and biological), as well as those of 
the physical and social environment of the spaces in which children develop 
(community, school and home) relevant in the context of a predominantly urban, 
developing, middle-income country, can be useful to propose a multidimensional 
intervention (MI) with evidence of effectiveness and sustainability, which considers 
previous interventions, and supports their correct application, verifies their effects and 
complements the program with innovative actions that, if proven effective, could be 
integrated to improve its effects. 
Taking as a starting point the experience of the institutions in the design, application 
and evaluation of actions and programs, as well as international experience, a 
collaborative project between INSalud is proposed to generate a multidimensional 
intervention project, which applies other innovative actions in the individual (girl/boy) 
and environmental (family, school and community) spheres. This is a project designed 
to be carried out in 4 stages. The project has financing from the health sector fund (with 
an extension to end on January 11, 2025). The objective of this study is to evaluate the 
effects of an MI on the physical-built and social environment around schools, as well as 
the nutritional status of the school population, through a community trial in schools in 
3 states of the republic. Mexican. The impact will be measured through anthropometric, 
biological, psychological, behavioral and environmental indicators. The target 
population of the intervention will be students between 9-10 years old who are in the 
4th grade of primary school. 
  
 

 
6  
  
  
      
      
As mentioned above, the study is made up of 4 iterative stages, in which each of its 
components will serve to enrich the following stages, which are described below: 
  
Stage 1. Situational diagnosis. Duration: 12 months. In the design of health promotion 
interventions, situational diagnostic assessment is necessary to be able to design an 
intervention adapted to the context and real needs of the target population. This first 
stage of the project will also allow us to identify previous experiences and derive from 
them available evidence on interventions that have been implemented in other 
populations. Likewise, it is necessary to identify the health problems of the population 
to which the intervention to be designed is directed, as well as the existing policies and 
programs and the participation of the target population to which the intervention to be 
designed is aimed. The purpose of the situational diagnostic evaluation is to guide the 
design of the intervention and increase its potential effect. The diagnosis includes 
various activities that are described below: 1) Systematic review of the literature; will 
allow the construction of formative research instruments; 2) Focused formative 
research; 3) Review and analysis of the political and structural environment for the 
design and implementation of a multidimensional intervention; 4) Validation of 
instruments and 5) Secondary analysis of a birth cohort (2005-2017). 
  
Stage 2. Design and development of the MI and evaluation instruments. Duration: 12 
months. The information generated from the situational diagnosis will serve to design 
the IM of this proposal, which will include different levels of intervention such as school, 
around school, home and community. The components of this stage are the following: 
1) Feasibility study; 2) Final design of the multidimensional intervention; and 3) 
Definition of the components of the multidimensional intervention. 
  
Stage 3 . Implementation, monitoring and evaluation of the multidimensional 
intervention. Duration: 10 months. The final IM design that will be implemented during 
this stage will depend on the modifications made in the stages described above. This 
stage consists of the following phases: 1) Randomization, 2) Initial evaluation, 3) 
Beginning of the intervention, 4) Monitoring and evaluation of the process and 5) Final 
evaluation. 
  
Stage 4 . Institutionalization of the intervention. Duration: 12 months. In the final stage, 
an analysis and formulation of recommendations will be carried out for the escalation 
and incorporation of the intervention to the Ministry of Public Education (SEP). In 
addition, meetings will be held with decision makers to seek the scaling of the program 

 
7  
  
  
      
      
to other schools and dissemination activities of the educational materials developed 
(applications and printed material) aimed at various population groups. 
  
  
Introduction 
 
Obesity is an important public health problem whose trend in Mexico has experienced 
a constant increase in recent decades 1,2,3,4 . This condition has as its origin a complex 
causal chain, of multifactorial etiology, where genetic, behavioral and environmental 
factors interact, including lifestyles, as well as psychological, social and economic 
determinants. It is characterized by an increase in body fat deposits and weight gain 
caused by a positive energy balance; characterized by an energy intake (which comes 
from food) greater than the energy expenditure (product of physical activity). Positive 
energy balance results in turn from inadequate dietary patterns and physical activity. 
Obesity early in life increases the risk of chronic diseases such as type 2 diabetes, 
cardiovascular disease, cirrhosis and 11 types of cancer, leading to premature 
mortality. Given the seriousness of the problem, it is important to identify and act on 
the immediate, underlying and basic causes of this condition, seeking its prevention. 
  
The environment is a determining component, since it can promote lifestyles that are 
not compatible with health. Eating habits and lifestyles in general are determined by 
environmental factors such as family, culture and society, as well as socioeconomic 
level (SES) and the physical characteristics of the spaces in which we live. It is still not 
clear whether the psychopathology present in cases of overweight and obesity is a 
cause or consequence of it, although it is likely that there is a reciprocal relationship 
between the individual and the environment. Overweight and obesity are accompanied 
by various psychiatric and psychological disorders, including low self-esteem, 
dissatisfaction with body image, depression, anxiety, phobias, eating disorders, post-
traumatic stress disorder, experiences of violence and alexithymia. 5 . Low self-esteem 
predicts the development of obesity in children 6 . People with low self-esteem or who 
overvalue weight and body shape will tend to seek thinness through inappropriate 
methods, which may result in the development of psychopathology. On the opposite 
side, there are those individuals who do not perceive themselves as overweight despite 
having it, which promotes its increase 7 . A relationship has been found between SES 
and the desire to have or not have a thin body figure: the higher the SES, the lower the 
desire, but there is also less information about care and less access to health services. 
Likewise, it is known that there is a difference by sex with respect to the attitude 
towards being overweight. In the 2006 National Nutrition and Health Survey 8 , it was 

 
8  
  
  
      
      
found that 2.4% and 0.3% of adolescents between 10 and 14 years old have moderate 
and high risk, respectively, of an eating disorder. While women, as well as people with 
a higher body mass index and socioeconomic level, are at greater risk of an eating 
disorder 9 . 
  
Obesity in Mexico has experienced an unusual increase in the last three decades in both 
adults and girls, boys and adolescents. This epidemic has been documented through the 
different National Health and Nutrition Surveys (ENSANUT). Currently more than 7 out 
of every 10 adults and approximately 4 out of every 10 girls, boys and adolescents live 
with overweight and obesity. For this reason, for several years, the National Institute of 
Public Health (INSP), the Salvador Zubirán National Institute of Medical Sciences and 
Nutrition (INCMNSZ) and the Ramón de la Fuente Muñiz National Institute of 
Psychiatry (INPRFM) have developed, independently, studies and interventions to 
generate proposals that could contribute to the solution of this public health problem. 
These include systematic reviews 10,11,12 , studies on the school environment 13,14,15,16 , 
community 17,18 , family and individual environments 19,20,21,22 . Due to the increase in 
the prevalence of overweight and obesity in Mexican children and the greater 
possibility of influencing dietary and physical activity patterns in children compared to 
adults, this proposal directs its efforts to the prevention of overweight and obesity in 
school-age children 23,24.  
  
The separate impact of these efforts is relatively low. For example, the INCMNSZ 
initiative prevented the increase in the percentage of cases with obesity in the treated 
group 12 ; and various INSP interventions have managed to document greater physical 
activity in children subject to an intervention 25 , as well as positive effects on the 
availability of healthy foods and reduction in the ingestion of non-recommended foods 
26 . However, better results could be achieved with multidimensional interventions, 
with a comprehensive model that takes advantage of the experience and strengths of 
the three National Institutes of Health (INSalud), with the potential to be scaled 
nationally. Therefore, this proposal represents an opportunity to consolidate the 
experience of the Institutes and generate a more effective, strengthened and exportable 
model. 
  
National policies developed to prevent overweight and obesity in the 
population  
  
Based on several studies, the Ministry of Health (SSA) developed the National 
Agreement for Food Health (ANSA) 27,28 from which the general guidelines for the sale 

 
9  
  
  
      
      
and distribution of food and beverages in school consumption establishments of basic 
education schools 29,30,31 that contemplated various measures such as: Improving the 
availability of healthy foods, the removal of soft drinks and sugary drinks (except juices 
and nectars), the installation of drinking fountains and the implementation of various 
strategies to increase the physical activity. The various evaluations of these guidelines 
have made it possible to identify barriers to the implementation of the proposed 
measures in schools. Among these is the limited time available in most of the country's 
schools to cover the entire curriculum, which makes it difficult to dedicate more time 
to physical activity, the reduced time of moderate and vigorous physical activity during 
classes of physical education, the lack of installation of drinking fountains or the lack of 
maintenance and cleaning thereof, the persistent availability of unhealthy foods and, on 
the other hand, a high availability of foods with high energy content and poor in 
nutrients (food scrap metal), street vendors and advertising around schools 32 . Finally, 
it is necessary to recognize that the time that children are in school, which corresponds 
to only 4.5 hours, for 5 days per week, is restricted to impact healthy practices and the 
health status of schoolchildren, especially if they are not It is accompanied by a 
comprehensive intervention that includes other environments (community and home) 
and at the various times of the day in which schoolchildren operate. 
 
As part of the policies implemented at the national level for the prevention of 
overweight and obesity in children and adolescents, the SEP, in collaboration with the 
SSA, have developed various programs for implementation in schools of the Mexican 
school system, such as the Action Program in the School Context (2010) which had the 
purpose of preventing and controlling overweight and obesity in basic education 
students. 
  
Proposal for a multidimensional intervention  
Approach 
  
The experience of INSalud, mentioned previously, in the study of various dimensions of 
the problem of overweight and obesity, including individual aspects (such as 
psychological and biological), as well as those of the physical and social environment of 
the spaces in which children develop (community, school and home) relevant in the 
context of a predominantly urban, developing, middle-income country, it may be useful 
to propose a multidimensional intervention (MI) with evidence of effectiveness and 
sustainability, which considers the proposed interventions, support their correct 
application, verify their effects and complement the program with innovative actions. 
  

 
10  
  
  
      
      
Taking as a starting point the experience of the institutions in the design, application 
and evaluation of actions and programs, as well as international experience, a 
collaborative project between INSalud is proposed to generate an IM program that 
takes advantage of the actions previously carried out in the school context, which 
ensures its correct implementation and applies other innovative actions at the 
individual (girl/boy) and environmental (family, school and community) levels. The IM 
will contemplate three axes: 1) Biological, 2) Psychological and 3) Social. With these 
actions we seek to create a group of “model” schools, in 3 federal entities of the republic 
(Campeche, Mexico City, and Morelos), that generate an environment in the schools and 
in the environments around the school, which, added to the promotion of behavioral 
changes through educational communication, resulting in the adoption of feeding, 
physical activity and mental health practices recommended for the school population. 
  
Theoretical framework 
Ecological model  
  
Obesity and overweight are caused by various factors, both genetic and environmental. 
As a result of the current epidemic observed throughout the world, it is recognized that 
the most important factors are environmental and social, among which are, for 
example: the availability and accessibility of food, changes in the national food system 
and marketing. , as well as promotion through various media. 33 
  
It has been listed in various publications that influences come from and are expressed 
at different levels of disaggregation in which the individual develops throughout life, at 
a personal or group level, in businesses, schools or institutions, work and even through 
of means of transportation, as shown in Figure 1. 34 To try to understand how an 
individual has a certain nutritional status (NS), it must be taken into account that each 
context acts at a different level. At a first level are the structural determinants of a 
society: social, economic, cultural, political and geographical aspects; At a second level 
are the underlying determinants that include aspects related to access to health 
services, availability and access to food, lifestyles and education. Structural and 
underlying determinants indirectly influence the individual's NE through proximate 
determinants. Finally, there are the proximate determinants and they are those directly 
related to energy consumption (diet, habits, physical activity) and the characteristics of 
the individual. 
 
 
 

 
11  
  
  
      
      
Figure 1. Ecological model, 2005. 
 
 
Source: Adapted from the book: Obesity in Mexico. 1 
  
Theory of planned behavior (Ajzen)  
The adoption by individuals of a certain behavior (e.g. consuming plain water) depends 
on a set of factors and variables that act at individual, social or environmental levels. 
Among the different theories that help us understand human behavior, we select the 
Theory of Planned Behavior 35,36 which will serve as a reference to guide the 
diagnosis/formative research and formulation of recommendations. 
In this model, a set of elements such as culture, socioeconomic level and exposure to 
the media can in turn condition constructs that contribute to behavior such as intention, 
attitude, subjective norm and perceived control. In the following table, we present the 
definitions of the mentioned constructs. 
   
Table 1. Definition of constructs for the Theory of Planned Behavior 
Construct 
Definition 
Intention 
It reflects how determined a person is to try to adopt a behavior or how much effort 
they plan to give to change the behavior. 
Attitude 
It reflects the agreement or disagreement with a behavior/conduct. 

 
12  
  
  
      
      
Rule 
subjective 
It is made up of: (1) the perception that other people important to the subject 
approve, think, expect and desire their behavior and (2) the subject's own 
motivation to accommodate the expectations or desires of those people. 
Perceived 
control 
It is the subject's perception of having a set of skills to carry out a specific behavior. 
  
Therefore, in the diagnosis/formative research phase, the different constructs of 
Ajzen's theory will be explored in relation to nutrition. 
 
School-based interventions have been suggested for the prevention of this condition, 
and they identified that the most common treatments involved lifestyle interventions 
(i.e., regulated screen time for children). Furthermore, interventions (diet, family 
behavior, PA promotion, supervised exercise, lifestyle, or multicomponent 
interventions) were reported to be associated with a reduction in BMI. 
 
Body response to changes in body composition 
The participation of inflammatory processes has acquired great relevance in recent 
years as part of the pathophysiological mechanisms that accompany the development 
and progression of obesity. As there is an increase in fat mass, adipocytes generate a 
greater amount of reactive oxygen species, promoting the expression and release of 
proinflammatory substances such as cytosines and adipokines. The increase in 
inflammatory substances produces an increase in oxidative stress, thus establishing a 
pathological cycle that exacerbates the disease. Furthermore, oxidative stress has been 
associated with insulin resistance and endothelial dysfunction, comorbidities 
associated with diabetes and cardiovascular diseases. 
  
Various studies carried out in adult and child populations have shown that obesity is 
associated with an increase in circulating concentrations of markers of inflammation 
and oxidative stress such as IL-6, C-reactive protein and TNFα 92,93,94 . Likewise, an 
imbalance has been observed in the antioxidant system, with a decrease in the activity 
of antioxidant enzymes (superoxide dismutase, catalase, glutathione peroxidase) 
combined with a decrease in nitric oxide, as well as an increase in the concentrations 
of stress markers. oxidative such as malondialdehyde (MDA), 8-oxo-deoxyguanosine 
and isoprostanes. 
  
Because these processes occur rapidly at the cellular level and are established as the 
amount of adipose tissue increases, it is feasible that they can be used as early markers 
and detect changes before the establishment of other pathological processes such as 

 
13  
  
  
      
      
insulin resistance, dyslipidemias and cardiovascular diseases. The above is useful not 
only for diagnosis in the clinic but for evaluation in short-term population 
interventions related to these conditions. 
  
• Assessment of inflammation in children living with obesity 
Obesity is a chronic inflammatory process that involves the accumulation of 
proinflammatory macrophages not only in adipose tissue, but in different organs such 
as the liver and muscle, etc., which contributes to the development of different chronic 
diseases associated with it. Obesity is also a risk factor for metabolic syndrome, a group 
of metabolic complications that include insulin resistance, hypertension, glucose 
intolerance, hepatic steatosis, dyslipidemia, and atherosclerosis. 
  
Insulin resistance associated with obesity is the greatest risk factor for the 
development of type 2 Diabetes (T2DM), which involves multiple organs, such as 
hypertrophic and fatty adipose tissue and fatty liver. Obesity was recently determined 
to correlate with chronic low-grade inflammation, suggesting that inflammation is 
necessary for obesity-associated insulin resistance and subsequent onset of T2DM. 
  
During the development of obesity, macrophages permeate white adipose tissue, and 
together with adipocytes, secrete various proinflammatory cytokines and chemokines 
100 . For example, visceral adipose tissue secretes resistin, interleukin (IL)-6, tumor 
necrosis factor (TNF)-α, IL-1β, and monocyte chemoattractant protein (MCP)-1, of 
which TNF-α e IL-6 has been shown to impair insulin sensitivity. It is important to 
highlight that the visceral adipose tissue in obese people is infiltrated by macrophages 
which cooperate in the generation and maintenance of inflammatory responses. 
Several studies have identified different polarization states of infiltrated macrophages 
within adipose tissue. Galectin-3 (also known as Mac-2) is a 30 kDA lectin located in 
the nucleus, cytoplasm and extracellular membrane which plays an important role in 
the exacerbation of different inflammatory processes. It is also a factor abundantly 
secreted by macrophages, and an important regulator of the polarization of 
macrophages themselves, which could serve as an indirect marker reflecting the 
degree of tissue inflammation observed in obesity. Furthermore, there is evidence of 
the role of Galectin-3 as a predictive marker for the development of heart failure. For 
example, in the Framingham Heart Study, it was observed that previously healthy 
patients in whom elevated levels of Galectin-3 were observed had a higher risk of 
developing cardiovascular disease. 

 
14  
  
  
      
      
Given all the negative implications that obesity can have on the development of chronic 
diseases with a significant impact on the quality of life of our population, in this study 
we have decided to implement intervention measures focused on trying to reduce 
obesity in the child population. 
 
General objective  
  
To evaluate the effects of an MI on the physical-built and social environment around 
schools and the nutritional status of the school population, through a randomized 
community trial, in schools in 3 states of the Mexican Republic, using anthropometric 
indicators. , biological, psychological, behavioral and environmental. 
Specific objectives  
  
1. 
Carry out a situational diagnosis in schools in three states of the Mexican 
Republic (Campeche, Mexico City and Morelos) to document the implementation of the 
strategies that are implemented and identify the risk and protective factors for 
overweight and obesity in the school population. 
2. 
Evaluate the effects of the strategies that are currently being implemented on 
the physical-built and social environment around schools and the nutritional status of 
the school population. 
3. 
Design, develop, pilot and implement an IM that allows to improve the state of 
health and nutrition of the school population, reaching the family environment and the 
school environment and the environments around the schools. 
4. 
To evaluate the effects of IM on health and nutrition status in the school 
population, through anthropometric, behavioral, environmental and psychological 
indicators. In the case of schoolchildren in Mexico City, biochemical indicators and body 
composition will be used. 
  
Research questions 
  
1. 
What are the main risk and protective factors for overweight and obesity in the 
school environment and in the environments around schools in primary education 
schools in three states of the Mexican Republic? 

 
15  
  
  
      
      
2. 
Is there a relationship between risky eating behaviors and the body mass index 
of schoolchildren? 
3. 
Are the strategies that are being implemented effective in reducing the presence 
of risk factors and increasing the presence of protective factors for overweight and 
obesity in the school environment and in the environments around schools? 
4. 
Are the strategies that are being implemented effective in reducing the presence 
of risk factors and increasing the protective factors for overweight and obesity in the 
family environment? 
5. 
Are the strategies being implemented effective in modifying key risk or 
protective behaviors related to overweight and obesity and mental health? 
6. 
Are the strategies that are being implemented effective in reducing the 
prevalence of overweight and obesity in schoolchildren? 
7. 
Are the strategies that are being implemented effective in reducing 
cardiometabolic risks in Mexican schoolchildren? 
8. 
Are the strategies that are being implemented effective to improve body 
composition in Mexican schoolchildren? 
9. 
What is the impact of MI on risky eating behaviors, internalization of the 
aesthetic ideal of thinness, dissatisfaction with body image, and negative affect in 
children? 
10. 
Can MI affect the degree of low-grade systemic inflammation in Mexican 
schoolchildren? 
 
Methodology 
  
The present study is divided into four stages. The general description of each stage is 
presented in Table 1. The study is a randomized community trial that includes 24 
schools from 3 states of the Mexican Republic (Campeche, Mexico City and Morelos) 
(Figure 2) and a randomized clinical trial in parallel in 4 of the schools in Cuernavaca, 
Morelos. Both studies together will address the questions raised in the previous section. 
The selected schools (8 in each federal entity) will be randomly assigned into two 
groups: 1) Schools control , in which the strategy will not be implemented (4 per state 
entity); and 2) Schools with multidimensional intervention, in which IM actions will be 
implemented (4 per federal entity). In these schools, an initial diagnosis of the 
environment around the schools, monitoring and evaluation of the implementation of 
the strategies will be carried out; In addition, an initial and final measurement will be 
carried out with anthropometric, behavioral and environmental modification 
indicators around the schools. 
  

 
16  
  
  
      
      
In parallel, a randomized clinical trial will be carried out in four of the schools in 
Cuernavaca, Morelos, of which two will be controls and two will receive the 
multidimensional intervention. In these schools, an initial diagnosis of the environment 
will be carried out, monitoring and evaluation of the strategies implemented and a 
more in-depth initial and baseline measurement will be carried out, since in addition to 
using anthropometric, behavioral and environmental modification indicators, the 
measurement of body composition using dual x-ray absorption densitometry (DXA), 
cardiometabolic health indicators such as glycated hemoglobin (HbA1c), lipid profile, 
liver function and biological markers, inflammation markers, among others. 
  
 
Table 2. Stages of the study, its components and duration. 
Stage 
Components 
Duration 
Stage 1 
1. Situational diagnosis. 
1.1 Systematic literature review, 
1.2 Focused formative research, 1.3 Review and analysis 
of the political and structural environment for the design 
and implementation of a multidimensional intervention, 
12 months 
 
1.4 Validation of instruments, 
1.5 Secondary analysis of a birth cohort (2005-2017). 
 
Stage 2 
2. Design and development of 
the IM 
and evaluation instruments. 
  
2.1 Feasibility study and validation/pilot test of the 
intervention materials. 
 
- 
Workshop to define IM 
- 
Field work 
 
2.2 Feedback and modification of the activities and 
communication materials of the initial MI proposal on 
healthy and sustainable eating, movement behaviors and 
psychosocial determinants. 
 
2.3 Implementation logistics 
 
12 months 
Stage 3 
3. 
Implementation 
of 
the 
multidimensional 
intervention. 
3.1 Basal measurement, 
3.2 Implementation, 
3.3 Monitoring of the intervention, 3.4 Final 
measurement. 
10 months 
Stage 4 
4. Institutionalization of the 
intervention 
4.1 Analysis of information, 
4.2 Conceptualization of escalation, 
4.3 Report writing. 
12 months 

 
17  
  
  
      
      
  
Selection of the sample of schools and children  
  
Those in charge of implementing strategies by the Ministry of Public Education (SEP) 
will be asked for a list of schools in each federal entity. From these, we will randomly 
select schools (4 control schools and 4 intervention schools per state) from urban 
locations that meet the selection criteria shown below. 
  
Within the school, one or two groups (depending on school enrollment and the number 
of students per group) of 4th grade will be randomly selected. Subsequently, we will 
distribute the letters of consent and assent to all the students in the assigned group, 
and those who return on the agreed date the letter of consent signed by the 
parents/guardians and the students (letter of assent), will be taken into account to 
participate in the study. The age of the boys and girls who will participate in this study 
will be between 9 and 10 years old. This age period corresponds to schoolchildren who 
will be in the 4th grade . 
  
Of the children eligible to participate, 30 boys and girls will be selected within each 
group for the purposes of applying the baseline and final measurements. It should be 
noted that we do not consider it appropriate to reject any student who wants to 
participate and who has parental/guardian permission, so they will be included in the 
study. All boys and girls in a school will be exposed to the corresponding type of 
intervention. 
  
School selection criteria 
  
For the study, the following characteristics of the schools will be taken into account: 
 
They must be located in the three federal entities in which the study will be carried out 
(Campeche, Mexico City and Morelos). In the case of Campeche and Mexico City, the 
educational authorities will be requested that primary schools be of public order, that 
they have an enrollment of at least 1,000 students, that they have two or more groups 
of each school grade and that they are morning or morning shift (8:00-12:30 hrs) or 
extended shift (8:00-14:00 hrs). 
 

 
18  
  
  
      
      
For the state of Morelos, it will be sought that primary schools be private, that they have 
an enrollment of at least 1,000 students, that they have a morning or morning session 
(8:00-12:30 hrs) or an extended day (8:00 a.m.-12:30 p.m.) 00-14:00 hrs). 
 
It is important to specify that, according to the National Commission for the Continuous 
Improvement of Education (MEJOREDU for its Spanish acronym), in primary education 
at the national level in urban localities, their distribution is homogeneous. On the other 
hand, the National Council for the Evaluation of Social Development Policy (CONEVAL) 
the cities that participate in the “Multidimensional intervention to improve healthy 
lifestyle practices and nutrition and health status in Mexican schoolchildren: 
Development of a intervention, randomized clinical trial and escalation proposal” have 
low levels of social backwardness (Cuernavaca: 1.196; Campeche: 0.557; Ciudad del 
Carmen: 0.5888; Mexico City: 0.9504), so the socioeconomic conditions are not 
different from each other. 
 
 

 
19 
 
Figure 2. Design of the randomized community trial and the randomized clinical trial. Mexico, 2023 
  
 
 
 

 
20 
 
 
1. Stage 1. Situational diagnosis 
  
Generalities of stage 1 
 
In the design of health promotion interventions, situational diagnostic evaluation is 
necessary to be able to develop an intervention adapted to the context and real needs 
of the target population. This first stage of the project made it possible to identify 
previous experiences and derive from them available evidence on interventions that 
have been implemented in other populations. Likewise, we identify the health problems 
of the population to which the intervention to be designed is directed, as well as the 
existing policies and programs and the participation of the target population for which 
the intervention is designed. The purpose of the situational diagnostic evaluation was 
to guide the design of the intervention and increase its potential effect 37 . 
  
The situational diagnosis was based on the Social Cognitive Theory 38 , the Ecological 
Theory of Behavior 39 and the work of Springer and collaborators 33 , which included 
evaluation in different environments: 
  
Political environment: Review and analysis of the political and structural environment 
for the implementation of an intervention. 
  
Social/cultural and organizational environment: Inquiry into existing groups that can 
support or serve as a platform to implement an intervention. 
  
Information environment: Exploration of the media, communication channels and 
opportunities that favor the implementation of an intervention. 
  
Environment of the environment (diet, physical activity and risky eating behaviors): 
Exploration of the situation in terms of availability of healthy and unhealthy foods and 
drinks, as well as infrastructure and opportunities to carry out physical activity and 
risky eating behaviors both in the environment school and community (included: 
school, family and community environment). 
  
The information that was generated from the situational diagnosis served to design the 
IM of the present proposal, which includes different levels of intervention such as the 
school, school, family and community environment. The diagnosis included various 
activities described below: 
  

 
21 
 
1) Systematic literature review. 
The systematic review covered the available scientific and gray literature on formative 
research and interventions and strategies for the prevention of overweight and obesity 
in girls, boys and adolescents implemented at the national and international level, 
identifying those that have been successful in different areas and that They could be 
part of the study. 
  
2) Focused training information. 
a) 
It allowed the updating of information on the availability of healthy foods and 
beverages within schools, focused on identifying barriers and opportunities for 
compliance with school guidelines, for healthy and sustainable eating, as well as 
opportunities for physical activity and activities. recreational activities during school 
hours. 
b) 
It explored the environment around schools and at home to identify availability 
of healthy foods and beverages, as well as infrastructure and opportunities for physical 
activity. 
c) 
It identified the barriers and opportunities for the implementation of 
interventions that allow improving healthy lifestyle practices at the school, home and 
community levels as perceived by school authorities, teachers, parents and community 
authorities. 
d) 
Identified communication channels and opportunities for communication that 
could favor the intervention (For example: ease of using technology to receive training 
through virtual courses, access and use of cell phones to receive SMS messages, among 
others). 
  
3. 
Review and analysis of the political and structural environment for the 
implementation of a multidimensional intervention. 
It served to obtain information on the political and structural context to implement the 
multidimensional intervention. 
  
4. 
Evaluation of the strategies or programs implemented. 
The implementation of interventions associated with overweight and obesity in 
Campeche, Mexico City and Morelos that have been implemented in previous years was 
documented in the selected schools. In addition, possible barriers and facilitators for 
the alignment and complementarity of school programs and policies with some current 
public policy instruments were explored, such as: 1) the knowledge areas of the “Learn 
at Home” program aimed at promoting healthy eating. and to the practice of physical 
activity, and 2) general guidelines for the sale and distribution of prepared and 
processed foods and beverages in schools of the National Educational System. 

 
22 
 
  
5. 
Instrument validation. 
During this stage, the instruments that will be used in the multidimensional 
intervention were validated. 
  
Below, each of the components that were part of the situational diagnosis is described 
in greater detail. 
  
1.1. 
Systematic review of the literature  
  
The accumulation of scientific evidence of formative research and interventions and 
strategies for the prevention of overweight and obesity in school children and 
adolescents, implemented at the national and international level, was carried out 
through a systematic review of the scientific literature and gray literature, identified in 
databases and search engines Medline/Pubmed, Cochrane Library, Lilacs, PsycINFO, 
Scopus and Web of Science, identifying those interventions that have been effective in 
different areas, through a systematic and clearly defined and explicit process that 
adhered to the design of search, Cochrane analysis. 
 
Study selection criteria: 
  
Inclusion criteria: 
• 
Articles, reports, theses and other manuscripts that described obesity 
interventions were identified, including strategies focused on physical activity, 
nutrition, sedentary behavior and risk eating behaviors (CAR), as well as eating 
disorders. Articles were also identified that explored aspects such as internalization of 
the aesthetic ideal of beauty-thinness, dissatisfaction with body image, negative affect, 
criticism-teasing, negative comments about weight and body shape, and stigmatization 
of obesity. 
• 
Studies published in English, Spanish and Portuguese languages. 
• 
Studies in the form of educational interventions, published from January 1, 2010 
to November 30, 2019. 
• 
Studies that measured the event of interest (strategies for the prevention and 
treatment of overweight and obesity in children and adolescents). 
• 
Studies that quantitatively estimated the implementation of interventions. 
  
 
Search methods for identifying studies: 
  

 
23 
 
The search process was carried out using the protocol for the systematic review that 
was developed including inclusion and exclusion criteria, methods for evaluating the 
quality of the studies and interpretation of the findings, among others. To find and 
choose the appropriate interventions and strategies, a systematic search for 
information was carried out through specialized engines and search engines with the 
application of subject headings from the Medical Subject Headings (MeSH), which 
covered the main areas of: measurement of obesity, comparison groups in 
interventions, measurement of nutrition, physical activity and public awareness, 
essentially through the search algorithms proposed with an equivalent syntax for each 
type of interventions proposed. 
  
All gray literature in Mexico (reports from government or other institutions, theses, 
summaries or unpublished research) was reviewed. We worked with a review group to 
interpret the results and establish recommendations and collaborate in the 
development of the final manuscript. 
  
With the systematic review, a synthesis of the interventions in schools that have been 
developed globally for the treatment and prevention of overweight and obesity was 
carried out. 
  
1.2. 
Focused formative research 
  
As part of the stage of situational diagnosis and design of the intervention, a formative 
research was carried out focused mainly on the schoolchildren, the actors that make up 
their immediate community (parents and teachers) and the environment that 
surrounds them, considering the determinants socio-environmental consequences of 
obesity. Formative research, or needs assessment, consisted of determining the 
interests, attributes, and needs of different populations within a community (primarily 
those likely to use the intervention, but also other groups of interest in the response or 
who may be affected by it). , as well as designing interventions that meet these needs 
and that are culturally acceptable and viable 40 .  
  
From the aforementioned literature review, information gaps for the development of 
IM were identified and when necessary, focused formative research was carried out 
(collection of information in the field) that fed back into the design of the intervention. 
  
At this stage, key information on healthy and sustainable eating, physical activity and 
CAR was briefly explored. Facilitating factors and barriers to the adoption of healthy 
behaviors and self-care were identified, as well as the most appropriate communication 

 
24 
 
channels to reach children, teachers, and caregivers responsible for schoolchildren. 
Among other information, the following were documented: a) Access and availability of 
food and beverages, food context (meal times, family environment, family meals), in 
addition to knowing if there are CARs; b) Opportunities and barriers to increase the 
time and intensity of physical activity; c) Availability of water; d) Advertising and street 
sales of unhealthy foods and beverages, e) Means of transportation to school and f) 
Access and availability of infrastructure for safe physical activity (for example, parks 
and other recreational sites, sidewalks, lighting, among others) and Community 
participation. 
  
The diagnosis was carried out in the intervention schools of Campeche, Mexico City and 
Morelos and there were two diagnostic modalities: 
  
• 
For IM schools, a more in-depth diagnosis was carried out which included focus 
groups and semi-structured interviews, and application of questionnaires aimed at 
parents, teachers, food and beverage vendors (inside and outside the schools), food 
inventory and beverages and infrastructure observation formats for physical activity 
inside and outside school and around the home. 
  
The diagnosis was also carried out in different environments in which intervention can 
be carried out, as well as among the different groups (target population) to which the 
interventions will be directed. 
  
Environments: 
• 
School: As a complement to the available scientific evidence, the conditions and 
resources available by the educational establishment for the development of the 
intervention and possible communication channels and opportunities to improve its 
implementation were investigated. 
• 
Home: Availability of healthy foods and drinks, CAR. 
• 
Community: Conditions of the school outskirts, nearby shopping centers or 
places where food and beverages are purchased, infrastructure and public spaces for 
recreation and physical activity as well as active transportation opportunities. 
  
Target population: 
Those in which the perception of barriers and opportunities for the implementation of 
the intervention and for the modification of behaviors, as well as communication 
channels, were explored: 
• 
4th grade boys and girls, 
• 
Teachers, 

 
25 
 
• 
school directors, 
• 
school administrative staff, 
• 
Food and beverage vendors (inside and outside of school), 
• 
Parents of family. 
  
Based on the above, the information that was collected for each level of interest is 
described below, as well as the methods and instruments that were used: 
  
a. Individual level 
  
The focus groups were conducted by a trained facilitator and a non-participant 
observer, who used guides with trigger questions to develop the sessions. 
multidimensional intervention schools , focus groups were carried out with boys and 
girls in the 4th grade of primary school. In total, 6 focus groups were held (2 per federal 
entity). Each group was made up of a minimum of four participants and a maximum of 
eight, which took place within the school facilities during school hours when the 
epidemiological traffic light allowed it, or virtually, with prior informed consent from 
the parents or guardians (Annex 1) and the consent of the children (Annex 2). Focus 
groups were conducted by a trained facilitator and a non-participant observer. A guide 
with a semi-structured format was used with triggering questions and supportive 
teaching materials piloted prior to its application. Through participatory techniques, 
information related to the school population's preference for food and beverages, and 
physical activity (activity preference) was obtained; barriers and windows of 
opportunity for the adoption and maintenance of healthy behaviors, as well as 
environments, were identified. harmful and favorable for physical and emotional 
development within school and at home, opinion of children about including health 
programs in schools, ways to get involved in said programs, opinion of children about 
changing eating habits and physical activity at home, communication channels and 
opportunities that could favor the intervention (Annex 3). 
  
In addition, 5 4th grade students from each school were randomly selected (5 students 
per school, in the 4 schools per state - total 60 students), to whom questionnaires were 
administered (via telephone / video call) with some of the topics included in the focus 
groups and other complementary topics. Additionally, an observation of the food 
consumed and the physical activity carried out at recess or at school was carried out, 
with prior assent and informed consent for the application of the questionnaire 
(Annexes 4 - 8). 
 
 

 
26 
 
b.  School environment  
  
Complementary to the available scientific evidence and the previous experience of 
INSalud, in the schools of the community trial (4 schools per federal entity, - 4X3=12 
schools in total), with prior authorization from the school director (Annex 9), through 
an observation guide applied inside the school, aspects such as: Practices, spaces and 
materials available for carrying out physical activities, in addition to asking some 
questions to the physical education teachers (Annexes 10 - 11). To document the 
availability and operation of drinking fountains, availability of other sources of drinking 
water, number of fixed and mobile establishments that sell food within schools, type of 
food and beverages that are sold during recess, among others, an inventory of sources 
of simple water and food and drinks (Annexes 1 2 - 1 3 ). 
  
The following activities were carried out: 
  
Directors, group teachers (4th grade), physical education teachers, and those 
responsible for food stores or vendors within the school. Through 24 semi-
structured interviews (8 interviews per state/4 interviews in 2 schools per state), 
knowledge and perception of current strategies to prevent overweight and obesity in 
schools, perception of healthy and non-recommended foods and beverages, barriers 
and opportunities to implement interventions that promote healthy lifestyles in 
schools, communication channels and opportunities to improve an intervention, as well 
as barriers to compliance with school guidelines (Annexes 1 4 - 18). 
Additionally, a questionnaire on health programs, habit change and perception of 
overweight and obesity was sent to the directors via email (Annexes 1 9 - 20 ). This 
questionnaire was applied in the diagnosis of the community trial schools (in total 16 
questionnaires, 1 per actor per school per federal entity (4X4X3=48)). 
  
c. Family atmosphere 
 
In clinical trial schools: To triangulate the information previously obtained, the 
parents, guardians or caregivers of the children who participated in the focus groups 
mentioned above (at least two interviews per school per federal entity – 2X4X3=24) 
were asked to provided relevant information for the study through an interview, where 
topics such as: Family nutrition (schedules, foods consumed most frequently, family 
meals, etc.), physical and recreational activities at home, use of media, were discussed. 
transportation to get to school, exposure to media, shopping centers and other places 
where they purchase food and beverages, and communication channels and 
opportunities to improve an intervention (Annexes 2 1 - 2 3 ). 

 
27 
 
  
Through focus groups with parents (6 focus groups = 2 per state/2 schools, with at least 
5 parents), information was obtained on parents' opinions about including health 
programs in schools, forms of getting involved in these programs, opinion about 
changing eating habits and physical activity at home, importance of their participation 
so that their children modify their behavior, what are the barriers they face to get 
involved in school programs and strategies to participate in these programs (Annexes 
24 - 2 5 ). 
  
Additionally, a questionnaire on the perception of overweight and obesity in parents 
and children and another on health programs and habits at home were applied to 
parents of at least 5 children per school (5X12=60), preference was given to parents or 
caregivers of the children who participated in the focus groups. The questionnaires 
were administered by telephone (Annexes 2 6 - 2 7 ). 
  
The semi-structured interviews and response to the questionnaires were voluntary and 
were carried out according to the time availability of the interviewees. The 
communication strategy used considering the COVID-19 pandemic was telephone calls. 
  
 
d. Community 
  
In community trial schools: In the school outskirts, information was obtained through 
an observation guide, about the fixed and mobile establishments that offer food and 
beverages (availability, type of food, costs, hours, proximity to access to the school, etc.), 
as well as the infrastructure for the practice of physical activity (Annex 2 8 ). The 
methodology described by Hernández-Barrera and collaborators 41 was used , which 
defines that the area of greatest vulnerability in the school periphery is within a 
perimeter of 100 meters around, due to the proximity and density of establishments 
and mobile food stalls. . The size of the perimeter was defined according to the 
recommendation of the Pan American Health Organization (PAHO) 42 . Using the ArcGIS 
software, the schools were geolocated and for each of them the perimeter was 
generated with the aforementioned dimension, considering the main entrance as the 
centroid of the perimeter. The Collector for ArcGIS mobile application was used to 
geolocate stores, establishments and food and beverage stands, as well as the 
characteristics of the infrastructure for the practice of physical activity (presence and 
quality of sidewalks and parks, availability of road signs, presence of obstructions to 
walking, aesthetics, among others) within this perimeter. In the identified 
establishments, an inventory of food and beverages was made, as well as their 
advertising through observation (Annexes 2 9 - 31 ). 

 
28 
 
 
Food vendors in the school periphery: in the schools of the multidimensional 
intervention, Through semi-structured interviews (6 interviews = 2 per state/school), 
knowledge and perception of healthy and unhealthy foods and beverages, motives and 
preference for the sale of certain products, perception of the problem of overweight 
and obesity in children and adolescents, communication channels and opportunities to 
improve an intervention. Additionally, a closed questionnaire was applied to 
complement the information collected through the semi-structured interviews. For the 
above, 2 vendors were selected per school, per federal entity, for a total of 24 
questionnaires. In this case, the interviews were voluntary and were carried out 
according to the time availability of the interviewees, within the educational 
establishments, when the epidemiological traffic light allowed it. Particularly, in the 
case of sellers, they were carried out in person when the epidemiological traffic light 
allowed it. 
  
Finally, in the multidimensional intervention schools, through a brief questionnaire, 
which was sent to the home of some randomly selected children (5 per school, per 
federal entity - 5X4X3= 60 questionnaires) and where parents were asked to respond 
and send back the questionnaires, the following community aspects were identified: 
Shopping centers and nearby establishments where the family buys food and drinks 
(stores, supermarkets, fixed markets, flea markets, etc.), access ( cost) and availability 
of vegetables and fruits in said establishments; advertising of unhealthy foods and 
beverages, presence of nearby walking destinations, safety (from crime and traffic), 
access to parks and other recreational sites, infrastructure for practicing physical 
activity, availability and access to public transportation systems . 
  
Both the interviews and the questionnaires and instruments were applied by a team of 
professionals experts in qualitative research techniques, focus groups and direct 
interviews with the study subjects (both the school population and adults). The 
information collected was captured through mobile devices on a platform designed for 
this purpose. For their part, the interviews and focus groups were audio recorded and 
transcribed. The information was coded and a thematic analysis was carried out using 
the N-vivo qualitative analysis software. The information was emptied into Excel 
matrices for the subsequent analysis-synthesis process of barriers and facilitators. 
Finally, the text that synthesized all this information was processed in Word. Table 3 
shows the indicators for diagnosis and methods for collecting information. 
  
  
 
 

 
29 
 
Table 3. Diagnosis indicators and description of the information obtained. 
Level of inquiry 
Actors 
Information collected 
Proposal inquiry method 
  
  
  
  
Individual. 
  
  
  
Boys 
and 
girls in the 
4th year of 
primary 
school. 
Preference for food, drinks and physical 
activities. 
Identification of barriers and facilitators for 
the adoption and maintenance of healthy 
behaviors. 
Identification of harmful and favorable 
environments for physical and emotional 
development within school and at home. 
Opinion on the importance of including health 
programs in schools, how to get involved in 
these programs and opinion on changing 
eating habits at home. 
Communication channels and opportunities 
that may favor intervention. 
2 focus groups in IM schools 
per federal entity, in total 6 
focus groups with 4th grade 
primary school boys and 
girls 
from 
the 
selected 
schools. 
  
Schools 
in 
Campeche, 
Morelos and Mexico City: 
Questionnaires administered 
to children who explored the 
same 
topics. 
The 
questionnaire was applied to 
5 children from each school 
per federal entity. 
(5 X4X 3= 60 children) 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Spaces and materials available for carrying 
out physical activities. 
  
Availability 
and 
operation 
of 
drinking 
fountains, availability of other sources of 
drinking water. 
  
Number of fixed and mobile establishments 
that sell food inside schools, type of food and 
beverages sold during recess inside the 
school. 
City Schools 
Mexico, 
Campeche, 
and 
Morelos: 
Guides 
for 
observing 
facilities 
at 
school 
(for 
physical 
activity 
and 
drinking fountains). 
Food 
and 
beverage 
inventories. 
In total, 4 schools were 
visited per federal entity 
(4X3=12 schools). 
Directors, 
4th 
grade teachers, 
physical 
education 
teacher 
and 
person 
responsible for 
food stores or 
vendors within 
the school. 
Knowledge 
and 
perception 
of 
current 
strategies to prevent overweight and obesity 
in schools and about healthy and non-
recommended foods and drinks. 
Barriers and opportunities to implement 
interventions that promote healthy lifestyles 
in schools. 
Communication channels and opportunities 
to improve an intervention. 
4 actors in 2 IM schools per 
federal 
entity, 
24 
semi-
structured interviews.  
 
  
School. 
Barriers 
to 
compliance 
with 
school 
guidelines. 
Physical activity during school hours 
 

 
30 
 
Table 3. Diagnosis indicators and description of the information obtained. 
Availability of healthy foods and beverages 
and non-permitted foods and beverages. 
Managers 
Teachers 
Administrative 
staff. 
Perception of obesity, eating behavior and 
physical activity. 
City Schools 
Mexico, 
Campeche, 
and 
Morelos: 
Questionnaire (1 manager 
for each school – 1X4X3= 12 
managers 
answered 
the 
questionnaire) 
  
  
  
  
  
  
  
  
  
  
  
  
Familiar. 
  
  
  
  
  
  
  
  
  
  
  
  
Parents 
of 
family. 
Family nutrition (schedules, foods consumed 
most frequently, family meals, etc.). 
  
Physical activities at home. 
Use of transportation to get to school. 
  
Exposure to the media, shopping centers and 
other places where they purchase food and 
beverages. 
 
Your 
opinion 
about 
including 
health 
programs in schools, ways to get involved in 
these programs, opinion about changing 
eating and physical activity habits at home, 
importance of your participation for your 
children to modify their behavior, what are 
the barriers to that they face to get involved 
in school programs, strategies to be able to 
participate. 
Communication channels and opportunities 
to improve an intervention. 
 Focus groups: one focus 
group in two IM schools per 
state, in total 6 focus groups. 
 
  
  
  
Interviews with parents or 
caregivers of children from 
community trial schools (at 
least two interviews per 
school per federal entity – 
2X4X3=24) 
  
 
Perception of obesity, eating behavior and 
physical activity. 
schools :  
Questionnaire 
sent 
to 
parents through the children 
(5X4X3= 60). 

 
31 
 
Table 3. Diagnosis indicators and description of the information obtained. 
  
  
  
  
  
  
Community. 
  
 
Parents 
of 
family. 
Shopping centers and nearby establishments 
where the family purchases food and drinks 
(stores, supermarkets, fixed markets, flea 
markets, etc.), access (cost) and availability of 
vegetables and fruits in said establishments; 
advertising of unhealthy foods and drinks 
aimed at children, street sales of unhealthy 
foods and drinks, presence of nearby walking 
destinations, safety (from crime and traffic), 
access to parks and other recreational sites, 
infrastructure for the practice of physical 
activity, availability and access to public 
transportation systems. 
  
Multidimensional 
intervention schools : 
Questionnaire 
(5 
questionnaires per school 
per 
federal 
entity 
- 
5X4X3= 60). 
Food 
outlets 
and 
infrastructure 
for 
physical 
activity on the 
school 
outskirts. 
  
Fixed and mobile establishments that offer 
food and drinks (availability, type of food, 
costs, hours, proximity to school access, etc.) 
as well as the characteristics of the 
infrastructure for the practice of physical 
activity (presence and quality of sidewalks 
and parks, availability of road signs, presence 
of obstructions to walking, aesthetics, among 
others) within a 100 m perimeter around the 
school. 
Multidimensional 
intervention 
schools 
: 
Observation guide, food and 
beverage 
inventory 
(1X12=12). 
  
  
  
  
Knowledge and perception about healthy and 
unhealthy foods and drinks, motives and 
preference for the sale of certain products, 
perception of the problem of overweight and 
obesity 
in 
children 
and 
adolescents, 
communication channels and opportunities 
to improve an intervention. 
Multidimensional 
intervention schools : semi-
structured 
interviews 
(6 
interviews = 2 x state/2 
schools) 
 
Food vendors 
on the school 
outskirts. 
Reasons and preference for the sale of certain 
products. 
Perception of the problem of overweight and 
obesity in children and adolescents. 
Communication channels and opportunities 
to improve an intervention. 
Multidimensional 
intervention schools : 2 
closed questionnaires per 
school per federal entity 
(2X4X3= 24 questionnaires). 
  
Due to the pandemic due to the SARS-CoV2 virus (COVID-19), in March 2020 the 
Federal Government of Mexico issued an Agreement from which classes were 
suspended in preschool, primary, secondary, normal and other schools. for the training 
of basic education teachers of the National Educational System, as well as those of the 

 
32 
 
upper secondary and higher types dependent on the SEP. 1Due to the above, the need 
to collect information on the project was considered, taking into account the 
epidemiological risk traffic light that existed at the time of the visit in the states 
contemplated in the framework of this study. On that occasion, the recruitment of 
participants and the collection of information was carried out in person. 
   
1.3. 
Review and analysis of the political and structural 
environment for the implementation of multidimensional 
intervention 
In this diagnostic phase, the main policy instruments related to the implementation of 
school-level interventions for health promotion in schoolchildren were compiled, 
specifically those focused on improving healthy lifestyle practices and health status. 
nutrition and health, such as programs, guidelines, standards, laws and regulations. 
With this information, an analysis of the design of the main public policies for health 
promotion in the school environment was carried out. The recommendations of the 
World Health Organization (WHO) for the creation of Health Promoting Schools 43 and 
the WHO recommendations for the school environment 44 were used as reference instruments . A 
mapping of actors was carried out to facilitate the implementation of measures that 
improve the various environments of healthy eating and physical activity. 
 
According to the results of the instruments previously applied, focus groups and/or in-
depth interviews were carried out with the informants who were considered key 
according to the particularities of each school. This allowed us to document, in the 
selected schools, the implementation of the interventions associated with the strategies 
to improve school health in Campeche, Morelos and Mexico City, with the purpose of 
identifying the actions that this program carries out, to be considered in the design and 
implementation of the multidimensional intervention. 
 
1.4. 
Instrument validation 
  
During the diagnosis stage, the validation of several instruments designed to evaluate 
risk eating behaviors (CAR for its Spanish acronym), monitoring of the intervention and 
evaluation of outcome variables of the intervention was carried out. 
  
Validation of CAR instruments : Validation of self-report instruments for measuring 
CAR, internalization of the aesthetic ideal of beauty, body dissatisfaction, negative 
 
1https://www.dof.gob.mx/nota_detalle.php?codigo=5589479&fecha=03/16/2020 

 
33 
 
affect, and negative comments about body shape and weight in boys and girls from 9 to 
12 years old was carried out. 12 years old, in two stages: 
  
1) The first stage consisted of carrying out 2 cognitive laboratories per school grade 
in groups of men and women of 10 children each, with the purpose of adapting the 
format and content of the measurement instruments to the age of the boys and girls 
participating in the study. For this, 40 girls and boys in the 4th grade of primary 
school were selected from schools in Mexico City (different from those selected for 
the situational diagnosis). The cognitive laboratories were audio recorded with the 
prior permission of the participants and their parents or guardians, transcribed 
and analyzed to detect the relevant themes indicated. 
2) In the second stage, based on the information obtained in the cognitive 
laboratories, relevant adaptations were made to the questionnaires both in form 
and content. The resulting version was exposed to the opinion of experts on the 
subject of obesity and eating disorders to reach a consensus. 
3) The validation of the above-mentioned instruments was carried out in children 
between 9-10 years of age in schools in Mexico City (different from those selected 
for diagnosis). The reliability and construct validity of each instrument were 
obtained through internal consistency analysis, exploratory and confirmatory 
factor analysis. For internal consistency, Chronbach's alpha and item-total 
correlations were used for the total scale and subscales. For construct validity, a 
principal components factor analysis with oblique rotation and a confirmatory 
factor analysis with structural equation models were performed 48 . 
      
1.4.1 Logistics diagnostic stage  
  
The survey was planned to be carried out with electronic devices (laptops/tablets) with 
simultaneous capture in the field; that is, carrying out observations, semi-structured 
interviews and focus groups with the support of recorders and laptops. The recorded 
audio and capture information was stored by the supervisors via the Internet to a 
central server, in which the database was automatically integrated with daily cuts. For 
the latter, the interviewers took the computers with the supervisor daily to back up the 
information. The supervisors integrated the information from the respective work 
group and uploaded it to the server via the Internet. For security reasons, the 
information was also backed up on USB keys in case of any eventuality. 
  
The field team consisted of one work couple per federal entity (in total 3 couples - 6 
interviewers) and one supervisor per federal entity (3 supervisors). The interviewers 
were personnel currently living in the same city where the study was carried out. Each 

 
34 
 
pair of the federal entities were in charge of collecting the information on the situational 
diagnosis in the selected schools in Campeche, Morelos and Mexico City. 
  
The collection of information was carried out in three months, and the analysis of the 
information in three months, finally the analysis of results and prioritization of 
intervention needs in 2 months. The development of the systematic literature review 
was carried out in 8 months, while the validation of the instruments took 6 months (see 
schedule). 
  
1.5. 
Analysis of information from the 2005-2017 birth cohort 
 
To identify information that contributes to generating instruments for the development 
of MI on dietary and physical activity factors that are at risk for the development of 
obesity and metabolic alterations in the school stage, a secondary analysis of the 
information from a birth cohort (2005 – 2017). This study collected data from the 
school population from the pregnancy stage of their mothers to the ages of 1, 6, 12, 24, 
and 48 months and to the ages of 5, 7, and 11 years of their children. During the first 
stage of this project, the information that was considered for analysis was: 
anthropometry, biochemistry (glucose, insulin, lipid profile), feeding practices 
(breastfeeding and lactation), diet, morbidity, and health history, to which ages of 1, 6, 
12, 24 and 48 months and at 5, 7 and 11 years of age. In addition, physical activity data 
measured by physical activity questionnaire at ages 5, 7, and 11 would be analyzed (and 
accelerometry for this last year). Additionally, conventional procedures were used to 
protect the confidentiality of the study population through the use of numerical 
identification codes in the databases used for the analyses. 
 
Stage 1 Ethical Considerations 
Obtaining information from primary sources for conducting interviews respects the 
principles of the Belmont Report (1979), which establishes three basic principles based 
on ethics, which refer to respect, benefit and justice for people. It is confirmed that 
people have autonomy and deserve to be treated as autonomous agents, also increasing 
their benefits if possible and decreasing, if possible or not, increasing damages and 
finally justice, where it is sought that all people are treated equally, according to their 

 
35 
 
needs and efforts. 2By taking precautions to protect privacy and confidentiality, we 
sought to reduce and eliminate the consequences of the investigation towards their 
physical and mental integrity. 
  
For the interview and focus group exercise, the letters of informed consent and assent 
in the case of schoolchildren, with the sections detailing the objective of the project, 
description of participation, means of collecting information, as well as the declaration 
of confidentiality, rights and benefits, ending with contact information. 
  
The confidentiality of the information was protected at all times; on the other hand, the 
collection of information is expected to have an impact in the future on the management 
of public policies focused on the health of the population in general and the child 
population in particular. Access to information is for academic purposes for those 
involved in the project. The rights available to all individuals range from decline to 
participation, withdrawing or not answering if they are uncomfortable with the 
questions asked, feel offended or threatened. It is declared that there is no financial, 
political or other conflict of interest with third parties. 
 
Generalities of the results of stage 1 
 
In general, in stage one it was identified that multi-component interventions that 
involve different actors, for example, including physical activity, nutrition and behavior 
changes, where the school, family and community are involved, could be the more 
effective both in preventing and reducing overweight and obesity in boys and girls 
between 6 and 12 years old. Also, programs were identified in the school context that 
have been implemented in Mexico, for example: national physical culture and sports 
program, action program in the school context (PACE), 5-step strategy for school health, 
Intersectoral Education Program Healthy (FEET), among others. 
Likewise, based on the review and analysis of the political and structural environment, 
the main policies and programs implemented in Mexico in the last 20 years in the school 
context were identified, for the promotion of healthy lifestyles: it was identified that 
throughout Each six-year period, various actions and programs have been implemented 
aimed at Mexican children and adolescents, in which, through Health Education (EPS) 
and Health Promotion (PS), it is desired to encourage the adoption of health styles. 
 
2 National Commission for the protection of human subjects of biomedical and behavioral research. 
Belmont Report Ethical principles and guidelines for the protection of human research subjects. Natl 
Institutes Heal [Internet]. 2003;12. Available from: 
https://www.etsu.edu/irb/Belmont Report in Spanish.pdf  

 
36 
 
Healthy lives through the teaching of topics such as: healthy eating, adequate hydration, 
physical activity, basic sanitation, among others.  
Birth Cohort Analysis Progress 
To date, the information on the biochemical indicators has been cleaned, the adiposity 
indicators have been generated for the different contacts, the dietary information for 4, 
5, 7 and 11 years has been processed, the dietary inflammation index has been 
estimated for each contact and they are finishing creating about 20 dietary indicators 
to characterize dietary patterns in children. Likewise, physical activity and inactivity 
indicators were estimated at the ages of 5, 7 and 11 years . 

 
37 
 
2. Stage 2. Design and development of the multidimensional 
intervention and evaluation instruments.  
 
Generalities of stage 2 
  
Next, the design that was proposed to carry out the IM is presented, derived from the 
results of the situational diagnosis, the focused formative research, the review and 
analysis of the political and structural environment, and the analysis of the 
implementation and evaluation of previous strategies. . 
Stage 2 objectives 
 
Design and develop a multidimensional intervention, considering the ecological model 
of behavior, which is based on the premise that individuals are a product of the 
environment. 
 
Implement a feasibility study to explore acceptance by future users and quantify the 
requirements of the intervention through the constructs of effectiveness, adoption, 
consistency of implementation and maintenance. 
 
Study design for stage 2 
 
To design stage two, we will start from the results of the review of the literature and 
the results obtained in formative research. From this, the data were analyzed 
considering the strategic axes of the intervention, target population, practices and 
expected goals. These axes were: 
 
1) Healthy and Sustainable Eating (ASS) 
2) Movement behaviors (CM) 
3) Psychosocial component (PC) 
 
Each of the axes has an intervention objective at a behavioral level (that is, the expected 
target practices), and differentiated strategies and activities were carried out by actor, 
taking into account their specific needs and described below: 
1) Healthy and sustainable diet (ASS for its Spanish acronym)  
The objective of the intervention at the behavioral level is: 
I. 
Increase the consumption of vegetables and fruits in girls and boys 

 
38 
 
II. 
Increase natural water consumption in girls and boys 
III. 
Reduce the consumption of sugary drinks in girls and boys 
IV. 
Reduce the consumption of ultra-processed foods in girls and boys 
Table 4 (Annex 32) shows the target population, the construct that was worked on 
based on Azjen's previously accepted behavioral theory, as well as the activities that 
were carried out to achieve the objectives of this axis, among which we can find: 
animated projections, snacks that incorporate fruits and/or vegetables, measurement 
of their hydration status through images where they can observe the color of their urine 
and relate it to the simple water consumption they have had, as well as activities 
through the messaging platform via mobile, WhatsApp. 
2) Movement behaviors (CM for its Spanish acronym) 
In this axis, the following practices were established as expected goals: 
I. 
 Increase levels of physical activity, mainly of moderate to vigorous intensity 
inside and outside of school hours. 
II. 
Reduce sedentary time, including screen time, inside and outside of school 
hours. 
III. 
Improve the duration and quality of sleep. 
Table 5 (Annex 32) presents the target population, the constructs that were related to 
the preselected theory of behavior. Among the activities that were carried out to 
achieve the goals of this axis were the educational projection on movement behaviors.  
3) Psychosocial component (PC for its Spanish acronym) 
 
The objectives of the intervention at the behavioral level (expected target practices) 
were: 
I. 
Reduce stigmatization regarding weight and body shape. 
II. 
Improve the emotional management of girls and boys regarding food. 
III. 
Identify signs of hunger and satiety. 
IV. 
Reduce Risky Eating Behaviors (CAR). 
V. 
Decrease the internalization of the aesthetic ideal of thin beauty 
Table 6 (Annex 32) shows the elements that were taken into account for the 
implementation of the psychosocial component. Some activities that were carried out 
were the holding of workshops on key topics of psychosocial determinants in boys and 

 
39 
 
girls, virtual workshops on topics of psychosocial determinants such as obesity and. 
healthy nutrition. 
 
Multidimensional intervention design 
 
To establish the IM design, these three steps were followed: 
2.1 Feasibility study and validation/pilot test of the intervention 
materials. 
 
- 
Workshop to define the IM Design. To develop the intervention package, four 
workshops were held with the project researchers to define the audience, 
behaviors and interventions, including the selection of target audiences, 
behavioral objectives, barriers to consider, and multilevel and multichannel 
interventions to achieve behavioral change. 
The objective of the workshops was to prioritize the package of activities of the 
Multidimensional Intervention, based on Ajzen's social marketing methodology 
and theory of planned behavior. 
 
- 
 Field work to identify the barriers and facilitators associated with the 
activities and recommendations proposed from the formative research and that 
were outlined in the workshops to define the design of the IM; as well as validate 
the components of the communication strategy that will be directed to the 
school community where the study intervention will be carried out. 
 
Feasibility study methodology  
In this study, a survey was carried out that approximately reflected the acceptance by 
future users and its distribution method. It also allowed the quantification of 
requirements. This survey was carried out in the different federal entities selected for 
this research project (Morelos, Campeche, Mexico City), where constructs such as: 
Effectiveness or efficacy, Adoption by staff, environments, systems were analyzed. 
and target communities, Consistency of implementation , costs and adaptations made 
during delivery, Maintenance of intervention effects on individuals and environments 
over time. The three strategic axes were represented by a field team made up of four 
expert professionals in the different areas, who also had comprehensive training 
regarding the implementation of the objectives and goals of the study and instruments. 

 
40 
 
Regarding work logistics, the coordinating team sought the pertinent permits and 
authorizations for the selected schools, once the permits were obtained; The field work 
team contacted the educational authorities of the schools to explain the implementation 
logistics that will derive from the school activities of each institution. After signing 
consent (Annexes 33-36) and informed assent (Annexes 37), the field team applied 
different instruments, such as guides for focus groups and interviews (Annexes 38-43), 
incorporating topics from the three strategic axes that They will seek precise 
information on knowledge, attitudes, practices and perceptions of the proposed 
activities, as well as group activities, in the target population. 
From this information, the activities, distribution method and implementation time 
were detailed. 
The design and results of the feasibility study are described in detail in Annex 44. 
 
2.2 Feedback and modification of the activities and communication 
materials of the initial IM proposal on healthy and sustainable eating, 
movement behaviors and psychosocial determinants based on the results 
of the field work.  
Based on the results of the feasibility study. 
 
2.3 Implementation logistics.  
Definition with each of the federal, state and school authorities for implementation. 
 
Description of the intervention by axis  
 
The objectives of the key components that are contemplated within the intervention 
are broken down below. 
 
 Table 7. Components of the Multidimensional Intervention for behavioral change: 
1. Healthy and Sustainable 
Eating: Nourishing Bodies and 
the Planet. 
Our program focuses on educating and empowering girls and boys about the 
importance of choosing foods that nourish their bodies, integrating the 
importance of caring for the environment. 
With the help of interactive educational activities, the connection between our 
dietary choices and their impact on the sustainability of the planet will be 
explored. Likewise, we will work with primary caregivers to provide them with 
tools that allow them to make informed decisions regarding family nutrition. 

 
41 
 
2. Movement Behaviors: Get 
Active for an Active Future. 
Encouraging movement habits from an early age is essential for healthy physical 
and mental development. Through fun games and exercises, we encourage girls 
and boys to incorporate more physical activity into their daily routines. 
Additionally, we will collaborate with teaching staff to integrate moments of 
movement into the educational environment, thus creating a culture of activity 
in the school. 
3. Psychosocial Component: 
Cultivating Resilient Minds. 
We recognize the importance of psycho-emotional aspects in general well-being. 
We will work closely with teachers to offer strategies that promote emotional 
intelligence, self-esteem and resilience in girls and boys. 
By cultivating these skills, we seek to prepare them to face challenges with the 
confidence and empathy required. 
 
In IM, each of the components, already mentioned above, were designed with the 
purpose of obtaining a lasting impact on the health and well-being of fourth-year girls 
and boys, as well as their families and school communities. By working together, we 
will build a future where health and sustainability are fundamental pillars in the 
education and growth of new generations. 
  
AXIS 1. HEALTHY AND SUSTAINABLE FOOD 
 
Increase consumption of vegetables and fruits 
Action description 
1. Capsule “Let's eat more fresh vegetables and fruits in all our meals.” 
With the aim of promoting healthy eating habits and encouraging the intake of fresh 
vegetables and fruits in their daily diets, one of the first activities involves the 
visualization during the Launch of the audiovisual material of the educational capsule 
titled "Let's eat more fresh vegetables and fruits in all our meals" designed for girls and 
boys. Through this capsule, we seek to raise awareness among girls and boys about the 
importance of incorporating fresh vegetables and fruits into their daily meals to 
maintain a balanced and healthy diet. The capsule offers information and practical 
advice on how to integrate these foods into your diet in a delicious, attractive and 
sustainable way. 
2. Promotion of healthy vegetable and/or fruit snacks 
It is an activity designed for girls and boys , which seeks to instill in them the importance 
of adopting conscious food choices and fostering a positive relationship with food, while 
promoting a healthy school environment. 

 
42 
 
The activity consists of that from Monday to Friday, all fourth grade primary school 
students bring with them a snack consisting of vegetables and/or fruits . To ensure 
compliance with this healthy practice, we have assigned a person in charge of 
supervising that snacks are brought during school hours before recess. 
Once students submit their healthy snacks, they will receive a ticket as a reward from 
the supervisor. These tickets will be cumulative and, at the end of the school year, you 
will have the opportunity to participate in a drawing. Among the prizes they can win 
are bicycles, balls and other prizes that promote well-being and fun. 
3. Sale of healthy vegetable and/or fruit snacks for the Promotion of Nutritious 
Snacks: Collaboration with School Vendors 
In the search to promote healthy eating habits among schoolchildren, the modification 
of the environment is sought with the sale of healthy snacks of vegetables and/or fruits 
in school cooperatives . This initiative is aimed at food vendors within schools, with the 
aim of providing nutritious and delicious options for the school community. 
An invitation to the Launch will be extended to food vendors operating within the 
school premises to join this noble cause. Your collaboration plays a fundamental role in 
promoting healthy eating in the school community. Additionally, at the launch, the 
following materials will be distributed in print: 
By incorporating healthy snacks of vegetables and fruits in your offering, you will be 
contributing to the well-being and comprehensive development of our students. This 
activity not only benefits the health of girls and boys, but also establishes a valuable 
message about the importance of making informed and balanced food decisions. 
newsletter : Encouraging nutritious snacks, fun movement and happy minds with 
our healthy intervention with the key messages to promote. 
On the day of launch, delivery will be made in printed format. This material is 
specifically designed for those in charge of caring for girls and boys in fourth grade, with 
the purpose of instilling healthy and positive habits from an early age. Its crucial 
influence in the formation of these beneficial behaviors is recognized. Through this 
publication, we seek to provide fundamental tools that allow them to guide girls and 
boys in aspects related to healthy and sustainable eating, as well as in promoting an 
active life and healthy psycho-emotional behaviors. 
Within the informative Gazette, you will find the 10 recommendations: 
● Let's eat more fresh vegetables and fruits in all our meals. Let's choose seasonal 
ones, which are cheaper and, when possible, locally produced. 
● Let's avoid ultra-processed foods, such as: sausages, chips, cookies, sweet bread 
and boxed cereals, since they have a lot of fat, salt and/or sugar. Let's choose 
foods without stamps or with as few stamps as possible. 

 
43 
 
● Let's do more physical activity like walking, running or dancing. Let's spend less 
time sitting or in front of the screen (cell phones, television, video games and 
others). Every move counts! 
● Let's drink more natural water throughout the day and with all our meals, 
instead of sugary drinks such as soft drinks, juices, waters prepared with 
powder sachets and sports drinks. Excess sugar is harmful to our body and the 
packaging pollutes the environment. 
● Let us consume beans, lentils or broad beans daily, prepared as stews, soups or 
with vegetables. They have protein and fiber, they are practical and economical. 
● Let's choose whole grains such as corn tortillas, oats, rice or tubers, such as 
potatoes. They have vitamins, fiber and give energy. 
● Let's eat less beef and processed meats. Instead, you can eat beans, lentils, eggs, 
chicken or fish. For our health and that of the planet, let's choose more plant-
based foods. 
● Let's enjoy our meals with family or friends when possible. Let's all participate 
in the planning and preparation of meals, without wasting food. 
4. Sending messages via WhatsApp throughout the school year. The messages are 
aimed at mothers, fathers, caregivers and teaching staff in short texts that touch on the 
topics of Healthy and Sustainable Eating, in order to raise awareness of the importance 
of increasing the consumption of vegetables and fruits, paying attention to the 
constructs of knowledge, attitude and subjective norm when presenting practical 
information to carry in your daily life. 
20-hour Virtual Course . The course is geared toward fourth grade teaching staff and 
will address a wide range of topics, including Healthy and Sustainable Eating, 
Movement Behaviors, and Psychoemotional Determinants. The course will be available 
from January to March 2024. During this period, both teachers and physical education 
teachers will have the flexibility to select the time that best suits their comfort and 
determine the duration they consider appropriate. However, it will be necessary to 
complete a total of 20 hours within this established period, as an essential requirement 
for the successful completion of the course. The fundamental purpose is to contribute 
to strengthening the foundations of knowledge by reinforcing key messages. 
Increase the consumption of natural water and reduce the consumption of sugary 
drinks 
Action description 
1. Capsule “Let's drink more natural water throughout the day and with all our 
meals.” 
During the launch of the IM, the information capsules will be announced. The objective 
is to promote an increase in the consumption of natural water and reduce the 

 
44 
 
consumption of sugary drinks. The capsule has the name “Let's drink more natural 
water throughout the day and with all our meals”, it is aimed at girls and boys to provide 
information about the benefits to the body and health that water consumption brings 
us, in addition to the advantages it has over sugary drinks. The capsule has simple and 
accessible language so that girls and boys can learn the information that is intended to 
be shared. 
2. Daily record of pee/urine color . 
The activity is aimed at girls and boys in order to provide knowledge about the 
importance of consuming natural water and reducing sugary drinks, at the same time 
showing how they can know their state of hydration or water consumption through the 
color of their urine by contrasting it with a scale present in the communication material 
called “pipimeter”, which tells them if it is necessary to increase water consumption 
according to the color of their urine. 
The activity will take place from the first week of IM implementation until its 
completion. The IM promoters will go to the fourth grade classrooms and explain to 
girls and boys about the importance of consuming natural water and reducing sugary 
drinks, they will show the “pipimeter” material so that they become familiar with what 
the color scale tells us, this instrument will be placed in the school bathrooms; Lastly, 
girls and boys will be given material to record the color of their urine, with the 
instruction to do it daily during the school day. 
3. Digital and printed infographic with the recommendation “Let's drink more 
natural water throughout the day and with all our meals” included in a Gazette with 
the rest of the key messages to promote. 
4. Sending messages via WhatsApp throughout the school year. The messages are 
directed to mothers, fathers, caregivers and teaching staff in short texts, addressing the 
topics of Healthy and Sustainable Eating, in order to raise awareness of the importance 
of increasing the consumption of natural water and reducing the consumption of 
beverages. sugary, fertilizing the constructs of knowledge, attitude and subjective norm 
by presenting practical information to carry in your daily life. 
5. 20- hour Virtual Course . The course is aimed at fourth grade teaching staff, in which 
Healthy and Sustainable Eating topics will be taught. It will take place from October to 
December 2023, where the teacher will have the possibility of taking the course at the 
time that is most comfortable for them and for the time that seems convenient to them 
with the condition of completing the 20 hours in the established period. The objective 
is to contribute to the knowledge constructs by reinforcing the key messages regarding 
the increase in the consumption of natural water and the decrease in the consumption 
of sugary drinks. 
 

 
45 
 
Reduce consumption of ultra-processed foods 
Actions. 
1. Capsule “Ultra-processed foods.” 
The capsule will be unveiled during the launch of Multidimensional Intervention. It is 
aimed at girls and boys with the aim of promoting the reduction of ultra-processed 
foods. It is titled "Ultra-processed foods" and contains information that ranges from 
what a food of this type is, mentioning its characteristics and the manufacturing 
process, to the possible damage to health that its consumption implies, it presents 
practical information to avoid or reduce their consumption, as well as making them 
aware of how to use labels and seals on packaging. All of this is communicated in simple 
and pleasant language so that the message is accessible to girls and boys. 
2.Sending videos to the WhatsApp platform, in the “ Healthy Reporter ” activity . 
Girls and boys are invited to make an informed video where an ultra-processed food is 
exposed, explaining the risks involved in its consumption and a healthy option to 
replace it, all with the help of educational material, such as a drawing they created. The 
videos will be made with the support of their mothers, fathers and caregivers, who will 
send the video to the IM's own WhatsApp group. This content will be selected to be 
projected during the two events that will take place in the middle of the IM and at its 
culmination. The objective of this activity is to contribute to the constructs of 
knowledge, attitude and subjective norm favorable to the consumption of vegetables 
and fruits, as well as to strengthen the subjective norm. 
3. Digital and printed infographic with the recommendation “Let's avoid ultra-
processed foods. Let's choose foods without stamps or with as few stamps as 
possible” included in a gazette with the rest of the key messages to promote. 
4. Sending messages via WhatsApp throughout the school year. The messages are 
aimed at mothers, fathers, caregivers and teaching staff in short texts that touch on the 
topics of Healthy and Sustainable Eating, in order to raise awareness of the importance 
of reducing the consumption of ultra-processed foods, contributing to knowledge 
constructs. , attitude and subjective norm when presenting practical information to 
carry in your daily life. 
20-hour Virtual Course . The course is aimed at fourth grade teaching staff, in which 
topics of Healthy and Sustainable Eating will be covered. It will take place from 
September to December 2023, where the teacher will have the possibility of taking the 
course at the time that is most comfortable for them and for the time that seems 
convenient to them with the condition of completing the 20 hours in the established 
period. The objective is to contribute to the knowledge constructs by reinforcing the 
key messages regarding the reduction in the consumption of ultra-processed foods. 

 
46 
 
 
AXIS 2. MOVEMENT BEHAVIORS 
 
Increase physical activity levels 
Mainly moderate to vigorous intensity inside and outside of school hours. Reduce 
sedentary time, including screen time, in and out of school hours. 
Action description 
1. Capsule “Let's do more physical activity like walking, running or dancing. Let's 
spend less time sitting or in front of the screen.” 
The capsule will be shown to the entire school community during the launch of the IM. 
This material is aimed at fourth grade girls and boys due to its simple and accessible 
language. It is called “Let's do more physical activity like walking, running or dancing. 
Let's spend less time sitting or in front of the screen.” Its objective is to promote physical 
activity in and outside of school, as well as to make them aware of the damage to health 
that can be caused by spending prolonged periods of time sitting or in front of a screen, 
and thus encourage its reduction. 
2. Active breaks regularly during classes. 
Girls and boys, with the support of teachers, take active breaks. The teaching staff would 
be given a manual and videos indicating various activities. 
Aimed at girls and boys. 
3. Active recreation. 
The IM promoters together with the physical education teachers, hand in hand with the 
implementation manual for active recreation, will carry out a series of exercises and 
activities aimed at fourth-grade primary school girls and boys. This activation will take 
place after recess, prior to returning to the classrooms. It is planned that active 
recreation will be implemented during the months in which the Multidimensional 
Intervention is implemented. At first the promoter will advise the teacher on physical 
education and over time the teacher will implement it in its entirety. 
4. Paint your patio workshop. 
In the first week of IM implementation, on a day agreed upon together with mothers, 
fathers and caregivers, fourth grade girls and boys, as well as school directors, games 
such as airplanes, hopscotch, stop, etc. will be painted. , in the courtyards of the school 
facilities. This activity has the purpose of providing spaces that encourage physical 
activity during the school day. 

 
47 
 
5 . Digital and printed infographic with the recommendation “Let's do more 
physical activity, like walking, running or dancing. Let's spend less time sitting or 
in front of the screen ” included in a Gazette with the rest of the key messages to 
promote. 
6. Sending messages via WhatsApp. 
Throughout the implementation, messages will be sent regularly via WhatsApp to 
mothers, fathers, caregivers and teaching staff on the topics of Movement Behaviors, 
aimed at raising awareness of the importance of increasing the practice of physical 
activity. The messages are made with the objective of contributing to the constructs of 
knowledge, attitude, subjective norm, perceived control, intention and practice of the 
key messages related to encouraging increased physical activity in school-age girls and 
boys. 
Improve the duration and quality of sleep. 
Action description 
1. Sending messages via WhatsApp. 
Throughout the implementation, messages will be sent regularly via WhatsApp to 
mothers, fathers, caregivers and teaching staff on the topics of Movement Behaviors, 
aimed at raising awareness of the importance of improving the duration and quality of 
sleep in girls and boys. . The messages are made with the objective of contributing to 
the constructs of knowledge, attitude, subjective norm, perceived control, intention and 
practice of the key messages related to improving practices, in girls and boys, related 
to sleep. 
 
AXIS 3. PSYCHOSOCIAL COMPONENT 
 
A pilot study was carried out for a comprehensive understanding of the workshops with 
a total of 100 children between 9 and 10 years old divided into groups of 12 members, 
4th grade students at the “Salvador Varela Reséndiz” public school, morning shift in the 
city of Zacatecas, Zacatecas in the month of June 2023. The purpose of the study was to 
determine the acceptance of the activities, measure the time of each one and per 
session, and assess the understanding of the topics and instructions. The response was 
generally favorable, but as a result of the study, adjustments were made to some 
activities, mainly regarding some reflection questions, simplifying the language and 
providing more specific explanations. 
 
Reduce stigmatization regarding weight and body shape. Reduce risky eating 
behaviors. (CAR) 

 
48 
 
Description of actions. 
1. Workshop “Prevention of stigmatization with weight and body shape; and 
Risky Eating Behaviors (CAR).” 
Face-to-face workshops will be implemented for girls and boys, and online for mothers, 
fathers, caregivers and teaching staff. on key topics of Psychosocial Determinants . The 
workshop is called “Prevention of stigmatization with weight and body shape; and 
Risky Eating Behaviors (CAR).” It will be applied in a session of one duration of 40 min 
for girls and boys, while the online workshop is planned for a duration of 1 hour. The 
purpose of the workshop is to contribute to the construct of knowledge about 
stigmatization with weight and body shape, as well as risky eating behaviors in girls 
and boys, in order to reduce them. 
2 . Sending messages via WhatsApp 
Throughout the implementation, messages will be sent regularly via WhatsApp to 
mothers, fathers , caregivers and teaching staff on the topics of Psychosocial 
Determinants, aimed at raising awareness of the importance of preventing weight 
stigmatization and the body figure; and CAR. The messages are made with the objective 
of contributing to the constructs of knowledge, attitude, subjective norm, perceived 
control, intention and practice of the key messages related to reducing the 
stigmatization of weight and body shape, and risky eating behaviors in girls. and school-
age children. 
Improve the emotional management of girls and boys regarding food 
Description of actions 
1. Workshop “ Emotional management of children about food.” 
An in-person, one-session workshop lasting 40 minutes will be implemented, aimed at 
girls and boys on key topics of Psychosocial Determinants, with the name “Emotional 
management of children on food.” This workshop aims to contribute the constructs of 
knowledge, attitude, subjective norm, perceived control, intention and practice of 
messages to the topic of management, in girls and boys, of emotions related to eating. 
2. Sending messages via WhatsApp 
Throughout the implementation, messages will be sent regularly via WhatsApp to 
mothers, fathers, caregivers and teaching staff on the topics of Psychosocial 
Determinants, aimed at raising awareness of the importance of emotional management 
of children regarding food. The messages are made with the objective of contributing 
to the constructs of knowledge, attitude, subjective norm, perceived control, intention 
and practice of the key messages to help identify emotions related to eating in school-
age girls and boys. 

 
49 
 
Identify signs of hunger and satiety. Reduce symptoms of anxiety and depression 
Description of actions. 
1. Workshop “Identification of hunger and satiety signals; and symptoms of 
anxiety and depression.” 
A one -session workshop will be implemented in person for girls and boys, and online 
for mothers, fathers, caregivers and teaching staff, where key topics of Psychosocial 
Determinants in girls and boys will be addressed, the workshop is named from 
“Identification of hunger and satiety signals; and symptoms of anxiety and depression . 
” The objective is to contribute to the constructs of knowledge, attitude, subjective 
norm, perceived control, intention and practice of key messages to help the school 
community identify signs of hunger and satiety, as well as reduce symptoms of anxiety 
and depression in girls and boys of school age. 
2. Workshop “Limits, parenting and self-care”. 
A one- session workshop will be taught in online format aimed at mothers, fathers and 
caregivers on key topics of Psychosocial Determinants in girls and boys, with the name 
“Limits, parenting and self-care.” The purpose of this workshop is to contribute to the 
constructs of knowledge, attitude, subjective norm, perceived control, intention and 
practice that help improve the relationship between mothers, fathers and/or caregivers 
with their girls and boys. 
3. Workshop “Teaching and self-care”. 
There will be given a One-session online workshop , aimed at teaching staff, where 
various key topics of Psychosocial Determinants in girls and boys will be addressed. 
The workshop is called “Teaching and self-care.” Its purpose is to contribute to the 
constructs of knowledge, attitude, subjective norm, perceived control, intention and 
practice in teachers related to their professional work. 
4. Sending messages via WhatsApp. 
During the implementation of the IM , messages will be sent via WhatsApp to mothers, 
fathers, caregivers and teaching staff , where topics pertaining to Psychosocial 
Determinants are addressed, with the aim of raising awareness of the importance of the 
Identification of hunger and satiety signals; and symptoms of anxiety and depression. 
This activity seeks to pay the constructs of knowledge, attitude, subjective norm, 
perceived control, intention and practice related to the key messages of the 
Psychosocial Determinants. 
Reduce the internalization of the thin aesthetic ideal of beauty. 
Description of actions. 
1. Workshop “Internalization of the aesthetic ideal of thin beauty.” 

 
50 
 
A one-session workshop will be conducted to fourth grade girls and boys , with the 
name “Internalization of the thin aesthetic ideal of beauty”, which will be taught in 
person and will address key topics of Psychosocial Determinants in girls and boys . The 
objective of this workshop is to contribute to the constructs of knowledge, attitude, 
subjective norm, perceived control, intention and practice on the key messages related 
to the internalization of the aesthetic ideal of thin beauty in girls and boys. 
2. Sending messages via WhatsApp. 
During the implementation of the IM, messages will be sent via WhatsApp to mothers, 
fathers, caregivers and teaching staff, the messages touch on topics of Psychosocial 
Determinants, with the aim of raising awareness of the importance of identifying 
hunger signs. and satiety; and symptoms of anxiety and depression. This activity seeks 
to pay the constructs of knowledge, attitude, subjective norm, perceived control, 
intention and practice related to the key messages of the Psychosocial Determinants 
aimed at publicizing the Internalization of the aesthetic ideal of thin beauty. 
 
Generalities of the results of stage 2 
 
The design of the IM was based on a wide range of local, national and international 
studies, tests and experiences for the promotion of healthy lifestyles in school-age girls 
and boys. The IM was developed with a Behavior Change Communication (BCC) 
approach, which involves the systematic application of interactive communication 
processes, based on behavioral theories and models, in our case: Social Marketing1 and 
Ajzen's Theory of Planned Behavior2 -3 and driven by the Ecological Model approach 
that considers the key factors for change at the individual, community and social level. 
The above consolidates a conceptual thought that looks at the relationships between 
individuals and their environment, as well as the principles of social marketing. 
 
The design and development of the IM includes the translation of the results of the 
formative research carried out in 2022 in the states of Morelos, Campeche and the State 
of Mexico. 
It also includes key decisions and strategies proposed in the Workshops developed by 
the team of researchers who collaborate in the IM of the selection of target audiences, 
behavioral objectives, barriers to consider and multilevel and multichannel 
interventions to achieve behavioral change. Likewise, the main results of the feasibility 
study carried out in Campeche and Morelos during the months of May-June 2023 are 
included. Derived from the results of the feasibility study, the activities for each 
component are proposed and adjusted. This document describes the design of the MI, 
that is, what to do to implement the package of interventions to foster an environment 
that promotes healthy lifestyles and send effective messages among the target 
audiences and the process used for the design. Therefore, it will guide and provide 
direction in the development of the rest of the intervention to ensure that activities, 
materials and messages are aligned and integrated towards the goal of modifying 

 
51 
 
behaviors to improve eating, nutrition, movement behaviors and Psychosocial aspects 
of school-age girls and boys. The results of stage 2 are detailed in annex 44. 
 
3. Stage 3. Implementation, monitoring and evaluation of the 
multidimensional intervention.  
 
In accordance with what was previously described (figure 2), to evaluate the effect of 
MI, two studies will be carried out in parallel: 1) Randomized community trial in 3 
states of the Mexican Republic: Campeche, Morelos and Mexico City and 2) Trial 
randomized clinical trial in Cuernavaca, Morelos with a more exhaustive evaluation. In 
both studies, the intervention will be implemented for the same time and an initial 
evaluation will be carried out, before implementation, and a final evaluation, at the end 
of the intervention. 
 
3.1. 
Basal Measurement 
The baseline measurement offers a set of evidence and insights about the initial 
situation of a project, as well as the context in which it intervenes, so that this 
information can be compared with the changes achieved in subsequent analyses. 
Baseline is defined as a set of indicators selected for systematic monitoring and 
evaluation of policies and programs. 
 
3.2. 
Implementation of the intervention 
For the selection of schools (control and intervention), the educational authorities of 
each of the participating states sent a list of schools that meet the inclusion criteria. In 
this sense and to reduce the risk of contamination between individuals, random 
selection was carried out. carried out at the school level. Additionally, we confirmed 
that the control and intervention schools do not share directors and/or teachers. 
 
This stage consists of the following phases: 
 
1. 
Randomization and recruitment of participants. Randomization will be 
carried out in 2 blocks (intervention and control) with 4 schools in each block, by state, 
in the program https://www.randomlists.com/ . 
 

 
52 
 
Subsequently, randomization will be carried out, and the control group and the 
intervention group will be established. Table 8 shows the list of schools proposed by 
the educational authority, differentiated by intervention and control group. 
 
Table 8. Primary schools integrated in the Multidimensional Intervention, stratified by state 
State 
Cluster 
School name 
Clue 
Morelos 
Intervention 
Latin American Institute 
17PJN0008D 
Intervention 
Loyola Educational Group 
73/LXII/12 
Control 
Hope School 
17PJN0571A 
Control 
Cervantes School of Morelos 
17PES0054Z 
Campeche 
Intervention 
Justo Sierra Mendez 
04DPR0362C 
Intervention 
Republic of Honduras 
04DPR0216S 
Intervention 
Gunner Boy 
04DPR0007M 
Intervention 
Lucila Alayola Laura 
04DPR0089M 
Control 
Presidente Ruiz Cortines School Center 
04DPR0353V 
Control 
Josefa Ortiz de Dominguez 
04DPR0716N 
Control 
CE Pdte. Avila Camacho 
04DPR0360E 
Control 
Children of workers 
04DPR0167Z 
Mexico City 
Intervention 
First of May 
09DPR2005X 
Intervention 
Somalia 
09DPR2231T 
Intervention 
Gen. José Mariano Monterde 
09DPR2302X 
Intervention 
State of Querétaro 
09DPR2816V 
Control 
Prof. Mazimiliano Molina Fuente 
09DPR5147P 
Control 
Prof. José S. Benitez 
09DPR0045K 
Control 
Jose Azueta 
09DPR0849Z 
Control 
Luis de la Brena 
09DPR2011H 
 
Additionally and only for the accelerometry component (measurement of physical 
activity, we request that we be allowed to include two public schools in Guadalajara, in 
order to increase the sample size (100 additional participants). The school chosen for 
this purpose is: School José María Morelos y Pavón primary school 
Pirul Street # 25 Lomas de la Solitude, Tonala, Jalisco. CP 45403 
 
Once the group to which each school will belong has been defined, the consent of the 
teachers and managers of the school cooperatives that will participate in the 
intervention will be requested (Annexes 45 – 46). Subsequently, a meeting will be held 
with parents and fourth grade primary school students to extend an invitation to 
participate. A total of 30 students will be selected for each control and intervention 
school. As part of the recruitment process, letters of consent and informed assent will 
be delivered and explained to participating parents and students (Annexes 47 – 50), 
respectively. Once the recruitment of participants is completed, the initial evaluation 
will be carried out. 

 
53 
 
2. Initial evaluation: Represents the first measurement, whose methodology 
must be replicated at the end of the project cycle. The baseline measurement 
must focus on: a) showing evidence that characterizes the target population at 
the beginning of the intervention, b) analyzing the dynamics of the context and, 
especially, those external factors that would affect the achievement of the 
project results for its subsequent monitoring, and c) determine the starting 
situation of the project's results and impact indicators, raising their first value 
using research techniques. 
 
3. Implementation: Once the baseline measurement has been carried out, 
considered as activity 1, the following activities will be carried out (Annexes 51 
– 55): 
Activity 2. Launch of the Multidimensional Intervention 
The school community (schoolchildren, teachers...) is made aware of the activities that will be carried out by 
each actor that will be part of the Multidimensional Intervention. 
Aim 
So that the school community is aware of the activities in which they will be participating 
within the IM. 
Development of 
the activity 
 
With some time in advance (at least 2 weeks before), an invitation is sent to the entire 
school community, with detailed information about the event. Subsequently, a reminder 
will be sent to them to attend the event. The invitation will be shared through teachers 
and directors to mothers, fathers, and caregivers of schoolchildren. Additionally, 4th 
grade teachers, physical education class teachers and school store salespeople will be 
sent the invitation through the promoters of the Multidimensional Intervention. 
The printed material of the communication campaign will be placed in the school 
facilities, for example: canvases and banners with key IM messages in strategic spaces 
inside and outside the school. 
So that the school community has the comfort of attending, the launch will take place 
within the school facilities, in a large space, indicated by the directors, and conditioned 
to carry out the activity optimally, placing chairs and installing visual and audio 
equipment. . The promoters will make known what the activity is about, what they seek 
to obtain with it and the benefits of participating in the workshops and other proposed 
dynamics. With the help of a PowerPoint presentation, the key messages will be shown 
to the school community, the development of the activities to whom they are directed 
and the moment in which they will be developed. 
Educational capsules with the key IM messages described below will be projected to the 
school community. Informed consent letters will be given to parents for authorization to 
participate and sign. Registration will be made (ADTA) to receive mobile messaging via 
WhatsApp with key messages aimed at mothers, fathers and 4th grade teachers. Printed 
material with the key messages will be given to the school community, for example: 
Manual on Movement Behaviors, flyers with all the key messages, magnet to stick on the 
refrigerator, etc. Finally, the contact channels will be announced in case they require 

 
54 
 
more information and any doubts that the school community may have will be dispelled 
to later close the launch. 
Who does it? 
 
The IM team is made up of: Doctors (or), Nutritionists (or), Lic. Physical Education, who 
are the promoters of the IM of the National Institute of Public Health and are the people 
who will be implementing the activities corresponding to the Intervention 
Multidimensional. 
Material 
 
To launch the IM you need: 
● 
Audio and video equipment. 
● 
Manual of movement behaviors. 
● 
Flyer with messages to send. 
● 
Refrigerator magnet. 
● 
Database for WhatsApp REGISTRATION. 
● 
PowerPoint presentations. 
● 
Educational capsules. 
It will be aimed at the entire school community, including mothers, fathers, caregivers of school-age girls and 
boys, school directors, 4th grade teachers, Physical Education class teachers and school store salespeople. 
 
 
 
Activity 3. Projection to the school community of the educational capsule with the key messages of 
CM, ASS and DS 
Screening of the educational capsules of the key messages of the IM regarding the importance of consuming 
fruits and vegetables, the importance of water consumption, the benefits of physical activity, and the school 
community during the launch of the IM. 
Aim 
1. Improve knowledge about the importance and benefits of consuming vegetables and 
fruits, generate favorable attitudes towards their consumption, and thereby favor the 
subjective norm regarding consumption, leading to creating confidence in girls and boys 
in their ability to eat them and increasing confidence. intention to consume them. 
2. Improve knowledge about the risks of consuming ultra-processed foods, increase 
negative attitudes towards the consumption of ultra-processed foods, strengthen the 
negative subjective norm regarding consumption, increase confidence in girls and boys 
in their ability not to consume ultra-processed foods, increase the intention to Do not 
consume ultra-processed foods and reduce the consumption of ultra-processed foods. 
Development 
of the activity 
 
The material will be shown with the help of audiovisual equipment, whether projector or 
screens, to mothers, fathers, caregivers and teaching staff, during the launch activity. 
Subsequently, the IM team will reflect with the participants on the content of the capsules. 
Who does it? 
The projection of the educational capsules will be carried out by the IM promoters. 

 
55 
 
Material 
 
The materials necessary for the activity are: 
● Educational capsules. 
● Audiovisual equipment. 
The screening will take place during the launch of the IM with the entire school community. The activity is 
aimed at the entire school community participating in the IM. 
 
Activity #4. Delivery of communication material: infographics and magnet 
Printed communication material, infographics of the IM's key messages and refrigerator magnets promoting 
water consumption are delivered to mothers, fathers and caregivers of school-age children. 
Aim 
1. 
Improve knowledge about the importance and benefits of consuming 
vegetables-fruits and natural water, generate favorable attitudes towards their 
consumption, and thereby favor the subjective norm regarding the consumption of 
vegetables-fruits and water, leading to creating in girls and boys the confidence in their 
ability to eat vegetables-fruits and natural water, as well as increasing the intention to 
consume them, all with the aim of increasing the consumption of vegetables-fruits and 
natural water. 
Development of 
the activity 
 
The IM promoters will present and explain each of the materials to the school community 
during the launch of the IM, delivering the physical material. 
The infographics contain key messages to promote knowledge about: 
1. 
Let's eat more vegetables and fruits: Let's eat more fresh vegetables and fruits 
in all our meals. Let's choose seasonal ones, which are cheaper and, when possible, 
locally produced. 
2. 
Let's drink more natural water every day: Let's drink more natural water 
throughout the day and with all our meals, instead of sugary drinks such as soft drinks, 
juices, waters prepared with powder sachets and sports drinks. Excess sugar is harmful 
to our body and the packaging pollutes the environment. 
3. 
Let's avoid ultra-processed foods and drinks. Let's avoid ultra-processed 
foods such as sausages, chips, cookies, sweet bread and boxed cereals, since they have a 
lot of fat, salt and/or sugar. Let's choose foods without stamps or with as few stamps as 
possible. 
4. 
Let's do physical activity. Let's do more physical activity like walking, running 
or dancing. Let's spend less time sitting or in front of the screen (cell phones, television, 
video games and others). Every move counts! 
Who does it? 
 
The delivery of printed materials and their presentation will be carried out by the 
promoters of the IM 

 
56 
 
Material 
 
To carry out the activity you need: 
● 
Audiovisual material. 
● 
Printed infographics. 
● 
Refrigerator magnet. 
The printed material is aimed at mothers, fathers, caregivers of 4th grade girls and boys, and teaching staff 
and is delivered during the launch of the IM. 
 
Activity #5. Communication strategy through WhatsApp messaging 
As part of the IM, an important messaging component via WhatsApp has been designed and included focused 
on topics to identify risk and protective factors for overweight and obesity in the school population. These 
messages facilitate access to information on health and nutrition issues for schoolchildren. 
Aim 
The purpose of these messages is to reinforce the learning of the topics addressed in 
the rest of the components on knowledge and appropriate feeding practices, movement 
behaviors and health. 
Development of 
the activity 
 
An invitation and registration (HIGH) is made to receive mobile messaging via 
WhatsApp with the key messages directed: The telephone number provided by the IM 
promoters is saved, with the name, later the word HIGH is sent and they will begin to 
receive a series of questions to be answered. 
 
Upon completion of registration you will receive the following message: 
Congratulations! We have completed your registration. The messages will soon 
begin to arrive on your cell phone.  
About 1 message will be sent per week for 10 months, for a total of approximately 46 
messages. Messages will be sent via WhatsApp throughout the school year, on the 
topics of healthy eating, movement behaviors and psychosocial determinants during 
childhood. In all cases, it is essential to encourage people to respond to messages and 
continue receiving all the benefits of sending messages. 
There are two types of messages: 
Informative: These are those that seek to teach or reinforce key messages. 
Challenges: These are messages that seek to motivate students to put health and 
nutrition learning into practice in a fun way and involving the entire school community. 
The idea of this activity is to reinforce the learning of the topics addressed in the rest 
of the components. Within the design, the following elements were considered: Spanish 
language, an average length of 130 characters, and a focus on profit framework. 
Additionally, messages will consider diversity, equity and inclusion through inclusive 
language and trying to avoid bias between groups that differ socially, economically, 
demographically or geographically. In addition to this, some messages will be 
accompanied by audiovisual material such as videos or infographics, as appropriate, to 
complement the recommendation that is being provided. Reminder: shipping 
frequency and time 
Sending WhatsApp messages: Every third day 
Planned days: Monday, Wednesday and Friday. However, you may occasionally send 

 
57 
 
messages on other days of the week. 
Shipping duration: Approximately nine months from the date of REGISTRATION. 
 
Note: If any person in the school community does not have a smartphone or does not 
have constant access to the internet, this activity will not be part of their activities 
within the IM. 
Who does it? 
 
The registration of contacts for the creation of the WhatsApp group and the sending of 
messages is the responsibility of the IM promoters. 
Material 
 
To carry out the activity you need: 
● 
Registration database 
● 
Equipment for sending messages. 
Contact registration will be done during the IM and messaging will be sent from the start of the intervention 
(October 2023) until it ends (June 2024). Sending key messages through WhatsApp is aimed at mothers, 
fathers, caregivers of girls and boys, and teaching staff at schools that participate in IM. 
 
Activity #6. Virtual course 
A 20-hour online course will be taught aimed at teaching staff, mothers, fathers and caregivers of 4th grade 
primary school boys and girls, on topics of the three components of IM. 
Aim 
To strengthen continuing education for teachers of selected primary schools and 
mothers , fathers and caregivers on topics of healthy and sustainable eating, 
movement behaviors, and psychosocial determinants in school girls and boys, this with 
the aim of increasing knowledge , practices, intention, attitude, subjective norm and 
perceived control. 
Development of 
the activity 
 
4th grade teachers, mothers, fathers and caregivers of girls and boys are invited to take 
the course virtually, whose design and structure is developed in a simple way, its 
contents are organized as follows: 
● 
Introduction 
● 
Division of the three components. 
 
1. Healthy and sustainable eating. 
2. Movement behaviors. 
3. Psychosocial determinants. 
● 
Recommendations for each component. 
➢ 
Central recommendation. 
➢ 
Detail of the recommendation. 
➔ 
Recommendation audio. 
➔ 
Downloading resources (printable, videos, etc.) 
➔ 
Evaluation (mini test with 2 to 5 “true/false” questions, multiple choice, etc.) 
➔ 
Additional information (extra resources such as infographics, videos, manuals, 
etc.) 

 
58 
 
The time dedicated to the course will be managed by each participant until the required 
hours are covered. Upon completion and completion of the evaluation, they will be 
given a certificate issued by the INSP. 
Who does it? 
The online course will be developed by researchers and promoters of Multidimensional 
Intervention. 
Material 
 
The material necessary to develop the activity will be: 
● Virtual course. 
● Computer. 
● Internet access. 
● Records. 
The activity will be carried out during the first two months after starting the Multidimensional Intervention. 
The course is aimed at 4th grade teaching staff in primary schools where MI is carried out, mothers, fathers 
and caregivers of girls and boys. 
 
Activity #7. P.E. Class 
It is planned to work together with physical education teachers to positively influence the development of 
the physical education class. The activities range from the delivery of sports equipment to use during class, 
to the training of teachers through courses and workshops. . The activities that will be carried out during the 
intervention have been proposed by the movement's technical behavior team. These consider: a) Providing 
appropriate material and equipment for the education class to the intervention schools; b) Avoid the 
cancellation of physical education classes; c) Provide knowledge about physical activity during physical 
education class and its benefits on health, academic performance, and social relationships of students, and 
work together with the physical education union to collect, provide feedback, select and distribute activities 
relevant and experientially supported to promote physical activity during classes. 
Aim 
Complement the constructs of knowledge, subjective norm, perceived control and 
intention to increase physical activity of moderate-vigorous intensity of girls and boys 
during physical education class. 
 
Optimizing the physical education class suggests that upon reaching adulthood, 
schoolchildren may be more likely to have a normal weight and fewer musculoskeletal 
problems. 
Development of 
the activity 
 
Participating schools and teachers will be provided with a variety of materials and 
equipment relevant to the class, which may include: hoops, balls, cones, ropes, nets, 
among other items. This is so that schools have the necessary material to carry out an 
adequate physical education class. To deliver information to the teachers of each 
school, content from the MOOC Quality Physical Education in Basic Education will be 
distributed among the school community. This course lasts 20 hours. With the same 
purpose of supporting teachers in their training, through work groups together with 
physical education teachers, we will seek to collect, provide feedback, select and 
distribute a series of intervention dynamics among schools to promote practice of 
moderate-vigorous intensity physical activity during most of the class 
To prevent physical education classes from being canceled, management meetings will 
be sought with the management staff of each school, the union of general and physical 
education teachers. 

 
59 
 
Who does it? 
 
The team of promoters in charge of implementation will be in charge of providing the 
materials mentioned above, as well as providing and explaining to teachers access to 
the Quality Physical Education course in Basic Education. 
Material 
 
The material that will be provided to schools to carry out this activity is: 
● Sports equipment: hoops, balls, cones, ropes, nets, among other elements. 
● Mooc Course. 
The material will be delivered at the beginning of the implementation and the course modules will be 
enabled from the second week of the start, teachers will be able to access it whenever they want, and being 
virtual, they will be able to advance in the course from their homes at the time it is provided to them. They 
will have 3 months at the beginning of the implementation to complete the course. The extra modules of the 
course will be aimed at teachers of the physical education class. 
 
Activity #8. Healthy Snack. To increase the consumption of vegetables and fruits 
4th grade girls and boys are encouraged to bring a healthy snack based on vegetables and/or fruits every 
day of the school year. 
Aim 
To improve knowledge about the importance and benefits of consuming vegetables 
and fruits, generate favorable attitudes towards their consumption, and thereby favor 
the subjective norm regarding the consumption of vegetables and fruits, leading to 
creating confidence in girls and boys in their ability. to eat vegetables and fruits and 
increase the intention to consume them, all with the aim of increasing the consumption 
of vegetables and fruits. To give rise to generating changes in the constructs of attitude, 
subjective norm, perceived control, intention and consumption practice of vegetables 
and fruits in girls and boys in 4th grade of primary school. Activity that contributes to 
the constructs of attitude, subjective norm, perceived control, intention and practice. 
Development of 
the activity 
 
This activity will be briefly explained at the launch, however, before starting the 
activity, clear and precise information will be given to the girls and boys in the 
classroom through the Multidimensional Intervention promoters. Girls and boys are 
invited to bring a vegetable or fruit of their choice to school as a healthy snack. 
The promoters will regularly visit the classrooms to register the girls and boys who 
bring the healthy snack. This registration will be carried out in a group that will be in 
charge of the promoters. Each girl and boy will be given a ticket or badge every time 
they manage to accumulate 5 registrations. This ticket will help the girl and boy so that 
in the middle of the school year and at the end of it, a type of raffle will be held, with 
the purpose of encouraging them to continue bringing the healthy snack. 
The raffles will be held on two different dates, the first in the middle of the school year 
and the second at the end of it. It will be done in person at an event within the school 
facilities, where 4th grade primary school girls and boys, mothers, fathers and 
caregivers are invited. The way the raffle is carried out will be through a raffle, where 
the tickets, tokens or numbers of the winning girls and boys will be drawn. The prizes 
are sports materials, such as balls, ropes and bicycles, with the intention of promoting 
physical activity in girls and boys. 

 
60 
 
Who does it? 
 
The IM team is made up of: Doctors (or), Nutritionists (or), Lic. Physical Education, who 
are the promoters of the IM of the National Institute of Public Health and are the people 
who will be implementing the activities corresponding to the Multidimensional 
Intervention. 
Material 
 
The materials to use for this activity are: 
● Database for the registration of girls and boys. 
● Printed information material. 
● Badges or tickets. 
● Sports equipment for the raffle. 
It will be carried out from the first two weeks after the launch and will continue during the 10-month 
duration of the Multidimensional Intervention. The activity is aimed at girls and boys in 4th grade of primary 
school. 
 
Activity #9. Physical activation before the start of the school day 
Physical activations are structured physical activity sessions , lasting 10 to 15 minutes and carried out on a 
massive scale. These sessions will be implemented in fourth grade children during the IM implementation 
time. 
Aim 
This behavior will contribute to the constructs of attitude, subjective norm, intention 
and practice of increasing the levels of physical activity and reducing the sedentary 
time of schoolchildren. 
Active breaks as well as physical activations had already been implemented by the SEP 
in conjunction with CONADE through the National School Physical Activation Program, 
but were discontinued with the change of administration and also due to the COVID-19 
pandemic. Therefore, one objective of the strategy is to resume these activations as 
they used to be done previously. 
 
Development of 
the activity 
 
The training regarding physical activations will be carried out in conjunction with 
active breaks in the Workshop to improve the knowledge of teachers and managers 
about the importance and benefits of promoting physical activity and limiting 
sedentary time, as well as active breaks and active recess, teachers and administrators 
will receive demonstrations of a variety of activities that they can implement in the 
activations and will learn about the health and academic benefits of these. 
 
The physical activations will be taught through structured routines that minimize the 
risk of injury and may be accompanied by music to motivate students. The activation 
is structured in 3 phases: 
 
Initial phase (warm-up): Dosed and ordered actions and movements at low intensity 
that prepare the body for better performance and must involve muscles and joints. The 
duration of this phase will be 20% of the total activation time (e.g. 2 min in a 10 min 
activation). 
 
Medullary phase (central phase): Motor actions, which require greater effort or 
difficulty in their execution and which comprise the main component to be developed. 

 
61 
 
Dynamic or recreational alternatives may be included, the games or exercises will be 
carried out with greater impetus, effort and difficulty (moderate intensity). This phase 
will last 60% of the total activation time (e.g. 6 min in a 10 min activation). 
 
Final phase (relaxation): Motor actions to reduce heart rate, respiratory rate and body 
temperature, returning to a normal state after the effort made in the spinal cord. It is 
characterized by slow and deliberate movements, encouraging you with deep breaths. 
The duration of this phase will be 20% of the total activation time (e.g. 2 min in a 10 
min activation). 
 
Who does it? 
 
The implementation of the physical activations will be carried out by the IM promoter 
or a volunteer from the school site (physical education teacher, classroom teacher or 
director and parent) with experience in the activations. If there is no experienced 
volunteer, it will be done in the same way as with active breaks, through the 3 stages 
explained in their respective session. 
 
Material 
 
● Health promoters 
● Manual for the implementation of physical activations 
The physical activations will be carried out 5 days a week, from Monday to Friday, throughout the school 
year, they will last 10 to 15 minutes, at the discretion of the person in charge of carrying it out and will be 
carried out before the start of classes in the schoolyard. The physical activations will be aimed at the 4th 
grade girls and boys participating in the implementation. 
 
 
Activity #10. Pipimeter . Increase consumption of plain water and avoid consumption of sugary 
drinks 
The communication material “ Pipimeter ” is presented and explained to the girls and boys, so that they 
become familiar with it and can record the color of their urine based on what the material shows us, and 
thus know how their urine is. water consumption. 
Aim 
 
To improve knowledge about the importance and benefits of consuming natural water, 
generate favorable attitudes towards the consumption of natural water, promote the 
subjective norm on the consumption of natural water, create confidence in girls and 
boys in their ability to drink natural water. , increase the intention to consume natural 
water, increase natural water consumption. Activity that contributes to the constructs 
of attitude, subjective norm, perceived control, intention and practice of natural water 
consumption. 
 
Development of 
the activity 
 
The IM promoters will present the material in the classrooms to the girls and boys in 
the 4th grade of primary school. They will be explained what it is and the color scale 
and how this shows their level of water consumption. They will be given a sheet to 
record the color of their urine, which they will do every time they go to the bathroom 
during the school day. The IM promoters will place the communication material “ 
Pipometer ” on the doors of the bathrooms and in front of the urinals of the schools so 
that girls and boys can register against the scale shown. Weekly the MI promoters will 
be checking that the girls and boys are recording their urine in the material. Girls and 

 
62 
 
boys who have the highest consumption of plain water will be recorded depending on 
the color of their urine. 
 
Who does it? 
 
The activity will be implemented by the IM team, which is made up of: Doctors (or), 
Nutritionists (or), Lic. Physical Education, who are the promoters of the IM of the 
National Institute of Public Health. 
Material 
 
To carry out this activity you need the following material: 
Pipimeter printed material 
Scotch tape 
Printed urine recording material. 
Printed information material on water consumption. 
From the start of the intervention (October 2023) until it ends (June 2024). Monday to Friday for 
approximately 10 months. The activity is aimed at 4th grade primary school girls and boys. 

 
63 
 
Activity # 11. Active pauses 
Active break activities for boys and girls can include games and dynamics, such as imitating animals, 
jumping, running, stretching, breathing movements, joint movements, among others. You can also include 
dancing, singing, and other activities that promote physical activity and fun. 
An active break will be taken 2 times a day, on the 5 days of classes (Monday to Friday), considering that the 
recommendation is to take an active break for every hour of sedentary time. 
 
Considering that the primary school school schedule is from 8:00 am to 2:00 pm, the first active break will 
be between 9:00 and 9:30 am, 1 hour after school starts; While the second active break will take place 1 hour 
after the end of the school break, a schedule will not be determined since the time of the school break is 
variable in each school. 
 
Active breaks will have a minimum duration of 5 to 6 minutes at the discretion of the teacher, and may be 
extended if the dynamics so demand. They must also have the following components: 
Phase 1) Warm-up, which consists of warming up and mobility. 
Duration: 1-2 min. 
Phase 2) Exercise or dynamic session: which consists of the central phase of physical activation through 
different strategies (e.g. High Intensity Interval Training ( HIIT) , dance, games, following instructions, etc.). 
Duration: 3-4 min. 
Phase 3) Cool down: which consists of a breathing exercise and a return to calm to incorporate into the 
school class. Duration 1-2 min. 
The teacher will be able to choose the ideal moment to take the active break so as not to interrupt the planned 
activities. The teacher will be recommended to take breaks when he observes and considers that the 
students have been sitting for a long time, considering the schedules mentioned above, or are tired of school 
activities and need to recover their attention with some dynamic activity. 
Aim 
This behavior will contribute to the constructs of knowledge, attitude, subjective norm, 
perceived control and intention to reduce prolonged sedentary time in girls and boys. 
The main objective of active breaks is to reduce sedentary time during the school day, 
trying to prevent students from spending more than two hours sitting continuously. 
Evidence has shown that sitting for long periods of time can increase the risk of 
cardiovascular diseases, diabetes, obesity and other health problems, which is why it 
is advisable to limit sedentary time with physical activities in the classroom. 
Development of 
the activity 
 
In order to improve adherence to the protocol, active pauses are initially carried out 
through an MI promoter to gradually be implemented by the teacher. The above will 
be achieved through three stages: 
Stage 1: An IM promoter and the classroom teacher will implement active pauses 
together. 
Stage 2: The classroom teacher will implement active pauses while the IM promoter 
observes and provides feedback at the appropriate time. 
Stage 3 onwards: The classroom teacher will make the active breaks on his or her own 
without the presence of the promoter. 
During this stage, the team of researchers will be on the lookout and the teachers will 
be able to contact them or the MI promoter at any time, to resolve doubts, if they have 
concerns or need more help. . 
 
Who does it? 
 
The active breaks will be taught by group teachers or managers trained through the 
Workshop to improve the knowledge of teachers and managers about the importance 

 
64 
 
 
 
Activity #13. Accelerometry  
Accelerometry is a method that allows objective monitoring of physical activity and provides a large amount 
of information about the physical activity patterns of girls and boys . The accelerometers will be distributed 
among a subsample of 500 girls and boys in schools. To control the use of accelerometers, the research team 
will use an exit and entry log. (Annex 56) 
   
ActiLife and Matlab software through an algorithm prepared by the research team. The Freedson cut-off 
points for school girls and boys will be used to estimate the time per day dedicated to different intensities of 
physical activity. 
Aim 
Evaluate the effect of the intervention on physical activity and sedentary time. 
Actigraph GT3X+ accelerometers ( ActiGraph , LLC, Pensacola, FL, USA) will be used. 
Development of 
the activity 
 
The accelerometers will be charged and initialized (programmed) prior to delivery to 
the girls and boys. ActiLife 6.13.4 software will be required for initialization and data 
download . When delivering the accelerometers to the girls and boys, the project will 
be explained clearly and briefly, the instructions for use will be explained, and the 
correct position of the device will be demonstrated. The device will be placed on the 
right side of the hip. It is important that the device and the belt are used appropriately 
each time the child uses them. When wear time has ended, the accelerometers will be 
collected by the research team at the school. Once collected, the data will be 
downloaded and compliance with the required time will be reviewed. 
 In order to verify the appropriate use of the accelerometers, members of the research 
team will be present in the schools during the mornings. To keep a record of the 
verification of accelerometer use, a daily checklist will be used (Annex 57). In addition 
to verifying use, the research team will be attentive to answering questions and 
clarifying instructions for use. Additionally, reminders about use will be sent via 
SMS/phone at the beginning of the week of use and one day during the weekend. Girls 
and boys who use the accelerometer daily will receive an incentive ( stickers ) at the 
time of verification by the research team. 
 
The accelerometers will be charged and initialized (programmed) prior to delivery to 
the girls and boys. ActiLife 6.13.4 software will be required for initialization and data 
download . When delivering the accelerometers to the girls and boys, the project will 
be explained clearly and briefly, the instructions for use will be explained, and the 
correct position of the device will be demonstrated. See instructions in Annex 58. The 
device will be placed on the right side of the hip. It is important that the device and the 
belt are used appropriately each time the child uses them. When wear time has ended, 
the accelerometers will be collected by the research team at the school. Once collected, 
the data will be downloaded and compliance with the required time will be reviewed. 
Who does it? 
 
Research team, Boys and girls 
Material 
Accelerometers 
 
and benefits of promoting physical activity and limiting sedentary time for 
schoolchildren. 
 
Material 
 
• 
Health promoter or teacher 
• 
Active breaks manual 
The active breaks will take place from the beginning to the end of the IM and are aimed at 4th grade girls 
and boys. 

 
65 
 
 
Activity #14. 24 hour reminder 
The 24-hour Reminder is a quantitative instrument that presents an excellent alternative to evaluate the 
food and drink consumption of the person interviewed in the last 24 hours. With this instrument you can 
know the preparations consumed, as well as each of the ingredients that make them up. (Annex 59) 
Aim 
Evaluate the type and quality of food available to the children included in the study. 
Development of 
the activity 
 
Complete a questionnaire with parents about what was consumed the previous day . 
Who does it? 
 
Research team 
Parents 
Material 
 
Questionnaire 
 
During the first two months of the implementation of the IM, group workshops will be 
held with the purpose of reinforcing behaviors within the three main components ASS, 
CM and CP , including girls and boys in the 4th grade of primary school, mothers, fathers 
and caregivers of girls. and children, managers, teachers and physical education 
teachers . Table 9 shows the topics, objectives and audiences of the IM workshops. 
 
Chart. 9 Topics, objectives and audience of IM workshops 
Workshop  
Aim  
Workshop participants  
Group workshop 1: Workshop to 
paint and recondition the patio 
Offer greater opportunities for 
physical activity to girls and boys 
within school facilities. 
4th grade girls and boys, mothers, 
fathers and caregivers of girls and 
boys. 
Group workshop 2: Emotional 
management of children about 
food. 
So that girls and boys become 
aware of the emotions related to 
eating and knowledge about how 
to manage them. 
Girls and boys of 4th grade. 
Group workshop 3: Importance 
and benefits of promoting physical 
activity. 
So 
that 
teaching 
staff 
and 
managers 
are 
aware 
of 
the 
benefits of physical activity in 
school-age girls and boys and, 
thanks to this, encourage its 
implementation within school. 
Aimed at teaching staff 
 
Group workshop 4: Healthy and 
sustainable eating 
To contribute to the construct of 
knowledge in mothers, fathers and 
caregivers about the benefits of 
eating a healthy diet for girls and 
boys. 
Mothers, fathers, caregivers of 
girls and boys and teaching staff 
 
 

 
66 
 
Group workshop 5: Prevention of 
stigmatization with weight and 
body shape. 
So that girls and boys become 
aware of the impact caused by 
criticism of figure and weight. 
Girls and boys of 4th grade. 
 
Group workshop 6: Prevention of 
stigmatization with weight and 
body shape. 
So that mothers, fathers and 
caregivers become aware of the 
impact caused by criticism of 
figure and weight. 
Mothers, fathers and caregivers of 
girls and boys. 
 
Group workshop 7: Obesity and 
healthy eating. 
This behavior will contribute to 
the knowledge constructs on the 
topic of obesity and healthy eating 
in girls and boys aimed at teaching 
staff. 
Staff 
 
Group workshop 8: Identification 
of hunger and satiety signals. 
That girls and boys become aware 
of the signs of hunger and satiety. 
Girls and boys of 4th grade. 
Group workshop 9: Identification 
of hunger and satiety signals, and 
symptoms 
of 
anxiety 
and 
depression. 
So that mothers, fathers and 
caregivers become aware of the 
signs of hunger and satiety in 
school-age girls and boys. 
Mothers, fathers and caregivers of 
girls and boys. 
 
Group workshop 10: Prevention of 
stigmatization with weight and 
body shape. 
So that teaching staff become 
aware of the impact caused by 
criticism of figure and weight. 
Staff 
Group 
workshop 
11: 
Internalization of the aesthetic 
ideal of beauty. Aimed at girls and 
boys 
So that girls and boys become 
aware 
of 
the 
content 
of 
information in the media and the 
normalization or internalization 
of a certain ideal of beauty 
reflected in them. 
  
Girls and boys of 4th grade. 
Group workshop 12: Obesity and 
healthy eating. 
This behavior will contribute to 
the knowledge constructs on the 
topic of obesity and healthy eating 
in girls and boys aimed at mothers, 
fathers and caregivers of girls and 
boys in fourth grades. 
Mothers, fathers and caregivers of 
girls and boys. 
Group workshop 13: Identification 
of hunger and satiety signals, and 
symptoms 
of 
anxiety 
and 
depression. 
Raise awareness among teaching 
staff about the management of 
anxiety related to eating in school-
age boys and girls. 
Staff. 
Group workshop 14: Parenting 
and self-care limits. 
Raise awareness among mothers, 
fathers 
and 
caregivers 
about 
parenting 
practices, 
emotional 
communication, 
anxiety 
Mothers, fathers and caregivers of 
girls and boys. 

 
67 
 
management, child development 
and limits. 
Group workshop 15: Teaching and 
self-care 
Raise teachers' awareness about 
emotional 
communication, 
anxiety 
management, 
child 
development and limits. 
Staff. 
Group 
workshop 
16: 
Official 
Mexican STANDARD NOM-251-
SSA1-2009, Hygiene practices for 
the processing of food, beverages 
or food supplements . 
Raise awareness among food 
vendors about good practices in 
the 
processing 
of 
food 
and 
beverages 
in 
the 
school 
environment 
Food sellers in stores and school 
cooperatives. 
 
3.3. 
Intervention monitoring  
Currently, it is known about the need to have evidence-based interventions to improve 
the nutritional status of a population. However, it is recognized that the impact of 
evidence-based interventions could be limited by a lack of certainty in the best 
strategies to implement and scale interventions 45 . Therefore, in the evaluation of an 
intervention, it is important not only to evaluate its impact, but also to include 
monitoring and evaluation of the implementation process. The objective of 
implementation research is to know and understand the execution of programs or 
interventions in real conditions and contexts, rather than controlling these conditions 
or removing their influence and possible effects. This involves working with the 
community in which a program or intervention is implemented, which includes both 
the different actors involved in the operation of the program and its users. 
Implementation research also includes the study of contextual factors that affect the 
program implementation process 46,47 . 
  
In order to conceptualize and evaluate the success or failure of the implementation of a 
program or intervention, it is necessary to use some characteristics that allow 
identifying aspects of the implementation response, called implementation outcome 
variables. Therefore, as previously mentioned, the following will be used in this study: 
Acceptability, adoption, feasibility and fidelity. 
  
Therefore, in the present study, implementation monitoring will be carried out in 
schools with multidimensional intervention. Additionally, simpler monitoring will be 
carried out in the control group schools , which will allow identifying possible 
important changes that may result in modifications in the diet and physical activity of 
this group. 
  
Procedure: 

 
68 
 
  
1. 
First phase: “Review of the operating rules of the intervention.” The review of 
the activities proposed by previous strategies in the school environment will be carried 
out to identify the components, periodicity and procedures planned to provide the 
intervention. 
  
2. 
Second phase: “Information gathering”. Information will be collected from the 
perspective of the children who receive the intervention and their parents, as well as 
the teachers and decision makers involved in the implementation of the intervention. 
  
Qualitative monitoring indicators 
  
In the monitoring of schools with a control and multidimensional group, the following 
will be carried out: 
  
In a subsample of the following informants, focus groups and semi-structured 
interviews will be carried out to identify barriers and possible solutions to improve the 
implementation of the intervention: 
  
Informants: 
a) 
4th grade boys and girls participating in the study. 
b) 
Parents of the children participating in the study. 
c) 
Teachers and directors and managers of the school cooperative or food sale 
within the school where the intervention takes place. 
d) 
Decision-makers: Key actors from each of the federal entities or school zones 
where the study will be carried out and who are related to the implementation of the 
intervention. 
e) 
Food vendors in and around the schools participating in the study. 
f) 
Community decision-makers: Key actors in the implementation of legislation 
and regulations related to the sale of food in the community and the development, 
maintenance and safety of the infrastructure of streets and areas for physical activity 
(e.g. parks, sports units, among others). ). 
  
Through qualitative methodology, a work team with knowledge and experience in 
implementation evaluation will collect the information. The information gathering 
techniques will be the same as those used in the situational diagnosis stage: Non-
participant observation, semi-structured interviews and focus groups, which were 
already described previously. 
  

 
69 
 
These activities will be carried out in all schools with control and IM groups in 
Cuernavaca, Morelos. The information derived from the interviews and audio focus 
groups will be recorded, considering the prior consent of the study subjects. In the case 
of monitoring for schools with a control group and IM in Campeche and Morelos, it will 
be carried out through observation, with simple recording instruments. The objective 
of these instruments will be to record the implementation of the intervention 
strategies. 
  
Table 10 describes the periodicity of each of the implementation monitoring indicators, 
the sample sizes for each indicator, as well as the number of focus groups per actor, in 
the case of the schools of Cuernavaca, Morelos. 
  
3. Third phase: “Information analysis”. The content analysis technique of the 
interviews will be used, triangulating with the observations made. For this, detailed 
summaries of the individual and group interviews will be made from field recordings, 
focus groups and observation exercises. Subsequently, content matrices will be 
developed to organize the information by relevant themes. The thematic categorization 
of the tables of contents will be made from the instruments plus the contributions of 
the informants. 
  
Quantitative monitoring indicators  
 
Table 10 describes the monitoring indicators proposed for the multidimensional 
intervention. The indicators to monitor during this phase are described below: 
  
Training component: Attendance at face-to-face sessions, courses or workshops with 
tutorial videos taught as part of the intervention, for school teachers. Monitoring will 
be done through an electronic platform designed to record attendance at these courses. 
  
Component of availability of food and beverages and infrastructure for physical 
activity within the school: Through direct observation, the availability of food and 
beverages, as well as the infrastructure for physical activity within the school campus, 
will be recorded. Special attention will be paid to the availability and operation of 
drinking fountains within the school campus. The information will be obtained through 
a food and beverage inventory format where the type and quantity of food available 
will be documented, as well as an infrastructure format for physical activity where the 
presence of drinking fountains and other characteristics that encourage this behavior 
will be documented. (for example, school playgrounds with painted games). In the case 

 
70 
 
of the availability of food and drinks at home, this will be done through a questionnaire 
that will be sent to be filled out by parents. 
  
Physical activity component: The quality of physical education classes and teacher 
behavior, active recess sessions, will be evaluated through direct observation. In the 
case of physical education classes and active recesses, 2 physical education classes and 
2 active recesses will be randomly selected in each school, during the monitoring week 
for each occasion (at 3 and 6 months after the intervention) 83,84,85 Other instruments 
will also be considered to evaluate PAFI components (e.g., active breaks, 
extracurricular activities, and active transportation programs) that are considered part 
of the IM based on the formative and policy evaluation . 
  
Educational communication component : SMS messages will be included, the 
number of messages received by parents and/or teachers through mobile devices on 
various topics (nutrition, physical activity, food risk behaviors, among others) will be 
estimated. Additionally, a brief exam will be taken on knowledge of the topics included 
in the messages. 
  
Community environment component: As advocacy actions to improve walking 
infrastructure (sidewalks, road signs, pedestrian crossings), street sales of unhealthy 
foods and beverages, advertising of unhealthy foods and beverages, means of 
transportation, physical safety and food, access to parks and other recreational sites, 
improvements in lighting and community participation around schools, promotion of 
healthy eating, the number of sessions held with the corresponding authorities will be 
documented. Likewise, using a food and beverage inventory, the number of food 
stores/stalls and advertising of unhealthy foods and beverages around the school 
(100m perimeter) will be evaluated. Finally, the infrastructure for physical activity 
(walking infrastructure, recreational spaces, etc.) will be evaluated using street-level 
audits within a 100 m perimeter around the school. 
  
Monitoring schools with a control group : As mentioned above, monitoring will be 
carried out in the schools with a control group . The above in order to identify possible 
strategies or actions carried out at the individual, school or family level to modify diet 
and physical activity. Monitoring in these schools will be carried out with the 
instruments indicated in table 10 and correspond only to those that will be used in the 
monitoring of schools with a control group and IM in Campeche, Morelos and Mexico 
City (marked with an * in table 4 aforementioned). Monitoring in the 12 schools with a 
control group (4 per federal entity) will be carried out only 6 months after starting the 
intervention.

 
71 
 
Table 10. Intervention monitoring indicators and periodicity of information collection. 
Level 
of 
inquiry 
Actors 
Information to collect 
Proposed method 
Federal entity where monitoring 
will be carried out 
 
 
 
 
 
Individual 
Boys and girls of 
4th 
year 
of 
primary school 2 
(annex 50) 
Perception of the intervention: Content 
of the messages and workshops on 
nutrition and self-care, physical activity, 
mental health 
Acceptability 
of 
the 
intervention: 
Barriers and windows of opportunity to 
make changes in promoting healthy 
eating, physical activity and self-care 
Fidelity, the number of strategies that 
were implemented aimed at children, 
and that were actually received, will be 
evaluated. 
Focus groups (2 focus groups per 
school, one for each grade level, 
with 6-7 children each) 
  
  
  
  
Questionnaire on participation in 
strategies directed at the individual 
level (for boys and girls), as well as 
acquired knowledge* 
Cuernavaca clinical trial schools 
  
  
  
  
  
Schools with control group and IM 
in Mexico City,  
Campeche, and Morelos 
 
Food 
vendors 
inside the school 
(annex 46) 
Acceptability 
of 
the 
intervention: 
Barriers and windows of opportunity 
for 
the 
implementation 
of 
each 
component of the intervention (on 
promotion of healthy eating, physical 
activity and self-care) 
Acceptability 
of 
the 
intervention: 
barriers and windows of opportunity 
for 
the 
implementation 
of 
each 
component of the intervention (on the 
Semi-structured interview (2 per 
school- 2X12=24) 
 
 
 
 
Questionnaire for food vendors 
Cuernavaca clinical trial schools 
 
 
 
 
Schools with control group and IM 
in Mexico City,  
Campeche, and Morelos 

 
72 
 
type of food and beverages available in 
food outlets within schools) 
 
Availability of food and drinks within 
the school, as well as the foods most in 
demand by students 
Availability of drinking water (drinking 
fountains, their operation, water jugs) 
Availability 
of 
infrastructure 
and 
materials for physical activity (painted 
school yards, hoops, balls, etc.) 
Food and beverage inventory * 
  
Availability 
and 
operation 
of 
drinking fountains or water jugs * 
 
 
 
 
Inventory of school infrastructure 
for physical activity 
Schools with control group and IM 
in Mexico City, Campeche, and 
Morelos  
 
Physical activity 
within schools 
(annex 50) 
active recreation 
 
 
Direct observation of the type of 
activities 
carried 
out 
during 
active recess sessions (2 pro-
school recesses 2X4X3=24)* 
Schools with control group and IM 
from Mexico City, Campeche and 
Morelos 
Community 
Availability 
of 
food and drinks 
around 
school 
and 
at 
home 
(annex 50) 
Feasibility, related to the infrastructure 
to carry out the planned activities of the 
intervention (food sales and areas for 
physical activity) 
  
  
In-depth interview with vendors 
around the school on the viability of 
the strategies proposed by the 
intervention to improve availability 
of healthy foods and beverages 
around the school (100 m radius) (2 
vendors per school- 2X12=24) 
 
Questionnaires for vendors around 
the school on the viability of the 
strategies 
proposed 
by 
the 
intervention to improve availability 
of healthy foods and beverages 
Cuernavaca clinical trial schools 
  
  
  
  
  
 

 
73 
 
around the school (100 m radius) (2 
vendors per school- 2X4X3=24) 
  
Availability of food and drinks 
around the school. Observation 
(100 m school radius) 
 
Food and beverage inventory. 2 
establishments will be selected 
around the school per federal entity 
(2X4X3=24)* 
 
Availability of infrastructure for 
physical activity around the school. 
Observation (100 m perimeter 
around the school) 
Schools with control group and IM 
from Mexico City, Campeche, and 
Morelos 
 
 
 
Schools with control group and IM 
from Mexico City, Campeche, and 
Morelos 
 
Schools with control group and IM 
from Mexico City, Campeche, and 
Morelos 
 
Schools with control group and IM 
from Mexico City, Campeche, and 
Morelos 
1 
It refers to the months after the start of the implementation of the intervention. 
2 
In the case of monitoring 3 months after starting the implementation, the focus groups will be carried out only with 4th 
grade boys and girls. 
* Information to be collected and instruments to be used in the control group schools (12 control group schools in 3 states: 
Mexico City, Campeche and Morelos) 6 months after the intervention began. Monitoring will consist of identifying possible 
strategies at the school or home level, as well as at the individual level, adopted in order to prevent overweight and obesity or 
improve nutrition and promote an increase in physical activity. 
** Based on the results of the feasibility of implementation of the remaining components of the PAFI (active transportation 
programs, active breaks and extracurricular activities) the need to include additional measurements and indicators of these 
components will be determined.

                                                                                                                                                                            
74 
 
Monitoring information collection 
  
Monitoring will be carried out 3 months after starting MI. The survey is planned to be 
carried out with electronic devices (lap-tops/tablets) with simultaneous capture in the 
field; that is, carrying out observations, semi-structured interviews and focus groups 
with the support of recorders and laptops. The recorded audio and capture information 
will be safeguarded by the supervisors via the Internet to a central server, in which the 
database will be integrated automatically, with daily cuts. For the latter, the 
interviewers will take the computers with the supervisor daily, to back up the 
information. The supervisors will integrate the information from the respective work 
group, and upload it to the server via the Internet. For security reasons, the information 
will also be backed up on USB keys in case of any eventuality. 
  
The field team will consist of one work couple per federal entity (in total 3 couples - 6 
interviewers) and one supervisor per federal entity (3 supervisors). The interviewers 
will be personnel who live in the same city where the study will be carried out. Each 
pair of the federal entities will be in charge of collecting the monitoring information in 
the control group schools and in the IM schools of Campeche, Morelos and Mexico City. 
All field staff will have personal identification and will wear t-shirts with the INSalud 
logo. 
  
Multidimensional intervention evaluation 
  
The evaluation of the effect of MI will be carried out both in schoolchildren 
participating in the community trial and in the clinical trial, including in the latter case 
measurements of body composition as well as biological measurements. The 
components of the evaluation are described below. 
  
Community trial 
 
In the schools that participate in the community trial with different types of 
intervention, measurements will be made to the school population at 2 moments from 
recruitment: 0 (recruitment and initial or baseline measurement) and at 6 months 
(final measurement). 
  
The main outcome variables and the instruments through which they will be measured 
are also presented in Table 10 and are summarized below: 
 

                                                                                                                                                                            
75 
 
At the individual level 
  
Health indicators: To evaluate the effect of the interventions implemented in this study, 
the following measurements in schoolchildren will be considered as biological 
measures: anthropometry (weight, height and waist circumference), body mass index 
(BMI) and blood pressure, in the same way described for the clinical trial. 
  
Behavioral change indicators: Changes in knowledge, attitudes, intention to change (as 
intermediate indicators) and behaviors (outcome indicators) on key topics, food and 
beverage consumption inside and outside of school, physical activity and sedentary 
lifestyle inside and outside school. out of school, CAR and ED, in children as well as in 
mothers and fathers. In children it will be measured through a printed questionnaire 
and in parents through the mobile application that is developed. 
  
School environment: Availability of food and drinks, physical activity. The number of 
physical education classes, active recesses, active breaks, active transportation 
programs and extracurricular activities will be measured through registration forms. 
The availability of food and beverages, as well as infrastructure for physical activity 
within the school will be measured with an inventory. 
  
Family environment: Food: Risky eating practices - eating out of hours, not eating at 
the table, physical activity with the family and sedentary time. It will be measured 
through questionnaires in children and the mobile application in parents. 
  
Community environment : At a perimeter of 100 meters around the school, the 
availability of food and beverages around the school, advertising of unhealthy foods 
and beverages, type of transportation used to get to school, and infrastructure for 
physical activity around the school will be measured. the school. 
  
Clinical trial 
A randomized clinical trial will be carried out in Cuernavaca, Morelos, which will be 
carried out at the National Institute of Public Health, Cuernavaca headquarters. Within 
the clinical trial there will be 2 control schools and 2 intervention schools, as shown 
previously in Figure 1, from which the children who will belong to each group will be 
selected, with prior consent and informed assent (Annexes 56 - 64) . The 
schoolchildren who participate in schools with MI, in addition to the previously 
mentioned evaluations, will undergo more detailed analyzes to determine the effect of 
said intervention. These measurements will be carried out at 0 months (baseline 

                                                                                                                                                                            
76 
 
measurement) and at 6 months (final measurement) (figure 3). For the evaluation of 
the effect of MI in this study, the following biological measurements will be considered 
in schoolchildren: 
  
a) 
Anthropometry: Weight (kg), height (cm), waist circumference (cm), and BMI 
(kg/m²). 
b) 
Body composition using dual x-ray densitometry. 
c) 
Biomarkers: The blood sample will be used to determine metabolic syndrome 
risk: cholesterol (mg/dl), lipids (HDL-c), triglycerides (mg/dl), glucose(mg/dl), 
glycated hemoglobin (%), leptin (ng/mL), adiponectin (µg/mL) and markers of oxidative 
stress and inflammation (galectin-3 (ng/mL) and Inter Leucine-6 (Pg/mL)). These last 
measurements will be carried out in serum. 
 
 
d) 
Blood pressure. 
 
A baseline sample will be taken at the beginning of the study and another sample at the 
end of the intervention stage (6 months) and a comparison will be made between the 
two groups (control group and multidimensional intervention group). To obtain the 
blood sample, take blood pressure and anthropometry, the “Manual of procedures for 
nutrition projects” developed by INSP researchers and which was used in the 2016 
National Health and Nutrition Survey (ENSANUT-2016) will be used. It is possible that 
during the participation of children and parents they may be photographed or 
videotaped (Annex 64-65) in order to demonstrate to the financing agencies that the 
project processes are carried out in a timely manner, during implementation, 
monitoring. of the intervention. 
 
 
Figure 3. Measurements from the clinical trial evaluation. 
 

                                                                                                                                                                            
77 
 
 
 
 
The activities that will be carried out in the clinical trial are broken down below: 
 
Anthropometric evaluation 
The weight, height and waist circumference of boys and girls in the 4th grade of 
primary school will be evaluated. Measurements will be made with a floor scale, with 
a precision of 100g and with a wall stadiometer, with a precision of 0.5 cm. The waist 
circumference will be measured using a tape measure, with an accuracy of 0.5 cm. 
These measurements will be made inside the school in a designated area. School 
authorities usually designate a location that is semi-private, usually in an empty 
classroom, or in the auditorium, or in a meeting area that is closed but accessible. The 
measurements are made with three field workers (female) present where the first 
measures, the second records and there is a third observing/supervising their quality; 
while ensuring confidentiality and correct performance of the measurement. Likewise, 
we will request the presence of a member of the school community while the 
measurements are carried out, however, the participation of the member of the school 
community is under the consideration of the school authorities. 
    
With the data obtained on weight and height, the BMI (kg/m 2 ) will be calculated. It 
should be noted that field workers will not have the opportunity to analyze the 
information or calculate BMI or make any medical diagnosis. Field workers will only 
take and record anthropometric measurements and will not be able to analyze them 
on the spot. 
  
•Environment diagnosis
•Questionnaire on behavioral and environmental modification factors
•Anthropometric/clinical measurement (weight, height, waist and blood 
pressure)
•Determination of body composition
•Biomarkers (blood chemistry, lipid profile, liver function, galectin-3, IL-6) 
Month 0. Initial 
Evaluation
•Environment diagnosis
•Questionnaire on behavioral and environmental modification factors
•Anthropometric/clinical measurement (weight, height, waist and blood 
pressure)
•Determination of body composition
•Biomarkers (blood chemistry, lipid profile, liver function, galectin-3, IL-6)
Month 6. Final 
evaluation

                                                                                                                                                                            
78 
 
Individual anthropometry results can be provided once the analysis is done. Once 
children with an overweight or obesity problem have been identified or diagnosed, a 
list will be made and provided to the school director to notify parents and suggest their 
evaluation by the school doctor or center. for guidance and treatment regarding the 
child's weight. Finally, the information will be analyzed with a group approach without 
revealing the identity of the individuals. The group results will be delivered to the 
school once the study is completed. 
 
a) 
Body composition using DXA 
Body composition will be measured through DXA (hologic, discovery WI, 93097), 
which includes the evaluation of fat-free mass, fat mass and fat percentage, using CORE 
software version 15 (Madison, WN). This method allows a more precise evaluation of 
the distribution of fatty tissue and lean tissue in the visceral area, which allows a more 
accurate estimate of cardiometabolic risk. 
 
The system that uses DXA generates X-rays at two different energy levels. The quality 
or length of the wave emitted by X-rays is expressed in kilo-Volt (kV). The generator 
alternately emits radiation (140 kilo maximum voltage [kVp] and low (70-100 kVp) 
that moves over the surface of the body to be studied. In this sense, there is the effective 
dose, which is the sum of the dose absorbed by each irradiated organ weighted by the 
type of radiation and the radio-sensitivity of said organ, expressed in Sievert (µSv), 
generated during the DXA test is extremely low 88 . 
 
DXA can be used in human populations of all ages due to its low radiation exposure. 
The radiation emitted by DXA is minimal, therefore, no special protection is required 
in the room where the measurement is performed or for the technical personnel 
performing the procedure. In whole body studies, this radiation ranges from 0.1 to 75 
µSv depending on the type of beam that emits the radiation. This dose is low compared 
to that used in other common The radiation from DXA is less than what a person 
receives on a cross-country flight or the radiation received on a normal day. This low 
exposure is safe for repeated measurements even for infants and children. However, 
for safety reasons it is recommended not to perform the measurement in pregnant 
women 90 . The overall scan takes 5 to 10 minutes and does not require sedation. 
 
According to NOM-229-SSA1-2002, bone densitometry (which allows evaluating body 
composition) does not require a license 91 . Room protection is not necessary, since the 
densitometer is internally protected. 

                                                                                                                                                                            
79 
 
In addition, body composition will be evaluated using an ultrasound with the Body 
Metrix device, which is a low-cost device that measures the thickness of subcutaneous 
fat in seven sites to calculate, using formulas, the percentage of body fat. 
 Based on the pathophysiology of obesity, the measurement of galectin-3 and IL-6 as 
biomarkers is proposed as a biological measure to evaluate at a systemic level the effect 
of the interventions implemented in this study. of inflammation. The objective of this 
component is to evaluate the alterations observed in the different systemic 
inflammation parameters analyzed (galectin-3, IL-6), in the children of the control and 
IM groups to which they were exposed during a period of 12 months. 
Regarding the galectin-3 serum analysis (which will be performed on 100 boys and 
girls; 50 in the control group and 50 in the multidimensional intervention), it will be 
carried out using the immunoassay technique (ELISA) using a commercially available 
kit. This technique consists of the incubation of serum samples obtained from the study 
subjects in well plates that contain antibodies against said glycoprotein, together with 
biotinylated antibodies that will bind to streptavidin conjugated with horseradish 
peroxidase; The activity of said enzyme will be measured with a spectrophotometer, 
which will allow the levels of galectin-3 in the samples to be quantified. No CRETI 
substance will be used for these procedures. 
  
b) 
Obtaining the blood sample 
180 children will be recruited from 4 schools in Cuernavaca, who will undergo a 
detailed evaluation at the INSP Cuernavaca headquarters (anthropometric studies, 
physical activity, DXA, sample collections for evaluation of cardiometabolic and 
inflammatory risk factors for chronic diseases, etc.). 
For biochemical determinations, two blood samples will be collected from each child 
(at the beginning and at the end of the study). To take a blood sample, new, disposable 
and sterilized material will be used in accordance with the standards for the 
management of Hazardous Infectious Biological Waste (RPBI). 
  
The samples will be taken by trained personnel, in the INSP laboratory at its facilities 
in Cuernavaca, by venipuncture of the antecubital vein under prior asepsis technique 
with a hypodermic needle (21g) or a vacutainer of the same caliber. The sample will be 
collected in a red-top tube which contains coagulation activator and separating gel to 
obtain serum. A total of 10mL of blood will be enough to obtain approximately 4-5mL 
of serum. The sample will be centrifuged at 3000rpm at the collection site, the serum 
component will be separated and the aliquots will be transported in coolers with liquid 
nitrogen, and subsequently stored at -80°C until analysis. The quantitative 

                                                                                                                                                                            
80 
 
determination of Galectin-3, Interleukin-6 (IL-6) will be performed by enzyme 
immunoassay (ELISA). 
  
• Biosecurity 
The sample collection will be carried out by trained personnel and will be processed at 
the INSP headquarters in Cuernavaca, under the supervision of Dr. Rosario Rebollar 
who will be in charge of the biosafety aspects of the project. For training, the 
procedures manual for nutrition projects will be used, which describes the general 
principles of obtaining blood samples and their management 105 . All material for 
sample collection will be new, disposable and sterilized. The blood sample will be 
correctly labeled for identification of the individual. 
  
As a consequence of the procedures to obtain the blood sample, a small bruise may 
appear, on rare occasions, without important consequences for the health of the 
participants. Other potential risks involved in participating in this study are unlikely, 
however, you may experience dizziness when your blood is drawn. The symptoms that 
may occur do not imply a greater risk; if they occur, you can use a cold compress to 
obtain relief. You can use the cold compress for 10 to 15 minutes every 3 to 4 hours as 
desired .  
 
 
The blood will be for study use only. All used material will be disposed of according to 
the standards for the management of hazardous Infectious Biological Waste (RPBI) 
described in the INSP Procedures Manual for Nutrition projects. 
 
To take blood samples, we must observe and comply with various safety rules that 
guarantee the safety of both study subjects and staff. 
The general procedures for personal protection are: mandatory use of a gown, gloves, 
face mask and glasses or goggles during the taking and handling of the blood sample. 
Don't forget to wash your hands before and after contact with the blood sample. 
Minimum universal precautions should be taken into account with all patients treated 
and do not forget the following: 
1. Every sample must be considered potentially infectious , so precautions must be 
taken to guarantee the safety of personnel and study subjects. 
2. Place a clean work field each time. 
3. Be careful when handling needles and lancets to avoid getting stuck. 
4. Do not leave used needles and lancets in the work field, throw them away 
immediately in an appropriate container. 

                                                                                                                                                                            
81 
 
5. If there is blood spillage, change the work field with a new one, 
discarding the contaminated in the contaminated waste bag. 
6. If you are stuck with a needle contaminated with blood from a study subject, find 
out if there is any type of infection and report it immediately. 
immediately report the incident to your supervisor. 
7. Prevent children from touching or playing with the equipment in use. 
 
Equipment and consumables 
Procedure for taking blood samples 
The sample must be taken under the most favorable conditions to avoid errors. This 
includes identifying the study subject, labeling the name of the vacutainer tube(s) to be 
used, identifying the puncture site and the volume to be collected. The patient should 
be in a comfortable position, sitting or lying down if he is an adult; if the child is in the 
arms of an adult or wrapped in a sheet with the point to be punctured outside of it to 
avoid movement. 
The personnel responsible for taking samples will use disposable gloves, which must 
be worn throughout the procedure. 
Before starting the procedure you must have all the necessary material within reach 
and prepared. 
In the presence of the study subject and family members, the warranty seal of the 
vacutainer equipment (which allows filling as many tubes as necessary) will be broken 
by screwing it into the universal tube holder without uncovering the needle. Before 
collecting blood samples, the identification of the study subject will be written on each 
vacutainer tube. 
Before proceeding to puncture, a vein of good caliber must be located, preferably in the 
elbow crease. The best way is to palp them to make that decision. To do this, place the 
tourniquet 10 to 15 cm above the selected site, to better visualize the vein. You should 
not keep the tourniquet on for more than 3 minutes, to avoid hemoconcentration. 
The veins most used for venipuncture are located in the anteulnar area. Among these 
we have: 
a) Ulnar vein: it is the longest and thickest of all and is preferred for bordering the 
muscles of the arm. 
b) Cephalic vein: has the same characteristics as the previous one, but is a little less 
thick. 
c) Basilic vein: smaller than the previous ones. This vein is close to the brachial artery, 
so puncture is risky and its area is more sensitive and painful for the patient. 
When palpating, do so with your fingertips, trying to follow the veins. Your knowledge 
of the anatomy of the veins of the upper extremities is also useful here. Sometimes if 

                                                                                                                                                                            
82 
 
you don't see the vein, you can force blood into the vein through a gentle bottom-up 
massage. 
Have the patient make and unclench his fist three to five times to better pump blood, 
and then have him keep his fist closed. 
If it is a child, it is advisable to place two fingers of your hand under the patient's elbow 
to prevent them from bending their arm during extraction. 
Once the vein to be punctured has been decided, an alcohol swab will be taken with 
tweezers, cleaning the area surrounding the vein from top to bottom and from the 
center to the periphery at least twice, rotating the swab in each of the movements to do 
not contaminate again. This can be repeated as many times as deemed necessary. 
Never return the alcohol swab to the starting point, unless it is new. Neither squeeze 
the excess alcohol from the swab to be used into the swab, nor on the floor, do it in the 
red bag. 
The needle will be inserted into the selected vein with the bevel facing up, with the tip 
of the needle at an angle of 15o to 30o above the surface of the chosen vein, pass through 
the skin in a firm and safe motion, to the lumen of the vein. vein, and insert into the 
opposite end of the needle the corresponding vacutainer tube that must be mounted on 
the universal plastic tube holder, pressing until the rear metal tip pierces the rubber 
stopper of the collecting tube. At this point the blood will begin to flow rapidly into the 
tube. 
Remove the tourniquet to allow better blood flow. The tube will be removed from the 
tube holder once the desired volume is reached. 
Avoid applying strong pressure to the puncture site during sample collection and 
needle extraction. 
The needle will be immediately placed in the sharps container intended for that 
purpose. 
The tube with the sample will be placed in a rack inside the cooler. A dry swab will be 
placed on the puncture site and pressed for a few minutes. 
The person responsible must remove the gloves at the end of the sample collection and 
discard them immediately. Under no circumstances may you reuse them again for this 
or other procedures. In the event that there has been an event 
Preparation and processing of blood samples. The staff will have identified a suitable 
place where they can process venous blood samples (preferably a Health Center, a 
school, municipal offices, municipal assistant office or ejidal police station) and will 
request permission from the corresponding authority by choosing a room that can be 
closed, that has contacts for electrical energy and, if possible, a sink. All samples will be 
concentrated there for processing as indicated below. 

                                                                                                                                                                            
83 
 
The blood sample must be centrifuged in portable centrifuges, approximately 30 
minutes after collection. This time allows the retraction of the clot and thus an 
improvement in serum yield. During this time the samples should be kept in the cooler. 
The tubes are balanced by weight before being placed in the centrifuge. That is, two 
tubes containing the same volume of sample must be placed in opposite locations. 
When there is an odd tube, an empty tube is used, which is filled with water to the same 
level as that containing blood, to balance them. 
Once the tubes have been balanced, centrifugation begins at low speed, which is 
gradually increased, with 10-second intervals until reaching _ parts of the centrifuge 
speed (around 3000 RPM). Centrifugation is maintained for approximately 20 minutes. 
After this time, the speed should be gradually reduced until the centrifuge stops 
completely. 
At the end of this procedure, the sample will be divided into two parts: at the bottom, 
the red erythrocyte mass (or globular package) will be located and on the surface there 
will be the slightly yellow or amber serum. Using a glass Pasteur pipette, the serum will 
be transferred to the cryotubes. These cryotubes have a capacity of 2 ml but should only 
be filled to 1.5 ml. If there is excess serum, fill another cryotube. After filling they will 
be covered again, ensuring that they are hermetically closed. 
Labeling of processed blood samples 
A subject identification label will be attached to each of the 2 ml cryotubes that will be 
used to permanently store the serum. Some of these, according to the study, are 
wrapped with aluminum foil. 
The labels of all cryotubes will be secured by covering them with a piece of transparent 
Diurex tape, which will go around the circumference of the tube 1 time. And the 
cryotubes obtained from the same study subject must be wrapped in self-adhesive 
plastic to deposit them in the nitrogen tank. 
Once all the cryogenic tubes have been labeled and protected, wrap them in transparent 
self-adhering plastic (the one used to wrap food at home or in the supermarket), place 
them as soon as possible in the liquid nitrogen tank to keep them frozen until they are 
delivered to the laboratory. for your analysis . Care of the study subject after taking a 
blood sample 
Once the extraction has been carried out, it is our responsibility to ensure that the study 
subject is fit to get up from the chair and leave. Some study subjects experience 
dizziness, weakness, or fainting after an extraction. 
To prevent him from falling and hurting himself, we must observe him and ask if he is 
okay before telling him to leave. 
If the patient is sweaty, has a very white face, or is shaking, he or she may need our help; 
We can smell alcohol. In case of possible fainting, we should tell him to place his head 

                                                                                                                                                                            
84 
 
between his legs, to help irrigate his brain. If necessary, we can put him to bed until he 
recovers. 
Study subjects who are fasting will be given instructions to have breakfast soon, in 
order to avoid fainting. 
Once the procedure for taking blood samples is completed, the staff has the obligation 
to leave the assigned place clean and tidy. This task includes cleaning the area, 
organizing the tubes and excess needles, and placing trash remains in the 
corresponding container as indicated below. 
 
  
c) 
Blood pressure 
Blood pressure will be measured using OMROM HEM-907 Baumanometers, which 
have 4 cuff sizes, allowing different arm diameters to be measured – including severe 
obesity – and due to their automatic design, they provide very precise measurements. 
The result of the blood pressure measurement will be delivered on an information card 
along with the weight and height results. Blood pressure measurement will take 
approximately 2 minutes. 
  
Statistic analysis 
  
First, for each group (control group and multidimensional intervention group), 
stratification will be carried out based on body mass index, and through multivariate 
correlation analysis and/or through Spearman's correlation coefficient, the correlation 
that will be determined will be determined. exists in each of the levels of the different 
cytokines and markers of inflammation and BMI. 
  
Subsequently, a comparison will be made between both groups, and it will be 
determined if the type of intervention had an impact by evaluating the baseline 
samples and the sample taken at the end of the intervention for each of the 
inflammation parameters evaluated (galectin-3 , IL-6 IL-1B, TNFa), first at a general 
level and subsequently by stratified group. To compare the samples in the serum, and 
the moments of collection (before and after the intervention), in terms of cytosine 
levels, Analysis of Variance (ANOVA) for repeated measures will be used. The p value 
<0.05 is considered statistically significant. 
 

                                                                                                                                                                            
85 
 
Likewise, for the community intervention, analyzes of the baseline characteristics of 
the population will be carried out. Differences between groups will be observed and, if 
necessary, adjustment variables will be used, as well as mixed effects models.  
   
Analysis of the information 
  
The information collected during the evaluations carried out on the control group and 
the evaluation of the effect of the multidimensional intervention will be analyzed. 
  
In the case of monitoring, as described in the corresponding section, information will 
be obtained with qualitative methodology, which will be analyzed through methods 
such as those described in said section. Quantitative information (example: Number of 
SMS messages received) will be presented summarized through measures of central 
tendency and dispersion, as well as frequencies, according to the nature of the 
information collected. 
  
In the case of the multidimensional intervention effect results, the initial (baseline) 
characteristics will be described by study group ( control group and multidimensional 
intervention). Measures of central tendency and dispersion will be presented for 
continuous variables and percentages for categorical variables. The effect of the 
intervention will be estimated in the outcome variables, described above, at both the 
individual, behavioral change and environmental levels (Table 10). For the effect at the 
individual level, an analysis of intention to treat 106 will be used , so it will include 
information from all participants according to the study group to which they will be 
assigned. Generalized linear models will be used 107 . 
 
 
 
 
 
 
 

                                                                                                                                                                            
86 
 
Schedule of activities for the implementation of the intervention 
 
Tables 11, 12 and 13 present the proposed schedule of activities for the implementation of the MI divided by state, which will be 
carried out simultaneously in the three entities. 
 
Table 11. Intervention project schedule 
Activity 
Place, date and time 
Participants and description of the activity 
Observations 
Information 
session (INSP 
proposal). 
October 31, 2023 
Time: 10:00am – 11:00am 
 
 
Directors 
Objective: To inform about the activities included in the IM. 
Virtual Meeting 
 
Baseline 
measurement 
of participants 
(intervention 
schools). 
School: May Day 
November 6 to 10, 2023 
Time: 8:00 a.m. – 2:00 p.m.  
School: Somalia 
November 6 to 10, 2023 
Time: 8:00 a.m. – 2:00 p.m.  
School: General José Mariano Monterde 
November 6 to 10, 2024 Time: 8:00 a.m. – 2:00 p.m. 
School: State of Querétaro 
November 6 to 10 
School: Prof. José S. Benítez 
November 6 to 9, 2023 
Time: 8:00 a.m. – 2:00 p.m.  
School: José Azueta 
November 6 to 9, 2023 
School: Luis de la Brena 
November 10 to 15, 2023 
School: Prof. 
Maximiliano Molina Fuente 
November 10 to 15, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
Participants:  
- 
Fourth grade girls and boys. 
Activities: 
- 
Signing of the informed consent addressed to parents or 
guardians of students 
- 
Assent addressed to 4th grade girls and boys. 
- 
Filling out questionnaires and anthropometric 
measurement for 4th grade girls and boys. 
 
Review the document 
“Considerations prior 
to the baseline 
evaluation”. 
 
Start date October 23 
and end date 
November 21 
(tentative) 

                                                                                                                                                                            
87 
 
 
Launch in each 
intervention 
school.  
School: May Day. 
November 27, 2023. 
Time: 8:00 – 10:00 a.m. 
School: Somalia. 
November 28, 2023. 
Time: 8:00 – 10:00 a.m. 
School: State of Querétaro. 
November 29, 2023. 
Time: 8:00 – 10:00 a.m. 
School: General José Mariano Monterde. 
November 30, 2023. 
Time: 8:00 – 10:00 a.m. 
Participants: Directors , teachers, fathers, mothers, tutors, food 
vendors, as well as fourth grade boys and girls. 
 
Activities:  
The purpose of the “Launch” is for the school community to be aware 
of the activities that will be carried out throughout the school year 
and, in this way, not only keep them informed, but also encourage 
their participation. The objective will be for the team to give an 
informative talk to the participants about the activities that will 
improve the nutrition and health of the girls and boys. 
1. We will project a presentation detailing the activities that will take 
place during the rest of the school year. This presentation will 
describe the duration, objective and activities by component aimed 
at fourth grade boys and girls, fathers, mothers, tutors, teachers and 
food vendors. 
2. We will show videos related to healthy and sustainable eating, as 
well as movement behaviors and psycho-emotional determinants. 
3. We will invite mothers, fathers and caregivers, as well as school 
teachers, to register through the WhatsApp platform to receive 
messages about healthy and sustainable eating, movement behaviors 
and determinants psycho-emotional of girls and boys. 
4. We will deliver printed communication material to mothers, 
fathers, people in charge of caring for girls and boys, as well as a 
Manual aimed at food vendors. This material will include magnets, 
infographics, brochures, among other information resources. 
5. We will place printed communication material called " Pipimeter " 
in the girls' and boys' toilets, whose objective is that they can 
monitor whether the color of their urine meets the water 
consumption recommendations. 
6. We will conclude the event with a Healthy Intervention question 
and answer session, aimed at clarifying any questions that attendees 
may have. 
Two hours are 
contemplated due to 
any delays that may 
occur , but it is 
expected that the 
entire event will take 
place. a maximum 
duration of 90 
minutes. 

                                                                                                                                                                            
88 
 
Start of activities in the four implementation schools (November 2023 to June 2024). 
Virtual course 
8 p.m.: Healthy 
intervention.  
Schools:  
1. First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
From December 1, 2023 to January 31, 2024. 
Time: Available 24 hours a day. 
Participants: 
- 
Fourth grade primary school teachers. 
- 
Optional. Fathers, mothers, guardians of fourth grade girls 
and boys. 
Activity: 
Self-managed 20-hour virtual course designed especially for 
teachers with the purpose of strengthening their understanding and 
mastery of the topics of healthy and sustainable eating and 
movement behaviors. Upon completing the course, participants will 
have the opportunity to receive a certificate with curricular validity 
issued by the School of Public Health of Mexico. 
During the Launch, 
you will be informed 
how you can access 
the “Virtual Course: 
Healthy Intervention”. 
Receiving 
messaging via 
WhatsApp 
(Mobile 
Health). 
Schools:  
1. First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
From December 1, 2023 to May 24, 2024. 
Messages will be sent on Mondays, Wednesdays and 
Fridays. 
 
Shipping time: 18:00.  
Participants:  
- 
Fathers, mothers, guardians of fourth grade girls and boys. 
- 
Physical education teachers. 
- 
Optional. Fourth grade primary school teachers. 
Activity: 
Messages will be sent via WhatsApp every third day throughout the 
school year, addressing topics related to healthy eating, movement 
behaviors and emotional health during childhood. The purpose of 
this activity is to consolidate the knowledge acquired in the other 
components of the program. 
During the “Launch” 
you will be told how 
you can access 
WhatsApp messaging. 
Promotion of 
the daily intake 
of vegetables 
and fruits in 
the school 
environment 
by promoting 
healthy snack 
options. 
Schools:  
1. First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
Monday to Friday from December 1, 2023 to May 24, 
2024. 
 
Time: To eat them during the break. 
Participants: 
- 
Fourth grade girls and boys. 
Activity: 
The habit of bringing a healthy snack, which includes vegetables, 
fruits or both, from Monday to Friday by girls and boys, will be 
promoted.  
Random supervisions 
will be carried out 
with the purpose of 
ensuring that the boys 
and girls bring their 
healthy snack, ideally 
on a daily basis. 

                                                                                                                                                                            
89 
 
Promotion of 
the daily intake 
of natural 
water in the 
school 
environment 
with the 
support of the ' 
Pipometer '. 
 
Schools:  
1. First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
Monday to Friday from December 1, 2023 to May 24, 
2024. 
 
Time: During the entire stay at school. 
Participants: 
- 
Fourth grade girls and boys. 
Activity: 
Promotion of the habit of consuming natural water and reaching the 
recommendation of 5 to 8 glasses a day. During the supervisions, the 
color of the urine will be recorded. On a permanent basis, they will 
be able to use the ' Pipimeter ', available in all school bathrooms, as a 
visual reference. 
Random supervisions 
will be carried out 
with the purpose of 
ensuring that children 
maintain the 
recommendations for 
natural water 
consumption. 
Workshop: 
Emotional 
management of 
children about 
food. 
1. 
First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
November 8 or 9, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for emotional management 
on topics related to food and nutrition 
In-person 
 
 
 
Workshop: 
Prevention of 
stigmatization 
with weight 
and body 
shape; and 
Risky Eating 
Behaviors. 
1. 
First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
November 15, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for the definition, 
recognition, management and weight stigma, risky eating behaviors. 
In-person 
 
 
Workshop: 
Identification 
of hunger and 
satiety signals; 
and symptoms 
of anxiety and 
depression. 
 
 
 
1. 
First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
November 22 or 23, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for the identification of 
signs of hunger, anxiety and depression. 
In-person 
 
 

                                                                                                                                                                            
90 
 
Workshop: 
Internalization 
of the aesthetic 
ideal of thin 
beauty 
1. 
First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
November 22 or 23, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for the aesthetic 
identification and internalization of beauty. 
In-person 
 
 
Workshop: 
Prevention of 
stigmatization 
with weight 
and body 
shape; and 
Risky Eating 
Behaviors. 
1. 
First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
November 22 or 23, 2023. 
Schedule To be defined 
Participants: Mothers and fathers or guardians 
 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
 
 
 
 
Workshop: 
Identification 
of hunger and 
satiety signals; 
and symptoms 
of anxiety and 
depression. 
1. 
First of May . 
2. 
Somalia 
3. 
Gen. José Mariano. Monterde 
4. State of Querétaro. 
November 8 or 9, 2023. 
Schedule: To be defined 
Participants: Mothers and fathers or guardians 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
 
 
Workshop: 
Prevention of 
stigmatization 
with weight 
and body 
shape; and 
Risky Eating 
Behaviors. 
1. 
First of May . 
2. 
Somalia 
3. 
Gen. José Mariano. Monterde 
4. State of Querétaro. 
November 15, 2023. 
Schedule: To be defined 
Participants: Mothers and fathers or guardians 
 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
 
 
Workshop: 
Limits, 
parenting and 
self-care. 
1. May Day 
2. Somalia 
3. Gen. José Mariano Monterde 
4. State of Querétaro 
 
November 22, 2023 Schedule: To be defined 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
Aimed at mothers and fathers or guardians 
 
 

                                                                                                                                                                            
91 
 
Workshop: 
Identification 
of hunger and 
satiety signals; 
and symptoms 
of anxiety and 
depression. 
1. 
First of May . 
2. 
Somalia 
3. 
Gen. José Mariano. Monterde 
4. State of Querétaro. 
November 22, 2023. 
5. 
Schedule to be defined 
Participants: Teaching staff. 
Virtual, schedule to be defined with the teaching staff 
 
 
 
 
Supervision of 
the promoter 
of the 'Healthy 
Intervention'. 
 
School: May Day . 
1. December 4, 6, 12 and 14, 2023.  
2. January 9, 11, 15, 17, 23, 25 and 29, 2024.  
3. February 6, 7, 14, 15, 21, 22, 26 and 27, 2024. 
4. March 6, 7, 13, 14 and 19, 2024. 
5. April 9, 11, 15, 19, 23, 24 and 29, 2024. 
6. 3, 7, 13, 17, 21, 23, May 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
School: Somalia. 
1. December 4, 6, 12 and 14, 2023.  
2. January 9, 11, 15, 17, 23, 25 and 30, 2024.  
3. February 6, 7, 14, 15, 21, 22, 26 and 27, 2024. 
4. March 6, 7, 13, 14 and 20, 2024. 
5. April 9, 11, 15, 19, 23, 24 and 29, 2024. 
6. May 3, 7, 13, 17, 21, 23, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
1. Verify that they have a healthy snack. 
The person in charge of the Healthy Intervention will go to each 4th 
grade classroom to verify that they bring it with them and, if they 
comply with this practice, they will be given a numbered ticket that 
will allow them to participate at the end of the school year in an 
incentive contest. . 
2. Recording the color of the last urine. 
During the visit to the classroom, the person in charge of this 
intervention will provide each girl and boy, at least twice a week, 
with a log-type recording sheet called 'My Pipimeter '. On this sheet, 
you can mark the color of your last urine observed in the bathroom. 
In addition, they will have the constant support of the ' Pipometer ', 
a visual resource that will be permanently installed in all school 
bathrooms as a reference. 
3. Make regular visits to food vendors in schools to encourage 
nutritious and healthy food and drink options. 
During these visits, guidance and support will be provided to food 
and beverage vendors to promote more nutritious and healthy food 
options. The main focus is to ensure that the food options offered at 
Activities 1 and 2 will 
take approximately 20 
minutes per 4th grade 
group, while 
interaction with food 
and beverage vendors 
will take 5 to 10 
minutes per food and 
beverage outlet. 
The schedule has been 
planned in a way that 
allows for transitions 
between groups and 
waiting times without 
interfering with 
teaching activities. 

                                                                                                                                                                            
92 
 
School: General José Mariano Monterde.  
1. December 5, 7, 11, 13, 2023. 
2. January 8, 10, 16, 18, 22, 24 and 31, 2024. 
3. February 8, 9, 12, 13, 19, 20, 28, 29, 2024. 
4. March 4, 5, 11, 12, 21, 2024. 
5. 8, 12, 16, 18, 22, 25, April 2024. 
6. 2, 6, 9, 14, 16, 20, 24 May 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
School: State of Querétaro . 
1. December 5, 7, 11, 13, 2023. 
2. January 8, 10, 16, 18, 22, 24, 2024. 
3. 1, 8, 9, 12, 13, 19, 20, 28, 29 February 2024. 
4. March 4, 5, 11, 12, 22, 2024. 
5. 8, 10, 16, 18, 22, 25, April 2024. 
6. 2, 6, 9, 14, 16, 20, 24 May 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
school are balanced and beneficial to the health of students. The 
ultimate goal is to transform the food sales environment at school 
into a place that promotes the health and well-being of students, thus 
helping to prevent problems such as overweight and obesity, and 
allowing girls and boys to grow up healthily. . 
Delivery of 
'Recognition of 
healthy 
perseverance' 
carried out by 
the promoter 
of the 'Healthy 
Intervention'. 
School: May Day. 
January 29, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
Within the framework of supervisions for 
“Verifying that they have a healthy snack” and “Recording the color of 
their last urine” during visits to 4th grade classrooms will be carried 
out: 
This activity will take 
approximately 5 
minutes additional to 
those contemplated 
during the 
supervision of the 
promoter of the 
'Healthy Intervention'. 
 
School: Somalia. 
January 30, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
School: General José Mariano Monterde. 
January 31, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 

                                                                                                                                                                            
93 
 
School: State of Querétaro. 
February 1, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
- Delivery of a Diploma for carrying a healthy snack.  
- Delivery of a Diploma for complying with the recommendations for 
natural water consumption. 
Promotion of 
the reduction 
of the 
consumption of 
sugary drinks 
and ultra-
processed 
foods - two, 
promoting 
healthier 
alternatives 
through the 
"Healthy 
Reporter" 
activity. 
Schools:  
1. 
First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
Invitation and instructions. January 29, 31 and 
February 2, 2024. 
Sending and receiving videos. From February 6 to 
March 1, 2024. 
Voting period for the best video. 
Winners publication. From April 8 to 12, 2024. 
 
Time: Not applicable. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fathers, mothers, guardians of fourth grade girls and boys. 
Activities: 
- Invitation to participate in the creation of a video focused on the 
identification of healthy alternatives that replace the consumption of 
sugary drinks and ultra-processed foods 
- Shipping instructions. 
- Sending and receiving videos from the 'Healthy Reporters' via 
WhatsApp 
- Publication of videos for voting by the school community via 
WhatsApp to select the best videos of the 'Healthy Reporters' 
- Publication of the winning children for the best video of 'Healthy 
Reporter' 
The above activities 
will be carried out 
through the WhatsApp 
platform. 
This activity will be 
presented at the 
Launch and the 
invitation will be 
extended to fourth 
grade girls and boys 
and their guardians to 
participate. 
 
Practical 
demonstration 
by the 
promoter of 
'Movement 
Behaviors' on: 
-Physical 
activation 
before the start 
of classes. 
-Active breaks 
-Active 
recreation 
School: May Day. 
December 4 and 6, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
Presentation and explanation to 4th grade teachers about physical 
activity practices: 
1. Physical activation before the start of classes: For 15 minutes 
before classes, a short session of physical activity will take place. 
2. Active Breaks: Active breaks will be encouraged, twice a day, 
which will include physical movements during classes to maintain 
energy and concentration. 
3. Active Recess: During recess, at least 15 minutes of moderate to 
vigorous physical activities will be promoted in play areas adapted 
according to the “Workshop for the conditioning of school spaces” 
and/or using the sports equipment provided to the school. . 
The promoter of 
'Movement Behaviors' 
will gradually carry 
out the activities 
during the course of 
the day. 
School: Somalia. 
December 4 and 6, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 
School: General José Mariano Monterde. 
December 5 and 7, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 
School: State of Querétaro. 
December 5 and 7, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 

                                                                                                                                                                            
94 
 
Promotion in 
the school 
environment of 
physical 
activation 
before the start 
of classes (led 
by teachers or 
Prof. EF) 
 
Schools:  
1. First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
Monday to Friday from December 1, 2023 to May 24, 
2024. 
 
Time: 08:00 to 08:15 h. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fourth grade primary school teachers. 
- 
Optional. Physical education teachers. 
Activities: 
Physical activation before the start of classes: For 15 minutes before 
classes, a short session of physical activity will take place. 
To know the recommended exercises, they can be consulted in the 
“Manual of physical activation, active breaks and active recesses 
within the school environment.” 
It is recommended 
that the other groups 
go to their respective 
classrooms; However, 
this strategy can be 
adjusted according to 
the needs of each 
school. 
Promotion of 
active breaks in 
the classroom 
(led by 
teachers) 
Schools:  
1. First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
Monday to Friday from December 1, 2023 to May 24, 
2024. 
 
Active break time 1: Between 09:00 a.m. and 09:30 
a.m. 
 
Active break time 2: Between 11:30 a.m. and 12:00 
p.m. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fourth grade primary school teachers. 
Activities: 
Active breaks will be encouraged, twice a day, which will include 
physical movements during classes to maintain energy and 
concentration. 
Example of exercises: 
Games and dynamics, such as imitating animals, jumping, running, 
dancing, stretching, breathing movements, joint movements. 
Frequency: 2 times a day. 
Active break 1 is expected to be one hour after school starts while 
active break 2 is expected to be one hour after the school break ends. 
duration 5 to 6 minutes, up to 10 minutes (flexible by type of 
dynamic). 
The schedules may 
vary depending on the 
dynamics of each 
school. 
To know the 
recommended 
exercises, they can be 
consulted in the 
“Manual of physical 
activation, active 
breaks and active 
recesses within the 
school environment.” 
Promotion of 
active 
recreation 
(ideally 
encouraged 
and supervised 
by teaching 
staff) 
Schools:  
1. First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
Monday to Friday from December 1, 2023 to May 24, 
2024. 
 
Time: Ideally during 15 minutes of school recess. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fourth grade primary school teachers. 
Activities: 
During recess, at least 15 minutes of moderate to vigorous physical 
activities will be promoted in play areas adapted according to the 
“Workshop for the conditioning of school spaces” and/or using the 
sports equipment provided to the school. 
To know the 
recommended 
exercises, they can be 
consulted in the 
“Manual of physical 
activation, active 
breaks and active 
recesses within the 
school environment.” 

                                                                                                                                                                            
95 
 
Supervision of 
the 'Movement 
Behaviors' 
promoter of: 
physical 
activation 
before the start 
of classes, 
active breaks 
and active 
recess 
School: May Day. 
1. December 11 and 13. 
2. January 8, 10, 15, 17, 22, 24, 29, 31 
3. February 6, 8, 12, 14, 19, 21, 26, 28 
4. March 4, 6, 11, 13, 19, 21. 
5. April 8, 10, 15, 17, 22, 24, 29. 
6. May 2, 6, 8, 13, 16, 20, 22. 
Time: 8:00 a.m. to 12:30 p.m. 
 
School: Somalia. 
1. December 11 and 13. 
2. January 8, 10, 15, 17, 22, 24, 29, 31 
3. February 6, 8, 12, 14, 19, 21, 26, 28 
4. March 4, 6, 11, 13, 19, 21. 
5. April 8, 10, 15, 17, 22, 24, 29. 
6. May 2, 6, 8, 13, 16, 20, 22. 
Time: 8:00 a.m. to 12:30 p.m. 
 
School: General José Mariano Monterde. 
1. December 12 and 14. 
2. January 9, 11, 16, 18, 23, 25 and 30. 
3. February 1, 7, 9, 13, 20, 22, 27 and 29. 
4. March 5, 7, 12, 14, 20, 22. 
5. April 9, 11, 16, 18, 23, 25. 
6. May 3, 7, 9, 14, 17, 20, 22, 24. 
Time: 8:00 a.m. to 12:30 p.m. 
 
School: State of Querétaro. 
1. December 12 and 14. 
2. January 9, 11, 16, 18, 23, 25 and 30. 
3. February 1, 7, 9, 13, 20, 22, 27 and 29. 
4. March 5, 7, 12, 14, 20, 22. 
5. April 9, 11, 16, 18, 23, 25. 
6. May 3, 7, 9, 14, 17, 20, 22, 24. 
Time: 8:00 a.m. to 12:30 p.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
The promoter of 'Movement Behaviors' will supervise: 
1. Physical activation before the start of classes: For 15 minutes 
before classes, a short session of physical activity will take place. 
2. Active Breaks: Active breaks will be encouraged, twice a day, 
which will include physical movements during classes to maintain 
energy and concentration. 
3. Active Recess: During recess, at least 15 minutes of moderate to 
vigorous physical activities will be promoted in play areas adapted 
according to the “Workshop for the conditioning of school spaces” 
and/or using the sports equipment provided to the school. " 
The 'Movement 
Behaviors' promoter 
will gradually 
supervise the 
activities during the 
course of the day. 

                                                                                                                                                                            
96 
 
Workshop: 
Conditioning of 
school spaces. 
1. First of May . 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
Saturday December 2, 2023. 
 
Time: 9:00 – 12:00 h. 
Participants: 
- 
Fathers, mothers, guardians of fourth grade girls and boys. 
- 
Fourth grade girls and boys. 
- 
Optional. Fourth grade primary school teachers. 
Activity: 
- 
Paint or recondition the school playground and fields. 
- 
The activity is directed by the promoter of 'Movement 
Behaviors'. 
- 
The Healthy Intervention team, represented by the 
promoters of 'Movement Behaviors', will be responsible for 
carrying and providing the necessary materials, such as 
paint and brushes, for the activity. 
Ideally, this activity 
should be carried out 
when there are no 
classes and when 
fathers, mothers, 
guardians of fourth 
grade girls and boys 
have more time to go 
to school. 
Workshop: 
Importance 
and benefits of 
promoting 
physical 
activity and 
limiting 
sedentary time 
in school girls 
and boys. 
1. May Day. 
2. Somalia 
3. Gen. José Mariano. Monterde 
4. State of Querétaro. 
 
 
Monday, December 4, 2023 (virtual mode)3 
 
Time: 6:00 p.m. – 7:00 p.m. 
 
 
Participants: 
- 
Fourth grade primary school teachers. 
Activity: 
- 
Paint or recondition the school playground and fields. 
- 
The activity is directed by the promoter of 'Movement 
Behaviors'. 
- 
The Healthy Intervention team, represented by the 
promoters of 'Movement Behaviors', will be responsible for 
carrying and providing the necessary materials, such as 
paint and brushes, for the activity. 
This activity will be 
presented at the 
Launch and the 
invitation will be 
extended to fourth 
grade primary school 
teachers to 
participate. 
Workshop: 
Healthy and 
sustainable 
eating and 
childhood 
obesity 
School: May Day 
January 12, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
 
School: Somalia 
January 12, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: General José Mariano Monterde 
January 19, 2024 
Participants: 
- 
Fourth grade girls and boys. 
Activity: 
- 
Playing videos on ' Let's eat more fresh vegetables and 
fruits', 'Let's avoid ultra-processed foods ', 'Let's drink 
more natural water every day and 'Let's do more physical 
activity'. 
- 
Through recreational activities, we will strengthen the 
understanding of fundamental messages that promote 
The Workshop will 
last approximately 60 
minutes per 4th grade 
group. 
The schedule has been 
planned in a way that 
allows for transitions 
between groups and 
waiting times without 
interfering with 
 
3 In the previous diagnosis carried out in schools in Campeche and Morelos, the teaching staff suggested that the workshops be carried out after the work day, preferably after 6:00 
p.m. 

                                                                                                                                                                            
97 
 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: State of Querétaro 
January 19, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
healthy and sustainable eating, thus contributing to 
preventing childhood obesity. 
teaching activities. 
Baseline 
measurement 
of participants 
(intervention 
schools). 
School: May Day 
June 1 to 15, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
 
School: Somalia 
June 1 to 15, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: General José Mariano Monterde 
June 16-30, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: State of Querétaro 
June 16-30, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
- 
Signing of the informed consent addressed to parents or 
guardians of students 
- 
Assent addressed to 4th grade girls and boys. 
- 
Filling out questionnaires and anthropometric 
measurement for 4th grade girls and boys. 
 
Review the document 
“Considerations prior 
to the final 
evaluation”. 
 
Start date June 1st. 
End date July 31, 
2024. 
Baseline 
measurement 
of participants 
(control 
schools). 
School: Prof. José S. Benítez 
June 1 to 22 
Time: 8:00 a.m. – 2:00 p.m.  
 
School: José Azueta 
June 1 to 22, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
 
School: Luis de la Brena 
June 1 to 22, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: Prof. 
Maximiliano Molina Fuente 
June 1 to 22, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
Participants:  
- 
Fourth grade girls and boys. 
Activities: 
- 
Signing of the informed consent addressed to parents or 
guardians of students 
- 
Assent addressed to 4th grade girls and boys. 
- 
Filling out questionnaires and anthropometric 
measurement for 4th grade girls and boys. 
 
 

                                                                                                                                                                            
98 
 
Table 12. Morelos intervention project schedule , October 2023 
Activity 
Place, date and time 
Participants and description of the activity 
Observations 
Information 
session (INSP 
proposal). 
October 31, 2023 
Time: 10:00am – 11:00am 
 
 
Directors 
Objective: To inform about the activities included in the IM. 
Virtual meeting 
 
Baseline 
measurement of 
participants 
(intervention 
schools). 
School: Lic. Benito Juárez García 
November 6 to 10, 2023 
Time: 8:00 a.m. – 2:00 p.m.  
School: Narciso Mendoza 
November 6 to 10, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
School: November 20 
November 6 to 10, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
School: Aquiles Serdán. Lions Club 1 
November 6 to 10, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
School: Braulio Rodríguez 
November 6 to 9, 2023 
Time: 8:00 a.m. – 2:00 p.m.  
School: Kids Heroes 
November 6 to 9, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
School: Mariano Matamoros 
November 10 to 15, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
School: Cuauhtémoc 
November 10 to 15, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
Participants:  
- 
Fourth grade girls and boys. 
Activities: 
- 
Signing of the informed consent addressed to parents or 
guardians of students 
- 
Assent addressed to 4th grade girls and boys. 
- 
Filling out questionnaires and anthropometric 
measurement girls and boys in 4th grade. 
 
Review the document 
“Considerations prior to 
baseline assessment”. 
 
Start date 23 October 
and term date 21 
November (tentative) 

                                                                                                                                                                            
99 
 
Launching in each 
school 
intervention.  
School: Lic. Benito Juarez Garcia 
27 November 
Hours: 8:00 – 10:00 p.m. 
School: 
Daffodil Mendoza 
28 November 
Hours: 8:00 – 10:00 p.m. 
School: November 20th 
29 November 
Hours: 8:00 – 10:00 p.m. 
School: Aquiles Serdan Lions Club 
November 30, 2023. 
Time: 8:00 – 10:00 a.m. 
Participants: Directors , teachers, fathers, mothers, tutors, food 
vendors, as well as fourth grade boys and girls. 
 
Activities:  
The purpose of the “Launch” is for the school community to be aware 
of the activities that will be carried out throughout the school year 
and, in this way, not only keep them informed, but also encourage 
their participation. The objective will be for the team to give an 
informative talk to the participants about the activities that will 
improve the nutrition and health of the girls and boys. 
1. We will project a presentation detailing the activities that will take 
place during the rest of the school year. This presentation will 
describe the duration, objective and activities by component aimed 
at fourth grade boys and girls, fathers, mothers, tutors, teachers and 
food vendors. 
2. We will show videos related to healthy and sustainable eating, as 
well as movement behaviors and psycho-emotional determinants. 
3. We will invite mothers, fathers and caregivers, as well as school 
teachers, to register through the WhatsApp platform to receive 
messages about healthy and sustainable eating, movement behaviors 
and determinants psycho-emotional of girls and boys. 
4. We will deliver printed communication material to mothers, 
fathers, people in charge of caring for girls and boys, as well as a 
Manual aimed at food vendors. This material will include magnets, 
infographics, brochures, among other information resources. 
5. We will place printed communication material called " Pipimeter " 
in the girls' and boys' toilets, whose objective is that they can 
monitor whether the color of their urine meets the water 
consumption recommendations. 
6. We will conclude the event with a Healthy Intervention question 
and answer session, aimed at clarifying any questions that attendees 
may have. 
Two hours are 
contemplated due to any 
delays that may occur, 
but it is expected that 
the entire event will 
take a maximum 
duration of 90 minutes. 

                                                                                                                                                                            
100 
 
Table 12. Morelos intervention project schedule , October 2023 
Start of activities in the four implementation schools (November 2023 to June 2024). 
Virtual course 8 
p.m.: Healthy 
intervention.  
Schools:  
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
Participants: 
- 
Fourth grade primary school teachers. 
- 
Optional. Fathers, mothers, guardians of fourth grade girls 
and boys. 
Activity: 
Self-managed 20-hour virtual course designed especially for 
teachers with the purpose of strengthening their understanding and 
mastery of the topics of healthy and sustainable eating and 
movement behaviors. Upon completing the course, participants will 
have the opportunity to receive a certificate with curricular validity 
issued by the School of Public Health of Mexico. 
During the Launch, you 
will be informed how 
you can access the 
“Virtual Course: Healthy 
Intervention”. 
Receiving 
messaging via 
WhatsApp (Mobile 
Health). 
Schools:  
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
 
From December 1, 2023 to May 24, 2024. 
Messages will be sent on Mondays, Wednesdays 
and Fridays. 
 
Shipping time: 18:00.  
Participants:  
- 
Fathers, mothers, guardians of fourth grade girls and boys. 
- 
Physical education teachers. 
- 
Optional. Fourth grade primary school teachers. 
Activity: 
Messages will be sent via WhatsApp every third day throughout the 
school year, addressing topics related to healthy eating, movement 
behaviors and emotional health during childhood. The purpose of 
this activity is to consolidate the knowledge acquired in the other 
components of the program. 
During the “Launch” you 
will be told how you can 
access WhatsApp 
messaging. 
Promotion of the 
daily intake of 
vegetables and 
fruits in the school 
environment by 
promoting healthy 
snack options. 
Schools:  
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
 
Monday to Friday from December 1, 2023 to May 
24, 2024. 
Participants: 
- 
Fourth grade girls and boys. 
Activity: 
The habit of bringing a healthy snack, which includes vegetables, 
fruits or both, from Monday to Friday by girls and boys, will be 
promoted.  
Random supervisions 
will be carried out with 
the purpose of ensuring 
that the boys and girls 
bring their healthy 
snack, ideally on a daily 
basis. 

                                                                                                                                                                            
101 
 
Table 12. Morelos intervention project schedule , October 2023 
 
Time: To eat them during the break. 
Promotion of the 
daily intake of 
natural water in 
the school 
environment with 
the support of the ' 
Pipometer '. 
 
It's Schools:  
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
 
Monday to Friday from December 1, 2023 to May 
24, 2024. 
 
Time: During the entire stay at school. 
Participants: 
- 
Fourth grade girls and boys. 
Activity: 
Promotion of the habit of consuming natural water and reaching the 
recommendation of 5 to 8 glasses a day. During the supervisions, the 
color of the urine will be recorded. On a permanent basis, they will 
be able to use the ' Pipimeter ', available in all school bathrooms, as a 
visual reference. 
Random supervisions 
will be carried out with 
the purpose of ensuring 
that children maintain 
the recommendations 
for natural water 
consumption. 
Workshop: 
Emotional 
management of 
children about 
food. 
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
 
November 8 or 9, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for emotional management 
on topics related to food and nutrition 
In-person 
 
 
 
Workshop: 
Prevention of 
stigmatization 
with weight and 
body shape; and 
Risky Eating 
Behaviors. 
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
 
November 15, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for the definition, 
recognition, management and weight stigma, risky eating behaviors. 
In-person 
 
 
Workshop: 
Identification of 
hunger and satiety 
signals; and 
symptoms of 
anxiety and 
depression. 
 
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
 
November 22 or 23, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for the identification of 
signs of hunger, anxiety and depression. 
In-person 
 
 

                                                                                                                                                                            
102 
 
Table 12. Morelos intervention project schedule , October 2023 
 
 
Workshop: 
Internalization of 
the aesthetic ideal 
of thin beauty 
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
 
November 22 or 23, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for the aesthetic 
identification and internalization of beauty. 
In-person 
 
 
Workshop: 
Prevention of 
stigmatization 
with weight and 
body shape; and 
Risky Eating 
Behaviors. 
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
 
November 22 or 23, 2023. 
Schedule To be defined 
Participants: Mothers and fathers or guardians 
 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
 
 
 
 
Workshop: 
Identification of 
hunger and satiety 
signals; and 
symptoms of 
anxiety and 
depression. 
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
November 8 or 9, 2023. 
Schedule: To be defined 
Participants: Mothers and fathers or guardians 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
 
 
Workshop: 
Prevention of 
stigmatization 
with weight and 
body shape; and 
Risky Eating 
Behaviors. 
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
November 15, 2023. 
Schedule: To be defined 
Participants: Mothers and fathers or guardians 
 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
 
 
Workshop: Limits, 
parenting and self-
care. 
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
Aimed at mothers and fathers or guardians 
 
 

                                                                                                                                                                            
103 
 
Table 12. Morelos intervention project schedule , October 2023 
 
November 22, 2023 Schedule: To be defined 
Workshop: 
Identification of 
hunger and satiety 
signals; and 
symptoms of 
anxiety and 
depression. 
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
November 22, 2023. 
Schedule to be defined 
Participants: Teaching staff. 
Virtual, schedule to be defined with the teaching staff 
 
 
 
 
Supervision of the 
promoter of the 
'Healthy 
Intervention'. 
 
School Lic. Benito Juárez García 
7. December 4, 6, 12 and 14, 2023.  
8. January 9, 11, 15, 17, 23, 25 and 29, 2024.  
9. February 6, 7, 14, 15, 21, 22, 26 and 27, 2024. 
10. 
March 6, 7, 13, 14 and 19, 2024. 
11. 
April 9, 11, 15, 19, 23, 24 and 29, 2024. 
12. 
3, 7, 13, 17, 21, 23, May 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
1. Verify that they have a healthy snack. 
The person in charge of the Healthy Intervention will go to each 4th 
grade classroom to verify that they bring it with them and, if they 
comply with this practice, they will be given a numbered ticket that 
will allow them to participate at the end of the school year in an 
incentive contest. . 
2. Recording the color of the last urine. 
During the visit to the classroom, the person in charge of this 
intervention 
will provide each girl and boy, at least twice a week, with a log-type 
recording sheet called 'My Pipimeter '. On this sheet, you can mark 
the color of your last urine observed in the bathroom. In addition, 
they will have the constant support of the ' Pipometer ', a visual 
resource that will be permanently installed in all school bathrooms 
as a reference. 
Activities 1 and 2 will 
take approximately 20 
minutes per 4th grade 
group, while interaction 
with food and beverage 
vendors will take 5 to 10 
minutes per food and 
beverage outlet. 
The schedule has been 
planned in a way that 
allows for transitions 
between groups and 
waiting times without 
interfering with 
teaching activities. 
School: Narcissus 
Mendoza 
7. December 4, 6, 12 and 14, 2023.  
8. January 9, 11, 15, 17, 23, 25 and 30, 2024.  
9. February 6, 7, 14, 15, 21, 22, 26 and 27, 2024. 
10. 
March 6, 7, 13, 14 and 20, 2024. 
11. 
April 9, 11, 15, 19, 23, 24 and 29, 2024. 
12. 
May 3, 7, 13, 17, 21, 23, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 

                                                                                                                                                                            
104 
 
Table 12. Morelos intervention project schedule , October 2023 
November 20   
7. December 5, 7, 11, 13, 2023. 
8. January 8, 10, 16, 18, 22, 24 and 31, 2024. 
9. February 8, 9, 12, 13, 19, 20, 28, 29, 2024. 
10. 
March 4, 5, 11, 12, 21, 2024. 
11. 
8, 12, 16, 18, 22, 25, April 2024. 
12. 
2, 6, 9, 14, 16, 20, 24 May 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
3. Make regular visits to food vendors in schools to encourage 
nutritious and healthy food and drink options. 
During these visits, guidance and support will be provided to food 
and beverage vendors to promote more nutritious and healthy food 
options. The main focus is to ensure that the food options offered at 
school are balanced and beneficial to the health of students. The 
ultimate goal is to transform the food sales environment at school 
into a place that promotes the health and well-being of students, thus 
helping to prevent problems such as overweight and obesity, and 
allowing girls and boys to grow up healthily. . 
School: 
7. December 5, 7, 11, 13, 2023. 
8. January 8, 10, 16, 18, 22, 24, 2024. 
9. 1, 8, 9, 12, 13, 19, 20, 28, 29 February 2024. 
10. 
March 4, 5, 11, 12, 22, 2024. 
11. 
8, 10, 16, 18, 22, 25, April 2024. 
12. 
2, 6, 9, 14, 16, 20, 24 May 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
Delivery of 
'recognition of 
healthy 
perseverance' 
carried out by the 
promoter of the 
'Healthy 
Intervention'. 
School: Lic. Benito Juárez García 
January 29, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
Within the framework of supervisions for 
“Verifying that they have a healthy snack” and “Recording the color of 
their last urine” during visits to 4th grade classrooms will be carried 
out: 
This activity will take 
approximately 5 
minutes additional to 
those contemplated 
during the 
supervision of the 
promoter of the 'Healthy 
Intervention'. 
 
School: Narciso Mendoza 
January 30, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
November 20 
January 31, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 

                                                                                                                                                                            
105 
 
Table 12. Morelos intervention project schedule , October 2023 
School: Aquiles Serdán Lions Club 1 
February 1, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
- Delivery of a Diploma for carrying a healthy snack.  
- Delivery of a Diploma for complying with the recommendations for 
natural water consumption. 
Promotion of the 
reduction of the 
consumption of 
sugary drinks and 
ultra-processed 
foods - two, 
promoting 
healthier 
alternatives 
through the 
"Healthy Reporter" 
activity. 
Schools:  
1. Lic. Benito Juárez García 
2. Narciso Mendoza 
3. November 20 
4. Aquiles Serdán Lions Club 1 
 
Invitation and instructions. January 29, 31 and 
February 2, 2024. 
Sending and receiving videos. From February 6 to 
March 1, 2024. 
Voting period for the best video. 
Winners publication. From April 8 to 12, 2024. 
 
Time: Not applicable. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fathers, mothers, guardians of fourth grade girls and boys. 
Activities: 
- Invitation to participate in the creation of a video focused on the 
identification of healthy alternatives that replace the consumption of 
sugary drinks and ultra-processed foods 
- Shipping instructions. 
- Sending and receiving videos from the 'Healthy Reporters' via 
WhatsApp 
- Publication of videos for voting by the school community via 
WhatsApp to select the best videos of the 'Healthy Reporters' 
- Publication of the winning children for the best video of 'Healthy 
Reporter' 
The above activities will 
be carried out through 
the WhatsApp platform. 
This activity will be 
presented at the Launch 
and the invitation will 
be extended to fourth 
grade girls and boys and 
their guardians to 
participate. 
 
Practical 
demonstration by 
the promoter of 
'Movement 
Behaviors' on: 
-Physical 
activation before 
the start of classes. 
-Active breaks 
-Active recreation 
School: Lic. Benito Juárez 
December 4 and 6, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
Presentation and explanation to 4th grade teachers about physical 
activity practices: 
1. Physical activation before the start of classes: For 15 minutes 
before classes, a short session of physical activity will take place. 
2. Active Breaks: Active breaks will be encouraged, twice a day, 
which will include physical movements during classes to maintain 
energy and concentration. 
3. Active Recess: During recess, at least 15 minutes of moderate to 
vigorous physical activities will be promoted in play areas adapted 
according to the “Workshop for the conditioning of school spaces” 
and/or using the sports equipment provided to the school. . 
The promoter of 
'Movement Behaviors' 
will gradually carry out 
the activities during the 
course of the day. 
School: Narciso Mendoza 
December 4 and 6, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 
November 20  
December 5 and 7, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 
School: Aquiles Serdán Lions Club 1 
December 5 and 7, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 

                                                                                                                                                                            
106 
 
Table 12. Morelos intervention project schedule , October 2023 
Promotion in the 
school 
environment of 
physical activation 
before the start of 
classes (led by 
teachers or Prof. 
EF) 
 
Schools:  
5. 
Lic. Benito Juárez García 
6. 
Narciso Mendoza 
7. 
November 20 
8. 
Aquiles Serdán Lions Club 1 
Monday to Friday from December 1, 2023 to May 
24, 2024. 
 
Time: 08:00 to 08:15 h. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fourth grade primary school teachers. 
- 
Optional. Physical education teachers. 
Activities: 
Physical activation before the start of classes: For 15 minutes before 
classes, a short session of physical activity will take place. 
To know the recommended exercises, they can be consulted in the 
“Manual of physical activation, active breaks and active recesses 
within the school environment.” 
It is recommended that 
the other groups go to 
their respective 
classrooms; However, 
this strategy can be 
adjusted according to 
the needs of each school. 
Promotion of 
active breaks in 
the classroom (led 
by teachers) 
Schools:  
5. 
Lic. Benito Juárez García 
6. 
Narciso Mendoza 
7. 
November 20 
8. 
Aquiles Serdán Lions Club 1. 
 
Monday to Friday from December 1, 2023 to May 
24, 2024. 
 
Active break time 1: Between 09:00 a.m. and 
09:30 a.m. 
 
Active break time 2: Between 11:30 a.m. and 
12:00 p.m. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fourth grade primary school teachers. 
Activities: 
Active breaks will be encouraged, twice a day, which will include 
physical movements during classes to maintain energy and 
concentration. 
Example of exercises: 
Games and dynamics, such as imitating animals, jumping, running, 
dancing, stretching, breathing movements, joint movements. 
Frequency: 2 times a day. 
Active break 1 is expected to be one hour after school starts while 
active break 2 is expected to be one hour after the school break ends. 
duration 5 to 6 minutes, up to 10 minutes (flexible by type of 
dynamic). 
The schedules may vary 
depending on the 
dynamics of each school. 
To know the 
recommended exercises, 
they can be consulted in 
the 
“Manual of physical 
activation, active breaks 
and active recesses 
within the school 
environment.” 
Promotion of 
active recreation 
(ideally 
encouraged and 
supervised by 
teaching staff) 
Schools:  
5. 
Lic. Benito Juárez García 
6. 
Narciso Mendoza 
7. 
November 20 
8. 
Aquiles Serdán Lions Club 1. 
 
Monday to Friday from December 1, 2023 to May 
24, 2024. 
 
Time: Ideally during 15 minutes of school recess. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fourth grade primary school teachers. 
Activities: 
During recess, at least 15 minutes of moderate to vigorous physical 
activities will be promoted in play areas adapted according to the 
“Workshop for the conditioning of school spaces” and/or using the 
sports equipment provided to the school. 
To know the 
recommended exercises, 
they can be consulted in 
the 
“Manual of physical 
activation, active breaks 
and active recesses 
within the school 
environment.” 

                                                                                                                                                                            
107 
 
Table 12. Morelos intervention project schedule , October 2023 
Supervision of the 
'Movement 
Behaviors' 
promoter of: 
physical activation 
before the start of 
classes, active 
breaks and active 
recess 
School: Lic. Benito Juárez 
7. December 11 and 13. 
8. January 8, 10, 15, 17, 22, 24, 29, 31 
9. February 6, 8, 12, 14, 19, 21, 26, 28 
10. 
March 4, 6, 11, 13, 19, 21. 
11. 
April 8, 10, 15, 17, 22, 24, 29. 
12. 
May 2, 6, 8, 13, 16, 20, 22. 
Time: 8:00 a.m. to 12:30 p.m. 
 
School: Narciso Mendoza 
7. December 11 and 13. 
8. January 8, 10, 15, 17, 22, 24, 29, 31 
9. February 6, 8, 12, 14, 19, 21, 26, 28 
10. 
March 4, 6, 11, 13, 19, 21. 
11. 
April 8, 10, 15, 17, 22, 24, 29. 
12. 
May 2, 6, 8, 13, 16, 20, 22. 
Time: 8:00 a.m. to 12:30 p.m. 
 
November 20  
7. December 12 and 14. 
8. January 9, 11, 16, 18, 23, 25 and 30. 
9. February 1, 7, 9, 13, 20, 22, 27 and 29. 
10. 
March 5, 7, 12, 14, 20, 22. 
11. 
April 9, 11, 16, 18, 23, 25. 
12. 
May 3, 7, 9, 14, 17, 20, 22, 24. 
Time: 8:00 a.m. to 12:30 p.m. 
 
School: Aquiles Serdán Lions Club 1. 
7. December 12 and 14. 
8. January 9, 11, 16, 18, 23, 25 and 30. 
9. February 1, 7, 9, 13, 20, 22, 27 and 29. 
10. 
March 5, 7, 12, 14, 20, 22. 
11. 
April 9, 11, 16, 18, 23, 25. 
12. 
May 3, 7, 9, 14, 17, 20, 22, 24. 
Time: 8:00 a.m. to 12:30 p.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
The promoter of 'Movement Behaviors' will supervise: 
1. Physical activation before the start of classes: For 15 minutes 
before classes, a short session of physical activity will take place. 
2. Active Breaks: Active breaks will be encouraged, twice a day, 
which will include physical movements during classes to maintain 
energy and concentration. 
3. Active Recess: During recess, at least 15 minutes of moderate to 
vigorous physical activities will be promoted in play areas adapted 
according to the “Workshop for the conditioning of school spaces” 
and/or using the sports equipment provided to the school. " 
The 'Movement 
Behaviors' promoter 
will gradually supervise 
the activities during the 
course of the day. 

                                                                                                                                                                            
108 
 
Table 12. Morelos intervention project schedule , October 2023 
Workshop: 
Conditioning of 
school spaces. 
5. 
Lic. Benito Juárez García 
6. 
Narciso Mendoza 
7. 
November 20 
8. 
Aquiles Serdán Lions Club 1 
Saturday December 2, 2023. 
 
Time: 9:00 – 12:00 h. 
Participants: 
- 
Fathers, mothers, guardians of fourth grade girls and boys. 
- 
Fourth grade girls and boys. 
- 
Optional. Fourth grade primary school teachers. 
Activity: 
- 
Paint or recondition the school playground and fields. 
- 
The activity is directed by the promoter of 'Movement 
Behaviors'. 
- 
The Healthy Intervention team, represented by the 
promoters of 'Movement Behaviors', will be responsible for 
carrying and providing the necessary materials, such as 
paint and brushes, for the activity. 
Ideally, this activity 
should be carried out 
when there are no 
classes and when 
fathers, mothers, 
guardians of fourth 
grade girls and boys 
have more time to go to 
school. 
Workshop: 
Importance and 
benefits of 
promoting 
physical activity 
and limiting 
sedentary time in 
school girls and 
boys. 
1. 
Lic. Benito Juárez García 
2. 
Narciso Mendoza 
3. 
November 20 
4. 
Aquiles Serdán Lions Club 1 
Tuesday, December 5, 2023 (virtual mode)4 
 
Time: 6:00 p.m. – 7:00 p.m. 
 
 
Participants: 
- 
Fourth grade primary school teachers. 
Activity: 
- 
Paint or recondition the school playground and fields. 
- 
The activity is directed by the promoter of 'Movement 
Behaviors'. 
- 
The Healthy Intervention team, represented by the 
promoters of 'Movement Behaviors', will be responsible for 
carrying and providing the necessary materials, such as 
paint and brushes, for the activity. 
This activity will be 
presented at the Launch 
and the invitation will 
be extended to fourth 
grade primary school 
teachers to participate. 
Workshop: 
Healthy and 
sustainable 
nutrition and 
childhood obesity 
School: Lic. Benito Juárez 
January 12, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
 
School: Narciso Mendoza 
January 12, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
November 20 
Participants: 
- 
Fourth grade girls and boys. 
Activity: 
- 
ultra-processed foods ', 'Let's drink more natural water 
every day and 'Let's do more physical activity'. 
- 
Through recreational activities, we will strengthen the 
understanding of fundamental messages that promote 
healthy and sustainable eating, thus contributing to 
preventing childhood obesity. 
The Workshop will last 
approximately 60 
minutes per 4th grade 
group. 
The schedule has been 
planned in a way that 
allows for transitions 
between groups and 
waiting times without 
 
4 In the previous diagnosis carried out in schools in Campeche and Morelos, the teaching staff suggested that the workshops be carried out after the work day, preferably 
after 6:00 p.m. 

                                                                                                                                                                            
109 
 
Table 12. Morelos intervention project schedule , October 2023 
January 19, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: Aquiles Serdán Lions Club 1 
 
January 19, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
interfering with 
teaching activities. 
Baseline 
measurement of 
participants 
(intervention 
schools). 
School: Lic. Benito Juárez 
June 1 to 15, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
 
School: Narciso Mendoza 
June 1 to 15, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: November 20 
June 16 to 30, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: Aquiles Serdán Lions Club 1 
June 16 to 30, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
- 
Signing of the informed consent addressed to parents or 
guardians of students 
- 
Assent addressed to 4th grade girls and boys. 
- 
Filling out questionnaires and anthropometric 
measurement for 4th grade girls and boys. 
 
Review the document 
“Considerations prior to 
the final evaluation”. 
 
Start date June 1. End 
date July 31, 2024 
Baseline 
measurement of 
participants 
(control schools). 
School: Braulio Rodríguez 
June 1 to 22, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
School: Kids Heroes 
June 1 to 22, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
School: Mariano Matamoros 
June 1 to 22, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
School: Cuauhtémoc 
June 1 to 22, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
Participants:  
- 
Fourth grade girls and boys. 
Activities: 
- 
Signing of the informed consent addressed to parents or 
guardians of students 
- 
Assent addressed to 4th grade girls and boys. 
- 
Filling out questionnaires and anthropometric 
measurement for 4th grade girls and boys. 
 
 

                                                                                                                                                                            
110 
 
Table 13. Intervention project schedule. Logwood. 
 
Activity 
Place, date and time 
Participants and description of the activity 
Observations 
Information 
session (INSP 
proposal). 
October 31, 2023 
Time: 10:00am – 11:00am 
 
 
Directors 
Objective: To inform about the activities included in the IM. 
Virtual Meeting 
 
Baseline 
measurement of 
participants 
(intervention 
schools). 
School: Justo Sierra Méndez 
November 6 to 10, 2023 
Time: 8:00 a.m. – 2:00 p.m.  
School: Republic of Honduras 
November 6 to 10, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
School: Gunner boy 
November 6 to 10 Time: 8:00 a.m. – 2:00 p.m. 
School: Lucía Alayola Laura 
November 6 to 10, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
Presidente Ruiz Cortines School Center 
November 6 and 7, 2023 
Time: 8:00 a.m. – 2:00 p.m.  
School: Josefa Ortiz de Domínguez 
November 8 and 9, 2023 
Time: 8:00 a.m. – 2:00 p.m.  
School: CE Pdte. Avila Camacho 
November 10 and 13, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
School: Children of workers 
November 14 and 15, 2023 
Time: 8:00 a.m. – 2:00 p.m. 
Participants : 
- 
Fourth grade girls and boys. 
Activities: 
- 
Signing of the informed consent addressed to parents or 
guardians of students 
- 
Assent addressed to 4th grade girls and boys. 
- 
Filling out questionnaires and anthropometric 
measurement for 4th grade girls and boys. 
 
Review the document 
“Considerations prior to 
the baseline evaluation”. 
 
Start date October 23 
and end date November 
21 (tentative) 
 

                                                                                                                                                                            
111 
 
Launch in each 
intervention 
school.  
School: Justo Sierra Méndez 
November 27, 2023. 
Time: 8:00 – 10:00 a.m. 
School: Republic of Honduras 
November 28, 2023. 
Time: 8:00 – 10:00 a.m. 
School: Gunner Boy 
November 29, 2023. 
Time: 8:00 – 10:00 a.m. 
School: Lucila Alayola Laura 
November 30, 2023. 
Time: 8:00 – 10:00 a.m. 
Participants: Directors , teachers, fathers, mothers, tutors, food 
vendors, as well as fourth grade boys and girls. 
 
Activities:  
The purpose of the “Launch” is for the school community to be aware 
of the activities that will be carried out throughout the school year 
and, in this way, not only keep them informed, but also encourage 
their participation. The objective will be for the team to give an 
informative talk to the participants about the activities that will 
improve the nutrition and health of the girls and boys. 
1. We will project a presentation detailing the activities that will take 
place during the rest of the school year. This presentation will 
describe the duration, objective and activities by component aimed 
at fourth grade boys and girls, fathers, mothers, tutors, teachers and 
food vendors. 
2. We will show videos related to healthy and sustainable eating, as 
well as movement behaviors and psycho-emotional determinants. 
3. We will invite mothers, fathers and caregivers, as well as school 
teachers, to register through the WhatsApp platform to receive 
messages about healthy and sustainable eating, movement behaviors 
and determinants psycho-emotional of girls and boys. 
4. We will deliver printed communication material to mothers, 
fathers, people in charge of caring for girls and boys, as well as a 
Manual aimed at food vendors. This material will include magnets, 
infographics, brochures, among other information resources. 
5. We will place printed communication material called " Pipimeter " 
in the girls' and boys' toilets, whose objective is that they can 
monitor whether the color of their urine meets the water 
consumption recommendations. 
6. We will conclude the event with a Healthy Intervention question 
and answer session, aimed at clarifying any questions that attendees 
may have. 
Two hours are 
contemplated due to any 
delays that may occur, 
but it is expected that 
the entire event will 
take a maximum 
duration of 90 minutes. 

                                                                                                                                                                            
112 
 
Start of activities in the four implementation schools (November 2023 to June 2024). 
Virtual course 8 
p.m.: Healthy 
intervention.  
Schools:  
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
From December 1, 2023 to January 31, 2024. 
Time: Available 24 hours a day. 
Participants: 
- 
Fourth grade primary school teachers. 
- 
Optional. Fathers, mothers, guardians of fourth grade girls 
and boys. 
Activity: 
Self-managed 20-hour virtual course designed especially for 
teachers with the purpose of strengthening their understanding and 
mastery of the topics of healthy and sustainable eating and 
movement behaviors. Upon completing the course, participants will 
have the opportunity to receive a certificate with curricular validity 
issued by the School of Public Health of Mexico. 
During the Launch, you 
will be informed how 
you can access the 
“Virtual Course: Healthy 
Intervention”. 
Receiving 
messaging via 
WhatsApp (Mobile 
Health). 
Schools:  
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
From December 1, 2023 to May 24, 2024. 
Messages will be sent on Mondays, Wednesdays 
and Fridays. 
 
Shipping time: 18:00.  
Participants:  
- 
Fathers, mothers, guardians of fourth grade girls and boys. 
- 
Physical education teachers. 
- 
Optional. Fourth grade primary school teachers. 
Activity: 
Messages will be sent via WhatsApp every third day throughout the 
school year, addressing topics related to healthy eating, movement 
behaviors and emotional health during childhood. The purpose of 
this activity is to consolidate the knowledge acquired in the other 
components of the program. 
During the “Launch” you 
will be told how you can 
access WhatsApp 
messaging. 
Promotion of the 
daily intake of 
vegetables and 
fruits in the school 
environment by 
promoting healthy 
snack options. 
Schools:  
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
Monday to Friday from December 1, 2023 to May 
24, 2024. 
 
Participants: 
- 
Fourth grade girls and boys. 
Activity: 
The habit of bringing a healthy snack, which includes vegetables, 
fruits or both, from Monday to Friday by girls and boys, will be 
promoted.  
Random supervisions 
will be carried out with 
the purpose of ensuring 
that the boys and girls 
bring their healthy 
snack, ideally on a daily 
basis. 

                                                                                                                                                                            
113 
 
Time: To eat them during the break. 
Promotion of the 
daily intake of 
natural water in 
the school 
environment with 
the support of the ' 
Pipometer '. 
 
Schools:  
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
Monday to Friday from December 1, 2023 to May 
24, 2024. 
 
Time: During the entire stay at school. 
Participants: 
- 
Fourth grade girls and boys. 
Activity: 
Promotion of the habit of consuming natural water and reaching the 
recommendation of 5 to 8 glasses a day. During the supervisions, the 
color of the urine will be recorded. On a permanent basis, they will 
be able to use the ' Pipimeter ', available in all school bathrooms, as a 
visual reference. 
Random supervisions 
will be carried out with 
the purpose of ensuring 
that children maintain 
the recommendations 
for natural water 
consumption. 
Workshop: 
Emotional 
management of 
children about 
food. 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
November 8 or 9, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for emotional management 
on topics related to food and nutrition 
In-person 
 
 
 
Workshop: 
Prevention of 
stigmatization 
with weight and 
body shape; and 
Risky Eating 
Behaviors. 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
November 15, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for the definition, 
recognition, management and weight stigma, risky eating behaviors. 
In-person 
 
 
Workshop: 
Identification of 
hunger and satiety 
signals; and 
symptoms of 
anxiety and 
depression. 
 
 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
November 22 or 23, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for the identification of 
signs of hunger, anxiety and depression. 
In-person 
 
 

                                                                                                                                                                            
114 
 
Workshop: 
Internalization of 
the aesthetic ideal 
of thin beauty 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
November 22 or 23, 2023. 
Hours 8:00 a.m. – 9:00 a.m. 
Participants: 4th grade girls and boys 
Activity: Theoretical-practical workshop for the aesthetic 
identification and internalization of beauty. 
In-person 
 
 
Workshop: 
Prevention of 
stigmatization 
with weight and 
body shape; and 
Risky Eating 
Behaviors. 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
November 22 or 23, 2023. 
Schedule To be defined 
Participants: Mothers and fathers or guardians 
 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
 
 
 
 
Workshop: 
Identification of 
hunger and satiety 
signals; and 
symptoms of 
anxiety and 
depression. 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
November 8 or 9, 2023. 
Schedule: To be defined 
Participants: Mothers and fathers or guardians 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
 
 
Workshop: 
Prevention of 
stigmatization 
with weight and 
body shape; and 
Risky Eating 
Behaviors. 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
November 15, 2023. 
Schedule: To be defined 
Participants: Mothers and fathers or guardians 
 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
 
 
Workshop: Limits, 
parenting and self-
care. 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
November 22, 2023 Schedule: To be defined 
Virtual, schedule to be defined with mothers and fathers or 
guardians. 
Aimed at mothers and fathers or guardians 
 
 

                                                                                                                                                                            
115 
 
Workshop: 
Identification of 
hunger and satiety 
signals; and 
symptoms of 
anxiety and 
depression. 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
November 22, 2023. 
Schedule to be defined 
Participants: Teaching staff. 
Virtual, schedule to be defined with the teaching staff 
 
 
 
 
Supervision of the 
promoter of the 
'Healthy 
Intervention'. 
 
School: Justo Sierra Méndez 
 
 
13. 
December 4, 6, 12 and 14, 2023.  
14. 
January 9, 11, 15, 17, 23, 25 and 29, 
2024.  
15. 
February 6, 7, 14, 15, 21, 22, 26 and 27, 
2024. 
16. 
March 6, 7, 13, 14 and 19, 2024. 
17. 
April 9, 11, 15, 19, 23, 24 and 29, 2024. 
18. 
3, 7, 13, 17, 21, 23, May 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
1. Verify that they have a healthy snack. 
The person in charge of the Healthy Intervention will go to each 4th 
grade classroom to verify that they bring it with them and, if they 
comply with this practice, they will be given a numbered ticket that 
will allow them to participate at the end of the school year in an 
incentive contest. . 
2. Recording the color of the last urine. 
During the visit to the classroom, the person in charge of this 
intervention 
will provide each girl and boy, at least twice a week, with a log-type 
recording sheet called 'My Pipimeter '. On this sheet, you can mark 
the color of your last urine observed in the bathroom. In addition, 
they will have the constant support of the ' Pipometer ', a visual 
resource that will be permanently installed in all school bathrooms 
as a reference. 
3. Make regular visits to food vendors in schools to encourage 
nutritious and healthy food and drink options. 
During these visits, guidance and support will be provided to food 
and beverage vendors to promote more nutritious and healthy food 
options. The main focus is to ensure that the food options offered at 
Activities 1 and 2 will 
take approximately 20 
minutes per 4th grade 
group, while interaction 
with food and beverage 
vendors will take 5 to 10 
minutes per food and 
beverage outlet. 
The schedule has been 
planned in a way that 
allows for transitions 
between groups and 
waiting times without 
interfering with 
teaching activities. 
School: 
Republic of Honduras 
13. 
December 4, 6, 12 and 14, 2023.  
14. 
January 9, 11, 15, 17, 23, 25 and 30, 
2024.  
15. 
February 6, 7, 14, 15, 21, 22, 26 and 27, 
2024. 
16. 
March 6, 7, 13, 14 and 20, 2024. 
17. 
April 9, 11, 15, 19, 23, 24 and 29, 2024. 
18. 
May 3, 7, 13, 17, 21, 23, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 

                                                                                                                                                                            
116 
 
School: 
Gunner Boy 
13. 
December 5, 7, 11, 13, 2023. 
14. 
January 8, 10, 16, 18, 22, 24 and 31, 
2024. 
15. 
February 8, 9, 12, 13, 19, 20, 28, 29, 
2024. 
16. 
March 4, 5, 11, 12, 21, 2024. 
17. 
8, 12, 16, 18, 22, 25, April 2024. 
18. 
2, 6, 9, 14, 16, 20, 24 May 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
school are balanced and beneficial to the health of students. The 
ultimate goal is to transform the food sales environment at school 
into a place that promotes the health and well-being of students, thus 
helping to prevent problems such as overweight and obesity, and 
allowing girls and boys to grow up healthily. . 
School: Lucila Alayola Laura. 
13. 
December 5, 7, 11, 13, 2023. 
14. 
January 8, 10, 16, 18, 22, 24, 2024. 
15. 
1, 8, 9, 12, 13, 19, 20, 28, 29 February 
2024. 
16. 
March 4, 5, 11, 12, 22, 2024. 
17. 
8, 10, 16, 18, 22, 25, April 2024. 
18. 
2, 6, 9, 14, 16, 20, 24 May 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
Delivery of 
'recognition of 
healthy 
perseverance' 
carried out by the 
promoter of the 
'Healthy 
Intervention'. 
School: Justo Sierra Méndez 
January 29, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
Within the framework of supervisions for 
“Verifying that they have a healthy snack” and “Recording the color of 
their last urine” during visits to 4th grade classrooms will be carried 
out: 
- Delivery of a Diploma for carrying a healthy snack.  
- Delivery of a Diploma for complying with the recommendations for 
natural water consumption. 
This activity will take 
approximately 5 
minutes additional to 
those contemplated 
during the 
supervision of the 
promoter of the 'Healthy 
Intervention'. 
 
School: Republic of Honduras 
January 30, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
School: 
Gunner Boy 
January 31, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 

                                                                                                                                                                            
117 
 
School: Lucila Alayola Laura. 
February 1, 2024. 
Time: 8:00 a.m. to 11:00 a.m. 
Promotion of the 
reduction of the 
consumption of 
sugary drinks and 
ultra-processed 
foods - two, 
promoting 
healthier 
alternatives 
through the 
"Healthy Reporter" 
activity. 
Schools:  
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
Invitation and instructions. January 29, 31 and 
February 2, 2024. 
Sending and receiving videos. From February 6 to 
March 1, 2024. 
Voting period for the best video. 
Winners publication. From April 8 to 12, 2024. 
 
Time: Not applicable. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fathers, mothers, guardians of fourth grade girls and boys. 
Activities: 
- Invitation to participate in the creation of a video focused on the 
identification of healthy alternatives that replace the consumption of 
sugary drinks and ultra-processed foods 
- Shipping instructions. 
- Sending and receiving videos from the 'Healthy Reporters' via 
WhatsApp 
- Publication of videos for voting by the school community via 
WhatsApp to select the best videos of the 'Healthy Reporters' 
- Publication of the winning children for the best video of 'Healthy 
Reporter' 
The above activities will 
be carried out through 
the WhatsApp platform. 
This activity will be 
presented at the Launch 
and the invitation will 
be extended to fourth 
grade girls and boys and 
their guardians to 
participate. 
 
Practical 
demonstration by 
the promoter of 
'Movement 
Behaviors' on: 
-Physical 
activation before 
the start of classes. 
-Active breaks 
-Active recreation 
School: Justo Sierra Méndez 
December 4 and 6, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
Presentation and explanation to 4th grade teachers about physical 
activity practices: 
1. Physical activation before the start of classes: For 15 minutes 
before classes, a short session of physical activity will take place. 
2. Active Breaks: Active breaks will be encouraged, twice a day, 
which will include physical movements during classes to maintain 
energy and concentration. 
3. Active Recess: During recess, at least 15 minutes of moderate to 
vigorous physical activities will be promoted in play areas adapted 
according to the “Workshop for the conditioning of school spaces” 
and/or using the sports equipment provided to the school. . 
The promoter of 
'Movement Behaviors' 
will gradually carry out 
the activities during the 
course of the day. 
School: Republic of Honduras 
December 4 and 6, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 
School: Gunner Boy 
December 5 and 7, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 
School: Lucila Alayola Laura. 
December 5 and 7, 2023. 
Time: 8:00 a.m. to 12:30 p.m. 

                                                                                                                                                                            
118 
 
Promotion in the 
school 
environment of 
physical activation 
before the start of 
classes (led by 
teachers or Prof. 
EF) 
 
Schools:  
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
Monday to Friday from December 1, 2023 to May 
24, 2024. 
 
Time: 08:00 to 08:15 h. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fourth grade primary school teachers. 
- 
Optional. Physical education teachers. 
Activities: 
Physical activation before the start of classes: For 15 minutes before 
classes, a short session of physical activity will take place. 
To know the recommended exercises, they can be consulted in the 
“Manual of physical activation, active breaks and active recesses 
within the school environment.” 
It is recommended that 
the other groups go to 
their respective 
classrooms; However, 
this strategy can be 
adjusted according to 
the needs of each school. 
Promotion of 
active breaks in 
the classroom (led 
by teachers) 
Schools:  
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
Monday to Friday from December 1, 2023 to May 
24, 2024. 
 
Active break time 1: Between 09:00 a.m. and 
09:30 a.m. 
 
Active break time 2: Between 11:30 a.m. and 
12:00 p.m. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fourth grade primary school teachers. 
Activities: 
Active breaks will be encouraged, twice a day, which will include 
physical movements during classes to maintain energy and 
concentration. 
Example of exercises: 
Games and dynamics, such as imitating animals, jumping, running, 
dancing, stretching, breathing movements, joint movements. 
Frequency: 2 times a day. 
Active break 1 is expected to be one hour after school starts while 
active break 2 is expected to be one hour after the school break ends. 
duration 5 to 6 minutes, up to 10 minutes (flexible by type of 
dynamic). 
The schedules may vary 
depending on the 
dynamics of each school. 
To know the 
recommended exercises, 
they can be consulted in 
the 
“Manual of physical 
activation, active breaks 
and active recesses 
within the school 
environment.” 
Promotion of 
active recreation 
(ideally 
encouraged and 
supervised by 
teaching staff) 
Schools:  
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
Monday to Friday from December 1, 2023 to May 
24, 2024. 
 
Time: Ideally during 15 minutes of school recess. 
Participants: 
- 
Fourth grade girls and boys. 
- 
Fourth grade primary school teachers. 
Activities: 
During recess, at least 15 minutes of moderate to vigorous physical 
activities will be promoted in play areas adapted according to the 
“Workshop for the conditioning of school spaces” and/or using the 
sports equipment provided to the school. 
To know the 
recommended exercises, 
they can be consulted in 
the 
“Manual of physical 
activation, active breaks 
and active recesses 
within the school 
environment.” 

                                                                                                                                                                            
119 
 
Supervision of the 
'Movement 
Behaviors' 
promoter of: 
physical activation 
before the start of 
classes, active 
breaks and active 
recess 
School: Justo Sierra Méndez 
 
13. 
December 11 and 13. 
14. 
January 8, 10, 15, 17, 22, 24, 29, 31 
15. 
February 6, 8, 12, 14, 19, 21, 26, 28 
16. 
March 4, 6, 11, 13, 19, 21. 
17. 
April 8, 10, 15, 17, 22, 24, 29. 
18. 
May 2, 6, 8, 13, 16, 20, 22. 
Time: 8:00 a.m. to 12:30 p.m. 
 
School: Republic of Honduras 
 
13. 
December 11 and 13. 
14. 
January 8, 10, 15, 17, 22, 24, 29, 31 
15. 
February 6, 8, 12, 14, 19, 21, 26, 28 
16. 
March 4, 6, 11, 13, 19, 21. 
17. 
April 8, 10, 15, 17, 22, 24, 29. 
18. 
May 2, 6, 8, 13, 16, 20, 22. 
Time: 8:00 a.m. to 12:30 p.m. 
 
School: Gunner Boy 
 
13. 
December 12 and 14. 
14. 
January 9, 11, 16, 18, 23, 25 and 30. 
15. 
February 1, 7, 9, 13, 20, 22, 27 and 29. 
16. 
March 5, 7, 12, 14, 20, 22. 
17. 
April 9, 11, 16, 18, 23, 25. 
18. 
May 3, 7, 9, 14, 17, 20, 22, 24. 
Time: 8:00 a.m. to 12:30 p.m. 
 
School: Lucila Alayola Laura. 
 
13. 
December 12 and 14. 
14. 
January 9, 11, 16, 18, 23, 25 and 30. 
15. 
February 1, 7, 9, 13, 20, 22, 27 and 29. 
16. 
March 5, 7, 12, 14, 20, 22. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
The promoter of 'Movement Behaviors' will supervise: 
1. Physical activation before the start of classes: For 15 minutes 
before classes, a short session of physical activity will take place. 
2. Active Breaks: Active breaks will be encouraged, twice a day, 
which will include physical movements during classes to maintain 
energy and concentration. 
3. Active Recess: During recess, at least 15 minutes of moderate to 
vigorous physical activities will be promoted in play areas adapted 
according to the “Workshop for the conditioning of school spaces” 
and/or using the sports equipment provided to the school. " 
The 'Movement 
Behaviors' promoter 
will gradually supervise 
the activities during the 
course of the day. 

                                                                                                                                                                            
120 
 
17. 
April 9, 11, 16, 18, 23, 25. 
18. 
May 3, 7, 9, 14, 17, 20, 22, 24. 
Time: 8:00 a.m. to 12:30 p.m. 
Workshop: 
Conditioning of 
school spaces. 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
Saturday December 2, 2023. 
 
Time: 9:00 – 12:00 h. 
Participants: 
- 
Fathers, mothers, guardians of fourth grade girls and boys. 
- 
Fourth grade girls and boys. 
- 
Optional. Fourth grade primary school teachers. 
Activity: 
- 
Paint or recondition the school playground and fields. 
- 
The activity is directed by the promoter of 'Movement 
Behaviors'. 
- 
The Healthy Intervention team, represented by the 
promoters of 'Movement Behaviors', will be responsible for 
carrying and providing the necessary materials, such as 
paint and brushes, for the activity. 
Ideally, this activity 
should be carried out 
when there are no 
classes and when 
fathers, mothers, 
guardians of fourth 
grade girls and boys 
have more time to go to 
school. 
Workshop: 
Importance and 
benefits of 
promoting 
physical activity 
and limiting 
sedentary time in 
school girls and 
boys. 
1. Justo Sierra Méndez 
2. Republic of Honduras 
3. Gunner Boy 
4. Lucila Alayola Laura. 
 
Friday, December 1, 2023 (virtual mode)5 
 
Time: 6:00 p.m. – 7:00 p.m. 
 
 
Participants: 
- 
Fourth grade primary school teachers. 
Activity: 
- 
Paint or recondition the school playground and fields. 
- 
The activity is directed by the promoter of 'Movement 
Behaviors'. 
- 
The Healthy Intervention team, represented by the 
promoters of 'Movement Behaviors', will be responsible for 
carrying and providing the necessary materials, such as 
paint and brushes, for the activity. 
This activity will be 
presented at the Launch 
and the invitation will 
be extended to fourth 
grade primary school 
teachers to participate. 
Workshop: 
Healthy and 
sustainable eating 
and childhood 
obesity 
School: Justo Sierra Méndez 
 
January 12, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
 
School: Republic of Honduras 
January 12, 2024 
Participants: 
- 
Fourth grade girls and boys. 
Activity: 
- 
ultra-processed foods ', 'Let's drink more natural water 
every day and 'Let's do more physical activity'. 
- 
Through recreational activities, we will strengthen the 
understanding of fundamental messages that promote 
The Workshop will last 
approximately 60 
minutes per 4th grade 
group. 
The schedule has been 
planned in a way that 
allows for transitions 
 
5 In the previous diagnosis carried out in schools in Campeche and Morelos, the teaching staff suggested that the workshops be carried out after the work day, preferably 
after 6:00 p.m. 

                                                                                                                                                                            
121 
 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: Gunner Boy 
January 19, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: Lucila Alayola Laura. 
 
January 19, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
healthy and sustainable eating, thus contributing to 
preventing childhood obesity. 
between groups and 
waiting times without 
interfering with 
teaching activities. 
Baseline 
measurement of 
participants 
(intervention 
schools). 
School: Justo Sierra Méndez 
 
June 1 to 15, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
 
School: Republic of Honduras 
June 1 to 15, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: 
Gunner Boy 
June 16 to 30, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: Lucila Alayola Laura. 
June 16 to 30, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
Participants: 
- 
Fourth grade girls and boys. 
Activities: 
- 
Signing of the informed consent addressed to parents or 
guardians of students 
- 
Assent addressed to 4th grade girls and boys. 
- 
Filling out questionnaires and anthropometric 
measurement for 4th grade girls and boys. 
 
Review the document 
“Considerations prior to 
the final evaluation”. 
 
Start date: 
June 1. 
End date July 31, 2024. 
Baseline 
measurement of 
participants 
(control schools). 
Presidente Ruiz Cortines School Center 
June 1 to 22, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
 
School: Josefa Ortiz de Domínguez 
June 1 to 22, 2024 
Time: 8:00 a.m. – 2:00 p.m.  
 
School: CE Pdte. Avila Camacho 
Participants:  
- 
Fourth grade girls and boys. 
Activities: 
- 
Signing of the informed consent addressed to parents or 
guardians of students 
- 
Assent addressed to 4th grade girls and boys. 
- 
Filling out questionnaires and anthropometric 
measurement for 4th grade girls and boys. 
 
 

                                                                                                                                                                            
122 
 
June 1 to 22, 2024 
Time: 8:00 a.m. – 2:00 p.m. 
 
School: Children of workers 
June 1 to 22 2024 
Time: 8:00 a.m. – 2:00 p.m. 

                                                                                                                                                                            
123 
 
 
4. Stage 4. Institutionalization of the intervention 
  
Analysis and formulation of recommendations for scaling and incorporating the intervention 
into the SEP. Meetings with decision makers to seek scaling up of the program to other schools 
and dissemination activities of the educational materials developed (Apps and printed 
material) aimed at various population groups. 
  
Ethical and biosafety aspects 
  
The research proposal will be reviewed by the Research, Biosafety and Ethics Committees of 
the National Institute of Public Health, the institution that will coordinate the project. Only after 
being approved by these committees will the work begin. Participants will be asked to sign a 
letter of informed consent. In the case of schoolchildren, the parents or person responsible for 
the minor will be the ones to sign this document. In addition, schoolchildren will be asked for 
their consent through the letter of informed consent. All participants will have complete 
freedom to withdraw from the study at any time they wish. Schoolchildren who participate in 
the randomized clinical trial will receive an incentive. 
  
Problems and limitations 
  
One of the first risks we face when carrying out this project is the refusal of people to 
participate in a long-term project and/or abandoning the project, however, for this reason a 
series of strategies have been designed to minimize these risks, for example, seeking the 
support of local authorities to facilitate entry into schools and the provision of meaningful 
incentives to motivate participation; as well as the delivery of results of laboratory studies. 
  
Mechanisms for transferring results and their feasibility 
  
The results of this investigation will be made known through different means: 
  
1. 
In the schools in which they participated, the results will be delivered and an oral 
presentation will be made. 
2. 
Meeting with decision makers to present results. 
3. 
Participation in conferences, research reports, scientific articles. 
4. 
The prevention model can be taught by students of health-related careers, after 
receiving training. This makes it easier for the program to be replicable, that is, it does not 
require specialists or prolonged training. It is an intervention of four sessions of 45 minutes 
each, brief enough to be accepted by school institutions to be taught during the school year 
during class hours. Involves parents through assigned tasks to be completed between sessions, 
so parents do not have to modify their daily activities to attend a workshop. 

                                                                                                                                                                            
124 
 
References  
                                                           
1 
Bonvecchio A, Safdie M, Monterrubio EA, Gust T, Villalpando S, Rivera JA. 
Overweight and obesity trends in Mexican children 2 to 18 years of age from 1988 to 
2006. Salud publica Mex. 2009;51 Suppl 4: S586-594.  
2 
Barquera S, Campos I, Rivera JA. Mexico attempts to tackle obesity: the process, 
results, push backs and future challenges. Obesity reviews: an official journal of the 
International Association for the Study of Obesity. 2013;14 Suppl 2: 69-78.  
3 
Rivera J, Irizarry L, González-de Cossío T. Overview of the nutritional status of 
the Mexican population during the last two decades. Special Article. Public Health Mex 
2009 : 51 suppl 4 . 
4 
Hernandez-Lamb S, Cuevas-Nasu L, Moran-Rouan MC, Mendez-Gomez 
Humaran I, Avila-Arcos MA, Rivera-Dommarco JA. Overweight and obesity in Mexican 
children and adolescents during the last 25 years. Nutr Diabetes. 2017;13(3). 
5 
Unikel C, Vazquez V, Kaufer-Horwitz M. Psychosocial determinants of 
overweight and obesity Mexico. Recommendations for a public State policy. Mexico: 
UNAM. 2012 
6 
Incledon E, Wake M, Hay M. Psychological predictors of adiposity: A systematic 
review of longitudinal studies. International Journal of Pediatric Obesity. 2011; 6(2-2), 
e1-e1 
7 
O'Dea JA, Caputi P. Association between socioeconomic status, weight, age and 
gender, and the body image and weight control practices of 6 to 19-year-old children 
and adolescents. Health Education Research. 2001; 16(5), 521-532. 
8 
Olaiz-Fernández G, Rivera-Dommarco J, Shamah-Levy T, Rojas R, Villalpando-
Hernández S, Hernández-Ávila M, and Sepúlveda-Amor J. National Health and Nutrition 
Survey 2006. National Institute of Public Health. 2006. 
9 
Palma-Coca O, Hernandez-Serrato MI, Villalobos-Hernandez A, Unikel-
Santoncini C, Olaiz Fernandez G, Bojorquez-Chapela I. Association of socioeconomic 
status, problem behaviors, and disordered eating in Mexican adolescents: results of the 
Mexican National Health and Nutrition Survey 2006. Journal of Adolescent Health. 
2011; 49(4), 400-4 
10 
Holub CK, Elder JP, Arredondo EM, Barquera S, Eisenberg CM, Sanchez 
Rosemary LM. Obesity control in Latin American and US Latinos: a systematic review. 
Am J Prev Med. 2013;44:529–537. 
11 
Lobelo F, Garcia de Quevedo I, Holub CK, Nagle BJ, Arredondo EM, Barquera S, 
et al. School-based programs aimed at the prevention and treatment of obesity: 
evidence-based interventions for youth in Latin America. The Journal of school health 
2013;83: 668-677.  

                                                                                                                                                                            
125 
 
12 
Mehta S, Dimsdale J, Nagle B, Holub CK, Woods C, Barquera S, et al. Worksite 
interventions: improving lifestyle habits among Latin American adults. Am J Prev Med 
2013;44: 538-542.  
13 
Theodore F, Juarez-Ramirez C, Cahuana-Hurtado L, Blanco I, Tolentino-Mayo L, 
Bonvecchio A. Barriers and opportunities for the regulation of food and beverage 
advertising to children in Mexico. Salud publica de Mex. 2014;56 Suppl 2: s123-129.  
14 
Safdie M, Levesque L, Gonzalez-Casanova I, Salvo D, Islas A, Hernandez-Cordero 
S, et al. Promoting healthful diet and physical activity in the Mexican school system for 
the prevention of obesity in children. Salud publica de Mex. 2013;55 Suppl 3: 357-373.  
15 
Jennings-Aburto N, Nava F, Bonvecchio A, Safdie M, Gonzalez-Casanova I, Gust 
T, et al. Physical activity during the school day in public primary schools in Mexico City. 
Salud publica de Mex. 2009;51: 141147.  
16 
Alvirde-Garcia U, Rodriguez-Guerrero AJ, Henao-Moran S, Gomez-Perez FJ, 
Aguilar-Salinas CA. Results of a community-based life style intervention program for 
children. Salud pública de Mex. 2013;55 Suppl 3: 406-414.  
17 
Soltero EG, Ortiz Hernandez L, Jauregui E, Levesque L, Lopez YTJ, Barquera S, et 
al. Characterization of the School Neighborhood Food Environment in Three Mexican 
Cities. Ecol Food Nutr. 2017;56: 139-151. 
18 
Barrera LH, Rothenberg SJ, Barquera S, Cifuentes E. The Toxic Food 
Environment Around Elementary Schools and Childhood Obesity in Mexican Cities. Am 
J Prev Med. 2016.  
19 
Medina C, Barquera S, Katzmarzyk PT, Janssen I. Physical activity during recess 
among 13–14 year old Mexican girls. BMC Pediatrics 2015;15.  
20 
Medina C, Janssen I, Campos I, Barquera S. Physical inactivity prevalence and 
trends among Mexican adults: results from the National Health and Nutrition Survey 
(ENSANUT) 2006 and 2012. BMC Public Health 2013;13: 1063.  
21 
Janssen I, Medina C, Pedroza A, Barquera S. Screen time in Mexican children: 
findings from the 2012 National Health and Nutrition Survey (ENSANUT 2012). Salud 
pública de Mex. 2013;55: 484-491.  
22 
Jauregui A, Medina C, Salvo D, Barquera S, Rivera-Dommarco JA. Active 
Commuting to School in Mexican Adolescents: Evidence from the Mexican National 
Nutrition and Health Survey. J Phys Act Health 2015;12: 1088-1095.  
23 
Romieu I, Dossus L, Barquera S, Blottiere HM, Franks PW, Gunter M, et al. Energy 
balance and obesity: what are the main drivers? Cancer Causes Control 2017;28: 247-
258.  
24 
Popkin BM. The nutrition transition in low-income countries: an emerging 
crisis. Nutr Rev. 1994;52: 285-298.  

                                                                                                                                                                            
126 
 
25 
Aburto NJ, Fulton JE, Safdie M, Duque T, Bonvecchio A, Rivera JA. Effect of a 
school-based intervention on physical activity: cluster-randomized trial. Medicine and 
science in sports and exercise. 2011;43: 18981906.  
26 
Safdie M, Jennings-Aburto N, Levesque L, Janssen I, Campirano-Nunez F, Lopez-
Olmedo N, et al. Impact of a school-based intervention program on obesity risk factors 
in Mexican children. Salud publica de Mex. 2013;55 Suppl 3: 374-387.  
27 
Health Secretary. National Agreement for Food Health: strategy against 
overweight and obesity. Sub-Secretary of Prevention and Health Promotion of the 
Ministry of Health. 2010. 
28 
Barquera S, Rivera J, Campos-Nonato I, Hernández-Barrera L, Santos-Burgoa C, 
Durán E, et al. Technical bases of the National Agreement for Food Health. Strategy 
against overweight and obesity. Health Secretary. 2010; 178. 
29 
General Guidelines for the sale or distribution of food and beverages in school 
consumption establishments of basic education schools. National Agreement for Food 
Health. Strategy against Overweight and Obesity: Mexico DF, 2010;34. 
30 
Barquera S, Tolentino ML, Safdie M, L. National guidelines for healthy nutrition 
in Mexican schools: an independent preliminary evaluation. Obesity Reviews. 2014; 
15: 249-270. 
31 
Rivera JA, Hernández AM, Aguilar SC, Vadillo OF, Murayama RC. Obesity in 
Mexico: recommendations for a state policy. Mex City Acad Nac Med UNAM. 2012 
32 
Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education Health 
Education. 
2008; 
63: 
97-121 
Available: 
http://linkinghub.elsevier.com/retrieve/pii/S003335064981524 
33 
BETTER. (2022). National indicators of continuous improvement of education in 
Mexico 
. 
https://www.mejoredu.gob.mx/images/publicaciones/indicadores-
nacionales-2022.pdf 
34 
CONEVAL. (2020). Población total, indicadores, índice y grado de rezago social, 
según localidad al interior de Morelos, 2020. 
https://www.coneval.org.mx/Medicion/IRS/Paginas/Indice_de_Rezago_Social_2020_
anexos.aspx 
35 
Ajzen I. From intentions to actions: A theory of planned behavior. Action control 
1985: 11-39.  
36 
Ajzen I. The theory of planned behaviour. Organizational behavior and human 
decision processes 1991; 50: 179-211.  
37 
Springer AE, Evans AE. Assessing environmental assets for health promotion 
program planning: a practical framework for healh promotion practitioners. Health 
Promotion Perspectives, 2016; 6(3): 111118  

                                                                                                                                                                            
127 
 
38 
Bandura A, Social foundations of thought and action: Social cognitive theory. 
Englewood Cliffs, NJ: Prentice Hall. 1986   
39 
McLery KR, Bibeau D, Steckler AK. An Ecological Perspective on Health 
Promotion Programs. Health Education and Behaviour. 1988; 15:351-377  
40 
United Nations. Boletín de estupefacientes: La ciencia de la epidemiología del 
uso indebido de drogas. United Nation Pub. 2004. 
41 
Barrera LH, Rothenberg SJ, Barquera S, Cifuentes E. The Toxic Food 
Environment around Elementary Schools and Childhood Obesity in Mexican Cities. Am 
J Prev Med. 2016; 51 (2):264-70. doi: 10.1016/j.amepre.2016.02.021.  
42 
Pan American Health Organization (PAHO). Recommendations from a Pan 
American Health Organization Expert Consultation on the Marketing of Food and Non-
Alcoholic Beverages to Children in the Americas. 2011;130  
43 
World Health Organization. What is a health promoting school? Disponible en: 
http://www.who.int/school_youth_health/gshi/hps/en/ (accesado en Junio, 2017) 
44 
World Health Organization. Report of the Comission on Ending Childhood 
Obesity. Geneva: World Health Organization; 2016   
45 
Menon P, Covic N, Harrigan P, Horton S, Kazi N, Lamstein S, Neufeld L, Oakley E, 
Pelletier D. Strengthenig implementation and utilization of nutrition interventions 
through research: a framework and research agenda.  Annals of the New York Academy 
of Sciences. Doi: 10.1111/nyas.12447 
46 
Peters DH, Tran NT, Adam T. Implementation research in health: a practical 
guide. Alliance for Health Policy and Systems Research, World Health Organization, 
2013  
47 
Lázaro et al. Evaluación de la Implementación. Guía práctica 4. España. 2009. 
Disponible 
en: 
http://www.dgfc.sgpg.meh.es/sitios/dgfc/esES/ipr/fcp1420/e/Documents/Guia3_E
valuacion_de_implementacion_ivalua.pdf  
48 
Weston, R. y Gore Jr., P. A Brief Guide to Structural Equation Modeling. The 
Counseling Psychologist. 2006; 34(5), 719-751. DOI: 10.1177/0011000006286345  
49 
Centers for Disease Control and Prevention. Comprehensive School Physical 
Activity Programs: A Guide for Schools. Atlanta, GA: U.S. Department of Health and 
Human Services; 2013.   
50 
Dobbins M, Husson H, DeCorby K, LaRocca RL. School-based physical ativity 
programs for promoting physical activity and fitness in children and adolescents aged 
6 to 18 (Review). The Cochrane database of systematic reviews. 2013(2):CD007651.  
51 
Centers for Disease Control and Prevention. Comprehensive School Physical 
Activity Programs: A Guide for Schools. Atlanta, GA: U.S. Department of Health and 
Human Services; 2013.   

                                                                                                                                                                            
128 
 
52 
Dobbins M, Husson H, DeCorby K, LaRocca RL. School-based physical ativity 
programs for promoting physical activity and fitness in children and adolescents aged 
6 to 18: Review. The Cochrane database of systematic reviews. 2013(2):CD007651.  
53 
Centers for Disease Control and Prevention. Comprehensive School Physical 
Activity Programs: A Guide for Schools. Atlanta, GA: U.S. Department of Health and 
Human Services; 2013.   
54 
Heath GW, Parra DC, Sarmiento OL, Andersen LB, Owen N, Goenka S, et al. 
Evidence-based intervention in physical activity: lessons from around the world. 
Lancet. 2012;380(9838):272-81.  
55 
Centers for Disease Control and Prevention. Comprehensive School Physical 
Activity Programs: A Guide for Schools. Atlanta, GA: U.S. Department of Health and 
Human Services; 2013.   
56 
Heath GW, Parra DC, Sarmiento OL, Andersen LB, Owen N, Goenka S, et al. 
Evidence-based intervention in physical activity: lessons from around the world. 
Lancet. 2012;380(9838):272-81.  
57 
Centers for Disease Control and Prevention. Comprehensive School Physical 
Activity Programs: A Guide for Schools. Atlanta, GA: US Department of Health and 
Human Services; 2013. 
58 
Centers for Disease Control and Prevention. Comprehensive School Physical 
Activity Programs: A Guide for Schools. Atlanta, GA: US Department of Health and 
Human Services; 2013. 
59 
Quality Physical Education. Guide for policy makers. United Nations 
Educational, Scientific and Cultural Organization, Paris. 2015. 
60 
Ickes MJ, Erwin H, Beighle A. Systematic Review of Recess Interventions to 
Increase Physical Activity. J Phys Act Health. 2013;10:910 -26. 
61 
Temple M, Robinson JC. A systematic review of interventions to promote 
physical activity in the preschool setting. J Specialists Ped Nursing. 2014;19:274-84.  
62 
Escalante Y, Garcia-Hermoso A, Backx K, Saavedra JM. Playground designs to 
increase physical activity levels during school recess: a systematic review. Health 
education & behavior: the official publication of the Society for Public Health 
Education. 2014;41(2):138-44.  
63 
Active Living Research. Do short physical activity breaks in classroom work? 
Research Brief. 2013.  
64 
Centers for Disease Control and Prevention. Comprehensive School Physical 
Activity Programs: A Guide for Schools. Atlanta, GA: U.S. Department of Health and 
Human Services; 2013.   

                                                                                                                                                                            
129 
 
65 
McDonald NC, Yang Y, Abbott SM, Bullock NM. Impact of the Safe Routes to 
School program on walking and biking: Eugene, Oregon study. Transport Policy 
2013;29:243-48.  
66 
The Walking School Bus: Combining Safety, Fun and the Walk to School. 
National Center for Safe Routes to School and the Pedestrian and Bicycle Information 
Center, NC.  
67 
Verstraete SJM, Cardon GM, De Clercq DLR, et al. A comprehensive physical 
activity promotion programme at elementary school: the effects on physical activity, 
physical fitness and psychosocial correlates of physical activity. Public Health Nutrition 
2007: 477-484  
68 
Wolch J, Jerret M, Reynolds K, et al. Childhood obesity and proximity to urban 
parks and recreation resources: A longitudinal cohort study. Health & Place. 2011; 
17(1):207-214  
69 
Lubans D, Morgan P. Evaluation of an extra-curricular school sport programme 
promoting lifestyle and lifetime activity for adolescents. Journal of Sports Sciences. 
2008; 26(5): 519-529  
70 
Wolch J, Jerret M, Reynolds K, et al. Childhood obesity and proximity to urban 
parks and recreation resources: A longitudinal cohort study. Health & Place. 2011; 
17(1):207-214  
71 
Jago R, Sebire SJ, Davies B, et al. Randomised feasibility trial of a teaching 
assistant led extracurricular physical activity intervention for 9 to 11 years olds: Action 
3:30.  
72 
Siopis G, Chey T, Allman-Farinelli M. A systematic review and meta-analysis of 
interventions for weight management using text messaging. J Hum Nutr Diet. 2015;28 
Suppl 2:1-15.  
73 
Price S, Ferisin S, Sharifi M, Steinberg D, Bennett G, Wolin KY, Horan C, Koziol R, 
Marshall R, Taveras EM. Development and Implementation of an Interactive Text 
Messaging Campaign to Support Behavior Change in a Childhood Obesity Randomized 
Controlled Trial.  J Health Commun. 2015;20(7):843-50.  
74 
de Niet J, Timman R, Bauer S, van den Akker E, Buijks H, de Klerk C, Kordy H, 
Passchier J. The effect of a short message service maintenance treatment on body mass 
index and psychological well-being in overweight and obese children: a randomized 
controlled trial. Pediatric Obes . 2012 Jun;7(3):205-19. 
75 
de Niet J, Timman R, Bauer S, van den Akker E, de Klerk C, Kordy H, Passchier J. 
Short message service reduces dropout in childhood obesity treatment: a randomized 
controlled trial. Health Psychol. 2012 Nov;31(6):797-805. 
76 
Sharifi M, Dryden EM, Horan CM, Price S, Marshall R, Hacker K, Finkelstein JA, 
Taveras EM. Leveraging text messaging and mobile technology to support pediatric 

                                                                                                                                                                            
130 
 
obesity-related behavior change: a qualitative study using parent focus groups and 
interviews. J Med Internet Res. 2013 Dec 6;15(12):e272.  
77 
McKenzie TL, Sallis JF, Nader PR. SOFIT: System for observing fitness instruction 
time. Journal of Teaching in Physical Education 1991;11:195-205  
78 
Rowe PJ, Schuldheisz JM, van der Mars H. Measuring physical activity in physical 
education: validation of the SOFIT direct observation instrument for use with first to 
eighth grade students. Pediatr Exerc Sci 1997;9:136-149  
79 
Mckenzie T. SOFIT (System for Observing Fitness Instruction Time). Description 
and Procedure Manual. San Diego State University, 2015. San Diego, CA. USA  
80 
Aburto NJ, Nava F, Bonvecchio A, Safdie M, González-Casanova I, Gust T, Rivera 
J. Physical activity during the school day in public primary schools in Mexico City. Salud 
pública Méx 2009; 51(2) :141-147  
81 
Safdie M, Aburto NJ, Lévesque L, Janssen I, Campirano-Núñez F, López-Olmedo 
N, Aburto T, Rivera JA. Impact of a school-based intervention program on obesity risk 
factors in Mexican children. Salud pública Méx, 2013: 55 (3): S374-S387.  
82 
CDC. Dual Energy X-Ray Absorptiometry (DXA) Procedures Manual.; 2007. 
83 
Shrimpton P, Wall B, Jones D, et al. Doses to patients from routine diagnostic X-
ray examinations in England. Br J Radiol . 1986;59(704):749-758. 
84 
Jebb S. Measurement of soft tissue composition by dual energy X-ray 
absorptiometry. Br J Nutr . 1997;77:151-163. 
85 
Official Mexican STANDARD NOM-229-SSA1-2002, Environmental health. 
Technical requirements for facilities, health responsibilities, technical specifications 
for equipment and radiological protection in medical diagnostic establishments with 
X-rays. [Access date: April 25, 2018] Available at: http://www.cenetec.salud.gob. 
mx/descargas/equipoMedico/normas/NOM_229_SSA1_2002.pdf 
86 
Piva SJ, Tatsch E, Mainardi JA et. al.  Assessment of Inflammatory and Oxidative 
Biomarkers in Obesity and Their Associations with Body Mass Index. Inflammation 
2013; 36 (1): 226-31.  
87 
Giordano P, Del Vecchio GC, Cecinati V et. al. Metabolic, inflammatory, 
endothelial and haemostatic markers in a group of Italian obese children and 
adolescents. Eur J Pediatr 2011 Jul;170(7):845-50. 
88 
Stępień M, Stępień A, Wlazeł RN et. to the. Obesity indices and inflammatory 
markers in obese non-diabetic normo- and hypertensive patients: a comparative pilot 
study. Lipids in Health and Disease 2014, 13:29. 
89 
Albuali , WH. Evaluation of oxidant-antioxidant status in overweight and 
morbidly obese Saudi children. World J Clin Pediatr 2014 February 8; 3(1): 6-13. 

                                                                                                                                                                            
131 
 
90 
De Tursi L, Vázquez A, Vázquez A et. to the. Oxidative stress: comparative study 
between a normal population group and a morbidly obese population group. Nutr Hosp 
2013;28(3):671-67S. 
91 
Boden G, She P, Mozzoli M, et al. Free fatty acids produce insulin resistance and 
activate the proinflammatory nuclear factor-kappaB pathway in rat liver. Diabetes. 
2005;54(12):3458– 3465.  
92 
Shoelson SE, Lee J, Goldfine AB. Inflammation and insulin resistance. J Clin 
Invest. 2006;116(7):1793– 1801.  
93 
Xu H, Barnes GT, Yang Q, et al. Chronic inflammation in fat plays a crucial role in 
the 
development 
of 
obesity-related 
insulin 
resistance. 
J 
Clin 
Invest. 
2003;112(12):1821–1830.  
94 
Herrero L, Shapiro H, Nayer A, Lee J, Shoelson SE. Inflammation and adipose 
tissue macrophages in lipodystrophic mice. Proc Natl Acad Sci U S A. 2010; 
107(1):240–245.  
95 
Weisberg SP, McCann D, Desai M, Rosenbaum M, Leibel RL, Ferrante AW Jr.  
Obesity is associated with macrophage accumulation in adipose tissue. J Clin Invest. 
2003;112(12):1796–1808.  
96 
Xu H, Barnes GT, Yang Q , et al. Chronic inflammation in fat plays a crucial role 
in the development 
of 
obesity-related 
insulin 
resistance. 
J 
Clin Invest.  
2003;112(12):1821–1830.  
97 
Liu FT, Rabinovich GA. Galectins: regulators of acute and chronic inflammation. 
Ann N Y Acad Sci. 2010;1183:158–182.  
98 
Dumic J, Dabelic S, Flogel M. Galectin-3: an open-ended story. Biochim Biophys 
Acta. 2006;1760(4):616–635. 
99 
Shamah-Levy T, Villalpando SH and Rivera JD. Manual of procedures for 
nutrition projects. National Institute of Public Health. 2006. Available at: 
http://www.health.gob.mx/units/cdi/documents/proy_nutrition.pdf 
100 
Sandeep K. Gupta. The intention-to-treat concept: A review. Perspect Clin Res. 
2011; 2(3): 109–112. 
101 
Field A. Discovering Statistics Using SPSS. 2nd edition. Sage Publications Ltd. 
2005.