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A girl eats a healthy snack at school in Mexico

MEXICO
What this article is about: This article outlines the development of a newsubject – ‘Vida Saludable’ or ‘Healthy Living’ – which is featured in theMexican national school curriculum. The subject aims to educate
schoolchildren whilst tackling the wider nutritional challenges facing
Mexico’s youth.
Key messages:• Vida Saludable is the latest in a growing body of nutrition-focused
initiatives that the Mexican government has introduced in recent years
with the objective of curbing the national obesity epidemic in thecontext of the COVID-19 pandemic.
• This comprehensive initiative highlights the value of collaboration
between government departments and organisations with the formationof the new subject showcasing the government’s ability to develop anovel, evidence-based, child and adolescent-focused intervention.
• Despite successes, remaining challenges revolve around implementing
a robust monitoring and evaluation system, as well as formallyincorporating the subject into the national curriculum and resolving
the associated timetabling issues.

© UNICEF México / Balam-ha Carrillo

Background‘Vida Saludable’:
Healthy living
is on the school
curriculum inMexico
By Angélica Hernández,
Gabriela Tamez Hidalgo andAnabel Fiorella Espinosa
Angélica Hernández is a former consultant at
UNICEF Mexico. She supported the Ministry ofEducation in the development of Healthy Livingcontent.
Gabriela Tamez Hidalgo is the former Directorof Curricular Strengthening in Basic Education
at the Ministry of Public Education, Mexico.
Fiorella Espinosa is a Nutrition Officer at
UNICEF Mexico. She is a public healthnutritionist and her main role at UNICEF is topromote the modification of the foodenvironment to improve the nutrition ofchildren and adolescents.

44Since the turn of the century, Mexico hasmade steady progress across a number ofnutrition indicators (Global Nutrition Report, 2021). Child and adolescent (5-19years) underweight prevalence, now at 8.8%
and 9.7% for girls and boys respectively,
has decreased year on year, exclusive breastfeeding in children under six months increased from 14.4% in 2012 to 28.6% in2018 and the dietary intake of adults older
than 25 years of fruits, legumes, wholegrains, fibre and polyunsaturated fat all fallabove the global average with sodium consumption falling below. For more than adecade, the government has also proactively
pursued favourable public health nutrition
policies such as salt iodisation, sodium reduction, sugar-sweetened beverage taxation, , introducing food warning labels
and restricting the marketing of ultra-processed foods towards children. The country
therefore appears to be ‘on course’ towards
meeting global nutrition targets.
However, progress in Mexico is a taleof two sides. As the burden of undernutrition
has fallen, overnutrition has risen. In 2020,
the combined prevalence of overweight
and obesity amongst the school-aged population (5-11 years) was 38.2% with theprevalence rising to 43.8% in adolescentsand up to 44.6% in adolescent women specifically (Shamah-Levy et al, 2021). Vegetables, nuts and seeds and omega-3 consumption are all under the global average,
with red and processed meat and sugarsweetened beverage consumption higher
compared to the global average (Global
Nutrition Report, 2021). Moreover, theemergence of the COVID-19 pandemic has
reaffirmed overweight and obesity as apublic health priority in Mexico due to thelinks with increased susceptibility toCOVID-19 (UNICEF, 2021).

FIELD EXCHANGE ISSUE 66, NOV 2021 www.ennonline.net/fex

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

The Vida Saludable
initiative
Background research anddevelopment
Although nutrition partially featured on theexisting national curriculum in the form ofcivic studies, science and physical education,
the Vida Saludable vision is to formally incorporate nutrition, physical education andhygiene into the learning roster to combat
the emergence of obesity, diabetes and sedentary lifestyle behaviours. Like many otherpublic health endeavours of such magnitude, Vida Saludable was informed by othercurrent public health projects. Approaches
such as the labelling of ultra-processed
foods, sugar-sweetened beverage taxation

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

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

through to high school students across thecountry via television, radio and the internet.
The intervention was shared in a novel format
through interactive games. However, once thegovernment acknowledged that the pandemic
was likely to be protracted, this platform became the long-term strategy for delivering theinitiative in the 2020-2021 school year.
To build upon remote education, food diaries
were provided to the students with each participant expected to reflect on their food anddrink consumption which was then followed
up by teachers. This made the students awareof any entrenched suboptimal dietary habits
such as excess salt or added sugar consumption.
The primary goal of this multi-platform approach
was to reinforce healthy habits, allowing students
to become more autonomous in their lifestyle
behaviours, irrespective of the wider obesogenic
environment they found themselves in.

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

Results
The Vida Saludable initiative has now been fully
implemented into the national curriculum inall 32 states in Mexico, targeting children aged
6-15 years, despite the initiative not yet being
officially enshrined in national policy. Testimonies from the participants involved so far
speaks to the popularity of the initiative
amongst children.
However, no quantifiable results are available
for the programme as yet. Changes in federal

administration, specifically within the MoE,
and subsequent changes in the education systemhave made it difficult to determine to date how
to quantify success and how success will bemeasured moving forwards. UNICEF and INSP
are currently aiming to support government efforts by conducting a study to analyse the design, implementation and specific outcomes of
the initiative through a non-representative
sample from three states, to inform future improvements to the initiative. In the middle ofthe 2021-2022 school year, the short-term results of the implementation of this initiative
will be analysed through quantitative and qualitative methods, including interviews withteachers and focus groups with students.

Lessons learned and next steps
The Vida Saludable initiative is an example of
how large-scale, seemingly insurmountablechallenges such as the national obesity epidemic
can be broken down into smaller objectives andtackled using a combination of unified and targeted interventions. Previous nutrition-focusedpolicies have had mixed success in Mexico although progress has been made on some nutrition indicators over recent years. However,collectively, such policies have laid the foundations for Vida Saludable to be successful andthis example highlights how a proactive government approach to a public health crisis has
the potential for impact. The introduction ofVida Saludable to the national curriculum
would have been a greater challenge had previous iterations of the scheme, such as ‘Scholar
Health’, not been in place. Such leadership fromthe government must be commended.
One of the success stories of Vida Saludableis the coordination of different inter- and intragovernmental actors during the development
phase. Firstly, the unified approach from theMoE and MoH highlights a level of coordination
that, up until now, has not always been apparent© UNICEF México / Balam-ha Carrillo

and increased access to water fountains inschools – all part of a collective effort to dissuade
the youth from consuming sugar-laden, fizzy
drinks – attempt to facilitate healthier lifestyle
behaviours in children and adolescents. Each ofthese initiatives is linked to the Mexican government’s wider policy objective of combating
obesity with the Vida Saludable initiative designed to build upon these policies, specificallytargeting the youth population who are particularly susceptible to the obesogenic environment.

Implementation and the COVID-19
pandemic
Vida Saludable learning began in July 2020 withthe ‘learn at home’ platform aimed at preschoolChildren eat a variety of healthysnacks at school in Mexico

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45

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at this level of government in Mexico. On apractical level, the consolidation of over 200
international documents and reports to guidethe initiative, along with the coordination ofthe large workforce required to do this, shows
promise for the future of Vida Saludable andsubsequent programmes that the government
prioritises to implement. This process also highlights the government’s commitment to evidence-based programming as well as a willingness to recruit external agencies, namely UNICEF,
to provide technical expertise in the interest ofdelivering a successful intervention.
A paucity of data demonstrating progress,success and impact represents the biggest challenge of the Vida Saludable initiative so far.
This is especially pertinent given the scale ofthe project, with national rollout susceptible todiminishing returns as some regions may perform worse than others, highlighting the needfor detailed subnational data. The construction
and subsequent implementation of a monitoring
system designed by the government, based on
the findings from the UNICEF and INSP study,
is a necessary addition to the programme thatwill provide both short- and medium-term results. The provision of this evaluation can therefore offer a valuable opportunity to incorporate
lessons learned moving forwards.
The lack of usable data has been mostly attributed to challenges at the policy level. Changes
in personnel within the government have hindered the implementation of a workable monitoring and evaluation strategy. These samechanges have also made it difficult for Vida Saludable to be integrated into national policy as,
long term, there is uncertainty regarding themost effective way to fit the subject into the national curriculum. The impact on timetabling
and the knock-on effect that introduction would
have on other subjects are key questions forthe initiative moving forwards.

In addition to these broader challenges,
changing the ingrained habits found within theMexican lifestyle has been problematic for theprogramme so far. For example, questions havearisen about how best to reach wider family
members within the household. This is the main
driver of a move away from ultra-processed
foods toward the purchase of food from local
markets which in turn is an important aim for
Vida Saludable. For this reason, the social determinants of health are being included in lessons
so that children can critically engage with thesubject matter and work with their parents toovercome the obstacles of behaviour change.
However, linked to the wider determinantsof health, there is an acknowledgement that
this programme may only go so far in deliveringchange. For example, promoting behaviourchange models in isolation is unlikely to confer
significant gains for families who live in conditions not conducive to healthy living. Thehygiene arm of Vida Saludable will not change
the lives of those who have limited access toappropriate water, sanitation and hygiene facilities, for example. Nutrition education canincrease agency and improve dietary decisionmaking but it will not be able to overcome theproliferation of ultra-processed foods, sugarsweetened beverages and a lack of access tofresh produce that constitutes the food environment found in some districts.
Therefore, a multi-sector approach to address
income generation, poverty alleviation, suboptimal food systems and making healthy
choices accessible to young people is required
to create an enabling environment, ensuring
the long-term success of Vida Saludable. Nevertheless, the introduction of Vida Saludable
holds promise, as wider policies are already inplace which point to the government’s willingness
to implement a multi-sector approach. Since
2010, and then updated in 2014, guidelines

have been published that prohibit the sale anddistribution of foods that do not meet specificnutritional criteria between Mondays and Thursdays. There is also a law that mandates the installation of drinking fountains in all schools
although this ambition is yet to be fully realised.
With the return of pupils to classes after the
initial impact of the COVID-19 pandemic, thedialogue between the MoE and MoH is being
resumed to push forward with these regulations
to facilitate healthier school environments.

Conclusion
Vida Saludable is the most recent in a growing
body of nutrition-focused initiatives that theMexican government has introduced in recent
years. Obesity amongst children and adolescentsis a public health priority and the government
has responded proportionately with this curriculum-based initiative which it hopes can stem thetide of unhealthy lifestyle habits that have crept
into daily life. However, although promising steps
have been taken, a paucity of data prevents any
conclusive evaluation of the programme so far.
The next steps for Vida Saludable will be to officially incorporate the subject into the national
curriculum which will give the initiative more
visibility as well as contribute to the broader
strategy of healthier living in Mexico. Above all,implementing an effective monitoring and evaluation strategy, with the support of UNICEF andINSP, is integral to documenting the success of
the initiative and determining whether Vida Saludable is a worthwhile endeavour.
For further information, please contact
Fiorella Espinosa at aespinosa@unicef.org
Furthermore, to see an example of Vida Saludable in action, please visit the following link:
https://www.youtube.com/watch?v=Lx43eT4
Kh_4

ReferencesCai, Q, Chen, F, Wang, T, Luo, F, Liu, X, Wu, Q et al (2020)
Obesity and Covid-19 Severity in A Designated Hospitalin Shenzhen, China. Diabetes Care. 43(1), 1392-1398.
Available At: https://care.diabetesjournals.org/content/diacare/43/7/1392.full.pdf'Aprende en Casa' educational video for thirdand fourth grade primary school students

Global Nutrition Report (2021) Country Nutrition
Profiles: Mexico. https://globalnutritionreport.org/
resources/nutrition-profiles/latin-america-andcaribbean/central-america/mexico/
Government of Mexico (2020) “Healthy Living”, A New
Subject in Study Plans. Available At:
https://www.insp.mx/avisos/vida-saludable-nuevamateria-en-planes-de-estudio
Shameh-Levy, T, Romero-Martinez, M, BarrientosGutierrez, T, Cuevas-Nasu, L, Bautista-Arredondo, S,Colchero, M et al (2021) Encuesta Nacional de Salud yNutricion 2020 Sobre Covid-19. Resultados Nationales.
Cuernavaca, Mexico: Instituto Nacional de SaludPublica. https://ensanut.insp.mx/encuestas/ensanutco
ntinua2020/doctos/informes/ensanutCovid19Resultad
osNacionales.pdf© Aprende En Casa

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

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UNICEF (2021) Country Office Annual Report 2020:
Mexico. Available at: https://www.unicef.org/media/100406/file/Mexico-2020-COAR.pdf
WHO (2018) Global Standards for Health Promoting
Schools. Available at: https://www.who.int/ publications/
i/item/global-standards-for-health-promoting-schools