This describes a health promotion portfolio to prevent childhood obesity in Mexico. Unfortunately Corporate Food is mighty and the federal government lack willpower—they’re also distrusted by the people—hence this strategy aims to strengthen local communities and spread through social networks to scale. Oh, and of course, promote delicious traditional Mexican food.
Mexico is experiencing the double burden of malnutrition with diseases of undernutrition coexisting with obesity and associated chronic diseases (World Health Organisation 2003; Rivera 2004). Arguably it was the North American Free Trade Agreement and trade liberalization that shifted the population from traditional diets high in complex carbohydrates and fibre to energy-dense foods that are high in fat and sweeteners (Popkin 1994; Rivera 2004; Clark 2012). Obesity increases the risk of a range of adverse health outcomes and once established, it is extremely difficult and costly to treat. Therefore, the prevention of weight gain among children is a public health priority.
In 2006, 26.3% of Mexican children aged 2 to 18 were overweight or obese. By age group, the prevalence was 16.7% in pre-school, 26.2% in primary school and 30.9% in adolescents. An upward trend was observed in the latter two groups, with the highest increase in primary school children. Prevalence rates were highest in urban areas (Mexico City and the northern regions) compared to rural regions (central and south). They were nearly twice as high in the first tertile of socioeconomic status compared to the fifth. Nevertheless, the prevalence of obesity also increased among indigenous children, who are considered to be “the poorest of the poor” (Bonvecchio 2009).
Schools are a popular setting to prevent child obesity—multi-component interventions fare well—yet overall the effect has been modest (Summerbell, Waters et al. 2005). Mexican schools present challenges; many lack basic infrastructure like playgrounds and drinkable water (Institutes of Medicine 2007). Food sold within must meet nutrition regulations, yet this doesn’t apply to nearby street vendors (Lozada, Sanchez-Castillo et al. 2008). Physical education classes should occur twice weekly, yet this isn’t enforced (Jennings-Aburto 2009). There is also limited time to effect change because schools operate on double shifts. In one Mexican school intervention, the physical activity effects were moderated by a decline in out-of-school activity (Aburto 2011). Hence, a more extensive intervention is necessary.
Homes are an ideal setting because parents directly determine the physical and social environment and influence the behavior, habits and attitudes of their children through modeling and reinforcement (Ritchie 2005). Evidence is lacking for Mexican families with primary school-aged children, however there are at least five mechanisms identified by which U.S. Latino parents influence their child’s risk of obesity: parenting style, parenting strategies, providing instrumental support (e.g. for physical activity), family behaviours (e.g. eating fast food at home) and modeling of healthy behavior (Ayala 2010). For Mexican families with younger children, barriers to healthy eating included permissive feeding styles, poor nutritional knowledge and lack of time. Knowledge of the health implications of obesity and healthy food choices facilitated it. Perceived barriers to physical activity included lack of time, the influence of siblings, screen viewing time, street safety and poor access to facilities (Brewis 2003; Rodríguez-Oliveros 2011).
Important Mexican cultural values are of familism and collectivism. Familism is the enduring sense of responsibility to care for one’s family. Collectivism is demonstrated by interdependence; the extended family and neighbours participate in the caregiving process (DiGirolamo 2008). Cultural values may also influence feeding practices; in one study, parents valued child fatness as a sign of health (Brewis 2003). Health and childcare advice is passed on from mothers, mothers-in-law and grandmothers. The mother is the promotor (health promoter) and ensures the health of her child by being mindful of the balance between the body, mind and soul (Gallagher 2008).
Thus the proposed intervention combines preexisting home, school and parenting programs with community-wide components to form a whole-of-community approach (Eisenmann 2008; Ayala 2010; Aburto 2011). It is based on social ecological and social cognitive models for the interplay of personal, behavioural and environmental factors to predict and influence behavior (Booth 2001; Bandura 2004).
Goals & objectives
Guided by the National Agreement for Nutritional Health, A Strategy against Obesity and Overweight, this is a community-wide intervention designed to modify key behaviours related to child obesity (Córdova-Villalobos 2010). It will embedded into the school curriculum affecting approximately 15 000 primary school children, their families and communities in Mexico (Bonvecchio 2009).
Its primary objective is to reduce the occurrence of overweight and obesity in children during the study period by:
- Decreasing consumption of energy-dense, nutrient-poor food
- Decreasing consumption of sugar-sweetened beverages
- Increasing consumption of fruit and vegetables and fibre-rich food
- Reducing screen time to less than two hours daily
- Increasing moderate to vigorous activity
Other objectives are to improve health literacy, increase community capacity and create health-enhancing environments.
A coalition of borough representatives (e.g. churches, schools, health, media, local business, organisations, key individuals) will engage the greater community to create a desired vision for the borough, develop incremental goals and implement the programs. Formative research will investigate the level of awareness of health guidelines and the beliefs, attitudes, barriers and facilitators for healthy living in parents and school-aged children. Formative evaluation will test the messaging, concepts and materials with the communities to ensure they are compelling, cultural- and age-appropriate. This approach will increase the community’s trust, ownership and improve the relevance of the intervention (Minkler 2004).
The coalition will partner with multi-sectors and levels of government to accelerate policy and environmental changes that effect the distal determinants of health e.g. fiscal policies, advertising regulations, street safety (Longjohn 2012).
Social marketing will increase the visibility and desirability of engaging in healthy lifestyles. Awareness of the intervention launch event will be raised through advertising, public relations, online and social media, with community outreach and street visibility. The event will reclaim a road from cars and will be marked with intervention flags and signage. Urban farmers will facilitate growing workshops. Approved street vendors will sell produce grown by small-scale farmers. Mothers and grandmothers will transform this produce into healthy, traditional dishes. Families will partake in physical activity e.g. cycling, dancing, soccer skills. The car-free zone can become a weekly occurrence; as time progresses, permanent walking and cycling trail projects will ensue.
Subsequent settings used in the intervention (e.g. living room, school, church halls) will be similarly marked with flags and signage to prompt desired behavior and reinforce feelings of community (Bosco 2002). Territorial markings can also announce changes in zoning outside schools and green areas.
Smaller public events and activities can be organized within walking distance from homes e.g. soccer, music lessons, art exhibitions. In return for intervention promotion, participating sports and leisure businesses will offer free trials and discounts. Organisations can collaborate with communities for neighborhood enhancing projects e.g. rooftop kitchen gardens. Shuttle buses can transport the community to neighboring sports and leisure centres.
Families will be encouraged to collaborate for private after-school activities e.g. dancing for children. A local radio station can provide dance music programming to support this activity. Initiatives can be promoted that help parents save time, money and energy with community collaboration e.g. neighborhood cooking clubs and car sharing.
Healthy traditional produce and dishes will be promoted to counter fast food marketing and instill pride in local food. It will also seek to elevate indigenous cultures, maintain history and the practice of home cooking.
Health education materials will reinforce the key messages of the national campaign Five Steps for Your Health of Move, Drink water, Eat fruits and vegetables, Measure yourself and Share your experience (Córdova-Villalobos 2010). To enable action, it will increase self-efficacy, overcome barriers and increase facilitators to healthy behavior. Access to facilities was an identified barrier to physical activity for parents of younger children (Rodríguez-Oliveros 2011). Communicating that physical activity needn’t be sports or exercise but incidental walking, dancing or playing could overcome this.
The school’s physical activity area will be refreshed with equipment and painted with activity markers. School and physical education teachers will receive professional development to enhance the delivery of the intervention. They will learn the benefits of healthy eating and active living, be trained on methods and materials and receive follow-up support. An event will introduce the school intervention to parents and children. A walking school bus can be organized. Parents will be asked to provide only water and fruit for recess. Schoolteachers will promote healthy eating, physical activity and less screen time through an interdisciplinary curriculum. Where feasible, two physical education classes will occur weekly with extra sessions at the beginning of each day. During recess, teachers will promote physical activity with activity cards with cultural- and age-appropriate ideas. Local and seasonal fruit and vegetables will feature in the curriculum, school environment and in communication to parents.
Promotoras are community health advisors who share similar ethnic, socioeconomic and geographic characteristics of the families they serve (Foltz 2012). Once trained, they will facilitate health education and social support workshops for mothers. Subjects will include nutrition, parenting style and strategies, media literacy, family behavior and modeling. For mothers unable to visit the workshops, support can be accessed online or by telephone.
Mothers will receive a monthly newsletter to guide the intervention at home. Together, the family will document their baseline practices then establish realistic and progressive goals. Next they will make environmental changes conducive to healthy behavior e.g. increase visibility of fruit and vegetables. The child will choose from a range of activities (e.g. from community events or activity cards) to swap with screen viewing time. The family will monitor their progress, earn points by accomplishing activities and be rewarded as they achieve goals. Parents will be encouraged to share their success with friends and online social networks and the child will share in school.
Promotoras will collaborate with mothers and grandmothers to facilitate cooking demonstrations at the markets and community events. She will share successful community strategies and stories through the newsletter, media, website and through social networks. Her insights will be sought from the borough coalition on challenges, enablers and solutions from the community.
The borough coalition will advocate for more healthful government trade and agricultural policies to favor local and sustainable food production. They will collaborate with organisations that train futures farmers in leadership and agro-ecological farming (e.g. UNOSJO) and provide marketing and regional distribution infrastructure. Excess produce may be sourced with a minimum price guarantee; this will counteract price volatility of international markets and cheap produce from highly subsidized U.S. farmers. The produce will then be distributed to intervention food service e.g. school canteen, government feeding programs, street vendors, cooking demonstrations, events. This will provide food security in the face of rising food prices and climate instability and anchor some of the population to rural areas (Nehring 2012).
This portfolio of programs will provide a substantially larger health gain than an individual intervention. Combined with a government mass media campaign to raise awareness, price interventions and regulation (e.g. taxing unhealthy foods, restricting food advertising, food labeling) it may also be cost-effective (Cecchini 2010).
A quasi-experimental design is most feasible to test the effectiveness of the community-wide intervention; there will be one intervention borough with two demographically matched (e.g. by size, age distribution, culture, socioeconomic status) comparison sites. A pretest and post-test will be done on the participants.
Process evaluation would measure whether the intervention was delivered as planned. This will involve measures like participation rates for coalition meetings, community events, promotora workshops and farmers’ markets. From the perspective of staff, measurements will include random compliance checks at schools or the barriers and facilitators for implementation. From a participant point of view, their perceptions, reactions and opinions of the intervention and its elements will be sought. The intervention will make iterative changes to the program in response.
Outcome evaluation will measure the short- and long-term changes resulting from the intervention. Primary outcomes measured will include activity levels, dietary intake and environment change. Secondary outcomes are weight and height, BMI and the prevalence of overweight and obesity. Other measurements include changes in self-efficacy, awareness, knowledge, attitudes and behaviors relating to diet and physical activity and a variety of parenting measures e.g. use of parenting strategies. Costs, harm, equity impacts and sustainability will also be assessed.
Aburto NJ, Fulton JE, Safdie M, Duque T, Bonvecchio A, Rivera JA. (2011). “Effect of a school-based intervention on physical activity: cluster-randomized trial.” Medicine and Science in Sports and Exercise 43(10).
Ayala GX, Elder JP, Campbell NR, Arredondo E, Baquero B, Crespo NC, Slymen DJ. (2010). “Longitudinal intervention effects on parenting of the Aventuras para Niños study.” American Journal of Preventative Medicine 38(2).
Bandura, A. (2004). “Health Promotion by Social Cognitive Means.” Health Education Behaviour 31(2).
Bonvecchio A, Margarita S, Monterrubio EA, Gust T, Villalpando S, Rivera JA. (2009). “Overweight and obesity trends in Mexican children 2 to 18 years of age from 1988 to 2006.” Salud Pública de México 51(4).
Booth SL, Sallis JF, Ritenbaugh C, Hill JO, Birch LL, Frank LD, Glanz K, Himmelgreen DA, Mudd M, Popkin BM, Rickard KA, St Jeor S, Hays NP. (2001). “Environmental and societal factors affect food choice and physical activity: rationale, influences, and leverage points.” Nutrition Reviews 59.
Bosco, FJ. (2002). “Place, space, networks, and the sustainability of collective action: the Madres de Plaza de Mayo.” Global Networks 1(4).
Brewis, A. (2003). “Biocultural aspects of obesity in young Mexican schoolchildren.” American Journal of Human Biology 15(3).
Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V, Chisholm D. (2010). “Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness.” The Lancet 376.
Clark SE, Hawkes C, Murphy SM, Hansen-Kuhn KA, Wallinga D. (2012). “Exporting obesity: US farm and trade policy and the transformation of the Mexican consumer food environment.” International Journal of Occupational and Environmental Health 18(1).
DiGirolamo AM, Salgado de Snyder N. (2008). “Women as primary caregivers in Mexico: challenges to well-being.” Salud Pública de México 50(6).
Eisenmann JC, Gentile DA, Welk GJ, Callahan R, Strickland S, Walsh M, Walsh DA. (2008). “SWITCH: rationale, design, and implementation of a community, school, and family-based intervention to modify behaviors related to childhood obesity.” BMC Public Health 8.
Foltz JL, May AL, Belay B, Nihiser AJ, Dooyema CA, Blanck HM. (2012). “Population-level intervention strategies and examples for obesity prevention in children.” Annual Review of Nutrition 32.
Gallagher MR, Gill S, Reifsnider E. (2008). “Child health promotion and protection among Mexican mothers.” Western Journal of Nursing Research 30(5).
Institutes of Medicine (2007). “Joint US-Mexico workshop on preventing obesity in children and youth of Mexican origin.” Institute of Medicine of the National Academies, the National Academies Press.
Córdova-Villalobos, JÁ. (2010). “Implementation in Mexico of the National Agreement for Nutrition and Health as a Strategy against Overweight and Obesity.” Cirugía y Cirujanos 78(2).
Jennings-Aburto N, Nava F, Bonvecchio A, Safdie M, González-Casanova I, Gust T, Rivera J. (2009). “Physical activity during the school day in public primary schools in Mexico City.” Salud Pública de México 51(2).
Longjohn M, Brownell K. (2012, March 23, 2012). “Community organising around obesity.” The Rudd Report. Retrieved September 26, 2012, from http://itunes.apple.com/nz/itunes-u/the-rudd-report/id341653648.
Lozada M, Sánchez-Castillo CP, et al. (2008). “School food in Mexican children.” Public Health Nutrition 11(9).
Minkler, M. (2004). “Community-based research partnerships: challenge and opportunities.” Journal of Urban Health 82(2).
Nehring, R. (2012). “Linking Social Protection and Agricultural Production: The Case of Mexico.” The International Policy Centre for Inclusive Growth.
Popkin, B. M. (1994). “The nutrition transition in low-income countries: an emerging crisis.” Nutrition Reviews 52(9).
Ritchie LD, Welk G, Styne D, Gerstein DE, Crawford PB. (2005). “Family Environment and Pediatric Overweight: What Is a Parent to Do?” Journal of the American Dietetic Association 105(5).
Rivera JA, Barquera S, González-Cossío T, Olaiz G, Sepúlveda J. (2004). “Nutrition transition in Mexico and in other Latin American countries.” Nutrition Reviews 62(7).
Rodríguez-Oliveros G, Haines J, Ortega-Altamirano D, Power E, Taveras EM, González-Unzaga MA, Reyes-Morales H. (2011). “Obesity determinants in Mexican preschool children: parental perceptions and practices related to feeding and physical activity.” Archives of Medical Research 42(6).
Summerbell CD, Waters E, Edmunds LD, Kelly S, Brown T, Campbell KJ. (2005). “Interventions for preventing obesity in children.” Cochrane Database System Review 3.
World Health Organisation (2003). “Diet, nutrition and the prevention of chronic diseases.” World Health Organisation Technical Report Series 916.
cc photo by SarahC73
Foreign Correspondent: Vivien Altman and Marianne Leitch, “Globesity – Fat’s New Frontier“, July 24, 2012.