1. RESULTS OF THE IMPLEMENTATION OF THE GENERAL GUIDELINES ON SCHOOL NUTRITION STANDARDS FOR FOOD AND BEVERAGES SOLD AND DISTRIBUTED IN ELEMENTARY AND SECONDARY SCHOOLS Workshop on prevention childhood obesity and school environment Aruba, June 2013

2. Content 1.Overweight and obesity in children and adolescents Current situation in Mexico 2. Strategies and actions for the prevention and care of overweight and obesity in Mexico 3.General Guidelines for Food and Beverage offered in basic education schools a.First stage qualitative evaluation b.Second stage quantitative evaluation 4.Conclusions

3. Overweight and obesity in children and adolescents (2011) In Mexico 29.3% of the total population (33 millions) are children (0 to 14 years old) (INEGI 2010) The National Survey on Health and Nutrition (ENSANUT 2012) shows that: 34.4% of children from 5 to 11 years old have excessive weight 19.8% overweight and 14.6% obesity Between 2006 and 2012 these numbers have not increased 35% of teenagers from 12 to 19 years old, present overweight or obesity. The obesity rate is higher in women (23.7%) that in men (19.6%) Between 2006 and 2012 the overweight and obesity increase in 5% -Instituto Nacional de Estadística y Geografía. Censo de población y vivienda 2010. INEGI, México 2010. -Gutiérrez JP, Rivera-Dommarco J, Shamah-Levy T, Villalpando-Hernández S, Franco A, Cuevas-Nasu L, Romero-Martinez M, Hernández- Avila M. Encuesta Nacional de Salud y Nutrición 2012. Cuernavaca, México: Instituto Nacional de Salud Publica, (MX) 2012.

4. Overweight and obesity in children and adolescents Prevalence on overweight and obesity in teenagers. ENSANUT 2012 Prevalence on overweight and obesity in children. ENSANUT 2012 MaleFemaleNational MaleFemaleNationalMaleFemaleNational ENN 1999 ENSANUT 2006ENSANUT 2012 OverweightObesity Male FemaleNational Male FemaleNational OverweightObesity ENSANUT 2006ENSANUT 2012

5. Causes Physical activity. ENSANUT 2012 More than half of children between 10 and 14 years old have not carried out any formal physical activity, in the last 12 months previous to the survey. Only 33% of surveyed children stay less than two hours (maximum recommended time) in front of the screens. School diet Several studies have indicated that the Mexican students consume an average of 433 calories in the school snack, with a change in the consumption pattern: Children 1 to 4 years old increased calories intake from 165 to 297 kcal. Students 5 to 11 years old increased calories intake from 190 to 343 kcal. Energy average allowance of lunch must be of 17.5% of total energy: Pre-school 227 kcal +/-5% Primary school 276 kcal +/-5% Secondary school 382 kcal +/-5% Rivera-Dommarco J, et al. El estado nutricional de la población de México: cambios en magnitud, distribución y tendencias de la mala nutrición de 1988 a 2006. Salud Pública Mex; 2008; 49, 267-269.

6. As an answer of Mexico’s government, the Ministry of Health, started the National Agreement for Nutritional Health: Strategy against overweight and obesity (ANSA), January 2010. Both government and society must act to combat the epidemic of obesity National policies should encourage and provide opportunities for increased physical activity and improve the availability and accessibility of healthy foods The severity of the problem calls for the participation and responsibility of different government sectors, civil society, private sector as well as individuals and families. Strategies and actions for overweight and obesity prevention in Mexico

7. Strategies and actions in school setting School as important setting to promote healthy nutrition and physical activity habits Action Plan for Schools Health Promotion and Education Regular physical activity Availability and access to healthy food and beverages in schools Action Plan for Schools Health Promotion and Education Regular physical activity Availability and access to healthy food and beverages in schools Guidelines on Nutrition Standards for Foods and Beverages offered in Schools

8. Implementation of guidelines Gradually, (by school years) to allow a sustained and continuous change, enabling acceptance and adjustment of all actors Energy per portion <= 140 kcal Total fats <= ≤ 40% Energy per portion < = 130 kcal Total fats <= ≤ 40% Reduction of sugar, saturated and trans fats, sodium and fiber Energy per portion <= 130 kcal Total fats <= ≤ 35% More reduction of sugar, saturated and trans fats and sodium Stage I (School year 2010-2011). Stage II (School year 2011- 2012) Stage III (Starting from school year 2012)

9. Closure of stage II

10. Guidelines criteria Food category Prepared food Beverages Liquid foods Milk Yogurt and fermented liquid food Fruit and vegetable juices Soybean liquid food Snacks Included cheeses for lunch Cookies, candies and desserts Oleaginous and legumes as snack General Criteria Average energy requirement for pre, elementary and secondary school Maximum amount of calories and macronutriments recommended for school snack Combination of food for correct diet, according to NOM-043-SSA2-2012, Promotion and Education for nutritional health. Daily consumption: 1) Vegetables and fruits, 2) Plain water, 3) Prepared food Recommendations for school snack Energy Value 15% to 20% (17.5% average) 25-30% fats, 55-60% carbohidrates, 10-15% protein Saturated fats <10%, trans fat <1%, Added sugars <10%, salt < 5g To include daily: One or more portions of vegetables and fruits One portion of prepared food according to nutritional criteria Plain water Twice a week: one portion ok semi or skimmed milk or yogurt, fermented dairy products, juices non caloric sweeteners free Once a week: salty snacks, cookies, candies and desserts that fulfill the nutritional criteria

11. Objective To identified the main factors that facilitate or obstruct the application of the nutritional guidelines Methodology Semi-structured face-to-face interviews 1.School principals 2.Parents 3.Members of Social Participation School Councils 4.Persons-in-charge of the school store 5.Primary and secondary school students First qualitative evaluation

12. Main results Most of the members of the educational community (teachers, parents and students) knew about the general guidelines (77.14%). 75.46% of school vendors fulfilled the general guidelines. The same beverages were offered in pre, primary and secondary schools. There was some resistance from parents used to sending a school snack with a high energy content and sugared beverages.

13. Objective To have the information concerning the application of the general guidelines in the second stage and to identify the factors which support or hinder its fulfillment Methodology National representative sample of 172 schools (122 elementary and 50 secondary) From June 11th to 29th, 2012 The surveys included school principals and teachers, members of the School Store Committee, parents, students and school vendors. Information was obtained concerning: Knowledge about guidelines Perception of change at schools according to several actors Food and beverages sold at school School snack Consumption of plain water Physical activation Educational materials Perception of obstacles and facilitators for the application of the guidelines Second stage evaluation

14. Knowledge about guidelines 90% of teachers and principals and 85% of the members of the committee knew them 60% of parents identified the guidelines as a measure against overweight and obesity Healthy school snack The actors recognized the sale of vegetables and fruit and a healthy lunch as the main criteria which define the guidelines 40% in elementary and 60% in secondary schools also identify drinking plain water as part of a healthy snack Perception of changes in the schools according to different actors 85% of all actors observed a favorable change in the sale of food in both levels and 45% and 55% in the sale of beverages 65% of school vendors in elementary schools and 75% in secondary schools mentioned that they have made changes in the preparation and in the foods they offer Second stage of the guidelines RESULTS

15. Reasons which help to the creation of guidelines for distribution of food and beverages at schools (elementary) PrincipalsCECE CIAFTeachers Parents Overweight / Obesity Diabetes Wide availability of high- calorie foods

16. Reasons which help to the creation of guidelines for distribution of food and beverages at schools (secondary) PrincipalsCECE CIAFTeachers Parents Overweight / Obesity Diabetes Wide availability of high- calorie foods

17. Second stage evaluation RESULTS FoodelementarySecondary Cookies and candies26.1%34.1% Non fried preparations19.2%20.9% Sugared beverages7.4%7.8% Fruits and vegetables11%6.1% Fried preparations10.2%5% Food and beverages sold in the school

18. Foods that the students refered they buy at school (stage II) RESULTS Cereal bars Salty Snacks Sweet Snacks Fried food or fast food Not fried food Milk/Yogurt Sugary beverages or soda Plain water Fruit or vegetable SecundaryElementary School

19. Content of school lunch referred by parents and observed in the student’s lunchbox (elementary) RESULTS Fruit or Vegetable Not fried food Plain water Milk / Yogurt Sugary beverages or soda Fried food or fast food Cereal Bars Sweet snack ParentsStudent's lunchbox

20. Content of school lunch referred by parents and observed in the students’ lunchbox (secondary) RESULTS Fruit or Vegetable Not fried foods Drinking water Milk / Yogurt Sugary drink or soda Fried food or fast food Cereal Bars Sweet snack ParentsStudent's lunchbox

21. Access and availability of plain water 72.9% in elementary schools and 62% in secondaries have any source of drinking plein water. There are 1.4 drinking fountain in function for each 100 children. Water supplyelementarySecondary Water sprue42.8%37.1% Carrafs in common areas21.815% Carrafs in classrooms32%8.7% Second stage of the guidelines RESULTS

22. Physical activation In 38% of elementary schools and 19% of the secondaries was observed physical activity the day of the visit with a duration of 14 minutes Second stage of the guidelines RESULTS Average duration of AF (min) 14.4±7.814.2±8.6 12.0±4.015.6±8.6 Elementary School Secondary With at least one period of physical activity At the start of the school dayAnother time

23. Educative Material for the application of the guidelines About 70% of the vendors and 65% of the CECE have them. 20% of the parents and 7% of the teachers have this material Second stage of the guidelines RESULTS Vendors TeachersParents Food Committee Physical activity committee Elementary School Secondary

24. Educational materials

25. Obstacles and facilitators percieved for the application of the guidelines 70% of the school members and 65% of parents agree that the guidelines have been fulfilled. Main obstacles: Family habits which are not very healthy The lack of interest of parents The preferences of students for food with a high content of sugar, fat and sodium The lack of information about the guidelines Main facilitators: Principal’s leadership Teachers’participation Parents’support Second stage of the guidelines RESULTS

26. Benefits of general guidelines in health and nutrition The guidelines benefit about 18 million students  11 954 867 from 65 739 elementary school  5 138 075 from 28 316 secondaries  TOTAL CHILDREN: 17 092 942 With the participation of :  64 092 principals  764 949 teachers  TOTAL SCHOOL COMMUNITY : 828 041 Source: Census of the Ministry of Education. Academic year 2001/12 OF

27. Conclusions During these evaluations we can observe the following: In the first stage there was resistance from the vendors because they didn’t have the educational materials and there is also a lack of cooperation from the parents. In the second stage there is more participation of all actors, the vendors had the educational material, they agreed to follow the guidelines because they knew them and parents take into consideration the guidelines to prepare the lunch of their chidren.

28. Challenges of the guidelines To put emphazis in students and teachers about the importance of physical activity, by means of educative campaigns which underline their benefits. To increase the participation of parents for motivating physical activity. To intensify the supervision of sale of food and beverages by the committees and principals

29. http://www.insp.mx/alimentosescolares/

30. LNCA. Zaira Valderrama Álvarez Nutrition Coordinator Mexico Ministry of Health zaira.valderrama@salud.gob.mx zaira.valderrama@salud.gob.mx