Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

1 
 

ORIGINAL  RESEARCH  
 

An educational initiative for Mexican school-aged children to promote the 
consumption of fruit, vegetables and physical activity 

 
 

Luz Arenas-Monreal1, Lilian E Pacheco-Magana1, Celina Rueda-Neria1, Josue Carrillo-
Estrada1, Margarita Marquez-Serrano1, Laura Magana-Valladares2, Marta Rivera-

Pasquel3  
 

1 Centre for Research in Health Systems, National Institute of Public Health, Cuernavaca, 
México; 
 

2 Academic Secretariat, National Institute of Public Health, Cuernavaca, México; 
 

3 Centre for Research in Nutrition and Health, National Institute of Public Health, 
Cuernavaca, México.  
 

 
 
 
Corresponding author: Luz Arenas-Monreal  
Address: Ave Universidad 655 Santa María Ahuacatitlán, Cuernavaca, Morelos. México CP 
62100; 
Telephone: (777)3293000 (ext: 5223); E-mail: luz.arenas@insp.mx 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

2 
 

Abstract 
 
Aim: To present the results of a community initiative focused on strengthening physical 
activity and the consumption of fruits, vegetables and natural water while discouraging the 
use of highly energetic food and sugary drinks in public schools of Morelos. 
Methods: A quasi-experimental study with an educational initiative focused on the school 
community of two primary schools and two junior high schools. Pre- and-post initiative 
measurements were made. The study took place in the municipality of Yautepec, Morelos, 
Mexico, in a rural area and an urban area, from August 2010 to July 2011.    
Results: Water consumption among school-aged children increased from 15.1% to 20.1% 
and soda consumption decreased from 21.4% to 13.2%. A slight increase in the consumption 
of fruits and vegetables was also measured (oranges, jicamas, bananas, tomatoes, prickly pear 
pads, lettuces), that are accessible in the region. It was found that the supply of fresh food is 
limited and that high energy density foods have an oversupply in both study areas. Physical 
activity increased with actions such as football and dancing, in accordance with the baseline 
measurement. No changes were observed in the nutritional condition of school-aged children 
(n=150; 13.3% with overweight and 7.3% with emaciation), or in adults who presented a 
body mass index higher than normal, 60.2% to 88.4%. 
Conclusion: In addition to educational activities, schools need to implement strategies to 
improve the access and availability of fresh foods while limiting the access of high energy-
density foods.  
 
Keywords: diet, educational initiative, Mexico, nutritional condition, school-aged children. 
 
Conflicts of interest: None. 
 
 
 
 
  



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

3 
 

Introduction 
Currently, the number of Mexican children and adolescents with overweight and obesity 
(O/O) is a public health problem (1), which has increased in school-aged children aged from 
5 to 11 years. According to The National Nutrition Survey (ENN in Spanish) in 1999, the 
increase was of 19.5%. The National Survey of Health and Nutrition (ENSANUT in Spanish) 
in 2006 reached 26%, and the ENSANUT 2012 went up to 34.4%, representing an increase of 
over 80% (1-3). 
The “Health in the World 2002” report of the World Health Organization (WHO), has 
pointed out health risks in different continents. In Latin America, addictions, blood pressure, 
low weight, together with overweight and obesity, represent one sixth of the morbidity 
burden. In this report, different cost-effective actions are mentioned to reduce the risks, such 
as decreasing salt and saturated fats intake to diminish the risks associated with 
cardiovascular diseases. It also states that one of the priority actions is to promote healthy 
environments for children (4). 
Strategies for healthy communities and schools consider that cities, towns and schools are the 
most adequate spaces to promote healthy lifestyles for the entire population and specifically 
for school-aged children. Since children and young people are in a formative stage of life, 
schools become an ideal place for educational initiatives, so that they can incorporate 
knowledge, skills and health practices that not only circumvent risk behaviours, but improve 
health (5).  
Various studies report educational initiatives aimed at school-aged children in their 
educational atmosphere. Some of these studies focus on increasing the knowledge of school-
aged children in relation to healthy food (6,7). There are also researches about school-aged 
children’s food intake preferences, which indicate that vegetables are not the food of their 
choice (8). Other initiatives are aimed at increasing school-aged children consumption of 
fruits, vegetables and reduce the consumption of beverages and high-energy density products 
and increase physical activity (9-13). Some authors mention that in the educational initiatives 
they have carried out, they focus on the entire school community (school-aged children, 
parents and teachers) in order to obtain better results and because parents and teachers help 
shape school-aged children behaviour (9-11).  
The objective of this manuscript is to present the results of an educational initiative focused 
on strengthening physical activity and the consumption of fruits, vegetables and natural 
water, while discouraging the intake of highly energetic food and sugary drinks in the school 
community of public schools in Morelos, Mexico. 
 
Methods 
A quasi-experimental study through an educational initiative focused on the school 
community of elementary and junior high schools was implemented. Previous and post-
initiative measurements were made. The study was conducted in the municipality of 
Yautepec, Morelos, in a rural area and an urban area, from August 2010 to July 2011. We 
employed a convenience sampling (n=150 students and n=178 adults) across rural and urban 
areas, and applied a pre-post test design based on quantitative and qualitative data. The 
educational initiative was carried out with students of the 4th, 5th and 6th grades of elementary 
school, and the 1st, 2nd and 3rd grades of junior high school located within the localities. In 
addition to school-aged children, teachers, managers and administrative staff of the schools, 



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

4 
 

as well as parents were included in order to strengthen the changes proposed for school-aged 
children and make them sustainable (9-11).   
 

Tools and techniques for data collection 
 

School-aged children 
The following measurements were taken at the beginning and at the end of the study: weight 
and height using a standardized anthropometric methodology (14). The weight was measured 
with an electronic scale (Tanita brand, model 1583, Tokyo, Japan) with capacity of 140 kg 
and accuracy of 100g. Height was measured using a wooden stadiometer with capacity of 2 
meters and precision of 1 mm. The ages and dates of birth were provided by the school-aged 
children and corroborated by their teachers or mothers. Anthropometric measurements were 
taken by the research team, which was previously trained according to standard techniques 
(15). The anthropometric indicators used to assess the nutritional condition of school-aged 
children were weight/height and height/age. Length and weight data were transformed into z-
scores by using the WHO/ANTHROPLUS (16).  A cut-off of -2.0 SD was used for 
classifying children as stunted based on individual height-for-age z-scores. A cut-off of +2 
SD was used to classify children as overweight or obese, based on individual weight-for-
height- age-z-scores (BMI)-for-age, according to international standards, sex- and age-
specific.  
Questionnaires applied at the beginning and at the end of the study included (17): i) dietary 
information: Food Frequency Questionnaire (FFQ). This questionnaire was taken from the 
school-aged children section of the 2006 National Health and Nutrition Survey, which is 
validated and was applied in all the regions of Mexico. The information was obtained using a 
7-day semi-quantitative FFQ. For each food item, the number of days of intake per week, 
times-a-day, portion size (very small, small, medium, large, and very large), and number of 
portions consumed were asked. The food groups were as follows: milk and dairy, fruits, 
vegetables, sugar sweetened beverages and sugar-free beverages, water and sweets and 
candy, as well as consumption of fruits and vegetables; ii) physical activity questionnaire for 
school-aged children.  
 

Adults 
Initially, measurements of weight, height and waist and hip circumferences were made. The 
applied technique was in agreement with Lohman and Martorell and standardization was 
according to Habicht (6,7). Weight and height were measured with the same instruments used 
with school-aged children. Adults’ waist was measured at the midpoint between the lower rib 
and upper margin of the iliac crest; it was taken with a rigid tape brand “Seca” with capacity 
of 2 meters and precision of 1mm. Hip circumference was measured horizontally at the 
widest portion of the buttocks. The indicators used to assess the nutritional status of adults 
were the Body Mass Index (BMI) and waist-to-hip ratio (WHR) circumference index. The 
classification used to categorize the BMI was taken from the WHO standards (18), which 
identifies four categories: malnutrition (<18.5kg/m2) normal BMI (18.5 to 24.9kg/m2), 
overweight (25.0 to 29.9 kg/m2), and obesity (≥30.0kg/m2). The classification of the 
International Diabetes Federation was used as a reference for the waist circumferences, which 
defines as cut-off waist circumference of >80 cm for women and >90 cm for men (19). WHR 
was calculated as waist circumference divided by the hip circumference, and a WHR ≥0.90 in 
men or a WHR ≥0.85 in women was classified as that representing abdominal obesity (20). 
 



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

5 
 

Schools and communities 
In schools and communities there were carried out: i) observation guides for the ethnographic 
record; ii) guided focus-group interviews, and; iii) community mapping. 
 

  



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

6 
 

Description of educational activities 
The educational initiative was based on the Paulo Freire’s  empowerment education theory, 
which departs of the knowledge, practices and circumstances of the population involved, and 
secondly is enriched with theory (new knowledge), so that people can make changes in their 
environment later on (21-23). 
During the educational sessions with school-aged children, participatory and playful 
techniques were used to promote collective reflection. The sessions were coordinated by 
facilitators previously trained and lasted 50 minutes. Overall, 15 sessions were held once a 
week, in each of the school grades (4th, 5th and 6th grades of elementary school and 1st, 2nd and 
3rd grades of junior high school). The sessions were divided into two axes: diet and physical 
activity.  
Under the first axis, the following topics were addressed: a) the healthy eating plate (24); b) 
the importance of eating fresh fruits and vegetables; c) drinking natural water; d) the damage 
caused to the human body by high energy density foods and sugary drinks; e) personal 
commitments to increase the intake of fruits, vegetables and natural water, and; f) actions 
within their family, school and community for healthy eating.  
For the second axis, the following topics were addressed: a) the importance of physical 
activity; b) the damage caused when being sedentary; c) personal commitments to carry out 
physical activity, and; d) actions within their family, school and community to perform 
physical activity. 
School-aged children carried out a series of activities (mural newspaper, school radio, health 
fairs, community tours, poster competitions, murals, sports tournaments and races within the 
school and their community) to spread their knowledge and make practical actions, both in 
their school and in their community. 
At the end of the educational sessions, a school committee was established in each school in 
order to address nutrition and physical activity issues. It also carried out advocacy actions 
with the schools’ directors and local authorities to improve the type of food and beverages 
that are offered within the educational institutions and the community, as well as various 
other actions to promote physical activity. Workshops with parents were conducted in eight 
weekly sessions (two hours per week). With teachers and school staff, the workshops were 
held in four monthly sessions, where each session lasted five hours long. At the end of each 
workshop, the groups of parents and teachers made commitments to carry out actions aimed 
at improving diet and physical activity in various fields such as: personal, family, school and 
community. 
 

Data analysis  
 

Quantitative component: for the anthropometric analysis, anthropometric indexes based on 
the measurements of weight, height and age were used. The indicator used for children, 
adolescents and adults was the BMI. For the classification of children in various categories, 
BMI distributions were used as well as the criteria proposed by the International Obesity 
Task Force (IOTF). This system identifies specific BMI breakpoints for each age and gender. 
The Anthroplus program and the Stata v13 statistical package were used. Univariate and 
bivariate analyses were obtained from the questionnaires’ data. Measures of central tendency 
were used for numerical variables, whereas frequency distributions were used for categorical 
variables. Percentages were analyzed and described at the beginning and at the end of the 



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

7 
 

initiative. The following statistical programs were used for the analysis: Stata v13, Excel 
2007 and WinEpi.  
 

Qualitative component: systematization of community mapping, ethnographic records and 
focus groups. 
 
Results 
The analysis was performed with 159 school-aged children with complete questionnaire data: 
food intake frequency, anthropometry, socio-demographic characteristics, and physical 
activity (pre- and post-intervention). Mean age was 12.3±1.9 years. Anthropometric data 
were presented with 150 school-aged children. There were no substantial changes in the 
nutritional condition (Table 1). 
 
Table 1. School-aged children anthropometry: Body Mass Index (BMI) by community 

according to gender (percentages) 
 

 
Parameter  

 Rural Urban 
Total Men Women Men Women 

(n=150) (n=17) (n=19) (n=59) (n=55) 
Overweight    

Pre 13.3 17.7 21.1 6.8 16.4 
Post 13.3 17.7 15.8 11.9 12.7 

Obesity      
Pre 1.3 5.9 0.0 1.7 0.0 
Post 2.0 5.9 0.0 1.7 1.8 

Emaciation      
Pre 7.3 11.8 15.8 3.4 7.3 
Post 7.3 11.8 15.8 3.4 7.3 

 
The mean BMI in the pre-intervention phase was 19.4±3.8, whereas in the post-intervention 
phase it was 20.5±4.0. It was found that most of the adult population was above the normal 
range of the BMI. In the rural community (n=121), it was found that BMI was between 
60.2% (community groups) and 85% (parents) above the cut-off that is considered adequate. 
In the urban community (n=77), BMI ranged from 69.8% (community groups) and 91.7% 
(parents). The results for teachers in rural schools were: BMI above normal in 88% of them. 
In urban schools it was 57.1% above the normal BMI. 
In 87% of rural schools parents, a WHR≥0.85 was found and 90.5% of them had a >80 cm 
waist circumference. Parents in urban areas showed 83.3% WHR ≥0.85 and a >80 cm waist 
circumference (data not shown). 
 

Consumption changes of drinks, fruits, vegetables and highly energetic food 
Natural water consumption increased (not significantly) in school-aged children (from 15.1% 
to 20.1%) in a 2-4 day range per week. Soda consumption significantly decreased in school-
aged children who consumed it daily (from 21.4% to 13.2%) and significantly increased in 
those who never consumed it or did it once a week (from 8.2% to 9.4% for the first case and 
from 30.8% to 42.2% for the second case) (Table 2). 



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

8 
 

The consumption for at least once a week of some fruits and vegetables, increased regarding 
products that are common in the area, or inexpensive in certain periods of the year (jicama, 
apples, pineapples, lettuces, prickly pear pads, cucumbers, squashes and chayote). The intake 
of oranges, mangos and melons increased from once a week to 2-4 times per week. There was 
no increase in the consumption of broccoli, cauliflower, cabbage or green beans (Figures 1 
and 2). No significant gender differences were found in the consumption analysis of water, 
soda, fruits and vegetables. 
 

Table 2. Beverages’ consumption of school-aged children per community according to 
intervention phase (percentages) 

 

 
Type of beverage  

Total Rural Urban 
Pre Post Pre Post Pre Post 

(n=159) (n=38) (n=121) 
Natural water consumption per week 

Never 3.8 0.6 7.9 0.0 2.4 0.8 
1 day 13.8 10.7 21.1 7.9 11.6 11.6 
From 2 to 4 days 15.1 20.1 7.9 29.0 17.4 17.4 
From 5 to 6 days  15.1 15.7 7.9 18.4 17.4 14.9 
7 days 50.9 51.0 52.6 42.1 50.4 53.7 
Did not answer 1.3 1.9 2.6 2.6 0.8 1.6 

Soda consumption per week       
Never 8.2 9.4 2.6 10.5 9.9 9.1 
1 day 30.8 42.2 42.1 42.1 27.3 42.1 
From 2 to 4 days 30.8 23.9 34.2 34.2 29.8 20.7 
From 5 to 6 days 8.8 11.3 5.3 7.9 9.9 12.4 
7 days 21.4 13.2 15.8 5.3 23.1 15.7 

 
The frequency of fried food consumption decreased slightly (81.2% vs. 79.3%), as well as the 
intake of industrial pastries. 
 

Figure 1. School-aged children’s fruit consumption percentage per week days (n=159) 
 



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

9 
 

 
 
In schools, teachers promoted the accessibility of natural water for school-aged children, and 
also made modifications (increased the consumption of fresh food and decreased the intake of 
high energy density food) in the type of food offered to school-aged children. 
Focus groups with school-aged children reported that they increased natural water and fruits 
intake. Simultaneously, they pointed out that they decreased their sugary drinks and junk 
food intake.  
 

Figure 2. School-aged children’ vegetables consumption percentage per week days 
(n=159) 

 

 
 
In addition, drinking natural water sweetened with fruits and the absence of soft drinks was 
observed in the ethnographic record of the rural community: 

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Banana day 1 Jicama day 1 Mango day 1 Mango days 2-4

30.8
28.3

34.0

29.6

35.2
37.7 38.4

P
e
r
c
e
n
t

Fruit/days

Pre
Post

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Tomato day 1 Squash day 1 Cucumber day 1 Cucumber days 2-4

32.1 31.4

24.5

28.9

34.6 35.2

30.8
32.7

p
e
r
c
e
n
t

Vegetables/days

Pre
Post



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

10 
 

“According to what was taught, did you do any changes?” 
–“I drink more water and eat more fruits”.  
–“We hardly eat junk food now”. 
–“I barely use Valentina sauce and I add less sugar to my coffee or tea” (junior high 
school and rural elementary school focus group: 33-44). 

Differences were observed in focus groups with teachers, who reported positive changes for 
the urban elementary school and the rural junior high school:  

–“Did you notice any changes in the children?” 
–“No doubt there were changes in the children and the school in general. Although, 
as you just said, only 4th, 5th and 6th graders participated in the educational activity, 
and now the children who were in 4th grade are in 6th grade. There were changes in 
the school: we no longer sell candy or soft drinks. There has been a change in the 
food that the school offers to students because of the advices and information that you 
gave us at the beginning of this project, along with the directions that have been 
implemented by the Basic Education Institute of the State of Morelos” (urban 
elementary school teachers’ focus group). 

In community mapping exercises of all groups, it was identified that there is a limited offer of 
fresh food, fruits and vegetables in both communities, while there is an oversupply of high 
energy density food and sugary drinks. 
 

Physical activity and sedentary lifestyle 
The calculation results of the metabolic rate measurement units (MET’s) of the students were 
as follows: mild MET: mean (SD)=17.8±13.7, corresponding to cleaning, games, board 
games, chats, music, reading and working; moderate MET: 18.2±20.2 corresponding to 
games or sports with a moderate wear out (skating, gym, swimming, riding bikes or 
motorcycles); vigorous MET: 64.4±48.1 including high physical performance activities 
(soccer, basketball, dancing, running, tennis, and the like). Weekly hours dedicated to each of 
the activities were as follows: mild activities: mean (SD): 6.3±5.2 hours; moderate activities: 
3.96±5.1 hours; vigorous activities: 8.5±7.1.  
There was a significant increase in the school-aged children’s physical activity like playing 
soccer (14% vs. 27%), and dancing (3% vs. 7%), among other activities, regarding the 
baseline.  
Sedentary activities decreased: the percentage of students who did not watch movies 
increased (from 23.9% to 30.8%), or played videogames (from 40.9% to 44.0%), and the 
hours per week children used to watch movies decreased from 6 to 7 hours per week (from 
3.8% to 0.6%). 
 
Discussion 
This study fostered changes in the eating habits of school-aged children, drinking natural 
water and eating more fruits and vegetables, while diminishing sedentary activities from the 
actions taken by the educational initiative.  
There were no significant changes between the two anthropometric measurements carried out 
at the beginning and at the end of the initiative, which happens to be consistent with a study 
carried out with schoolchildren in Hawaii, who showed no significant changes between the 
measurements of BMI (25). Bayer et al. have reported similar results in a longitudinal study 



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

11 
 

in which no significant changes were obtained in the BMI (26). In a literature review of 
research carried out in Brazil, it was reported that there was an increase in the level of 
knowledge and food choices in school-aged children, but there were no changes in the 
nutritional status (27). 
It was found that parents and teachers have high percentages of O/O, similar to the 
percentage reported by ENSANUT in 2012. This aspect is relevant since it points out that one 
of the factors associated with school-aged children O/O is the high BMI of their parents (28). 
Due to the above, it is important to incorporate parents and teachers into educational 
initiatives aimed at school-aged children so that dietary changes can be sustainable. In fact, 
the incorporation of parents and teachers has been reported in several studies (9-11), and in a 
study carried out in Mexico, the integration of parents and teachers was recommended since 
the beginning of the study in order to obtain better results (29).  
The post educational initiative data showed an increase in water consumption and the 
elimination of sugary drinks at school, which is consistent with the findings of James et al. 
(30), who reported an increase in water consumption and a reduction of sugary drinks.  
Other studies have reported an increase in healthy eating knowledge but without showing any 
changes in the nutritional condition, which is similar to the results of this research (6,31), but 
differs in that school-aged children made changes in their eating habits with the intake of 
fruits, vegetables and natural water, which was the main objective of the educational 
initiative. The results obtained in our study are similar to those reported in other studies 
(9,11-13). 
Changes in the nutritional condition of school-aged children require the link between the 
educational initiative and structural social actions such as public policies addressing the type 
of food that is sold at schools and community environments, the production and manufacture 
of high-energy food and the strict regulations on food advertising aimed at this population. 
Wijesinha-Bettoni et al. have reported that, in Mexico, educational and health authorities do 
not have strategies or actions to provide vegetables and fruits to school-age children in food 
programs carried out in schools (32). 
The information gathered from the teachers’ focus groups showed that they appreciated the 
changes in school-aged children involved with the educational initiative, as well as their 
commitment and concern for school’s diet, which is similar to what Schetzina et al. have 
previously reported (33).  
Sedentary activities dropped after the initiative, which coincides with Veugelers et al. (34), 
and Lawlor et al. (11), who reported similar results in their studies.  
The limitations of this study were: the educational initiative was targeted for the 4th, 5th and 
6th graders; the implementation time was short and did not include another school for 
comparison. Other limitations of this study are related to the context of schools and 
communities, since the supply of fruits and vegetables is low in contrast to the oversupply of 
products and drinks of high energy density, and there are no spaces to perform physical 
activity. Due to the size of the population included in the study, the results cannot be 
extrapolated to other regions of the country. 
 

Conclusions 
This study shows that, although moderate, it is possible to achieve a change in behaviour with 
a specific educational initiative. This study should be expanded to increase the number of 



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

12 
 

educational sessions with school-aged children and with all members of the school 
community, to strengthen scientific evidence with diet and physical activity subjects that 
must be part of the school curriculum, to make progress on the health of this population 
group.  
Educational activities that modify school-age children’s behaviours are not enough for 
reducing overweight and obesity. The implementation of diverse and simultaneous actions is 
needed, such as an increase in the supply access and availability of fresh and healthy foods. 
This is why the promotion of policies and regulations regarding the type of food and diet at 
schools and communities is essential. 
 
References 

1. Olaiz-Fernández G, Rivera-Dommarco J, Shamah-Levy T RR, Villalpando-
Hernández S, Hernández-Ávila M, Sepúlveda-Amor J. Encuesta Nacional de Salud y 
Nutrición 2006. Cuernavaca, México: Instituto Nacional de Salud Pública; 2006 [in 
Spanish]. 

2. Rivera-Dommarco J, Shaman-Levy T, Villalpando-Hernández S, Gonzáles de Cossio 
T, Hernández-Prado B, Sepulveda J. Encuesta Nacional de Nutrición 1999. Estado 
Nutricio en niños y mujeres en México. Cuernavaca, Morelos, México: Instituto 
Nacional de Salud Pública; 2001 [in Spanish]. 

3. Gutiérrez JP, Rivera-Dommarco J, Shaman-Levy T, Villalpando-Hernández S, Franco 
A, Cuevas Nasu L, Romero-Martínez M, Hernández-Avila M. Encuesta Nacional de 
Salud y Nutrición 2012. Resultados nacionales. Cuernavaca, México: Instituto 
Nacional de Salud Pública (MX); 2013 [in Spanish].  

4. Organización Mundial de la Salud. Informe sobre la salud en el mundo. Ginebra; 
2002 [in Spanish].  

5. World Health Organization. School for health, education and development: A call for 
action. Geneva, Switzerland; 2007. 

6. Oliva RR, Tous RM, Gil BB, Longo AG, Pereira CJ, García LPP. Impacto de una 
intervención educativa breve a escolares sobre nutrición y hábitos saludables 
impartida por un profesional sanitario. Nutrición Hospitalaria 2013;28:1567-73 [in 
Spanish]. 

7. Calvo PM, Moreno P, Rodríguez AC, Abreu R, Alvarez MR, Arias A. Intervención 
educativa sobre los conocimientos de los escolares de la alimentación saludable. Hig 
Sanid Ambient 2015;15:1295-301 [in Spanish]. 

8. Sánchez GR, Reyes MH, González UMA. Preferencias alimentarias y estado de 
nutrición en niños escolares de la Ciudad de México. Bol Med Hosp Infant Mex 
2014;71:358-66 [in Spanish]. 

9. Fretes G, Salinas J, Vio F. Efecto de una intervención educativa sobre el consumo de 
frutas, verduras y pescado en familias de niños preescolares y escolares. Arch 
Latinoam Nutr 2013;63:37-45 [in Spanish]. 

10. Kipping RR, Howe LD, Jago R, Chittleborough CR, Mytton J. et al. Effect of 
intervention aimed at increasing physical activity, reducing sedentary behavior and 
increasing fruit and vegetable consumption in children: Active for life year 5 
(AFLY5) school based cluster randomized controlled trial. BMJ 2014;348:g3256. 



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

13 
 

11. Lawlor DA, Kipping RR, Anderson EL, Howe LD, Chittleborough CR, Moure-
Fernandez A, et al. Active for Life Year 5: a cluster randomised controlled trial of a 
primary school-based intervention to increase levels of physical activity, decrease 
sedentary behaviour and improve diet. Public Health Res 2016;4. DOI: 
10.3310/phr04070. 

12. Rinat RG, Durán SR, Garrido MJ, Balmaceda SH, Atalah ES. Impacto de una 
intervención en alimentación y nutrición en escolares. Rev Chil Pediatr 2013;84:634-
40 [in Spanish]. 

13. Quizán PT, Anaya BC, Esparza RJ, Orozco GME, Espinoza LA, Bolaños VAV. 
Efectividad del programa promoción de alimentación saludable en estudiantes de 
escuelas públicas del estado de Sonora. Estudios Sociales 2013;XXI:176-203 [in 
Spanish]. 

14. Lohman T, Roche A, Martorell R. Anthropometric standarization reference manual. 
Champlaign, IL:Human Kinetics; 1988. 

15. Habicht JP. Standardization of anthropometric methods in the field. PAHO Bull 1974; 
76:375-84. 

16. WHO AnthroPlus for personal computers Manual: Software for assessing growth of 
the world’s children and adolescents. Geneva: WHO; 2009. 
http://www.who.int/growthref/tools/en/ (accessed: November 15, 2010). 

17. Hernández B, Gortmaker SL. Laird NM, Colditz GA, Parra Cabrera S, Peterson KE. 
Validez y reproducibilidad de un cuestionario de actividad e inactividad física para 
escolares de la ciudad de México. Salud Publica Mex 2000;42:315-23 [in Spanish]. 

18. World Health Organization. Obesity: Preventing and managing the global epidemic, 
report of a WHO consultation. Geneva. World Health Organ Tech Rep Ser; 2000. 

19. Alberti K, Zimmet P, Shaw J. The metabolic syndrome a new worldwide definition.  
Lancet 2005;366:1059-62. 

20. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus 
and its complications. Part 1: diagnosis and classification of diabetes mellitus 
provisional report of a WHO consultation. Diabet Med 1998;15:539-53.  

21. Freire P. Pedagogía del oprimido. México: Siglo XXI Editores; 2005.  
22. Wallerstein N, Bernstein E. Empowerment education: Freire’s ideas adapted to health 

education. Health Education Quarterly 1988;15:379-94. 
23. Wallerstein N, Sanchez V, Velarde L. Freirian praxis in health education and 

community organizing. A case study of an adolescent prevention program. In: 
Minkler M. (ed) Community organizing and community building for health. New 
Jersey USA: Rutgers University Press. 2009; pp. 218-36. 

24. Secretaría de Salud. Norma Oficial Mexicana NOM-043-SSA2-2005, Servicios 
Básicos de Salud. Promoción y Educación para la Salud en materia alimentaria. 
Criterios para brindar orientación. México, DF; 2006 [in Spanish].  

25. Iversen CS, Nigg C, Titchenal A. The Impact of an Elementary After-School 
Nutrition and Physical Activity Program on Children’s Fruit and Vegetable Intake, 
Physical Activity, and Body Mass Index: Fun 5. Hawai‘I Medical Journal 
2011;70(suppl 1):37-41. 



Arenas-Monreal, Pacheco-Magana, Rueda-Neria, Carrillo-Estrada, Marquez-Serrano, Magana-Valladares, 
Rivera-Pasquel. An educational initiative for Mexican school-aged children to promote the consumption of 
fruit, vegetables and physical activity (Original research). SEEJPH 2016, posted: 30 September 2016. DOI: 
10.4119/UNIBI/SEEJPH-2016-130 

 
 
 
 

14 
 

26. Bayer O, Nehring I, Bolte G, Kries R. Fruit and vegetable consumption and BMI 
change in primary school-age children: a cohort study. Eur J Clin Nutr 2014;68:265-
70. 

27. Ramos PF, da Silva SLA, Costa RAB. Educacão alimentar e nutricional em escolares: 
uma revisão de literatura. Cad Saude Publica 2013;29:2147-61 [in Portuguese]. 

28. Doustmohammadian A, Abdollahi M, Bondarianzadeh D, Houshiarrad A, MSc, 
Abtahi M. Parental Determinants of Overweight and Obesity in Iranian Adolescents: 
A National Study. Iran J Pediatr 2012;1:35-42. 

29. Shamah-Levy T, Morales-Ruán C, Amaya-Castellanos C, Salazar-Coronel A, 
Jiménez-Aguilar A, Méndez-Gómez HI. Effectiveness of a diet and physical activity 
promotion strategy on the prevention of obesity in Mexican school children. BMC 
Public Health 2012;12:152. 

30. James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing 
consumption of carbonated drinks: cluster randomized controlled trial. BMJ 
2004;328:1-6. 

31. Lobos Fernández L, Leyton Dinamarca B, Kain Bercovich J, Vio del Río F. 
Evaluación de una intervención educativa para la prevención de la obesidad infantil 
en escuelas básicas de Chile. Nutrición Hospitalaria 2013;20:1156-64 [in Spanish]. 

32. Wijesinha-Bettoni R, Orito A, Löwik M, Mclean C, Muehlhoff E. Increasing fruit and 
vegetable consumption among schoolchildren: Efforts in middle-income countries. 
Food Nutr Bull 2013;34:75-94. 

33. Schetzina KE, Dalton WT, Lowe EF, Azzazy N, VonWerssowetz KM, Givens C, 
Stern HP. Developing a coordinated school health approach to child obesity 
prevention in rural Appalachia: results of focus groups with teachers, parents, and 
students. Rural Remote Health 2009;9:1157.  

34. Veugelers P, Fitzgerald AL. Effectiveness of School Programs in Preventing 
Childhood Obesity: A Multilevel Comparison. Am J Public Health 2005;95:432-5. 

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