ABSTRACT

Objectives.

Mexico’s 2018 Report Card evaluates the opportunities available for Mexican children and youth to reach healthy levels of physical activity, sleep, and sedentary behavior.

Methods.

The Report Card is a surveillance system that gathers data from national surveys, censuses, government documents, websites, grey literature, and published studies to evaluate 16 indicators in four categories: Daily Behaviors; Physical Fitness; Settings and Sources of Influence; and Strategies and Investments. Data were compared to established benchmarks. Each indicator was assigned a grade from 1 – 10 (< 6 is a failing grade) or “incomplete” if data was insufficient/unavailable.

Results.

Daily Behavior grades were: Overall Physical Activity, 4; Organized Sport Participation, 5; Active Play, 3; Active Transportation, 5; Sleep, 7; and Sedentary Behavior, 3. Physical Fitness, received a 7. Settings and Sources of Influence grades were: Family and Peers, incomplete; School, 3; and Community and Environment, 4. Strategies and Investments were: Government Strategies, 6; and Non-Government Organizations, 2.

Conclusion.

Low grades in 11 of the 16 indicators indicate that schools, families, communities, and government need to work together to improve physical activity opportunities for children and youth in Mexico.

Keywords
Physical fitness; child health; youth sports; health behavior; public health surveillance; health promotion; Mexico

RESUMEN

Objetivos.

El boletín de notas de México correspondiente al 2018 evalúa las oportunidades a disposición de la población infantil y joven mexicana para que puedan desarrollar niveles adecuados de actividad física y sueño, y disminuyan el sedentarismo.

Métodos.

El boletín es un sistema de vigilancia que recopila los datos obtenidos en las encuestas nacionales, censos, documentos gubernamentales, sitios web, literatura gris y estudios publicados con respecto al análisis de 16 indicadores en 4 categorías: comportamientos diarios, estado físico, entornos y fuentes influyentes, y estrategias e inversión. Los datos fueron cotejados con los puntos de referencia establecidos. A cada indicador se le asignó una calificación entre 1 y 10 (< 6 significa reprobado) o fue marcado como “incompleto” si los datos eran nulos o insuficientes.

Resultados.

Las calificaciones obtenidas para los comportamientos diarios fueron: actividad física en general: 4; participación en actividades deportivas organizadas: 5; juego activo: 3; modalidades de transporte activas: 5; sueño: 7; y sedentarismo: 3. El estado físico obtuvo un 7. Las calificaciones para los entornos y fuentes influyentes fueron: familiares y pares: “incompleto”; escuela: 3; comunidad y entorno: 4. Para las estrategias e inversión: estrategias gubernamentales: 6; entidades no gubernamentales: 2.

Conclusiones.

Las bajas calificaciones obtenidas en 11 de los 16 indicadores demuestran que las escuelas, las familias, las comunidades y el gobierno tienen que aunar esfuerzos para mejorar las oportunidades que tiene la población infantil y joven en México para desarrollar niveles de actividad física satisfactorios.

Palabras clave
Aptitud física; salud del niño; deportes juveniles; conductas relacionadas con la salud; vigilancia en salud pública; promoción de la salud; México

RESUMO

Objetivos.

O Report Card de 2018 para o México avalia as oportunidades disponíveis para que crianças e jovens mexicanos atinjam níveis adequados de atividade física, sono e comportamento sedentário.

Métodos.

O Report Card é um sistema de vigilância que reúne dados de pesquisas nacionais, censos, documentos governamentais, websites, literatura cinzenta e estudos publicados para avaliar 16 indicadores em quatro categorias: Comportamentos Diários, Forma Física, Ambientes e Influências, e Estratégias e Investimentos. Os dados foram comparados com indicadores de referência estabelecidos. A cada indicador foi atribuída uma pontuação de 1 a 10 (pontuações abaixo de 6 indicam reprovação) ou "incompleta" se os dados fossem insuficientes/indisponíveis.

Resultados.

As pontuações para o Comportamento Diário foram as seguintes: atividade física geral: 4; participação em esportes organizados: 5; brincadeiras ativas: 3; transporte ativo: 5; sono: 7; comportamento sedentário: 3. A pontuação para a Forma Física foi de 7. As pontuações para Ambientes e Influências foram: família e amigos, incompleta; escola: 3; comunidade e ambiente: 4. As pontuações para Estratégias e Investimentos foram: estratégias governamentais: 6; organizações não-governamentais: 2.

Conclusão.

As pontuações baixas em 11 dos 16 indicadores indicam que as escolas, famílias, comunidades e o governo precisam trabalhar juntos para oferecer mais oportunidades de atividade física às crianças e jovens no México.

Palavras-chave
Aptidão física; saúde da criança; esportes juvenis; comportamentos relacionados com a saúde; vigilância em saúde pública; promoção da saúde; México

Movement behaviors, namely physical activity, sleep, active play, and sedentary behavior are strong independent factors influencing children’s health (¹1. Tremblay M, Carson V, Chaput J-P, Connor Gorber S, Thy Dinh, Duggan M, et al. Canadian 24-Hour Movement Guidelines for Children and Youth: An Integration of Physical Activity, Sedentary Behavior, and Sleep.Appl Physiol Nutr Metab. 2016;41(6 Suppl 3):S311–S327. doi:10.1139/apnm-2016-0151
https://doi.org/10.1139/apnm-2016-0151... ). Evidence-based guidelines recommend children 5 – 17 years of age accumulate 60 minutes of moderate to vigorous physical activity (MVPA) every day (²2. World Health Organization. Global recommendations on physical activity for health [Internet]. Geneva: WHO; 2010 [cited 2018 June]. Available from: https://www.who.int/dietphysicalactivity/publications/9789241599979/en/.
https://www.who.int/dietphysicalactivity... ), spend no more than 2 hours per day in recreational screen time, sleep 8 – 11 hours per night, and spend several hours engaged in a variety of structured and unstructured light physical activities (¹1. Tremblay M, Carson V, Chaput J-P, Connor Gorber S, Thy Dinh, Duggan M, et al. Canadian 24-Hour Movement Guidelines for Children and Youth: An Integration of Physical Activity, Sedentary Behavior, and Sleep.Appl Physiol Nutr Metab. 2016;41(6 Suppl 3):S311–S327. doi:10.1139/apnm-2016-0151
https://doi.org/10.1139/apnm-2016-0151... ). More than 40% of Mexican children do not meet these recommendations, and this shortfall may contribute to the rising prevalence of obesity and cardio-metabolic disorders observed in this population (³3. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 [Internet]. México: INSP; 2016 [cited 2018 May 21]. Available from: https://www.insp.mx/avisos/4576-resultados-ensanut-mc-2016.html.
https://www.insp.mx/avisos/4576-resultad... ). Since adequate levels of physical activity, sleep, and sedentary behavior are associated with lower adiposity and better cardio-metabolic health (⁴4. Hamilton MT, Hamilton DG, Zderic TW. Role of low energy expenditure and sitting in obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease. Diabetes. 2007;56(11):2655. doi:10.2337/db07-0882
https://doi.org/10.2337/db07-0882... ), implementing strategies to improve these behaviors in Mexico is imperative.

Mexico’s Report Card on Physical Activity for Children and Youth aims to evaluate opportunities available for the country’s children and youth to engage in health-enhancing movement behaviors. It is framed on an ecological perspective that considers how sociocultural and physical environmental factors and their interactions affect an individual’s behavior (⁵5. Sallis JF, Cervero RB, Ascher W, Henderson KA, Kraft MK, Kerr J. An ecological approach to creating active living communities. Annu Rev Public Health. 2006;27:297–322. doi:10.1146/annurev.publhealth.27.021405.102100
https://doi.org/10.1146/annurev.publheal... ). The Report Card is part of the Global Matrix 3.0, a global surveillance system across 49 countries, including Mexico (⁶6. Aubert S, Barnes JD, Abdeta C, Abi Nader P, Adeniyi AF, Aguilar-Farias N, et al. Global Matrix 3.0 Physical Activity Report Card Grades for Children and Youth: Results and Analysis From 49 Countries. J Phys Act Health. 2018;15(S2):S251-S73. doi:10.1123/jpah.2018-0472
https://doi.org/10.1123/jpah.2018-0472... ). An abstract summarizing Mexico’s grades for 11 indicators reported in the Global Matrix 3.0 has been published elsewhere (⁷7. Galaviz KI, Argumedo G, Gaytan-González A, González-Casanova I, González Villalobos MF, Jáuregui A, et al. Results from Mexico’s 2018 Report Card on Physical Activity for Children and Youth. J Phys Act Health. 2018;15(S2):S384-S5. doi:10.1123/jpah.2018-0462
https://doi.org/10.1123/jpah.2018-0462... ). The purpose of this paper is to provide a full report of the 16 indicators in Mexico’s 2018 Report Card—11 Global Matrix indicators and five additional indicators. This full report identifies potential strategies to improve physical activity opportunities for Mexican children and youth.

MATERIALS AND METHODS

The Report Card is a surveillance system that uses secondary data to monitor physical activity levels in and opportunities for children. The study was conducted through three main steps: (i) identify data sources for each indicator; (ii) compare the data to established benchmarks; and (iii) assign a grade to every indicator. Grades are assigned by a panel of researchers, government and health care practitioners, and public health experts.

Mexico’s 2018 Report Card has 16 indicators grouped into four categories: I. Daily Behaviors (Overall Physical Activity, Organized Sports and Physical Activity Participation, Active Play, Active Transportation, Sedentary Behavior, and Sleep); II. Physical Fitness (Cardiorespiratory Fitness, Body Composition, Flexibility, Muscle Fitness, and Muscle Strength); III. Settings and Sources of Influence (Family and Peers, School, Community, and Environment); and IV. Strategies and Investments (Government and Non-Government Organizations).

The main sources of information consulted were the National Health and Nutrition Survey 2016 (ENSANUT), national census, and reports (³3. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 [Internet]. México: INSP; 2016 [cited 2018 May 21]. Available from: https://www.insp.mx/avisos/4576-resultados-ensanut-mc-2016.html.
https://www.insp.mx/avisos/4576-resultad... , ⁸8. Instituto Nacional de Estadística y Geografía. Encuesta intercensal [Internet]. 2015 [cited 2018 May 24]. México. Available from: https://www.inegi.org.mx/programas/intercensal/2015/.
https://www.inegi.org.mx/programas/inter... – ¹¹11. Secretaría de Educación Pública [Internet]. Informe sectorial 1: Educación Física y Deporte en el Sistema Educativo. 2015 [cited 2018 May 20]. Available from: http://www.dgb.sep.gob.mx/acciones-y-programas/ESDM/Informes_Sectoriales/1_Edu_Fisica_Deporte_universitario.pdf.
http://www.dgb.sep.gob.mx/acciones-y-pro... ). Information was also obtained from websites, grey literature, and studies published in 2013 – 2017 that reported data on children and youth from 1 – 17 years of age. These were identified in Academic Search Complete, EBSCO host, Web of Science, Medline, SCIELO, Cochrane México, and Biblioteca Virtual en Salud databases (Table 1). Grades were assigned according to the proportion of children and youth meeting the established benchmarks developed for the Global Matrix (⁶6. Aubert S, Barnes JD, Abdeta C, Abi Nader P, Adeniyi AF, Aguilar-Farias N, et al. Global Matrix 3.0 Physical Activity Report Card Grades for Children and Youth: Results and Analysis From 49 Countries. J Phys Act Health. 2018;15(S2):S251-S73. doi:10.1123/jpah.2018-0472
https://doi.org/10.1123/jpah.2018-0472... ). The criteria for grade assignment are shown in Table 2. Grades < 6 represent failing grades. An “incomplete” grade was assigned when data was insufficient/unavailable for the indicator. For grade assignment, national data took precedence over regional data—to better capture how the country was doing as a whole. Objectively-measured data took precedence over self-reported data, and age and gender disparities were considered.

RESULTS

Grades for the 2018 Report Card and for previous years are presented in Table 2.

I. Daily Behaviors

Overall Physical Activity: 4.

According to ENSANUT 2016 (¹²12. Medina C, Jauregui A, Campos-Nonato I, Barquera S. Prevalence and trends of physical activity in children and adolescents: results of the Ensanut 2012 and Ensanut MC 2016. Salud Publica Mex. 2018;60(3):263-71. doi:10.21149/8819
https://doi.org/10.21149/8819... ), although 60.5% of youth (15 – 19 years of age) accumulate the recommended 60 minutes of MVPA per day, only 17.2% of children 10 – 14 years of age (an age category included for the first time) do the same. ENSANUT also reveals a higher prevalence of physical activity in 10 – 14-year-old boys (21.8%) than girls (12.7%), and in 15 – 19-year-old boys (69.9%) than girls (51.2%). National data for children less than 10 years of age were not available. Only regional accelerometry (¹³13. Ayala-Guzmán CI, Ramos-Ibánez N, Ortiz-Hernández L. Accelerometry does not match with self-reported physical activity and sedentary behaviors in Mexican children. Bol Med Hosp Infant Mex. 2017;74(4):272-81. doi:10.1016/j.bmhimx.2017.02.006.
https://doi.org/10.1016/j.bmhimx.2017.02... ) and questionnaire data (¹⁴14. Trujillo Becerra LB, Nabor Chávez L, Patricia García O, Aracely Anaya-Loyola M. Obesity in Mexican preschooler is associated to low physical activity and diet imbalance. Faseb Journal. 2013;27.) were found, both showing low levels of physical activity for those less than 10 years of age. Considering this, a grade of 4 was assigned to this indicator.

Organized Sports and Physical Activity Participation: 5.

Data from ENSANUT 2016 (¹²12. Medina C, Jauregui A, Campos-Nonato I, Barquera S. Prevalence and trends of physical activity in children and adolescents: results of the Ensanut 2012 and Ensanut MC 2016. Salud Publica Mex. 2018;60(3):263-71. doi:10.21149/8819
https://doi.org/10.21149/8819... ) show 48.6% of children (10 – 14 years of age) participated in one or more organized sports during the previous 12 months. The National Index of Youth Participation shows a similar proportion of youth (15 – 19 years of age) engaging in sports, a higher proportion still in rural areas (¹⁵15. Robles G, Ramírez S, Crivelli M, Barbosa J. Índice Nacional de participación juvenil 2015-2016. México D.F. México ; 2016.). This index also shows that sports participation was 4^th among activities to perform in spare time (¹⁵15. Robles G, Ramírez S, Crivelli M, Barbosa J. Índice Nacional de participación juvenil 2015-2016. México D.F. México ; 2016.). Reports from the National Commission on Physical Culture and Sports (¹⁶16. Comisión Nacional de Cultura Física y Deporte [Internet]. Juegos Nacionales de Educación Media Superior 2017. 2017 [cited 2018 Feb 28]. Available from: http://conadems2017.conade.gob.mx/BusquedaParticipante.aspx?IDEvento=62.
http://conadems2017.conade.gob.mx/Busque... , ¹⁷17. Comisión Nacional de Cultura Física y Deporte [Internet]. Resultados Olimpiada Nacional y Juvenil 2017 [cited 2018 Feb 28]. 2017. Available from: http://olimpiadanacional2017.conade.gob.mx/ResultadosOlimpiada.aspx.
http://olimpiadanacional2017.conade.gob.... ) show a decrease in sports participation by children and youth from 2016 – 2017. Thus, a grade of 5 was assigned to this indicator.

Active Play: 3.

Because national data on active play is lacking, to obtain a grade for this indicator, published studies reporting regional data were reviewed. A study conducted in Tlaltizapan, Morelos, of 236 children from 9 – 12 years of age found that average, self-reported time spent on active play was 1.8 – 2.3 hours per day (¹⁸18. Palos-Lucio G, Flores M, Rivera-Pasquel M, Salgado-de-Snyder VN, Monterrubio E, Henao S, et al. Association between migration and physical activity of school-age children left behind in rural Mexico. Int J Public Health. 2015;60(1):49-58.). A study in Mexico City (¹⁹19. Martínez-Andrade GO, Cespedes EM, Rifas-Shiman SL, Romero-Quechol G, González-Unzaga MA, Benítez-Trejo MA, et al. Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City. BMC Pediatr. 2014;14(1).) reported that children from 2 – 5 years of age spend 3.9 hours per day in active play. A study in Chihuahua, Mexico (²⁰20. De la Torre-Diaz MdL, Cervantes-Borunda M, Cabanas MD, Benítez-Hernández ZP, López-Ejeda N, Marrodán MD, et al. Food and physical activity differences in mestizos and Tarahumara schoolchildren from Chihuahua city (Mexico). Nutrición Clínica Y Dietética Hospitalaria. 2014;34(2):80-7.), found that among Tarahumara indigenous groups (n = 50), 45% of schoolchildren from 6 – 14 years of age spend 4 or more hours in active play per week, and among the Mestizo (n = 61), 27%. A multi-city study of 1 509 children from 6 – 11 years of age reported that 76% engage in outdoor play on at least one day per week (²¹21. Lee RE, Soltero EG, Jáuregui A, Mama SK, Barquera S, Jáuregui E, et al. Disentangling Associations of Neighborhood Street Scale Elements with Physical Activity in Mexican School Children. Environ Behav. 2016;48(1):150-71.). Collectively, these studies indicate that Mexican children spend few hours per day engaging in active play (between 2 – 4 hours/ day), earning this indicator a grade of 3.

Active Transportation: 5.

Mexico’s National Institute of Statistics and Geography reports that 54.8% of children over 3 years of age walk to school, while 1.5% ride a bicycle (⁸8. Instituto Nacional de Estadística y Geografía. Encuesta intercensal [Internet]. 2015 [cited 2018 May 24]. México. Available from: https://www.inegi.org.mx/programas/intercensal/2015/.
https://www.inegi.org.mx/programas/inter... ). According to ENSANUT 2016 (¹²12. Medina C, Jauregui A, Campos-Nonato I, Barquera S. Prevalence and trends of physical activity in children and adolescents: results of the Ensanut 2012 and Ensanut MC 2016. Salud Publica Mex. 2018;60(3):263-71. doi:10.21149/8819
https://doi.org/10.21149/8819... ), among children 10 – 14 years of age, 69% have an active commute to/from school. In a study of 213 children 10 – 14 years of age in Mexico City (²²22. Yarabetzy Pantoja I, Sandoval X, Osvaldo Talavera J, Perez M. Physical Activity and Inactivity and its Association with Overweight and Obesity on Children and Adolescents between 10 to 14 Years Old. Faseb J. 2016;30.), 54.5% of girls and 69.1% of boys use inactive transportation to school. Since only one-half of Mexican children are active in their commute to/from school, this indicator received a grade of 5.

Sedentary Behavior: 3.

Data from ENSANUT 2016 (³3. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 [Internet]. México: INSP; 2016 [cited 2018 May 21]. Available from: https://www.insp.mx/avisos/4576-resultados-ensanut-mc-2016.html.
https://www.insp.mx/avisos/4576-resultad... ) show that 22.7% of children (10 – 14 years) and 21.4% of youth (15 – 19 years) spend 2 hours or less per day in front of a screen (³3. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 [Internet]. México: INSP; 2016 [cited 2018 May 21]. Available from: https://www.insp.mx/avisos/4576-resultados-ensanut-mc-2016.html.
https://www.insp.mx/avisos/4576-resultad... ). Among the children, more girls (24.4%) than boys (21.0%) met the screen time recommendation, while among the youth, more boys (25.3%) than girls (17.4%) met it. ENSANUT shows more screen time in urban areas than in rural ones, and in children with obesity than in those with normal weight. Higher screen time was also seen in northern parts of Mexico and among children of higher socioeconomic groups (³3. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 [Internet]. México: INSP; 2016 [cited 2018 May 21]. Available from: https://www.insp.mx/avisos/4576-resultados-ensanut-mc-2016.html.
https://www.insp.mx/avisos/4576-resultad... ). Hence, a grade of 3 was assigned.

Regarding other age groups, a study of 365 mothers in a northern city (²³23. Diaz-Ramirez G, Jimenez-Cruz A, Souto-Gallardo MD, Bacardi-Gascon M. Effect of the Exposure to TV Food Advertisements on the Consumption of Foods by Mothers and Children. J Pediatr Gastroenterol Nutr. 2013;56(1):86-8.) reported that 75% of their children (8 months – 5 years of age) watch television for 1.9 – 2.5 hours per day (²³23. Diaz-Ramirez G, Jimenez-Cruz A, Souto-Gallardo MD, Bacardi-Gascon M. Effect of the Exposure to TV Food Advertisements on the Consumption of Foods by Mothers and Children. J Pediatr Gastroenterol Nutr. 2013;56(1):86-8.). Other studies found that children 6 – 12 years of age (n = 60) spend an average of 1.6 hours (²⁴24. González Devia LJ, Monroy Romero PA, Almonacid Urrego CC, Orjuela OL, Huérfano MJ, Mendieta Zerón H. Comparative study of risk factors related to cardiovascular disease in children from Bogotá, Colombia and Toluca, Mexico. Revista de la Facultad de Ciencias Médicas (Córdoba, Argentina). 2014;71(2):98-105.) and 10-year-olds spend 2.7 hours per day watching television (²⁵25. López-Barron RG, Jiménez-Cruz A, Bacardi-Gascon M. Modifiable environmental obesity risk factors among elementary school children in a Mexico-us border city. Nutr Hosp. 2015;31(5):2047-53.). Among 881 undergraduate students (17 – 19 years of age), a study found that 46.8% spend 2 hours or less in front of a screen (²⁶26. Hidalgo-Rasmussen CA, Ramírez-López G, Hidalgo-San Martín A. Physical activity, sedentary behavior and quality of life in undergraduate adolescents of Ciudad Guzman, State of Jalisco, Mexico. Cienc Saude Coletiva. 2013;18(7):1943-52.). Only one study used accelerometers (²⁷27. Medina C, Barquera S, Katzmarzyk PT, Janssen I. Physical activity during recess among 13-14 year old Mexican girls. BMC Pediatr. 2015;15:17.); it found that girls at a private school in Mexico City spent 73.4% of their time awake engaged in sedentary activities (²⁷27. Medina C, Barquera S, Katzmarzyk PT, Janssen I. Physical activity during recess among 13-14 year old Mexican girls. BMC Pediatr. 2015;15:17.).

Sleep: 7.

Data from ENSANUT 2016 (³3. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 [Internet]. México: INSP; 2016 [cited 2018 May 21]. Available from: https://www.insp.mx/avisos/4576-resultados-ensanut-mc-2016.html.
https://www.insp.mx/avisos/4576-resultad... ) show that 91% of children from 10 – 14 years of age slept 9 hours or more per night. More girls (95%) than boys (87%) met the sleep recommendation for this age group. Girls slept an average of 10.1 hours, and boys, an average of 9.6 hours/night. Among 15 – 17-year-olds, 65% were sleeping at least 8 hours/night. More girls (68%) than boys (62%) met the sleep recommendations. In this age group, girls slept 7.5 hours/night on average, and boys, 7.4 hours (³3. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 [Internet]. México: INSP; 2016 [cited 2018 May 21]. Available from: https://www.insp.mx/avisos/4576-resultados-ensanut-mc-2016.html.
https://www.insp.mx/avisos/4576-resultad... ). Based on these national data, this indicator received a grade of 7.

II. Physical Fitness

Four indicators in this group--Cardiorespiratory Fitness, Flexibility, Muscle Fitness, and Muscle Strength—were not assigned a grade (see Discussion).

Body Composition: 7.

ENSANUT 2016 (³3. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 [Internet]. México: INSP; 2016 [cited 2018 May 21]. Available from: https://www.insp.mx/avisos/4576-resultados-ensanut-mc-2016.html.
https://www.insp.mx/avisos/4576-resultad... ) data show that 66.8% of 5 – 11-year-olds have a healthy Body Mass Index (BMI) for their age; the proportion was similar for boys (66.3%) and girls (67.2%). Among those 12 – 19 years of age, 63.7% have a healthy BMI for their age, with more boys (66.5%) than girls (60.8%) falling in the normal category (³3. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 [Internet]. México: INSP; 2016 [cited 2018 May 21]. Available from: https://www.insp.mx/avisos/4576-resultados-ensanut-mc-2016.html.
https://www.insp.mx/avisos/4576-resultad... ). Based on this, a grade of 7 was assigned to this indicator.

III. Sources of Influence

Family and Peers: Incomplete.

Data on the influence of family and peers on the physical activity of Mexican children and youth are lacking. Hence, an “incomplete” grade was assigned.

School: 3.

A report by the Ministry of Education shows 36.3% of school-aged children in public schools receive 1 hour of physical education (PE) per week (¹¹11. Secretaría de Educación Pública [Internet]. Informe sectorial 1: Educación Física y Deporte en el Sistema Educativo. 2015 [cited 2018 May 20]. Available from: http://www.dgb.sep.gob.mx/acciones-y-programas/ESDM/Informes_Sectoriales/1_Edu_Fisica_Deporte_universitario.pdf.
http://www.dgb.sep.gob.mx/acciones-y-pro... ). Data from the 2013 Basic Education Census (²⁸28. INEGI-SEP. Censo de Escuelas, Maestros y Alumnos de Educación Básica y Especial [Internet]. 2013 [cited 2018 Feb 28]. Available from: http://cemabe.inegi.org.mx/Reporte.aspx.
http://cemabe.inegi.org.mx/Reporte.aspx... ) by the National Institute of Geography showed that there were 96 000 PE teachers at the country’s 207 682 public schools (preschool through high school). Based on the shortfall of PE classes and PE teachers, a grade of 3 was assigned to this indicator.

Community and the Built Environment: 4.

Data from the National Institute of Statistics and Geography show (⁹9. Instituto Nacional de Estadística y Geografía [Internet]. Resultados sobre infraestructura y características del entorno urbano. 2010 [cited 2018 March 20]. Available from: http://www3.inegi.org.mx/sistemas/microdatos/default_urbano.aspx.
http://www3.inegi.org.mx/sistemas/microd... ) that one-third of neighborhoods with more than 5 000 residents have paved streets and trees, and 45% have public lighting. The National Registry of Sports Infrastructure (²⁹29. Comisión Nacional de Cultura Física y Deporte. Censo Nacional de Infraestructura Deportiva [Internet]. 2015 [cited 2018 Feb 28]. Available from: http://sistemas.conade.gob.mx/portalCenso/index_2.aspx.
http://sistemas.conade.gob.mx/portalCens... ) reported that in 2015 there were 45 497 sports facilities across 32 Mexican states, but data on usage and accessibility are lacking. The 2017 National Victimization Survey (¹⁰10. Instituto Nacional de Estadística y Geografía [Internet]. Encuesta Nacional de Victimización y Percepción de Seguridad Pública. 2017 [cited 2018 Feb 28]. Available from: http://www.beta.inegi.org.mx/proyectos/enchogares/regulares/envipe/2017/.
http://www.beta.inegi.org.mx/proyectos/e... ) found that nearly 75% of parents stopped allowing their children to go outside due to neighborhood safety concerns. The Ministry of Agriculture, Land, and Urban Development reported that by 2017, new infrastructure developments and/or renovations had improved 1 163 public spaces (³⁰30. Secretaría de Desarrollo Agrario Territorial y Urbano. Avanza la SEDATU en rescate de espacios públicos y en regeneración urbana [Internet]. 2017 [cited 2018 Aug 31]. Available from: https://www.gob.mx/sedatu/articulos/avanza-la-sedatu-en-rescate-de-espacios-publicos-y-en-regeneracion-urbana?idiom=es.
https://www.gob.mx/sedatu/articulos/avan... ); however, green space in Mexico is insufficient, with just 3.8 m² per inhabitant (³¹31. Ciudades Competitivas y Sustentable. Documento Diagnóstico de Rescate de Espacios Públicos. 2014.). Regarding infrastructure for active transportation, bikeability, and walkability, improvements have been made in large cities, i.e., Mexico City, Guadalajara, and León (³²32. Aguirre K, Leal-Vallejo A, Treviño-Theesz X, Lazalde H GJ. Ranking de ciclociudades. México: Instituto de Políticas para el Transporte y el Desarrollo; 2015.). Urban mobility programs, such as Bus Rapid Transit, were also launched in many cities to enhance sustainable mobility, but information on fund allocations for these initiatives is lacking. A grade of 4 was assigned to this indicator.

IV. Strategies and Investments

Government Strategies: 6.

According to a 2017 Government National Report (³³33. Gobierno de los Estados Unidos Mexicanos. Quinto Informe de Ejecución del Plan Nacional de Desarrollo [Internet]. In: Republica Pdl, editor. México 2017 [cited 2018 Aug 31]. Available from:https://www.gob.mx/cms/uploads/attachment/file/313371/5_IE_PND_VERSIO_N_FINAL_190318_RGB.pdf.
https://www.gob.mx/cms/uploads/attachmen... ), the National Sports Infrastructure program received $ 5 867.5 million Mexican pesos in 2013 – 2017. During this period, 382 new physical activity-related facilities were developed, 397 were renovated, and 103 were expanded, plus equipment was delivered for several initiatives across the country (³⁴34. Gobierno de los Estados Unidos Mexicanos. Sexto Informe de Ejecución del Plan Nacional de Desarrollo [Internet]. In: República Pdl, editor. México 2018 [cited 2019 Aug 31]. Available from:http://sil.gobernacion.gob.mx/Archivos/Documentos/2018/09/asun_3730635_20180901_1535843813.pdf.
http://sil.gobernacion.gob.mx/Archivos/D... ). However, there is no information on the extent to which these resources reached children and youth.

In 2017, Mexico introduced the National Physical Culture and Sports Week. Several activities were promoted through this campaign (e.g., sports, recreational activities) across the country and in a variety of settings (e.g., schools, workplaces). It reached 3 035 776 people, but how many of these were children and youth is unknown.

In addition, four national initiatives to promote physical activity were identified. México Incluyente reached 4.3 million people through physical education and physical activity in community settings (³³33. Gobierno de los Estados Unidos Mexicanos. Quinto Informe de Ejecución del Plan Nacional de Desarrollo [Internet]. In: Republica Pdl, editor. México 2017 [cited 2018 Aug 31]. Available from:https://www.gob.mx/cms/uploads/attachment/file/313371/5_IE_PND_VERSIO_N_FINAL_190318_RGB.pdf.
https://www.gob.mx/cms/uploads/attachmen... ). México con Educación de Calidad was directed at enhancing the quality of education through strategies such as professional teacher training and improvements to sports infrastructure and programs in schools (³⁵35. Gobierno de los Estados Unidos Mexicanos. Plan Nacional de Desarrollo 2013-2018 [Internet]. In: República Pdl, editor. México 2013 [cited 2018 Aug 31]. Available from: http://pnd.gob.mx/.
http://pnd.gob.mx/... ). Ponte al 100 offered functional capacity assessments for children and adults, along with individual improvement plans at 2 828 centers across the country (³⁶36. Gobierno de los Estados Unidos Mexicanos. Segundo Informe de Ejecución del Plan Nacional de Desarrollo [Internet]. In: Republica Pdl, editor. México 2014 [cited 2018 Aug 31]. Available from: www.gob.mx/cms/uploads/attachment/file/30345/2_ie_2014_CONSOLIDADO.pdf.
www.gob.mx/cms/uploads/attachment/file/3... ). Finally, Muévete en 30 promoted physical activity as a means to prevent obesity, and reached 4 million children and youth (³⁷37. Gobierno de los Estados Unidos Mexicanos. Cuarto Informe de Ejecución del Plan Nacional de Desarrollo [Internet]. In: Republica Pdl, editor. México 2016 [cited 2018 Aug 31]. Available from: www.gob.mx/cms/uploads/attachment/file/207257/4_IE_2016_21_03_17-ilovepdf-compressed.pdf.
www.gob.mx/cms/uploads/attachment/file/2... ). The impact and degree to which these initiatives have been implemented is unknown; therefore, a grade of 6 was assigned to this indicator.

Non-Government Strategies: 2.

National data on programs and investments by Non-Government Organizations (NGOs) to promote physical activity are lacking. There have been several small initiatives implemented in various parts of the country. Most of these were funded by the food industry, focused on promoting competitive sports, and were small-scale and of short duration. Data on their reach and impact was limited. For this reason, this indicator was assigned a grade of 2.

The most prominent initiative was the Ponte al 100 program developed by the Fundación Movimiento es Salud in partnership with the federal government, and funded by The Coca-Cola Company (³⁸38. Fundación Movimiento es salud. Ponte al 100 [Internet]. [cited 2018 June 31]. Available from: http://www.ponteal100.com.
http://www.ponteal100.com... ). Another national initiative was Play 60 Character Camp, sponsored by PepsiCo Incorporated and focused on promoting physical activity in 50 schools; it reached 23 000 students (³⁹39. Expok. Fundación PepsiCo México y NFL México benefician a más de 23,000 estudiantes [Internet]. 2017 [cited 2018 June 31]. Available from: https://www.expoknews.com/fundacion-pepsico-mexico-ynfl-mexico-benefician-a-mas-de-23000-estudiantes/.
https://www.expoknews.com/fundacion-peps... ). Other initiatives funded by the food industry promoted competitive sports participation, e.g., Torneo Futbolito Bimbo and Paly 60 Character Champ. Small initiatives introduced by private foundations were also found. These promoted physical activity promotion, equity, and sports participation, e.g., Fundación Real Madrid and Fundación Mexicanos Activos.

DISCUSSION

Mexico’s 2018 Report Card provides the most comprehensive evaluation of the opportunities available for children and youth to reach adequate levels of physical activity and sleep, and to reduce sedentary behavior. This evaluation shows that movement behaviors are below recommended levels among Mexican children and youth. It also demonstrates that initiatives undertaken by schools, communities, and the government have not achieved sufficient improvements. Gaps remain in monitoring physical activity and behavior in children less than 10 years of age, and on the efforts made by Mexican families to get their children and youth moving.

Grades for Daily Behavior indicators were low, with some grades improving or worsening against the 2016 Report Card. The grade for Physical Activity dropped from 6 in 2016 (⁴⁰40. Galaviz KI, Arroyo MA, González-Casanova I, Villalobos MF, Jáuregui A, Ulloa EJ, et al. Results From Mexico’s 2016 Report Card on Physical Activity for Children and Youth. J Phys Act Health. 2016;13(11 Suppl 2):S206-S12.) to 4 in 2018. This was due to low physical activity levels found in the new age group included in ENSANUT 2016 (¹²12. Medina C, Jauregui A, Campos-Nonato I, Barquera S. Prevalence and trends of physical activity in children and adolescents: results of the Ensanut 2012 and Ensanut MC 2016. Salud Publica Mex. 2018;60(3):263-71. doi:10.21149/8819
https://doi.org/10.21149/8819... ): only 17.2% of 10 – 14-year-olds met the physical activity recommendations. The grade for the Sports Participation indicator increased from 4 in 2016 to 5 in 2018 because the proportion of children and youth participating in Organized Physical Activity or Sports rose from 41.4% to 48.6%, according to ENSNAUT (¹²12. Medina C, Jauregui A, Campos-Nonato I, Barquera S. Prevalence and trends of physical activity in children and adolescents: results of the Ensanut 2012 and Ensanut MC 2016. Salud Publica Mex. 2018;60(3):263-71. doi:10.21149/8819
https://doi.org/10.21149/8819... ). Sedentary Behavior grades have been steadily declining in every edition of the Report Card, from 5 in 2012 when 50% of children had less than 2 hours of daily screen time (⁴¹41. Rodríguez MdP, Colley R, Tremblay M, López J, Janssen I, Jáuregui E, et al. Mexico’s 2012 Report Card on Physical Activity for Children and Youth. Mexico: CHEO Research Institute, Universidad de Guadalajara, Queen’s University; 2012.), to 3 in 2018 when close to 80% exceeded the recommended limit.

Other Daily Behaviors did not change or were included for the first time in this evaluation. Sleep, included for the first time, received an encouraging grade of 7, setting a precedent for future monitoring of this behavior. As with other Daily Behaviors reported in national surveys, there is no sleep data on children less than 10 years of age. The grades for Active Play and Active Transportation remain the same because the data used for the first Report Card has not be updated for subsequent Report Cards. New national data are needed to determine if these indicators are changing.

For the first time, Physical Fitness was added to the Report Card, but national data on cardiorespiratory fitness, muscular strength, and flexibility of Mexican children and youth were not found. We could only assess the Body Composition indicator and found that 1 in 3 Mexican children and youth have high BMI for their age (³3. Instituto Nacional de Salud Pública. Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 [Internet]. México: INSP; 2016 [cited 2018 May 21]. Available from: https://www.insp.mx/avisos/4576-resultados-ensanut-mc-2016.html.
https://www.insp.mx/avisos/4576-resultad... ). Since unhealthy body weight puts children at risk of developing diabetes, cardiovascular disease, and having a shorter lifespan, effective strategies to promote healthy weight in Mexican children and youth are imperative.

The grades for Settings and Sources of Influence indicate physical activity opportunities remain insufficient or are inadequate. As on the 2016 Report Card (⁴⁰40. Galaviz KI, Arroyo MA, González-Casanova I, Villalobos MF, Jáuregui A, Ulloa EJ, et al. Results From Mexico’s 2016 Report Card on Physical Activity for Children and Youth. J Phys Act Health. 2016;13(11 Suppl 2):S206-S12.), the grade for the School indicator was 3, given the insufficient PE lessons and PE teachers in public schools (¹¹11. Secretaría de Educación Pública [Internet]. Informe sectorial 1: Educación Física y Deporte en el Sistema Educativo. 2015 [cited 2018 May 20]. Available from: http://www.dgb.sep.gob.mx/acciones-y-programas/ESDM/Informes_Sectoriales/1_Edu_Fisica_Deporte_universitario.pdf.
http://www.dgb.sep.gob.mx/acciones-y-pro... , ²⁸28. INEGI-SEP. Censo de Escuelas, Maestros y Alumnos de Educación Básica y Especial [Internet]. 2013 [cited 2018 Feb 28]. Available from: http://cemabe.inegi.org.mx/Reporte.aspx.
http://cemabe.inegi.org.mx/Reporte.aspx... ).

The Community and Built Environment indicator received a grade of 4 in the present Report Card, the same as in 2016 (⁴⁰40. Galaviz KI, Arroyo MA, González-Casanova I, Villalobos MF, Jáuregui A, Ulloa EJ, et al. Results From Mexico’s 2016 Report Card on Physical Activity for Children and Youth. J Phys Act Health. 2016;13(11 Suppl 2):S206-S12.). More investment is needed to boost the development and recovery of parks and public spaces, as well as to build infrastructure that promotes walking, bike riding, and public transportation use. As in all editions of the Report Card, data are still needed to evaluate efforts that Mexican families are making to encourage physical activity among their children.

The grades for Strategies and Investments suggest insufficient effort to promote physical activity among Mexican children and youth. For the Government indicator, the grade remains at 6 since it was based on programs and initiatives implemented by the same government administration assessed in the 2016 Report Card (⁴⁰40. Galaviz KI, Arroyo MA, González-Casanova I, Villalobos MF, Jáuregui A, Ulloa EJ, et al. Results From Mexico’s 2016 Report Card on Physical Activity for Children and Youth. J Phys Act Health. 2016;13(11 Suppl 2):S206-S12.). The degree to which the physical activity strategies were implemented, the proportion of the population reached, and the impact on children and youth are unknown. The level of coordination among the various, relevant government agencies is also unclear. The grade for NGOs remains at 2, reflecting the lack of information on the reach and impact of their initiatives. Overall, most of these initiatives were funded by the food industry and focused on promoting competitive sports. They were small-scale and of short duration. NGO initiatives should be objectively evaluated to determine their impact and potential, and results should be shared transparently.

Mexico’s 2018 Report Card is part of the Global Matrix 3.0, a global initiative aimed at evaluating and comparing standardized scores of physical activity behaviors and opportunities for children and youth. When compared with the 48 participating countries, Mexico ranked 33^rd in Overall Physical Activity, 40^th in Sources of Influence, and 24^th in Daily Behaviors (⁶6. Aubert S, Barnes JD, Abdeta C, Abi Nader P, Adeniyi AF, Aguilar-Farias N, et al. Global Matrix 3.0 Physical Activity Report Card Grades for Children and Youth: Results and Analysis From 49 Countries. J Phys Act Health. 2018;15(S2):S251-S73. doi:10.1123/jpah.2018-0472
https://doi.org/10.1123/jpah.2018-0472... ). Countries that ranked in first place in Overall Physical Activity and Sources of Influence had a strong and widespread sports culture, infrastructure and policies for active transport, and evidence of existing support from government, schools, and parents. Countries that ranked in first place in Daily Behaviors were those where active transportation is more common than automobile transportation and where access to screen-based recreation is limited (⁶6. Aubert S, Barnes JD, Abdeta C, Abi Nader P, Adeniyi AF, Aguilar-Farias N, et al. Global Matrix 3.0 Physical Activity Report Card Grades for Children and Youth: Results and Analysis From 49 Countries. J Phys Act Health. 2018;15(S2):S251-S73. doi:10.1123/jpah.2018-0472
https://doi.org/10.1123/jpah.2018-0472... ).

There are numerous opportunities to improve Mexico’s global ranking and overall physical activity grades. We offer the following main recommendations:

1. Provide quality physical education to all children in Mexico: this entails training competent PE teachers, providing adequate facilities and equipment, having an inclusive curriculum for all genders and backgrounds, creation of community alliances, and establishing monitoring and evaluation mechanisms.

2. Establish a surveillance system for all movement behaviors and include children from 1 – 18 years of age.

3. Evaluate the impact of existing national policies and programs aimed at promoting physical activity in children and youth, and determine whether each should be continued, modified, or discontinued.

Limitations.

This report has certain limitations. Grades were based on national data and do not capture regional variation. Data on movement behaviors come from self-reports, often prone to overestimation. Screen time was used as a proxy indicator of sedentary time, and results were not stratified by type (i.e., watching television, playing video games, or other forms). There are no national data from children less than 10 years of age for any movement behavior; therefore, behaviors in this population could not be assessed. Definitions and measures of Active Play varied, suggesting there is currently no consensus for operationalizing and measuring this behavior. Additionally, the lack of data on family support continues to be a limitation. Lastly, we may have missed sources of information that were not available and/or accessible at the time of this evaluation.

CONCLUSIONS

Mexico’s 2018 Report Card shows children and youth are far from meeting recommended levels of physical activity, sleep, and sedentary behavior. The Report Card also shows that school, community, and government initiatives have been insufficient or inadequate for improving these behaviors. Given the obesity and cardio-metabolic disease epidemic that Mexico is facing, efforts should be directed at promoting health-enhancing physical activity and sleep levels, and combating sedentary behaviors among children and youth. This Report Card can inform school, community, and government strategies to promote active lifestyles for children and youth, so they may become healthy, productive adults who contribute to the development of Mexico.

Author contributions.

KIG and JLT designed the study. All authors collected and analyzed the data, interpreted results, and contributed to writing the manuscript. GA and KIG drafted the manuscript. All authors reviewed and approved the final revised version.

Acknowledgements.

The authors wish to thank the Active Healthy Kids Global Alliance (Ottawa, Ontario, Canada) for developing the Report Card methodology.

Funding.

This work was funded by the University of Guadalajara (Guadalajara, Mexico). KIG was partially supported by the Georgia Center for Diabetes Translation Research (Atlanta, Georgia, United States, P30DK111024). GA was funded by The National Council on Science and Technology of Mexico (CONACyT, 409083). The funders had no role in the study design, data collection or analysis, decision to publish, or preparation of the manuscript.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or PAHO.

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