#CPAF15 WS3: Nutrition challenges in the Caribbean (Christine Bocage, Caribbean Public Health Agency (CARPHA))

Preventing disease
Promoting and protecting health

Preventing disease, promoting and protecting health
Christine Bocage
Senior Technical Officer, Food Security and Nutrition
Caribbean Public Health Agency (CARPHA)
Presented at the Caribbean and Pacific Agrifood Forum
W3:The Agriculture Nexus and the Way Forward
November 2, 2015

• Nutrition Issues in the Caribbean
• Why are we at this Stage?
• Nutrition Challenges in the Caribbean
• What has CARPHA been doing? /CARPHA Success Factors:
– Nutrition- specific
– Nutrition sensitive
• Conclusion
Overview of Presentation

Nutrition Issues
Nutritional Status:
• Undernutrition (Stunting and wasting; underweight)
• Overnutrition (Obesity) and the related NCDs
• Micronutrient Deficiencies
– Nutritional Anaemia (mainly Iron-deficiency
Anaemia)
– Vitamin A Deficiency

Micronutrient Deficiencies
• Even though Vitamin A deficiency is not a serious problem
in the region (<1% in many countries), iron deficiency
anaemia remains a major public health issue in children and
[pregnant women.
• In many countries iron deficiency anaemia is about 30% and
this has been the case as far back as 1997 and again
recorded in 2002.
• In 2007, CFNI/PAHO/WHO undertook an Adolescent Survey
in a few Caribbean countries (Antigua and Barbuda, St. Kitts
and Nevis, Montserrat) and the results are similar.

Survey of Adolescents in Antigua and Barbuda: Prevalence of
Anaemia by WHO Standards
WHO
cut-offs

• Vitamin E is not routinely checked but based on a
survey conducted in Jamaica in 1997, it was shown
that about 50.4% of children 1-4 years were
deficient and 17% of children 5-16 years.
• Moderate Iodine deficiency is uncommon but may
surface in Guyana, Suriname and Belize.
Micronutrient Deficiencies

Overweight and Obesity
(Adults)
Obesity is the major risk factor for
NCDs

WHO STEPwise Approach to NCD Risk factor Surveillance

Leading Causes of Death
CARPHA Member States*, 2000-2012
* Excluding Haiti

Broad Groupings of Conditions Causing Death
in CARPHA Member States

Childhood Obesity

Childhood Obesity
• Childhood obesity epidemic
• In 2010 prevalence of overweight children<5
years was estimated at 42 million: close to 35
million of those lived in developing countries.
• In the Caribbean obesity in <5 age group
(Pre-school children) doubled over the
past decade

2010
Source: CFNI, March 2012
Burgeoning
Obesity
0
5
10
15
20
25
30
%
Proportion of overweight children in the
region
at risk of overweight overweight

Source: School Health data, 2000
 Obesity,
major risk
factor for
NCDs
 Adolescent
population
obesity up
to 14%
Burgeoning Obesity
0
2
4
6
8
10
12
14
16
18
85th-95th P 95th P
Overweight among 10-14 yr old - St Vincent
male
female

Prevalence of Overweight/Obesity
Country Publication
Year
Obese/Overweight
Antigua
(4-20 years)
Walwyn, L. et al
2012
(4029 students)
Overweight -20.5% ; Obese - 6.3%
Bahamas
(Grade 10/Form 4)
Taylor, S. et al
2011
(719 students)
Overweight – 13.9%; Obesity –
14.0%
Rivers, K.L. et al 2013
(861 students)
Overweight – 15%; Obese -15.2%;
severely obese -7.9%
Barbados
(11-16 years)
2007
(400 students)
Overweight – 32.0%; Obesity – 19%

Country Publication
Year
Risk Factors
Trinidad and
Tobago
(5-17 years)
2012
(32 schools)
7 Type 2 Diabetes
1 Type 1 Diabetes
5 Pre-diabetics
2012
(2066 students)
Risk Factor Profile
At least 1 risk factor – 44.3%
At least 2 risk factors –
23.1%
At least 3 risk factors – 2.9%
Bahamas
(13-19 years)
2013
(861)
Impaired fasting glucose –
16.1%
Diabetes – 1.3%
Diabetes

Why are we at this stage?

Greater quantities of
energy dense foods
Increased use of fast
foods (proliferation of
fast food outlets).
Promotions/
Advertisements
Increased food
purchasing
opportunities
Increased frequency of
eating occasion
Why are we at this stage?

Why are we at this stage? – Super sizing

1500
1700
1900
2100
2300
2500
2700
2900
19961-63 1971-73 1981-83 1991-93 2001-2003
Calories/caput/day Energy Availability in the Caribbean
1961-2003
Average
Energy
supply
RDA
Source: CFNI
Increased national availability of energy, fats, proteins and
sugar

Energy availability in selected CARPHA
member states for 2011
0
500
1000
1500
2000
2500
3000
3500
ENERGY(Kcal/cap/dy)
COUNTRY
ENERGY

Protein availability in selected CARPHA
member states for 2011
0
10
20
30
40
50
60
70
80
90
100
PROTEIN(g/cap/dy)
COUNTRY
Population food Goals
PROTEIN

77.9 78.4
79.6 80.1
80.8 81
84 83.7
81.2
82.7
50
55
60
65
70
75
80
85
90
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
GmsFatperCaputperday
Trends in Fat Availability in 10 Selected Caribbean Countries, 2000-2009
(grams/caput per day)
Source: FAO Statistics 2009: www.fao.org
Population Food Goals

30
40
50
60
70
80
90
100
110
120
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
gmssugar/caput/day
Trends in Sugar Availability in 10 Selected Caribbean
Countries, 2000-2009 (Grams Sugar/Caput/Day)
Sugar
Source: FAO Statistics 2009: www.fao.org
Population Food
Goal

TrendsinFruitandVegetableConsumptionintheCaribbean
1961-2003
0
50
100
150
200
250
300
350
400
1961-63 1971-73 1981-83 1991-93 2001-2003
calories/caput/day
Local Imported Goal
Source: FAO

Physical inactivity

0
10
20
30
40
50
60
70
80
ANT BAR BEL BVI CAY DOM GRE MONT GUY SKN St.
Lucia
SVG TRT
Physical Activity levels and Consumption of
Carbonated Beverages (12-15 year olds)
Physical Activity for 60 mins Sedentary Carbonated beverages
Physical inactivity
GSHS – Global School-based Student Health Survey

0
20
40
60
80
100
120
140
160
180
200
ANU BAH BEL DOM MONT SKN SVG TRT
Breastfeeding Rates
Initiation 1-2 months 3 months 4 months 5 months 6months
Source: Country Food & Nutrition Policies ; IYCN Policies
Falling breastfeeding Rates (Average Exclusive BF rate is 39%
with some countries as low as 5%)

Nutrition Challenges

Challenges
• Double burden of undernutrition and overnutrition
• Shift away from individual solutions to population-based
solutions
• Habits; Beliefs; Traditions; Culture – difficult to change bad
lifestyle behaviours
• Information Sources –some spurious and from unqualified
persons
• Lack of resources (Human, Financial)

Challenges
Nationally and Regionally - A lack of human resources
• A survey conducted in 2014 assessed the qualifications and
training of Nutrition and Dietetics Professionals in the
Caribbean, as well as their distribution and employment status
within the region.
• The numbers of nutrition and dietetic professionals are small
and insufficient. When compared to other health professionals
the results were as follows:
• Dietitians and Nutritionists - 14.25 per 10,000 population
• Physicians - 79.2 per 10,000 population
• Nurses and Midwives 199.7 per 10,000 population

Challenges
In schools
• Lack of implementation and evaluation of structured life skills
programmes such as Health and Family Life Education (HFLE)
In the community
• Getting the community involved in the design and
implementation of projects for the prevention of obesity
particularly in high-risk low-income groups.
• Sustainability - if do not have a community leader and
adequately sensitized individuals.
• The ability to have a presence in the community. Actions
wane if there is a perception that they are forgotten.
• Security.

Challenges
Public/Government
• Cost to make the public aware, and convinced of, the
need to develop and maintain healthy lifestyle habits.
• Provision of support and incentives.
• Insufficient support from Governments to put
measures in place to reduce food and nutrition
insecurity (policies; legislation; guidelines etc)

Challenges -NCD Related Legislation
• Legislation in English-speaking Caribbean countries and territories
applicable to the prevention and control of NCDs are few.
• Only the Bahamas, Jamaica, Montserrat and St. Lucia have enacted
legislation specifically referring to obesity, diabetes and cardiovascular
diseases.
– National Insurance (Chronic Diseases Prescription Drug Fund) Act,
2009 of the Bahamas;
– National Health Fund Act 2003 of Jamaica;
– Public Health Act (Chapter 14:01) of Montserrat;
– Public Hospitals (Management) Act (Chapter 11:03) of St. Lucia.
• Physical Planning Act, 2003 of Antigua
• Consumer Protection Act, 2002 of Barbados
• Education Act, 1887 of Dominica
• Health Authority Act 2003 of Anguilla, 2003

CARPHA’S Response to the Nutrition Issues
Key Success Factors:
Nutrition-specific interventions
Nutrition-sensitive interventions

Required response
• Sustained multi-sectoral, multi-level
action required.
• Must include strong policy and
legislative measures to address
primary prevention:
Obesogenic environments:
– food production,
– trade
– local prices,
– Advertising and marketing
– Compulsory standards for food
labelling
– Compulsory standards and
guidelines for physical
environment in schools

• Plan of Action for Promoting
Healthy Weights in the
Caribbean: Prevention and
Control of Childhood Obesity
represents a Collaborative
Plan of Action
Goal
• To halt and reverse the rise
in child and adolescent
obesity in the Caribbean by
2025.

Main Pillars
• CARPHA’s Response is based on the
Sacks et al 2009 framework which
include:
– Sociological or “upstream”
approach
– The behavioural or “midstream”
approach
– Health service or “downstream”
approach.
• We added a 4th pillar “ Capability
and capacity development to
support the response.

Plan of Action
Priority Areas (Mix of Nutrition
Specific and Nutrition Sensitive
Approaches)
Prevention
• Regulation, Policy and Advocacy
• Education and Behaviour Change
Interventions
Management and Control
• Treatment and Support
• Addressing Stigmatization
Surveillance , M and E, and Research
• Surveillance and data analysis
• Monitoring, evaluation and research
Strengthening Systems to support action
• Strengthening systems in education,
health and other critical sectors
• Strengthening capacity for multi-sectoral
and multi-level government action

• Regulation, Policy and Advocacy
Objectives:
• To make the environments where Caribbean children live
and learn more supportive of physical activity and healthy
eating.
• To create incentives to discourage unhealthy consumption
patterns and to encourage healthier dietary choices.
• Education and Behaviour Change Interventions
Objectives:
• To empower communities to embrace active living and
healthful eating.
• To provide parents and children with accurate information
about food, nutrition and exercise to enable informed
decisions

Treatment and Support
Objective:
• To provide children and families who are affected by
overweight/obesity with the necessary care and support.
Outcome
1. Evidence-based weight management services more available, accessible
and acceptable to children.
Addressing Stigmatization
Objective:
• To safeguard children who may be affected by overweight/obesity
from bias and stigmatization associated with their condition.
Outcome
1. National policies and programmes more responsive to the ethical issues
concerning childhood obesity and childhood weight management.

Strengthening systems within Government
Objective:
• To improve the capability of systems within Government to mount
effective responses.
Outcome
1. Systems in education, health and trade sectors better equipped to
conduct activities in the Plan of Action.
Strengthening multi-sectoral action
Objective:
• To foster multi-sectoral cooperation in responding to the epidemic.
Outcome
1. National multi-sectoral country teams have the technical capacity to
develop and implement multi-sectoral Action Plans for population-
based childhood obesity prevention.

Surveillance to support action
Objective:
• To provide core data for tracking the movement and determinants of the
epidemic.
Outcome
1. Quality comparable data on nutrition status and the food environment
available for policy and programming.
Monitoring, evaluation and research
Objective:
• To provide information for measuring and assessing results of the Plan
of Action.
Outcome
1. Childhood obesity programmes informed by comparable data on the cost
and consequences of the epidemic and the impact of prevention measures.

Priority Area #1: Prevention

Regulation, Policy and Advocacy
Objectives:
• To make the environments where Caribbean children live
and learn more supportive of physical activity and healthy
eating.
• To create incentives to discourage unhealthy consumption
patterns and to encourage healthier dietary choices.
Outcomes
1. Member States enact strong regulatory frameworks for
reducing obesogenic environments.
2. Evidence-based policies to support production, access and
consumption of safe, affordable, nutritious, high quality food
commodities implemented in Member States.
3. Infant and child feeding policies, programmes and
interventions strengthened

Outcome 1:
Member States enact strong regulatory frameworks
for reducing obesogenic environments.
2015 Output:
Legislative Brief outlining comprehensive strategy
and technical support to CARPHA Member States
(CMS to adapt Brief)
Work in progress: Yes
CARPHA/IDLO MOU- Draft Work plan

CARPHA/IDLO Memorandum of Understanding
Goal:
– Strengthen legal environments for responding to obesity, diabetes and for promoting
healthy diets and physical activity in the Caribbean
Objectives:
• Build regional technical capacity in law and NCDs
• Conduct and publish research to support law and policy reform
• Support regional networking on relevant legal issues
• Expert Advisory Group
– UWI Caribbean Law Institute Centre (CLIC)
– PAHO, Legal Counsel
– CARICOM
– Chair, PHNAC
– Ministry of Health, Trinidad and Tobago, Legal Adviser
– Healthy Caribbean Coalition
– IDLO & CARPHA

Outcome 2:
Evidence-based policies to support production, access and consumption
of safe, affordable, nutritious, high quality food commodities
implemented in Member States.
2015 Outputs:
• Food and nutrition policies and guidelines -in progress
• Guidelines for Feeding Children in Schools - in progress
• National School Nutrition Policies - in progress
• Guidelines for Fiscal incentives– in progress
• Food-based Dietary Guidelines – in progress
• Trade Policies
• Joint COTED/COHSOD meeting -in development
• Technical Brief - developed

Technical Brief
Comprehensive dictates that a portfolio of actions are required:
– Food labelling
– Nutrition standards and guidelines for schools and other institutions
– Food marketing
– Nutritional quality of food supply (levels of harmful ingredients)
– Trade and fiscal policy measures
– Food chain incentives
• Recommendations:
– Joint COTED-COHSOD declaration setting out a commitment to adopt a
comprehensive approach across all six areas
– Establish a cross-sectoral working group at the regional level including
CARICOM, CARPHA, trade, agriculture, education, civil society, CROSQ,
– Set time-bound targets for implementation

Outcome 3:
Infant and child feeding policies, programmes and interventions strengthened.
2015 Outputs:
– Cadre of health personnel trained to implement the Baby Friendly
Hospital Initiative (BFHI) - in progress
– Technical support to CMS to update/develop National Infant and Young
Child Feeding Policies - in progress
– National Childhood Obesity Policies - in progress
– Technical support to monitor growth and development of children - in
progress
– IYCF dietary guidelines - in progress
Ongoing work of CARPHA’s Public Health Nutrition Unit

• Education and Behaviour Change Interventions
Objectives:
• To empower communities to embrace active living and healthful eating.
• To provide parents and children with accurate information about food,
nutrition and exercise to enable informed decisions
Outcomes
1. Strengthened community capacity to provide opportunities for healthful
eating and physical activity in their environments (home, schools, places
of worship etc.)
2. National obesity prevention initiatives scaled up in accordance with the
Caribbean Charter for Health Promotion.
3. Social Marketing Campaigns for obesity prevention strengthened to
integrate traditional and new forms of media.
4. Education officials better equipped to strengthen the school curriculum
to promote emphasis on nutrition and physical activity.

Outcome 1:
Community capacity to provide opportunities for healthful eating
and physical activity in their environments strengthened
2015 Outputs:
– Multi-country whole of community behaviour change
intervention project
– Technical support to CMS to implement
• Submitted a few Grant Proposals
• School intervention in 1 CMS (4 components)

Outcome 2:
Obesity Prevention initiatives scaled up in accordance with
the Caribbean Charter for Health Promotion
2015 Output:
Technical support to CMS to design/re-design health promotion
strategies and messages
Any work in progress:
Launch of Regional Health Communication Network,
January 2015 – main purpose to develop, implement and
monitor and evaluate communication responses to identified
priority public health issues.

Priority Area #4: Strategic Information -
Surveillance

Outcome 1
• High Quality comparable data on nutrition status
and the food environment available
2015 Outputs:
– Surveillance system (Country reports on
nutritional and anthropometric status)
– Validated data collection instruments for conduct
of Food Consumption Survey
Work in progress: Yes

Conclusion
• We do have many challenges to food and nutrition
security but, with committed governments, and using
a combination of nutrition specific (BFHI, Early
Childhood Development, Growth Monitoring) and
nutrition sensitive approaches (research, public
policies and actions among other things), we can
overcome those challenges.
• Need to work with multi-sectoral partners/continued
support by and co-operation of all sectors

#CPAF15 WS3: Nutrition challenges in the Caribbean (Christine Bocage, Caribbean Public Health Agency (CARPHA))

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#CPAF15 WS3: Nutrition challenges in the Caribbean (Christine Bocage, Caribbean Public Health Agency (CARPHA))