#cpaf15 ws3: nutrition challenges in the caribbean (christine bocage, caribbean public health agency...

Preventing diseasePromoting and protecting health

Preventing disease, promoting and protecting health

Nutrition Challenges in the Caribbean: Key Success Factors of CARPHA Nutrition Sensitive and Nutrition Specific Interventions

Christine BocageSenior Technical Officer, Food Security and Nutrition

Caribbean Public Health Agency (CARPHA)

Presented at the Caribbean and Pacific Agrifood ForumW3: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 IssuesNutritional 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 Cay

man

St. K

itts

Grenad

a

Montserra

tBVI

Antigua

St. V

incent

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

85th-95th P 95th P0

2

4

6

8

10

12

14

16

18

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 Diabetes1 Type 1 Diabetes5 Pre-diabetics

2012(2066 students)

Risk Factor ProfileAt 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


19961-63 1971-73 1981-83 1991-93 2001-20031500

1700

1900

2100

2300

2500

2700

2900

Energy Availability in the Caribbean 1961-2003

Average Energy supply

RDA

Cal

orie

s/ca

put/d

ay

Source: CFNI

Increased national availability of energy, fats, proteins and sugar


Energy availability in selected CARPHA member states for 2011

Ant

Bah

Bdos Be

l

Ber

Dom Gre

Guy

Hai

Jca

St L

St K

&N SVG

Sur

T&T

0

500

1000

1500

2000

2500

3000

3500

ENERGY

COUNTRY

ENER

GY

(Kca

l/cap

/dy)


Protein availability in selected CARPHA member states for 2011

Ant

Bah

Bdos Be

l

Ber

Dom Gre

Guy Hai

Jca

St L

St K

&N SVG

Sur

T&T

0102030405060708090

100

PROTEIN

COUNTRYPopulation food Goals

PRO

TEIN

(g/c

ap/d

y)


2000 2001 2002 2003 2004 2005 2006 2007 2008 200950

55

60

65

70

75

80

85

90

77.9 78.479.6 80.1 80.8 81

84 83.7

81.282.7

Trends in Fat Availability in 10 Selected Caribbean Countries, 2000-2009 (grams/caput per day)

Gm

s Fa

t per

Cap

ut p

er d

ay

Source: FAO Statistics 2009: www.fao.org Population Food Goals

http://www.fao.org/


2000 2001 2002 2003 2004 2005 2006 2007 2008 200930

40

50

60

70

80

90

100

110

120

Trends in Sugar Availability in 10 Selected Caribbean Countries, 2000-2009 (Grams Sugar/Caput/Day)

Sugar

gms

suga

r/cap

ut/d

ay

Source: FAO Statistics 2009: www.fao.org Population Food Goal

http://www.fao.org/


Trends in Fruit and Vegetable Consumption in the Caribbean1961-2003

0

50

100

150

200

250

300

350

400

1961-63 1971-73 1981-83 1991-93 2001-2003

calorie

s/ca

put/d

ay

Local Imported Goal

Source: FAO


Physical inactivity

Preventing disease, promoting and protecting healthANT BAR BEL BVI CAY DOM GRE MONT GUY SKN St. Lucia

SVG TRT0

10

20

30

40

50

60

70

80Physical Activity levels and Con-

sumption of Carbonated Beverages (12-15 year olds)

Physical Activity for 60 mins Sedentary Carbonated beverages

Physical inactivity

GSHS – Global School-based Student Health Survey


ANU BAH BEL DOM MONT SKN SVG TRT0

20

40

60

80

100

120

140

160

180

200

Breastfeeding Rates

Initiation 1-2 months 3 months 4 months 5 months 6monthsSource: 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)


ChallengesNationally 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


ChallengesIn 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


Framework for Action 2014-2019• 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.


Framework for Action 2014-2019Main 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 ActionPriority 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 AdvocacyObjectives:

• 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 InterventionsObjectives:

• 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

Priority Area #1: Prevention


Priority Area #2:Management and Control

Treatment and SupportObjective:

• To provide children and families who are affected by overweight/obesity with the necessary care and support.

Outcome1. Evidence-based weight management services more available, accessible

and acceptable to children.

Addressing StigmatizationObjective:

• To safeguard children who may be affected by overweight/obesity from bias and stigmatization associated with their condition.

Outcome1. National policies and programmes more responsive to the ethical issues

concerning childhood obesity and childhood weight management.


Priority Area #3:Strengthening Systems to support Action

Strengthening systems within GovernmentObjective:

• To improve the capability of systems within Government to mount effective responses.

Outcome1. Systems in education, health and trade sectors better equipped to

conduct activities in the Plan of Action.

Strengthening multi-sectoral actionObjective: • 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.


Priority Area #4: Strategic InformationSurveillance 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 researchObjective:

• To provide information for measuring and assessing results of the Plan of Action.

Outcome1. Childhood obesity programmes informed by comparable data on the cost

and consequences of the epidemic and the impact of prevention measures.


Regulation, Policy and AdvocacyObjectives:

• 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.

Outcomes1. 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



P1: Prevention- Regulation, Policy and AdvocacyOutcome 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: YesCARPHA/IDLO MOU- Draft Work plan


CARPHA/IDLO Memorandum of UnderstandingGoal:

– 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



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 BriefComprehensive 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



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

Work in progress: YesOngoing work of CARPHA’s Public Health Nutrition Unit


• Education and Behaviour Change InterventionsObjectives:

• 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 decisionsOutcomes

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.



P1: Prevention- Behaviour Change InterventionsOutcome 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

Work in progress: Yes• Submitted a few Grant Proposals• School intervention in 1 CMS (4 components)


P1: Prevention- Behaviour Change InterventionsOutcome 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 messagesAny 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


P4: Strategic Information - SurveillanceOutcome 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

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