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

Workshop 3: The Agriculture Nutrition Nexus and the Way Forward at The Caribbean-Pacific Agri-Food Forum 2015 (CPAF2015) taking place 2-6 November in Barbados with support from the Intra-ACP Agricultural Policy programme, organized in partnership with the Barbados Agricultural Society (BAS) and the Inter-American Institute for Cooperation on Agriculture (IICA). http://www.cta.int/en/news/caribbean-pacific-agri-food-forum.html

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

  1. 1. Preventing disease Promoting and protecting health
  2. 2. 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
  3. 3. Preventing disease, promoting and protecting health • 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
  4. 4. Preventing disease, promoting and protecting health 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
  5. 5. Preventing disease, promoting and protecting health 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.
  6. 6. Preventing disease, promoting and protecting health Survey of Adolescents in Antigua and Barbuda: Prevalence of Anaemia by WHO Standards WHO cut-offs
  7. 7. Preventing disease, promoting and protecting health • 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
  8. 8. Preventing disease, promoting and protecting health Overweight and Obesity (Adults) Obesity is the major risk factor for NCDs
  9. 9. Preventing disease, promoting and protecting health WHO STEPwise Approach to NCD Risk factor Surveillance
  10. 10. Preventing disease, promoting and protecting health Leading Causes of Death CARPHA Member States*, 2000-2012 * Excluding Haiti
  11. 11. Preventing disease, promoting and protecting health Broad Groupings of Conditions Causing Death in CARPHA Member States
  12. 12. Preventing disease, promoting and protecting health Childhood Obesity
  13. 13. Preventing disease, promoting and protecting health 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
  14. 14. Preventing disease, promoting and protecting health 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
  15. 15. Preventing disease, promoting and protecting health 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
  16. 16. Preventing disease, promoting and protecting health 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%
  17. 17. Preventing disease, promoting and protecting health 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
  18. 18. Preventing disease, promoting and protecting health Why are we at this stage?
  19. 19. Preventing disease, promoting and protecting health 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?
  20. 20. Preventing disease, promoting and protecting health Why are we at this stage? – Super sizing
  21. 21. Preventing disease, promoting and protecting health 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
  22. 22. Preventing disease, promoting and protecting health Energy availability in selected CARPHA member states for 2011 0 500 1000 1500 2000 2500 3000 3500 ENERGY(Kcal/cap/dy) COUNTRY ENERGY
  23. 23. Preventing disease, promoting and protecting health 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
  24. 24. Preventing disease, promoting and protecting health 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
  25. 25. Preventing disease, promoting and protecting health 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
  26. 26. Preventing disease, promoting and protecting health 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
  27. 27. Preventing disease, promoting and protecting health Physical inactivity
  28. 28. Preventing disease, promoting and protecting health 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
  29. 29. Preventing disease, promoting and protecting health 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%)
  30. 30. Preventing disease, promoting and protecting health Nutrition Challenges
  31. 31. Preventing disease, promoting and protecting health 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)
  32. 32. Preventing disease, promoting and protecting health 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
  33. 33. Preventing disease, promoting and protecting health 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.
  34. 34. Preventing disease, promoting and protecting health 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)
  35. 35. Preventing disease, promoting and protecting health 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
  36. 36. Preventing disease, promoting and protecting health CARPHA’S Response to the Nutrition Issues Key Success Factors: Nutrition-specific interventions Nutrition-sensitive interventions
  37. 37. Preventing disease, promoting and protecting health 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
  38. 38. Preventing disease, promoting and protecting health • 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.
  39. 39. Preventing disease, promoting and protecting health 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.
  40. 40. Preventing disease, promoting and protecting health 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
  41. 41. Preventing disease, promoting and protecting health • 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
  42. 42. Preventing disease, promoting and protecting health 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.
  43. 43. Preventing disease, promoting and protecting health 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.
  44. 44. Preventing disease, promoting and protecting health 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.
  45. 45. Preventing disease, promoting and protecting health Priority Area #1: Prevention
  46. 46. Preventing disease, promoting and protecting health 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
  47. 47. Preventing disease, promoting and protecting health 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
  48. 48. Preventing disease, promoting and protecting health 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
  49. 49. Preventing disease, promoting and protecting health 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
  50. 50. Preventing disease, promoting and protecting health 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
  51. 51. Preventing disease, promoting and protecting health 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 Work in progress: Yes Ongoing work of CARPHA’s Public Health Nutrition Unit
  52. 52. Preventing disease, promoting and protecting health • 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.
  53. 53. Preventing disease, promoting and protecting health 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 Work in progress: Yes • Submitted a few Grant Proposals • School intervention in 1 CMS (4 components)
  54. 54. Preventing disease, promoting and protecting health 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.
  55. 55. Preventing disease, promoting and protecting health Priority Area #4: Strategic Information - Surveillance
  56. 56. Preventing disease, promoting and protecting health 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
  57. 57. Preventing disease, promoting and protecting health 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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Workshop 3: The Agriculture Nutrition Nexus and the Way Forward at The Caribbean-Pacific Agri-Food Forum 2015 (CPAF2015) taking place 2-6 November in Barbados with support from the Intra-ACP Agricultural Policy programme, organized in partnership with the Barbados Agricultural Society (BAS) and the Inter-American Institute for Cooperation on Agriculture (IICA). http://www.cta.int/en/news/caribbean-pacific-agri-food-forum.html

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