The Barbados Food Consumption and Anthropometric Survey was carried out in 2000/2001 by the National Nutrition Centre (NNC) of the Ministry of Health, in collaboration with the Barbados Statistical Service (BSS) and the Ministry of Agriculture and Rural Development. It received funding and technical assistance from FAO and the Ministry of Health, and technical assistance from the Caribbean Food and Nutrition Institute (CFNI).
The main purpose of the survey was to provide a basis for policy and programme planning by determining the food intake and dietary patterns of the adult population aged 18 years and over, the prevalence of obesity and diagnosed nutrition-related chronic non-communicable diseases (CNCDs), and the relationship of these to dietary patterns.
The specific objectives of the survey were to:
determine the nutritional adequacy of Barbadians' diets;
examine food choices, food purchasing patterns and food sources;
assess the extent of home food production and its contribution to household diets;
determine the prevalence of obesity (and undernutrition) and diagnosed nutrition-related CNCDs, and their relationship to dietary patterns;
investigate the association between demographic, social and economic characteristics and dietary practices.
The survey gathered information on:
demographic and socio-economic factors;
health status - prevalence of four diagnosed CNCDs (diabetes, hypertension, heart disease and cancers);
nutritional status - weights and heights measured to calculate body mass index (BMI) and the prevalence of undernutrition, overweight (pre-obesity) and obesity;
food acquisition habits - production, purchase, use of ready-to-eat meals;
food and health practices - dieting, food preparation, exercise;
food patterns - through a food frequency questionnaire;
dietary intakes - using the 24-hour recall method, to derive daily intakes and adequacy of intakes of energy, macronutrients (fats, carbohydrate and protein) and the important micronutrients (vitamins and minerals).
Key findings of the survey are presented as highlighted text in this section.
THE SURVEY SAMPLE: DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICS
A total of 1 051 households were represented in the sample. Some important findings were that:
25.2% were single-person households;
16.9% of households consisted of men only, and 17.6% of women only;
44.6% of households were headed by women.
Nearly a quarter of the households failed to provide information on income. The following findings are based on those households that provided such information:
the median monthly income per person was B$600 (approximately US$300);
using the United Nations Development Programme (UNDP) poverty cut-off (B$5 503 per annum), 14.9 percent of households fell below the poverty line;
significantly lower per capita monthly incomes were found in:
- large families;
- women-only households;
- households headed by women.
A total of 1 704 individuals (945 women and 759 men) from the survey households completed questionnaires. The following is a profile of those respondents:
the mean age was nearly 49 years (and the range 18 to 99 years);
20.5 percent of men and 22.6 percent of women were aged 65 years or more;
68 percent of men and 53.1 percent of women were employed; 25.8 percent of men and 40.2 percent of women were students, housewives or retired; thus 6.2 percent of men and 6.7 percent of women were not working, but may have been seeking employment;
educational attainment was high: 67.2 percent had completed secondary-level education or higher. The majority of respondents with primary school education only were in the older age groups.
HEALTH AND NUTRITION
Respondents were asked whether they had been diagnosed with one or more of the CNCDs - diabetes, high blood pressure, heart disease or cancer - and whether either parent had suffered from any of these diseases. Respondents were also asked whether they were on any form of diet.
The prevalence of CNCDs was high - 24.2 percent of men and 37.5 percent of women stated that they had been diagnosed with one or more of the conditions investigated.
Among respondents over 50 years of age, prevalence rose to 39 percent in men and 61 percent in women.
In the whole sample, the prevalence of hypertension was highest (17.3 percent in men and 28.8 percent in women), followed by that of diabetes (10.1 percent in men and 15.2 percent in women).
Comparable figures from earlier years are lacking. However, it would seem that the prevalence of both diabetes and hypertension has risen since the previous national food and nutrition survey (1981). Similarly, figures from the 1993 Wildey study (Foster et al., 1993) suggest that the prevalence of diabetes has risen, especially among women.
On the whole, reported adherence to dietary regimens for CNCDs was poor. More individuals diagnosed with diabetes (50.2 percent) than those with hypertension (32.5 percent) claimed to follow diets that could assist in the dietary management of the disease. Women's reported adherence was better than that of men.
A family history apparently provoked preventive action (through appropriate dieting) in 10 percent of people without diabetes and 17 percent of people without hypertension. Such preventive action, i.e. the targeting of high-risk individuals, is an important component of a health promotion strategy.
Weights and heights were measured in order to calculate BMI as an indicator of nutritional status. Respondents were asked whether they considered themselves to be underweight, overweight or of the correct weight, and whether they took planned exercise.
The prevalence of overweight (pre-obesity) and obesity among adult Barbadians is alarmingly high: 55.8 percent in men and 63.8 percent in women. This is clearly a matter for serious concern, given the established links between obesity, a high prevalence of CNCDs and high mortality.
The prevalence of mild undernutrition was low, and there was virtually no moderate or severe undernutrition.
Trends in nutritional status are difficult to discern because earlier surveys used different indicators. However, it seems that the prevalence of obesity (excluding overweight or pre-obesity) has risen since the 1993 Wildey study, at least among men.
Of special concern is the finding that the prevalence of overweight and obesity is already high among young men (nearly 30 percent) and young women (more than 50 percent) aged 18 to 29 years. These are the older adults of tomorrow.
Overweight and obesity are more likely to be found among individuals with poorer educational attainment (after controlling for age), and in households with lower food expenditure (after controlling for household size).
Very few overweight or obese respondents claimed to be on a weight reduction diet: 7.3 percent of men and 10 percent of women. Clearly Barbadian adults take little or no action until a CNCD has been diagnosed. This indicates a lack of understanding of the risk that obesity presents, and an absence of preventive action.
48 percent of men and 37.6 percent of women stated that they engaged in planned exercise. Walking was by far the most popular form of exercise. This survey's finding represents a small fall since the 1992 Barbados Risk Factor survey, which found that 48 percent of both men and women engaged in planned exercise.
The first step towards weight reduction is the recognition that one is overweight. Correct perception of own nutritional status in the survey sample was poor (although possibly better than it was in 1981): only 40.1 percent of overweight or obese men and 59.2 percent of such women recognized their condition. An encouraging finding, however, is that a higher proportion of young women (18 to 29 years) have a correct perception of their nutritional status.
Obese respondents were more likely to want to change their weight, a finding that suggests that a weight reduction or a healthy lifestyle campaign may be well received by those who need it most.
FOOD AND FOOD ACQUISITION PRACTICES
32.2 percent of households engaged in food crop production, fruit trees being the most frequently mentioned crop. Home food production has fallen steadily over the past 30 years: in 1969, 74 percent of households produced food, and in 1981, 56.2 percent.
11.2 percent of households reared livestock, with poultry, sheep and pigs being the animals mentioned most frequently.
Access to land was the primary constraint to increased food production.
Food purchasing practices
The fish market was the most popular source of fish (66 percent of households), with supermarkets (18 percent) and fishers (15 percent) also mentioned.
For the sample as a whole, supermarkets were the primary source of fruits, vegetables and other groceries, but wayside vendors were also popular for the purchase of fruits and vegetables.
However, lower-income households and households headed by women were more likely to purchase produce from wayside vendors and fish from the fish market (lower-income households only) than other households. This finding has implications for any programme aiming to improve access and promote healthy food choices through supermarkets.
Purchasing ready-to-eat meals and eating out are widely prevalent in Barbados: 45.3 percent of men and 31 percent of women consume ready-to-eat meals at least once or twice a week. Fast-food outlets were the most popular source of ready meals, followed by canteens and restaurants.
Young adults (< 30 years) were more likely to eat out: more than 76 percent of young men and 66 percent of young women ate out at least once or twice a week. Not surprisingly, the use of fast-food outlets was also highest in this age group. These findings, together with the high level of obesity in young adults, highlight the need to engage the private sector in efforts to promote and make available healthier food choices.
While 80 percent of respondents felt that they consumed adequate amounts of fruits and vegetables, only 14 percent of them actually consumed the daily amount recommended by the World Health Organization (370 g). However, underreporting of consumption may have occurred.
FOOD AND NUTRIENT INTAKES
Valid dietary intake data were obtained from 1 600 respondents. Healthy eating guidelines (for nutrients and foods) broadly include:
a reduction in fat intake (in absolute terms and in relation to energy intake), especially of saturated fats;
a diet that is rich in micronutrients (especially the antioxidants);
a reduction in the consumption of sugar;
an increase in the consumption of fruits and vegetables.
The survey identified the best food sources of energy and of the nutrients investigated, both in Barbados' food supply and as consumed by the survey respondents. This is essential information to guide the design of programmes that promote healthy eating.
Intakes of energy and macronutrients (fats, protein and carbohydrates)
Median energy intake was 2 136 kcals (8.95 MJ) for men and 1 715 kcals (7.17 MJ) for women. Compared with daily requirements, these figures represent 80 percent adequacy for men and 82 percent for women.
The methodology used for dietary intake generally underestimates actual consumption. The survey findings for energy intake are not unusually low, and are similar to those from the United Kingdom, where high levels of obesity are also found.
Protein intakes are high, reflecting a high consumption of meat, fish and poultry. Meat was also a rich source of fats and saturated fats.
The survey found that the
percentage of calories derived from fat in the Barbadian diet (close to 25
percent) is below the recommended WHO maximum of 30 percent, but well above
recommended Caribbean maximum of 15 to 20 percent.
The fact that the average contribution of fat to energy intake is not excessive (and well below that of the United Kingdom, for example) is no reason for complacency. It is important to recognize that nearly one-third of the respondents were consuming high-fat diets, and exceeding the recommended WHO maximum of 30 percent.
Of equal concern is the finding that a significantly higher proportion of younger (< 50 years) than older (³ 50 years) Barbadians exceeded the WHO maximum. This indicates a disturbing trend towards higher-fat diets.
The contribution of carbohydrates to the calorie intake is acceptable, at about 59 percent. However, the consumption of sugar and high-sugar beverages is high: carbonated beverages are among the six best sources of energy and carbohydrates.
The consumption of sugar and carbonated beverages by younger adults (< 30 years) -both men and women - exceeds by far their consumption by all other age groups.
Vitamins and minerals (micronutrients)
Owing to incomplete food composition data, intakes of some micronutrients may be underestimated. This applies especially to zinc, and to a lesser extent folate.
Men's average intakes of most vitamins and minerals were adequate when compared with the recommended dietary allowances (RDAs) for the Caribbean. Possible exceptions are intakes of calcium and zinc.
Women's average intakes of three minerals (calcium, iron and zinc) and folate fell below the RDAs.
In the case of zinc, the survey recommends further research before action is taken, because the survey figures are likely to be underestimates. Barbadians are unlikely to be suffering from zinc deficiency.
In view of the possible link between calcium intake and osteoporosis in later years, programme planners may wish to consider recommending increased intakes of calcium, especially among women. This link, however, remains controversial, and action should probably await the outcome of further research.
Of serious concern are the iron intakes of women of child-bearing age: relative to RDAs, women aged 18 to 49 years achieved only 80 percent adequacy. Equally disturbing is that more than 40 percent of these women were consuming very low levels of iron: less than 70 percent of the RDA.
These findings present a challenge to the nutritionist. Increasing the consumption of iron-rich foods generally also leads to increases in energy intakes, which are undesirable in the Barbadian context. This dilemma highlights the importance of exercise as an essential component of a weight reduction strategy, and the importance of an effective education programme for pregnant women and women of childbearing age.
Adequacy of folate intakes is also poorest among women of child-bearing age, and this is another matter of concern in view of the link between low folate status and certain types of birth defects. Clearly, nutrition promotion programmes need to encourage higher folate intakes among women of childbearing age, and planners may wish to consider a supplementation programme for women who are planning a pregnancy (supplementation during pregnancy is of little use, unless started very early).
Intakes of other micronutrients (vitamins A and C, thiamine, riboflavin and niacin) were generally adequate, although lower than those found among United Kingdom adults under 65 years (with the exception of vitamin C). This may reflect a lower consumption of fortified foods, such as breakfast cereals. Barbadians' intakes of micronutrients could be raised by the fortification of one or two key foods, such as crackers (biscuits) or bread.
The survey found that, even after correcting for energy intake, substantial proportions of men and women still have inadequate intakes of a number of micronutrients.
This finding has important policy and programme implications. Clearly what is needed is not more or less of the same diet, but rather a more diverse diet, with foods that contribute significantly to the intakes of certain vitamins and minerals, but not to fat intake. Examples of such foods are fruits and vegetables and low-fat dairy products.
Micronutrient adequacy was poorest among young men and women (< 30 years), and older men (³ 65 years).
Poorer micronutrient adequacy was associated with less healthy diets containing more alcohol, fats and sugar, and fewer fruits and vegetables.
Dietary diversity is an important predictor of dietary adequacy: as diversity increased, micronutrient adequacy improved.
Lower expenditure on food was associated with poorer diversity and poorer micronutrient adequacy.
Respondents from households engaged in food production are likely to have greater dietary diversity. This finding justifies past efforts to encourage home food production. However, further efforts to increase home food production may not meet with much success, so other strategies to improve the Barbadian diet should also be considered.
Most Barbadians enjoy a high standard of living. Nonetheless, the basic analyses of survey data suggest that economic and demographic factors (often interrelated) may influence food and nutrient intakes and health status.
In comparison with respondents from wealthier households, respondents from households in the lowest third of the income per capita range are:
more likely to be women, older, and unemployed or employed in manual occupations, as well as to have lower educational attainment;
more likely to suffer from diabetes and hypertension;
more likely to have inadequate intakes of micronutrients (and less likely to take micronutrient supplements);
less likely to take planned exercise;
less likely to consume meals outside the home;
less likely to consume sufficient fruit and vegetables.
In comparison with their counterparts living in households composed of both sexes:
men and women living in single-sex households are more likely to be older, have a lower educational attainment, and be unemployed (or work in manual occupations);
women in single-sex households have poorer intakes of iron, cereals, fruits and vegetables, and legumes - their diets lack diversity;
men in single-sex households consume fewer cereals, fruits and vegetables, legumes, meat and dairy products - their diets are both less diverse and less adequate in terms of micronutrient content.
Despite significantly lower per capita incomes, households headed by women appear to be coping well nutritionally, compared with households headed by men. In fact, the main nutritional difference to emerge was that older (³ 45 years) men and women living in female-headed households achieved greater dietary diversity than their counterparts in male-headed households.
Barbados, as most other countries, is experiencing a major demographic shift towards an ageing population. In general, nutrient adequacy was good in older Barbadians (³ 65 years), and better than that of younger Barbadians (and that of older people in the United Kingdom). There are significant differences in dietary patterns compared with younger (< 65 years) people: older people consume more starchy roots and tubers, but less sugar, carbonated beverages, cereals, legumes and fruits. CNCDs are more prevalent in older people, who are therefore more likely to be on diets, which may restrict dietary diversity. The poorest dietary diversity was found among older people living alone.
Three special issues were examined in detail: iron-deficiency anaemia, healthy lifestyles, and the situation of young Barbadians. Based on the points already mentioned, the survey concluded the following:
Women of child-bearing age have low intakes of dietary iron, and the intakes of more than 40 percent of these women are severely deficient. The risk of iron-deficiency anaemia and its consequences is high in this section of the population.
Healthy lifestyles should be promoted, both as a preventive action (against CNCDs) and for the management of CNCDs. The survey concluded that:
- respondents who claimed to be dieting either were not in fact doing so, or had poor compliance with dietary guidelines;
- the dietary message that has been best understood, by both men and women, seems to be the need to reduce sugar;
- advice to increase fruit and vegetable consumption is largely ignored;
- a comprehensive weight reduction strategy that includes taking planned exercise is not followed;
- overweight individuals in general do not diet until they have been diagnosed with a CNCD: less than 10 percent of overweight respondents not suffering from a CNCD stated that they were dieting, in contrast with nearly 41 percent of overweight respondents with a diagnosed CNCD. In short, no preventive action is being taken.
The survey reported some disturbing findings about the food and nutrition situation of young Barbadians (< 30 years). Unless preventive action is taken soon, a generation of Barbadians is emerging who will enter middle and old age already overweight or obese and with poor dietary practices, such as a high consumption of high-calorie fast foods, sugars and carbonated beverages, and a low consumption of vegetables. On the positive side, younger Barbadians are educated to a higher level and may show some awareness of their own dietary deficiencies (such as having better recognition of inadequate intakes of fruit and vegetables). These findings emphasize the importance of starting health and nutrition promotion early, i.e. during adolescence, and the need for collaboration across government sectors, non-governmental agencies, and the private sector.
Achieving good nutrition is a crucial step towards achieving a healthy population. Research repeatedly highlights the links between diet and health. Both obesity and low intakes of antioxidants are established risk factors for a range of CNCDs, while recent studies have shown that the increased consumption of fruits and vegetables can reduce blood pressure and heart disease rates, the latter by as much as 15 to 20 percent. Whether such dietary effects work through increased antioxidant levels, changes in fat profiles or other means is not clear. There are also indications now that higher than normal intakes of some micronutrients may delay the onset of AIDS in HIV-positive individuals. Other links between diet and disease include calcium with osteoporosis, salt with hypertension, and folate with birth defects.
The cost of diet-related disease is high both to a country's health system and economy and to its people, in human and financial terms. In common with many of its Caribbean neighbours, Barbados has experienced changes that may have had a negative impact on lifestyles and health: socio economic development, changed patterns of food acquisition and consumption, and increasingly sedentary lifestyles. The survey results highlight a number of key nutritional and nutrition-related problems that merit urgent attention. The survey report contains a wealth of information to guide the choice and design of appropriate policies and programmes. The following are some proposed areas for action, in the context of an overall nutrition strategy, and the operational strategies needed to achieve successful programmes. The overarching goal of such a nutrition strategy is clear, and reflects the goals of Barbados' National Plan of Action on Nutrition (approved by Cabinet in 1998) and the mission of NNC: the improvement of the nutrition and health of all sections of the population - and the maintenance of such improvement - through information, access to a safe, affordable food supply, and the promotion of healthy lifestyles.
MAKING INFORMED CHOICES
Creating an informed consumer is an essential first step towards achieving lifestyle change. Barbados has clear advantages in this regard: its food supply is plentiful, it has an educated population, and most Barbadians enjoy a high standard of living. To make informed choices, the consumer needs:
ready access to safe, cheap, healthy foods.
TAKING PREVENTIVE ACTION
While the dietary management of CNCDs receives commendable attention from NNC, the survey found that prevention of obesity and CNCDs appear not to be adequately addressed. Preventive action could include the following elements:
a public awareness campaign;
the targeting of high-risk individuals;
the promotion of healthy lifestyles, including:
- healthy eating;
- legislation and taxation to reduce smoking and alcohol consumption;
- promoting exercise by providing opportunities and facilities.
IMPROVING DIETARY MANAGEMENT
Current practices in the dietary management of CNCDs should be examined to find ways of increasing the diversity of foods in diet plans. When providing dietary counselling, health professionals need to stress foods that the client can eat, or should eat more of, and not just those to be avoided. Moreover, every effort should be made to reach overweight clients who are not suffering from a CNCD, in order to encourage weight reduction before a chronic disorder such as diabetes or hypertension develops. Individual weight reduction plans, including those for CNCD sufferers, should be comprehensive and include all aspects of a healthy lifestyle, especially an exercise programme.
SPECIAL TARGETED PROGRAMMES
Women of child-bearing age
Using the survey results and other information, nutritionists need to find ways of improving dietary folate and iron intakes and the bioavailability of the latter, without increasing the intake of energy.
The finding that substantial obesity exists among young adults highlights the need for starting action at an early age. Imaginative approaches are needed to make nutrition exciting to schoolchildren, and to further strengthen the existing food, nutrition and home economics programmes in schools.
Most of the actions recommended for the previous two categories will also have an impact on young adults. However, young adults greatest need is for an awareness of their own nutritional status, of the risks associated with obesity, and of the importance of early action.
The survey found that, on the whole, older Barbadians were coping well, nutritionally. Moreover, many of the actions described for the previous three categories can be designed to encourage active older people to participate. However, special attention should be paid to older people's dietary: meals with high fibre content and high micronutrient density, more frequent, smaller meals, and improved dietary diversity that accommodates food preferences. The emphasis must be on improving quality of life, and on enabling the older person to remain independent and living at home for as long as possible.
An essential precondition for all action is demonstrated political commitment, which translates into financial support and a willingness to engage all relevant sectors to address the problems. NNC alone cannot undertake the necessary actions.
Strategic use of NNC resources
It is recommended that NNC re-examine its approach to addressing the nutrition problems that are prevalent in Barbados. The individual dietary counselling that is currently offered by the technical staff of NNC can be carried out in collaboration with other health professionals with suitable training. In addition, the community nutrition programmes should be targeted, not only to the traditional vulnerable groups, but also to specific groups such as young people. The data that have been collected provide community-based nutrition programmes with the tools to develop effectively targeted interventions at the community level.
Virtually all the proposed actions require strategic alliances and often unconventional partnerships. At the very least, the collaboration of other government departments and ministries (such as those of agriculture and education) and the cooperation of the private sector (especially the food sector) are crucial to the success of an overall nutrition strategy.
Monitoring the food and nutrition situation
A simple, cost-effective system should be established to monitor progress in the implementation of a nutrition strategy and the achievement of its goals. Frequent food consumption surveys are costly and unrealistic. What is needed instead is the routine gathering of simple data on food patterns, nutritional status and CNCDs. There are a number of possible ways of achieving this.