Achieving good nutrition is a crucial step towards achieving a healthy population. Research repeatedly highlights the links between diet and health, the best recognized of which are those between diet and diabetes, hypertension, heart disease and certain cancers. Other links include calcium with osteoporosis, salt with hypertension, and folate with birth defects, to name but a few.
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 and that include 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. This chapter proposes some broad 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.
The primary food and nutrition-related problems and issues identified by the survey are:
a high prevalence of obesity;
a high prevalence of CNCDs;
a need to improve the dietary management of CNCDs;
the limited action taken to prevent the development of CNCDs;
the need for programmes targeted to:
- women of childbearing age (especially in relation to iron intakes);
- older adults;
- younger adults (and schoolchildren).
This chapter proposes some policies, programmes and actions to address these issues.
Creating an informed consumer is an essential first step towards changing lifestyles. 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 the following:
Nutrition knowledge. To develop an understanding of what constitutes a balanced diet, to gain knowledge on the richest food sources of nutrients, and to learn to make realistic assessments of the quantities of foods needed to achieve healthy eating. The development of simple food-based guidelines is essential. Innovative techniques are needed to impart nutrition knowledge. One possibility is to focus on one food, or one group of foods, at a time (such as fish, fruits, vegetables and low-fat dairy products), and to create a mini-campaign around the item(s).
Food labelling. Clear, simple information is needed on both imported and local foods. Labelling should be limited to information on key nutrients and ingredients. Supportive legislation is needed to achieve this, and to avoid unsubstantiated or false health and nutrition claims and advertising.
Ready access to safe, cheap, healthy foods. The survey found that dietary diversity and micronutrient adequacy are limited among certain vulnerable groups. Access to a varied supply of affordable foods, especially fresh fruits and vegetables, will enable all Barbadians, particularly those from lower-income households, to make healthy choices. Here there is a clear role for supermarkets: not simply to ensure that these foods are readily available, but also to spotlight healthy choices through special offers, promotions and recipes, as well as the use of marketing strategies such as aisle arrangements and advertising inside and outside the supermarket.
While the dietary management of CNCDs receives commendable attention from NNC, the survey found that the prevention of obesity and CNCDs appears not to be adequately addressed. Preventive action could include the following elements:
A public awareness campaign. To create an understanding and recognition of risk factors, by the individual and by health professionals.
The targeting of high-risk individuals. Health professionals need to determine the risk status of the individuals in their care, and recommend early preventive action. Key risk factors are a family history of CNCDs, obesity (and pre-obesity), and smoking. Medical practitioners (or nurses) should assess BMI routinely, with the aid of a BMI chart; alternatively a "girth tape" can be used for the self-assessment of obesity. With coloured zones (green, yellow and red) the tape is easy to use and understand. Because much weight gain is associated with pregnancy, urging lactating mothers to lose excess weight gained in pregnancy will always prove useful.
The promotion of healthy lifestyles, including:
- healthy eating - in addition to ensuring access to an affordable healthy diet, preventive action could include the micronutrient fortification of a key food, such as crackers (which are an important part of the Barbadian diet);
- legislation and taxation to reduce smoking and alcohol consumption;
- promoting exercise, and providing opportunities and facilities - including the provision of subsidized membership to health clubs, for example, by businesses and industries for their workforce, or by the health system for high-risk individuals; the creation of public spaces for walking and jogging; the granting of time off work for exercise; and the improvement of sports and gym facilities in schools, together with the scheduling of more time for physical education. Encouraging home gardens would serve the dual purpose of providing exercise and improving dietary diversity (as well as reducing food costs).
Current practices in the dietary management of CNCDs should be examined to find ways of increasing the diversity of the 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 clients who are overweight but 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.
Women of childbearing age. Using the survey results and other information, nutritionists need to find ways to improve dietary folate and iron intakes, and the bioavailability of the latter, without increasing the intake of energy. Compliance with iron supplementation programmes can be problematic, so alternative forms of supplementation and dosage (such as weekly supplementation) could be examined.
Schoolchildren. The finding that substantial obesity exists among young adults highlights the need to start action at an early age. Imaginative approaches are needed to make nutrition exciting to schoolchildren, and to strengthen further the existing school food, nutrition and home economics programmes. It would be possible to include nutrition in the physical education programme to encourage boys to become involved. Other techniques include: developing an interactive computer tool enabling students to assess their own diets and how they can be improved; emphasizing the "science" of nutrition, and teaching nutrition in the broader context of national (and international) development; and promoting healthy lifestyles through competitive group work and more exercise.
Young adults. Most of the actions recommended for schoolchildren will also have an impact on young adults. However, what young adults need most is awareness of their own nutritional status, of the risks associated with obesity, and of the importance of early action. Given that it is unrealistic to imagine that the trend towards eating out can be reversed, collaboration with the private sector, especially with the major fast-food chains, becomes imperative. Much is possible: extending the range of foods on offer to include attractively presented, flavourful and reasonably priced healthier choices; working with a nutritionist to find ways to reduce the fat and sugar content of foods currently available; and displaying nutrition information prominently.
Older people. The survey found that older Barbadians were, on the whole, coping well nutritionally. Moreover, many of the actions described for other age groups can be adapted to encourage the participation of active older people. However, special attention could be paid to older people's dietary needs: meals with high fibre content and high micronutrient density; more frequent, smaller meals; and improving dietary diversity while accommodating food preferences. The emphasis must be on improving the quality of life, and on enabling older people to remain independent and living at home for as long as possible. Support and training is needed for the care givers of frail, older people and the staff of residential and nursing homes. A special effort is required to reach older people who live alone. These, and all other related actions, should be carried out in cooperation with the National Committee on Ageing and other groups and agencies, both national and community-based.
Political commitment. An essential precondition for action is demonstrated political commitment that translates into financial support and the willingness to engage all relevant sectors to address problems. NNC alone cannot undertake the actions described in the previous section.
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 currently offered by the technical staff of NNC can be carried out in collaboration with other health professionals with suitable training, and group counselling activities can be maintained. In addition, community nutrition programmes should be targeted not only to the traditional vulnerable groups, but also to specific groups such as young people who, as the survey shows, do not perceive themselves to be at risk for the development of CNCDs. The data that have been collected provide community-based nutrition programmes with the much needed tools to develop effectively targeted interventions at the community level.
Strategic alliances. Virtually all the actions proposed here require the forging of strategic alliances, and the forming of 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 through food industry, supermarket and fast-food chains) are crucial to the success of an overall nutrition strategy. A National Coordination Committee on Food and Nutrition already exists, but there is still a need for specific strategic alliances to address specific actions, rather than a large, all-encompassing committee.
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 possibilities for doing this:
- the routine weighing and measuring of schoolchildren of a specific age;
- the use of data from duplicate supermarket checkout slips to monitor food expenditure patterns;
- the monitoring of simple food frequency data (perhaps limited to a few key foods, such as sugar, fruits and vegetables, oil and butter) and nutritional status (weights and heights of young adults) at a few representative sentinel sites.
Other data can be accessed to provide relevant information:
- data on the number of people diagnosed with diabetes, hypertension and other selected chronic disorders;
- haemoglobin data from antenatal clinics;
- sales data from selected fast-food chains
 Guyana will shortly be
assessing pregnant womens compliance with the use of
sprinkles, an iron and folate supplement packaged in daily dose
sachets, which is sprinkled over food. Other micronutrients can be included in
 In addition to increasing physical education, schools can promote exercise in classes through, for example, breaking classes for a brief ten-minute exercise regimen, and encouraging a daily exercise plan of walking a mile a day in school. These are being tried out in the United States, and could also be explored in Barbados.
 Sentinel sites are specific geographic areas of limited size that are selected to represent larger areas. They can include rural and urban sites with different socio-economic populations.