The first section of Chapter 6 describes the potential uses government, NGOs and other stakeholders in the Caribbean can make of food consumption and anthropometric information. The second section shows how the results from these surveys can be applied more effectively.
Food consumption and anthropometric surveys aim to identify the characteristics of nutrition-related diseases and the eating habits associated with them. The goal is to detect or predict changes that might apply to standards and guidelines intended to improve health and well-being of the population. It is recognized that applications may not be appropriate to all situations; accordingly, the country context will be paramount in the consideration of the applications below. Diagram 6.1 illustrates the linkages between the different phases in moving from data collection to decision-making and captures the main steps described in previous chapters of this document. The direction of the arrows in the diagram emphasizes several feedbacks and interactions that must inform each phase and the overall process.
The withdrawal of the World Food Programme from the Caribbean has led many governments to initiate school-feeding and other supplementation programmes. These initiatives should be guided by the results of appropriate food consumption surveys so that the types, quantities and balance of these supplements are cost-effective and efficacious. The need for fortification of different types of foods in special and general programmes can also be determined. The surveys can also be used to evaluate such programmes. For example, if designed appropriately, a food consumption survey can determine whether a school lunch programme significantly improves children's diets.
One major factor that retards progress in health development in the Caribbean is the inequity of access to health services and healthy food. Food consumption surveys can expose the inequities of food and nutrient intake by sex, age, income, location and other factors. Identifying these inequities is critical in developing strategies to reduce food insecurity and nutrition-related illnesses in the region.
More and more Caribbean families are eating foods away from their homes in the form of "fast foods", snacks and carbonated drinks. It is well known that these foods are usually high in fats, sugar and salt. Food consumption surveys will help to determine how often, when and where such foods are eaten and, more importantly, to what extent they fail to meet set dietary criteria. In addition, anaemia continues to be a major problem in young children and pregnant women in the Caribbean. A food consumption survey will reveal the range and quantity of iron-rich foods; it will also show the foods that inhibit and enhance the absorption of those iron-rich foods. Clearly, this information is critical in developing strategies to combat anaemia in the region. In addition, previous research shows that Caribbean women over 20 years are especially at high risk of overweight and obesity and that their intakes of fat in particular can be of special importance to programming educational and other interventions.
The Caribbean has not experienced much collaboration between the private and public sector with regard to food production, manufacturing and promotion. This public-private partnership is very important if healthy foods are to be made available, accessible and consumed by all sectors of the population. Findings from consumption surveys could predict the demand for several foods and beverages and this public-private partnership can jointly plan for the production and promotion of healthy foods for the public.
ASSESSMENT OF CURRENT DIETARY INTAKE
Chronic diseases such as stroke, heart disease, diabetes and cancer are the causes of most deaths in the Caribbean. Nutrition is the most important element in preventing and managing these chronic diseases, and as a result assessing dietary intake is vital in determining the nutritional risk associated with these diseases. In addition, surveys of what people eat give valid information that will allow policy-makers and programme planners to develop education programmes or remedial efforts to improve nutritional status and health. Food consumption surveys can ascertain the size and nature of groups that might be at risk because of inadequate or excessive intake of nutrients. As a result, food consumption surveys will show the dietary changes necessary for meeting the dietary goals for improved health and well-being. They will also shape the direction of educational efforts.
As has been highlighted above, anthropometric data are also very useful for assessing the nutritional status of population groups. When used in conjunction with food consumption data, they provide a more complete nutritional profile. Anthropometry has been included in most of the consumption studies conducted in the Caribbean. This has allowed for the analysis and description of eating patterns in relation to obese and non-obese states. When disaggregated by sex, age, location and other factors, the interpretations of these data are clearer and the recommendations more appropriate.
Eating habits in the Caribbean have been changing in the last few decades. More and more unbalanced diets with a smaller range of nutrients being consumed can be observed. Food surveys can:
detect the extent of these nutritional deficiencies and the necessary educational programmes required to address them;
identify populations at nutritional risk for possible intervention with fortification, education and supplemental programmes.
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Diagram 6.1 From data to decision-making in food consumption and anthropometric surveys |
TREND ANALYSIS IN EATING PATTERNS
The rapid transition of the dominant health problems from undernutrition to the chronic nutritional diseases in the Caribbean necessitates a close examination of the changes in dietary patterns. Regular consumption surveys can reveal the nutrients that are increasing and decreasing in the diet of different population groups by factors such as location, social status, age and sex, among others. These patterns of consumption will enable policy-makers and administrators to plan corrective strategies at different points in the food chain so that healthy foods can be available and affordable to all population groups.
The combination of weight/height and height/age indices provides an excellent opportunity to examine both recent and chronic nutritional deficiencies. The correlation of these data with the current and past food consumption data can provide a much greater understanding of the nutrition problems and assist tremendously with the appropriate designing of nutrition policies and programmes.
As an evaluation tool, these surveys can also identify changes in food and nutrient consumption that might be expected to reduce risk. Analysts can therefore correlate food consumption and dietary patterns with incidence of disease over time. For the Caribbean, this is especially critical with the heightened interest in chronic diseases and the enormous cost of them to society.
Globalization and liberalization policies have increased the volume of food trade across countries and regions. The Caribbean is particularly affected by this trade and some countries in the region import almost all of their food. Repeated consumption surveys will identify shifts in the types of foods introduced into the marketplace. In addition, information on the nutrient contribution of these foods (e.g. low and high fat, snack products, frozen mixtures, fruits and vegetables) will enable better policy decisions and educational programmes to be developed.
The changing consumption pattern of nutrients over time will help policy-makers determine whether the national dietary standards are achievable and reasonable in relation to the disease profile of the country. The findings of such repeated surveys will allow for the re-examination of standards set.
Food consumption trends can predict the demand for certain agricultural products and marketing facilities. Through such information policy-makers have an excellent opportunity to influence consumption patterns by proving incentives and disincentives for healthy and non-healthy products, respectively.
Dietary trends project the future demand for food in particular socio-economic groups. They also show the effects of certain socio-economic factors on the demand for food. Policy makers can therefore predict the impact of certain interventions given the socio-economic conditions prevailing.
The cost of food consumed over time can be also deduced from these repeated surveys. Because food is a major component of household expenditure, consumption surveys provide essential data in understanding vulnerability of different populations groups. Some Caribbean countries have used food consumption and food-expenditure data as part of their poverty assessments. This information is therefore vital to the construction of cost-of-living indices.
DIETARY GUIDELINES
Few countries in the Caribbean have up-to-date empirical information on what population groups eat. It is therefore urgent that consumption surveys are conducted so that dietary guidelines based on scientific evidence can be developed. Dietary guidelines are necessary to influence eating patterns that are consistent with good health, and can be developed only if there is a clear understanding of what nutrients do and how much of each may be needed.
FOOD SAFETY
People in the Caribbean should have access to good-quality, safe, nutritious and wholesome food. Unfortunately, many national health authorities do not fully appreciate the critical importance of food safety to public health, tourism and the food trade. Every day people in the Caribbean face many hazards related to the food they consume such as the abusive application of agricultural chemicals, environmental contamination, use of unauthorized additives, genetically modified organisms and improper food-quality control. Although food consumption surveys may not be able to detect these hazards, they can determine the level of intake of the foods that are known to contain these contaminants.
Food consumption surveys can identify the size and nature of populations at risk from use of particular foods and food products. Manufacturers can identify the volume of consumption of certain products of interest. They can also predict food items in which a food additive can safely be permitted in specified amounts. These surveys can also identify extreme and unusual patterns of intake of foods or food ingredients, including food additives. This will provide vital information for food regulation and education.
It has been made clear that the purpose of food consumption and anthropometric surveys is to recommend and facilitate action on short- and long-term measures designed to prevent and control nutrition-related diseases. The Caribbean experience highlights that key strategies are necessary in order to facilitate policy action on the basis of survey results.
Recommendations include:
involving decision-makers from the beginning of the process;
increasing their awareness of the usefulness of data and information that can be generated by the surveys;
ascertaining key stakeholders' specific information needs;
securing key stakeholders' commitment to the process and identifying what contribution they can make;
determining the appropriate method and scope of survey (qualitative vs. quantitative, how much detail, objectives, geographical coverage, target groups);
ensuring that sample design and strategy will answer policy-oriented questions with the required precision;
managing data collection and analysis with rigour;
explaining and interpreting results for different audiences;
communicating findings by preparing reports for different audiences;
planning a dissemination strategy for various stakeholders through workshops, scientific and technical papers, mass media, and community meetings.
Factors can enhance this process are:
relevance;
quality of the research;
cost-effectiveness;
a multi-faceted approach;
report content;
timeliness and frequency;
dissemination;
messages from the findings;
partnerships. These shall be examined in more detail now.
RELEVANCE
It is vital that the relevance of food consumption and anthropometric surveys is highlighted to policy-makers. It is important to make explicit to policy-makers how data from food consumption and anthropometric surveys can be used to improve healthcare programmes and consumer choices in the particular country context. Researchers should therefore present food consumption reports to policy-makers that show not only current eating patterns but also the linkages and predicted benefits of an altered food consumption pattern and the expected profile of nutritional and health status in the country.
Furthermore, as the nutrition problems change and resources become more limited, it will be necessary to identify more carefully vulnerable groups and risk factors. These concerns have to be highlighted and discussed early in the planning process to ensure that the survey findings will be relevant and useful to decision-makers.
QUALITY OF THE RESEARCH
Particular attention must be given to the survey's design, methodology and analysis. If the survey is conducted with appropriate rigour there will be less room for different interpretations of the data. The quality of the research is vital. Policy-makers will hesitate in making decisions when controversy surrounds the findings so it is necessary to demonstrate the credibility of the results. It is also important to ensure that limited financial resources do not impinge on the quality of the research output. Utilizing the expertise at the University of the West Indies, CFNI and other institutions will encourage professional confidence by policy-makers in the research output. Publishing the results in reputable regional and international journals could also inspire confidence in the work produced.
COST-EFFECTIVENESS
Economic implications are often a major consideration in helping a policy-maker ascertain the worthiness of support. Researchers should consider the cost-effectiveness of any recommendations when designing the original hypothesis and design. For example, in the Caribbean, we know that many children and adults consume huge amounts of "empty calories" i.e. high-energy foods with few nutrients; we also know that more than half of Caribbean women are overweight. Were there to be a recommendation arising from an anthropometric and food consumption survey that urgent steps be taken to counsel and treat all these affected persons individually, the implications of such a decision would demand an outlay of funds larger than the entire health budget of any Caribbean country. Thus, constraints in resources would in the end modulate the vigour with which survey recommendations are pursued and interventions actualized. Researchers should then consider the cost of possible interventions not only when the recommendations are being made after the survey, but even when developing the original hypothesis and design.
A MULTIFACETED APPROACH
One strategy for the recognition and implementation of food consumption survey findings should be to ensure that policy-makers or their representatives are included in the survey team throughout the research process. Clearly, surveys in which officials have been involved from the early stages, and in which findings are discussed with officials and their input sought at every stage have a higher chance of having its findings adopted. In the cases of Barbados and Guyana - the Ministry of Health - and with Dominica - the Ministry of Agriculture - were integrally involved with the food consumption surveys. In Jamaica the University worked closely with the Ministry of Health in the food consumption and lifestyle surveys. The presentation of the survey reports was organized by the respective ministries. Other strategies include:
community mobilization around the objectives of the survey;
the adoption of the research findings by the national nutrition and dietetic professional bodies such as the Caribbean Association of Nutritionists and Dieticians.
PARTNERSHIPS
The few consumption studies conducted in the Caribbean were led by one entity - usually a government ministry or university with limited involvement of other sectors or stakeholders. If the results of these surveys are to be used by the key stakeholders then there must be greater collaboration between government, food industry, scientific and professional community the media and the public. This collaboration should start from the setting of objectives. No one group possesses all the knowledge, resources and incentives to achieve positive dietary change. Too often, nutrition research results in the Caribbean have remained in the domain of academia and the government ministries. To achieve the effective impact from food consumption and anthropometric findings, public-private partnerships will be crucial in nutrition education and other public communications.
REPORT CONTENT
Too often, reports on food consumption surveys to policy makers merely present the results and discussion, rather than transforming them into conclusions and practical recommendations. Two major barriers to the transfer of food consumption data to decision-making are: (1) time to understand the implications of the findings and (2) lack of information in a form that policy-makers can use. Both relate to the type of report that is presented to the policy maker. Policy-makers need information on which standards, norms and guidelines can be established. Although based on empirical data from food consumption surveys, food guidance is an inexact science. It is a compromise between competing nutritional goals and what can be achieved with the kinds and quantities of foods available to the target population. Report recommendations must therefore be presented in ways that the policy-maker can apply.
It is important then to consider publishing the findings not only in peer-reviewed scientific journals but also in local journals and newsletters to which the national policy and programme leaders have access.
TIMELINESS AND FREQUENCY
Policy-makers in the Caribbean need timely information of the current situation. In the past reports took years to be finalized and presented. There needs to be major improvements in the gap between data collection and reporting so that the results can be useful in programme management and evaluation. Methods of handling data must be improved so that reports can be disseminated within a few months of assessment.
Some Caribbean countries have had only one consumption survey in recent history, other have none. Even surveys conducted every ten years tell us nothing about the effects of change in food prices or food supplies or factors related to programme development and operation.
DISSEMINATION
Survey findings can only be useful if it they are made known to people who can use them. It is important to ensure that there are effective mechanisms for regular dissemination of the survey results in order to allow an early application of research findings in policy and programmes. The results on many nutrition research studies in the Caribbean have been communicated through publications in journals and presentations at conferences and other scientific meetings. Findings communicated through these channels have only a low probability of reaching policy makers and being applied in policy decisions. Regular reports of the survey process and the findings in simple and non-technical language to community and government officials is therefore vital.
It is worth considering a variety of modes for disseminating the results of food consumption and anthropometric surveys. Some important considerations include reaching a wide variety of audiences, from lay people, to policy-makers to donors. Feedback to local communities, particularly those that participated in the study, is highly recommended.
For example, in 2003 a national workshop was convened in Guyana to present and discuss the findings and policy implications of the food consumption survey. The workshop was followed by a series of regional and community-level meetings where the findings for the particular groups were discussed in more detail. In Barbados, results of the survey were disseminated successfully through a workshop in 2003 for potential users of results. At the workshop the executive summary was distributed. The workshops targeted food companies, e.g. fast food outlets, supermarkets; non-governmental organizations, cancer support groups, retired persons; government departments, gender affairs, poverty alleviation groups; and ministries: Agriculture, Education, Health and Farmers.
These are recent surveys and the impact of the dissemination process is yet to be determined. However, Cuba has been successful in establishing the link between survey results and their application - especially the ones relating to the nutritional status of children that have helped in identifying the extent of nutritional problems in certain areas and groups.
Despite these efforts, a general weakness of past nutrition and food consumption surveys in the Caribbean has been the lack of attention paid to a communication and dissemination plan for the findings. Furthermore, if a plan existed there was no specific budget allocated to it.
MESSAGES FROM THE FINDINGS
The Caribbean offers numerous avenues to transmit diet and health messages to the consumers through nutrition education, labelling, advertising and the media. While some of this is being carried out already, there is clearly a need to become more sophisticated in constructing and communicating the messages. The goal should be to reach individual consumers with messages of practical value so that they can prepare more healthy meals. Too often, the messages fail to take into account taste, enjoyment and an array of social and cultural forces that influence food choices and preparation
