4. VULNERABILITY PROFILES

This section presents the factors that contribute to specific nutrition conditions or situations, and describes the individuals who are more or less likely to be nutritionally vulnerable. In the first three sections it sets out to answer the following questions:

• Who are the overweight or obese individuals?

• Who is more likely to have a diet that is inadequate in micronutrients?

• Who is more likely to be consuming a diet that lacks diversity?

The answers to these questions can provide valuable information for programme planners and decision-makers in their efforts to design better-targeted programmes and formulate appropriate policies. Multiple regression analysis was used to answer the questions, so the explanatory factors that emerge as predictors or "descriptors" of the nutrition condition are those that are significant after controlling for all other variables.

The last two sections of the chapter examine economic and demographic vulnerability, and ask the following questions:

• How do poorer households differ from wealthier households in nutritional, health and socio-economic terms?

• Are households where there are only men or only women more nutritionally vulnerable than other households?

• Are female-headed households more nutritionally vulnerable than those headed by men?

• Are older people more nutritionally vulnerable than younger people? If so, how do their diets and socio-economic conditions differ from those of younger people?

Determinants of overweight and obesity^[16]

Body mass index (BMI) was used as an indicator of overweight and obesity. High BMI rather than low BMI is the primary nutritional concern in Barbados (see the subsection on Nutritional status in Chapter 3), both because of the link between obesity and mortality and because of its established link to CNCDs such as diabetes, hypertension, coronary heart diseases and certain cancers, as well as to the increased health care costs associated with the management of these and related complications.

The multiple regression analysis found that 24.7 percent of the variability in BMI was explained by factors that entered the analysis. The following factors were significantly associated with high BMI, i.e. with overweight and obesity:

• Lower educational attainment. In general, Barbados enjoys a high level of literacy and educational attainment, however the analysis identified those who completed only primary school as being more likely to be overweight (even after controlling for age).

• Employment. Those in employment were more likely to have a high BMI than those not in employment. Information on income was unfortunately not available for a large proportion of the sample. As an alternative, the analysis included information on whether the individual was employed and the nature of that employment. It is important to state that the "unemployed" included students, housewives and retired people, in addition to those who were genuinely unemployed.

• Lower food expenditure. Food expenditure information was collected in six categories rather than as actual food expenditure. It was therefore not possible to calculate per capita food expenditure. However, even after controlling for household size, the analysis found that lower food expenditure was significantly associated with higher BMI.

• Increasing age. The relationship between age and BMI is not linear (see Figures 2 and 3). The prevalence of overweight and obesity increases with age until about 65 years, when it starts to fall.

• Gender. Barbadian women are more likely to be overweight or obese than Barbadian men. The prevalence of overweight and obesity (BMI > 25 kg/m²) was nearly 64 percent among women and 56 percent among men.

• Desire for weight change. Respondents with a high BMI were more likely to want to change their nutritional status. This finding shows that a weight reduction or healthy lifestyle campaign could be positively received by those who need it most.

• Hypertension. Not surprisingly, overweight and obese individuals were more likely to be suffering from diagnosed high blood pressure.

• Dietary diversity. Overweight and obese respondents were more likely to have a low dietary diversity score; in other words, these individuals were consuming a diet that not only provided more energy than they needed (hence the high BMI), but was also more monotonous.

Determinants of micronutrient adequacy

Using the micronutrient adequacy score as the indicator, multiple regression analysis found that 25 percent of the variability in the score was explained by the following factors, after controlling for all other relevant factors. Poorer micronutrient adequacy was associated with:

• household size - larger households were more likely to have a lower score;

• lower food expenditure;

• men in male-only households, compared with men in households composed of both sexes;

• gender - women were more likely than men to have poor scores;

• not dieting - this factor covered a range of diets, including weight-reducing diets, low-fat, low-cholesterol or low-salt diets. This finding could suggest that respondents with poorer micronutrient adequacy scores were generally less concerned about healthy lifestyles, as supported by the following dietary factors;

• higher alcohol consumption;^[17]

• higher percentage of energy from fats;

• higher percentages of energy from carbohydrates and sugars;

• lower consumption of fruits and vegetables;

• poorer diversity of diet.

Determinants of dietary diversity

Using the dietary diversity score as the indicator, multiple regression analysis found that 13.2 percent of the variability in the dietary diversity score was explained by the following, after controlling for all other relevant factors:

• Lower food expenditure.

• Not growing own food - respondents from households engaged in food production activities were more likely to benefit from a diverse diet. This is an important finding because it justifies past efforts to encourage home food production. However, further efforts to increase home food production are unlikely to meet with much success, and other strategies to improve the Barbadian diet should also be considered. It is also important to bear in mind the list of constraints that respondents identified as affecting their engagement in, or increasing of, home food production activities. The most important of these was insufficient access to land (see subsection on Food production in Chapter 3).

• Households with only male or only female members were more likely to have poor dietary diversity scores than households with both male and female members. In the case of female-only households, this may be a reflection of poverty (see the following two sections on Poverty profile and Older people). Male-only households were not poorer than households with both sexes, so their low dietary diversity may reflect a poorer ability (or willingness) to prepare food.

• Individuals diagnosed with diabetes were more likely to have poorer dietary diversity. This may be a reflection of the diabetic diet, and nutritionists should perhaps seek ways of improving the diversity of this diabetic. Poorer diversity was also associated with a higher BMI (overweight and obesity, as indicated in the previous section on Determinants of overweight and obesity).

• Poorer diversity was associated with lower dietary and micronutrient supplement usage, as well as with the unhealthy practice of adding oil or butter to gravy. In general this indicates a lack of concern for a healthy lifestyle, or perhaps poverty.

• Respondents with lower diversity scores were also more likely to have lower energy intakes. This may seem to contradict the relationship between diversity and obesity. However, obesity is not simply a result of high energy intakes, but is also an outcome of a low level of physical activity.^[18]

• Poorer micronutrient adequacy scores were associated with poorer diversity, a finding that re-emphasizes the importance of a diverse diet.

Poverty profile: links with nutrition, health and socio-economic factors

Most Barbadians enjoy a high standard of living. Nonetheless, the results of the regression analyses suggested that economic factors may influence food and nutrient intakes and health status. The study therefore examined respondents in the following categories to see whether they differed significantly from other respondents, in socio-economic, demographic, health and nutritional terms:

• the lowest third of the income^[19] per capita range;

• single-sex (male only or female only) households;^[20]

• female-headed households.

LOWER-INCOME RESPONDENTS

Regarding socio-economic and demographic factors, respondents from poorer households were found to be significantly more likely to:

• be older;

• be women;

• be unemployed, or employed in manual occupations;

• come from larger households;

• have lower educational attainment;

• engage in food production activities (growing food and rearing animals);

• purchase fruits and vegetables from wayside vendors, rather than supermarkets;

• purchase fish from the fish market, rather than supermarkets.

From a health and nutrition perspective, respondents from poorer households were significantly more likely to:

• be diagnosed with diabetes;

• be diagnosed with hypertension;

• have diets in which carbohydrates contributed a larger proportion of the energy;

• consume more cereals;

• add oil, butter or margarine to gravies and sauces (one of the three "unhealthy" practices investigated).

On the other hand, respondents from poorer households were significantly less likely to:

• take exercise;

• consume meals outside the home, especially at fast-food outlets;

• take micronutrient supplements;

• consume adequate amounts of fruits and vegetables;

• achieve micronutrient adequacy (i.e. they had lower micronutrient adequacy scores).

SINGLE-SEX HOUSEHOLDS

More than a quarter of the sample (25.6 percent of men and 25.3 percent of women) lived in single-sex households. Men and women in single-sex households were compared with their counterparts in households comprising both sexes. Women in single-sex households were more likely to:

· be older;

· be unemployed;

· have a lower educational attainment.

These women were also less likely to:

• engage in food production activities^[21] (grow food or rear animals);

• take exercise;

• consume meals outside the home;

• have adequate intakes of iron;

• consume cereals, legumes, fruits, vegetables and items providing calories only, such as sugar, carbonated beverages and alcohol;

• have diverse diets (i.e. their dietary diversity scores were lower).

Men in single-sex households were more likely to:

• be older;

• have higher per capita incomes (but see footnote 23);

• have lower educational attainment;

• work in manual occupations (rather then administrative, managerial and professional occupations);

• purchase fish at fish markets, rather than supermarkets;

• take dietary supplements (such as Supligen);

• consume alcohol;

• be diagnosed with hypertension.

These men were less likely to:

• take micronutrient supplements;

• remove skin and fat from meats and poultry (two of the "healthy" practices investigated);

• consume cereals, legumes, meat, dairy products, fruits, vegetables, fats and oils;

• have diverse diets (i.e. their dietary diversity scores were lower);

• achieve micronutrient adequacy (i.e. their micronutrient adequacy scores were lower).

FEMALE-HEADED HOUSEHOLDS

A high proportion of Barbadian households are headed by women: 44.6 percent. The survey also found that 23.6 percent of men and 58.9 percent of women lived in households headed by women. It found that these households had significantly lower median incomes than households headed by men (B$1 200 per month, compared with B$2 000), and that a higher proportion of them fell below the UNDP poverty line (19.8 percent, compared with 5.8 percent).

The survey found the following two differences in methods of food acquisition between male- and female-headed households:

• Households headed by women were significantly less likely to grow food crops.

• They were significantly more likely to purchase fruits and vegetables from wayside vendors.

Female-headed households were also more likely to engage in the healthy practice of removing the skin and fat from poultry during food preparation.

There were significant differences between the mean ages of men and of women dwelling in female- and male-headed households (Table 4.1):

• Men in female-headed households were younger than men in male-headed households.

• Women in female-headed households were older than women in male-headed households.

Table 4.1 Mean ages of respondents living in female-and male-headed households, by sex

These age differences made it necessary to examine differences between the inhabitants of male- and female-headed households in two separate age groups (< 45 years and ³ 45 years). Few differences emerged from these analyses, despite the findings regarding household incomes already noted. The following were the significant differences:

• Younger men (< 45 years) in female-headed households, compared with those in male-headed households, were more likely to:

  - be unemployed;
  - have lower BMI;

  and less likely to:

  - suffer from high blood pressure;
  - consume alcohol.

• Younger women (< 45 years) in female-headed households, compared with those in male-headed households, were more likely to consume meals outside the home. This may be because women in female-headed households are more likely to work outside the home.

• Older men (³ 45 years) in female-headed households, compared with those in male-headed households, were more likely to: -have high protein intakes; -have high dietary diversity scores.

• Older women (³ 45 years) in female-headed households, compared with those in male-headed households, were more likely to:

  - suffer from a chronic disorder, especially hypertension;

  - have a low educational attainment (60 percent completed primary school only, compared with 45 percent of women in male-headed households);

  - have high dietary diversity scores.

In summary, respondents living in female-headed households appear to be no more nutritionally vulnerable than their counterparts in male-headed households, despite lower incomes. Arguably, the higher dietary diversity scores, at least among older men and women in female-headed households, indicate better diets.

Older people

Recent demographic trends in the Caribbean, as elsewhere in the world, indicate a major increase in the proportion of the population to be made up of older people. It is forecast that this proportion will reach or exceed 10 percent by 2025 in most Caribbean countries.

In Barbados, this figure has already been exceeded: in 1997, 12 percent of the population (32 730 men and women) were aged 60 years and over, and this proportion is expected to rise to 23.2 percent (67 037 people) by 2025, with 62 percent of these people being at least 75 years of age. In the survey sample, 20.5 percent of men and 22.6 percent of women were aged 65 years or over.

Older people face a range of risk factors that make them especially vulnerable to poor nutrition. These include the following:

• Economic factors. Many older people rely on limited pensions, savings and gifts from relatives, which are often inadequate to meet their needs or the rising cost of living.

• Social isolation. Emigration, the breakdown of the extended family and the death of younger adults from AIDS leaves many older people without essential social and support networks.

• Physical and mental disabilities and disorders. These include impaired mobility and poor functional ability (often related to bone, joint and muscle disorders such as arthritis), poor dentition, vision and hearing, and senile dementia.

• Poor health. Older adults are those most likely to suffer from CNCDs, such as diabetes, hypertension and cardiovascular disorders. Furthermore, in many countries, access to health care is limited because of poverty, poor mobility and a health system that is geared more to meeting the needs of infants, children and younger adults. In Barbados, however, older people enjoy ready access to health services, and utilization is high.

• Physiological changes. Age-related changes in taste, smell, appetite and gastrointestinal function can limit or substantially alter food preferences and consumption patterns. There are also age-related changes in nutritional requirements, which frequently go unrecognized by older people and their families. In addition, older people are often on long-term medication, which can have an impact on taste, appetite and nutrient needs and absorption.

Because a substantial proportion (22 percent, N = 352) of the sample comprised older people (³ 65 years), it was possible to analyse their food and nutrition situation, and related socio-economic and health factors. The analysis included:

• comparisons with United Kingdom (HMSO 1990 and 1998) and United States data (CDC, 1988-1994): dietary intakes (UK), and BMI (UK and USA);

• a comparison of the health and nutrition of older adults (³ 65 years) with those of younger adults (< 65 years);

• a comparison of men and women aged ³ 65 years;

• a comparison of older people living alone with those not living alone.

COMPARISON WITH UNITED STATES AND UNITED KINGDOM DATA

Table 3.10 provides comparative data from Jamaica, the United Kingdom and the United States. The mean BMI of older Barbadian men is lower than the mean BMIs of men in either the United Kingdom or the United States. Barbadian women, have a mean BMI that is close to those of women in the United Kingdom and of white United States women, but lower than that of black United States women; it is also higher than the mean BMI of older, urban Jamaican women.^[22]

Table 4.2 compares dietary intake data from the Barbados survey with similar data from the United Kingdom. With the exception of fats, calcium and zinc, the dietary intakes of all nutrients are substantially higher among older Barbadian men and women than among their United Kingdom counterparts. Especially noteworthy are the substantially higher intakes of all micronutrients, except calcium and zinc. Clearly older Barbadians fare better in the comparison than younger Barbadians, whose intakes of all micronutrients except iron and vitamin C were lower than those of their United Kingdom counterparts.

Table 4.2 Comparison of Barbados and United Kingdom dietary intakes: median intakes of older men and women, aged ³ 65 years

COMPARISON WITH YOUNGER ADULTS

In general, older people in Barbados appear to enjoy good nutritional status and dietary intakes (see Tables 3.10, 3.17 and 3.18). Although the prevalence of undernutrition increases slightly after the age of 64 years, overweight and obesity decline (see Figures 2 and 3). Older people's nutrient intakes are adequate in relation to their RDAs for all nutrients except zinc (see comments on zinc intakes in the sections on Recommendations for future surveys: difficulties encountered and limitations of the survey in Chapter 2, and Nutrient intakes in Chapter 3) and calcium, the latter especially in the case of women.

Analysis to compare the health and nutrition of older and younger Barbadians showed positive and negative features from the perspective of older people. On the positive side, older adults were significantly more likely to:

• meet their nutrient needs for energy, iron, vitamin A, thiamin, riboflavin and niacin;

• consume starchy roots, tubers and fruit.

Also on the positive side, they were less likely to:

• be overweight;

• consume sugars, carbonated beverages and alcohol;

• eat meals outside the home (fast-food outlets, etc.).

On the negative side, older people were more likely to:

• be diagnosed with diabetes and/or hypertension and/or suffer from a coronary heart disorder;

• be on a diet that restricts diversity (hence their lower dietary diversity scores);

• add butter, oil or margarine to gravies (one of the "unhealthy" practices investigated by the survey).

Also on the negative side, they were less likely to:

• consume cereals, legumes and fruit;

• take micronutrient supplements (which is not necessarily a negative feature when dietary intakes are adequate).

COMPARISON OF OLDER MEN AND WOMEN

Older women were more likely than older men to:

• be overweight;

• suffer from a CNCD: diabetes, hypertension, and coronary heart disease;

• be on a diet, generally related to a CNCD.

Men were more likely than women to:

• consume alcohol;

• eat meals outside the home;

• consume legumes, meats, sugars, and carbonated beverages;

• achieve micronutrient adequacy.

COMPARISON OF OLDER PEOPLE LIVING ALONE WITH THOSE LIVING WITH OTHERS

Older people living alone appear to be more vulnerable to poor nutrition than those living in households with family (or other) members.

They were less likely to:

• meet their protein and thiamin requirements;

• consume cereals, starchy roots, fruits and tubers, meat and vegetables;

• achieve dietary diversity;

• take micronutrient supplements;

• remove skin and fat from poultry and meat (one of the "healthy" practices investigated).

SUMMARY

In Barbados, the growth of the older population has been accompanied by the development of a number of programmes, both public and private, to meet the needs of older people. A pension provides the main, often the sole, income during retirement. Facilities for older adults include government institutions (eight polyclinics and three satellite clinics in a government hospital, as well as three district hospitals; a residential home for older adults, a hostel and an activity centre), and private or non-governmental institutions (more than 40 private nursing and residential care homes, one day-care centre, a meals centre, and a senior citizens' village complex). In addition, the government's Alternative Care for the Elderly programme purchases space from private nursing homes for the care of ambulant older people.

Fifty percent of admissions to government institutions are the result of chronic medical disorders, lack of social support, poor housing, poverty, and lack of adequate home care. A high percentage of these people die soon after admission: for the period 2000 to 2002, 47.5 percent of older people admitted to a government institution died within the first six months of admission. The reasons for this include apathy, withdrawal and inappropriate management of malnutrition.

While commendable progress has been made to address these issues, including the establishment of a non-governmental organization (NGO), the Barbados Association of Retired Persons, and the National Committee on Ageing, the following areas need attention:

• improving the quantity and quality of home and community-based care to permit older people to remain in their homes and communities if they wish;

• supporting families in their efforts to provide better care for older relatives;

• enacting legislation that addresses the abuse and neglect of older people, the deprivation of property and financial assets, and all forms of age discrimination;

• providing better nutrition support and guidance for older people, and making available nutrition information for older people, their care givers and health professionals. The survey results point to specific nutrition issues that need to be addressed: dietary diversity, improving the dietary management of CNCDs, and increasing the consumption of fresh fruits and vegetables;

• reaching and supporting older people living alone;

• recognizing the rights, contributions and dignity of older people.

While the survey results point to a generally good nutritional status and dietary intake for older people, there are trends indicating that younger adults may be engaging in dietary practices that will lead to a higher proportion of nutritional problems in the future.