5. SPECIAL ISSUES

This chapter focuses on the three important nutritional problems found in the Barbadian population: iron-deficiency anaemia, obesity-related CNCDs (in the context of a discussion of healthy lifestyles), and the situation of younger Barbadians.

Iron-deficiency anaemia

Iron-deficiency anaemia has long been recognized as one of the most common (and intractable) nutritional disorders. Clinical signs and symptoms are generally non-specific and often go unrecognized. Anaemia in young children is especially common at weaning age, and is associated with growth faltering, increased susceptibility to infection, fatigue and impaired mental and motor development, leading to poor school achievement. In adults, it is most common in women of child-bearing age, although it is also found in older women^[23] and in men. Anaemia in adults is associated with fatigue, impaired work capacity and lower productivity in manual occupations, especially those involving hard labour. This can have serious implications for a household's income, and hence for a country's economy and development. Severe anaemia in pregnancy can lead to increased maternal morbidity and mortality and lower birth weight.

The availability and absorption of dietary iron is influenced by many factors. Dietary iron is found in the following two forms:

• Non-haem iron is found in foods of both animal and plant origin, and has a low bioavailability (generally 1 to 10 percent), which is increased or decreased by other dietary constituents and by the haemoglobin status of the individual. Dietary constituents that enhance iron absorption include vitamin C, amino acids and protein, while inhibitors of iron absorption include phytates, certain phenolic compounds and calcium. In addition, an anaemic individual absorbs more non-haem iron than a non-anaemic individual.

• Haem iron is found only in foods of animal origin, and has a high bioavailability (20 to 30 percent), which is little affected by other dietary constituents or by the haemoglobin status of the individual. However, dietary calcium can substantially reduce haem iron absorption.

The best sources of iron are meats (especially offal). Legumes are the best plant-based source, while the much-promoted green leafy vegetables are in fact very poor sources of iron (1 to 2 percent absorption). Absorption of dietary iron from plant sources can be substantially increased by including the enhancers of non-haem iron as part of a meal (e.g. a high-vitamin C drink) and avoiding inhibitors (e.g. milk, tea or coffee) at meal times.

The Barbadian diet encompasses many foods that are rich in iron, and provides some excellent sources of enhancers of iron absorption. Meats, offal, poultry, fish, legumes and fortified breakfast cereals and flours are rich sources of iron, while fresh fruit and juices (especially the Barbadian cherry, guavas and citrus fruit) are excellent sources of vitamin C to enhance the absorption of non-haem iron.

In Barbados, pregnant women are routinely screened for anaemia as part of antenatal care. Screening among children and other adults is not routine, and is conducted only if an individual displays the signs and symptoms of anaemia or has experienced severe blood loss. In 1969, Barbados' nutritional surveillance system indicated that the prevalence of anaemia among adult females (pregnant and non-pregnant) was 19 percent, but this figure was arrived at using a different cut-off from that used in later surveys. The 1981 National Nutrition Survey recorded a prevalence of 27.5 percent among adult females^[24] and 19.1 percent among adult males. The prevalence of iron-deficiency anaemia among Barbadian women is similar to that of their counterparts in St Lucia, Grenada, St Kitts and Guyana, but the prevalence among Barbadian males is lower than that of males from these countries. Curacao appeared to have a low prevalence of iron-deficiency anaemia in 1995: 7.2 percent among women and 0.5 percent among men (LeBlanc et al., 1995).

Table 5.1 Distribution of iron adequacy among women, by age

The survey did not obtain information on haemoglobin levels. This discussion of survey results therefore relies on dietary intake data and information from the food frequency questionnaire.

While dietary intakes of iron for the survey sample as a whole were more than adequate, there were considerable ranges in iron intakes and in the achievement of adequate iron nutrition. Men of all age groups consumed on average sufficient iron to meet their needs (see Tables 3.17 and 3.18), as did older women (> 64 years and, to a lesser extent, 50 to 64 years). Women of child-bearing age, however, were not meeting their iron needs (78 and 82 percent of their RDAs were being met by women aged < 30 years and 30 to 49 years, respectively). This is a matter for concern, because this group is the most vulnerable to iron-deficiency anaemia. Table 5.1 shows the percentage of each age group of women falling into three adequacy categories: < 70 percent, 70 to 90 percent, and > 90 percent of the RDA.

The rise in iron adequacy with increasing age was highly significant among women (see also Table 3.18). Among men, there was no significant change in iron adequacy with age (Table 3.18). Nearly 60 percent of women of child-bearing age were not meeting their requirements for iron (< 90 percent adequacy). Of even greater concern is the fact that more than 40 percent of these women had very low iron intakes: less than 70 percent of the RDA.^[25] A regression analysis not only confirmed that men had significantly better iron adequacy than women, but also that poor iron adequacy was related to low fruit and vegetable consumption and poor dietary diversity.

Iron intakes are also strongly related to energy intakes. This presents the nutritionist with a dilemma: in the Barbadian context energy intakes should be reduced in order to address the problem of obesity. However, such a reduction would bring with it a reduction in iron intake, which is undesirable in women of child-bearing age. Nutritionists planning nutrition promotion programmes need to find ways to improve iron intake (and absorption) while limiting energy intakes. This also highlights the importance of an exercise programme as an essential component of a weight reduction strategy, and improvements in the education programme for women of child-bearing age as part of an anaemia reduction strategy.

Healthy lifestyles

The survey results presented in Chapter 3 show clearly that the primary nutritional problem of Barbadians is overweight and obesity (55.5 percent in men and 63.8 percent in women). Unfortunately, a direct comparison with Barbados' 1981 National Health and Nutrition Survey is not possible, as a different indicator of overweight and obesity was used. In that survey, 53 percent of women and 29.7 percent of men were identified as overweight or obese (> 110 percent weight for height).

Table 5.2 Prevalences of hypertension in Barbados, Jamaica and St Lucia*

* The cut-offs used to define hypertension were 160/95 mm Hg for systolic and diastolic pressures.

Linked to the high prevalence of overweight and obesity, the current survey also found a high prevalence of CNCDs (10.1 percent of men and 15.2 percent of women were diagnosed with diabetes, and 17.3 percent of men and 28.8 percent of women with hypertension). Again, data from the 1981 Barbados survey are not directly comparable. That survey report states that "approximately 6.6 percent of the total adult sample had had a previous history of diabetes". This is probably comparable with the current survey's figure of 12.9 percent for the total sample.

The 1981 survey also measured blood pressure. Using cut-offs of 160 mm Hg for systolic pressure and 90 mm Hg for diastolic pressure, the prevalence of hypertension was 28 percent for women and 27 percent for men. However, in relation to the current survey, a more comparable figure is 21 percent, namely the proportion of the 1981 sample that had received treatment for hypertension. This is a little lower than the current survey's figure of 23.7 percent diagnosed with hypertension in the whole sample.

A study conducted in 1996 (Freeman et al.) compared the prevalence of hypertension in Barbados, Jamaica and St Lucia (Table 5.2), and found it to be highest in Barbados.

The 1993 Wildey study from Barbados (Foster et al., 1993) found a diabetes prevalence of 15 percent among men and 16 percent among women. Again the data are not directly comparable with the current survey, because the Wildey study was limited to adults aged 40 to 79 years living in the outskirts of Bridgetown, and the diagnosis of diabetes was based on fasting plasma glucose levels. However, the Wildey study also stated that 10.8 percent of sample men and 10.2 percent of sample women had previously been diagnosed with diabetes. Comparable figures from the current survey are 13.1 percent for men and 19.6 percent for women aged 40 to 79 years, suggesting that the prevalence of diabetes has risen since 1993,^[26] especially among women.

Not surprisingly, the prevalence of overweight and obesity (see Figure 2) and of diabetes and hypertension are higher in older people (diabetes: 15.8 percent for men and 27 percent for women; hypertension: 28.2 percent for men and 47.1 percent for women).

The survey also found that while the prevalence of overweight (BMI of 25.1 kg/m² to 30 kg/m²) was higher among men (40.4 percent) than women (34.2 percent), the prevalence of obesity (BMI > 30 kg/m²) was almost twice as high among women (29.6 percent) than men (15.4 percent). This latter finding can be compared with the Wildey study, which showed that the prevalence of obesity in women was three times that in men (30 percent compared with 10 percent). It would seem therefore that the prevalence of obesity has risen between 1993 and 2000 among men but not among women.

While the prevalence of overweight and obesity is higher in the older age groups, it is still alarmingly high among young adults (< 30 years), especially young women (see Figure 2). This bodes ill for the future, especially in light of the high usage of fast food and the poorer dietary patterns (lowest micronutrient adequacy scores) in this age group (see following section on Younger adults).

Obesity is not the only linking factor between diet and CNCDs. Low intakes of antioxidants have been shown to be linked to higher risks of a range of CNCDs. Studies aimed at reducing the CNCD risk through the use of micronutrient supplements have proved disappointing (at least in relation to cardiovascular risk), but a number of recent studies have shown that 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.

The promotion of healthy lifestyles is a major issue facing most industrialized nations, as well as many of the developing nations that are coping with a double burden of disease and malnutrition, i.e. infectious diseases and CNCDs coupled with undernutrition and overweight. Healthy lifestyles encompass a range of factors: improved diets, increased exercise, reduced alcohol consumption and smoking, and reduced stress. Such lifestyle and behavioural changes present a major challenge because they are difficult to achieve in the short term and few studies have demonstrated their long-term sustainability. The Barbados Diabetes Intervention Study illustrated clearly that although positive changes can be achieved, continued support and interventions are needed to ensure sustainability.

There seems to be a lack of comprehensive data on physical activity in the Caribbean region. The 1992 Barbados Risk Factor Survey Report stated that 48.4 percent of the sample supplemented their daily routine with additional exercise or physical activity in their leisure time. Walking was the most popular activity, followed by dancing, cycling, swimming, aerobics, ball games and gardening. Men engaged in more planned exercise than women. This survey found that an even smaller proportion of respondents claimed to take planned exercise (42.2 percent) than in 1992, and again fewer women (37.6 percent) than men (48 percent) participated. Activity choices were similar, with walking being the most popular form of exercise.

Over the past few decades, in common with many of its Caribbean neighbours, Barbados has experienced a number of changes that may have had a negative impact on lifestyles. These include the following:

• Socio-economic development has increased the availability of foods that are imported, processed, nutritionally dense (especially in terms of high fat and sugar contents), inexpensive and easily prepared.

• There has been a rapid increase in the number of fast-food outlets, and the use of these outlets is now high, especially among the young (see subsection on Food practices in Chapter 3).

• Home food production activities have fallen sharply - in 1969, 74 percent of Barbadian households produced food; by 1981 this figure had fallen to 56.2 percent; and the survey found that only 32.2 percent of households planted food crops and 11.2 percent raised livestock.

• Increasingly sedentary lifestyles associated with socioeconomic development have reduced energy expenditure through the use of automobiles, increased television viewing, sedentary work, labour-saving devices in the home and at work, and reduced household-level food production activities.

In addition to dietary intake and food frequency data, socio-economic data and information on the presence or absence of a diagnosed non-communicable disorder, the survey also gathered information on a number of health-related issues: planned exercise, eating meals outside the home (including the use of fast-food outlets), food practices that could influence fat intake, alcohol consumption, dieting (a range of diets relevant to obesity and CNCDs were investigated), and the use of dietary and micronutrient supplements. This information is summarized in Chapter 3. The bureau also collaborates with and assists government and non-governmental agencies with the implementation of various programmes.

This section seeks to answer the following questions: Who suffers from CNCDs, and what food and nutrition features do they exhibit? and Who diets, and how has dieting made a difference to their food and nutrient intakes? Specifically, it examines more closely:

• the profile of men and women who suffer from a CNCD;^[27]

• the comparison between overweight dieters and overweight non-dieters;

• the comparison between dieters and non-dieters with a CNCD.

PROFILE OF MEN AND WOMEN WITH DIABETES AND/OR HYPERTENSION^[28]

Table 5.3 summarizes the findings, separated by sex, and places the features that characterize CNCD sufferers into three categories: socio-economic and demographic features; health, food and nutrition features; and food practices.

Table 5.3 Features of respondents with diabetes and hypertension, by sex

* This table includes only those features that were found to be significantly different between CNCD sufferers and non-sufferers.

The table shows that, with the exception of male hypertensives, CNCD sufferers are likely to be older men and women of lower socio-economic status and poorer education. Male hypertensives are found at both extremes of the occupation scale. Not surprisingly, CNCD sufferers are more likely to be overweight, and overall their diets lack diversity. The lack of diversity may to some extent reflect efforts to diet: there are encouraging signs that CNCD sufferers have reduced their consumption of fats and oils, alcohol, sugar and carbonated beverages, as well as the practice of adding fat to gravy. It is more discouraging however that they have also reduced their consumption of fruit and vegetables, and that there was no significant difference between CNCD sufferers and non-sufferers in the percentages of energy obtained from fats.

The fact that respondents with CNCDs ate outside the home and at fast-food outlets less frequently is likely to be a reflection of their age (see the section on Older people in Chapter 4),^[29] rather than indicating a conscious effort to follow a healthier lifestyle. Fast foods are now increasingly popular among younger Barbadians, and there is concern that they will continue this practice even when they reach the more vulnerable age for CNCDs.

One notable absence from the list of healthy lifestyle practices is the taking of planned exercise. While it is encouraging that substantial percentages of Barbadian men (48 percent) and women (37.6 percent) claim to take planned exercise, it is surprising that there is no difference between respondents with CNCDs and those without.

COMPARISON OF OVERWEIGHT DIETERS AND OVERWEIGHT NON-DIETERS

The decision to diet to lose weight involves recognizing that one is overweight, that this carries serious health risks, and that one can, and wants to, take action to rectify the situation. Behaviour modification is long, complex and difficult, as evidenced by the failures of so many weight reduction efforts.

The subsection on Perceptions of nutritional status, dieting and exercise in Chapter 3 noted that only about 40 percent of overweight men and 59 percent of overweight women recognized that they were overweight or obese. Of respondents who were overweight or obese, only 7.3 percent (N = 28) of men and 10 percent (N = 55) of women stated that they were on a weight reduction diet. This is in the context of a prevalence of more than 60 percent for overweight and obesity among Barbadian adults.

Analysis to compare overweight dieters and non-dieters was limited by the small sample size of dieters. However, in both men and women, dieters appeared to engage more in planned exercise. Women dieters had a higher educational standard and ate more vegetables. Men dieters were more likely to be from households where fish, fruits and vegetables were bought from supermarkets. They also consumed fewer fats and cereals, and showed lower energy intakes. There were no other significant differences between dieters and non-dieters in food and nutrient intakes.

COMPARISON OF DIETERS AND NON-DIETERS WITH A CNCD

A substantially larger proportion of respondents with CNCDs claimed to follow a diet than was found among overweight and obese respondents: approximately 50 percent of diabetics and 30 percent of hypertensives stated that they were on a diet to control the disorder.

Unfortunately, however, there were few significant differences in the consumption of foods and none at all in nutrient intakes between CNCD respondents who claimed to be on a diet and those who were not dieting. Women dieters consumed fewer dairy products and less fruit, sugar and carbonated beverages. Men consumed less alcohol, sugar and carbonated beverages. Female dieters had poorer diet diversity, were older and ate outside the home less frequently than their non-dieting counterparts. Male dieters came from smaller households and ate fewer meals outside the home.

The following conclusions can be drawn:

• Respondents who claimed to be dieting either were not in fact doing so, or had very poor dietary compliance.

• The dietary message that has been best understood by both men and women seems to be the importance of reducing sugar.

• The advice to increase fruit and vegetable consumption is being ignored.

• A comprehensive weight reduction strategy, including planned exercise, is not being followed.

• Overweight individuals in general do not diet until they have been diagnosed with a CNCD - less than 10 percent of overweight respondents who had no 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.

Younger adults

The results of this survey highlighted some disturbing features about the food and nutrition situation and food practices of younger adults.^[30] These features should alert health and nutrition planners to problems that lie ahead as this generation of Barbadians approaches the age of increasing vulnerability to CNCDs. In this study, young men and women (< 30 years) were profiled by comparing them with their older counterparts and each other.

YOUNG WOMEN COMPARED WITH OLDER WOMEN

Regarding young women (< 30 years), the following two important findings have already been highlighted:

• the high prevalence of more than 50 percent of overweight and obesity (see Figure 2) among young women;

• the high prevalence of iron inadequacy - more than 60 percent of young women were consuming less than 90 percent of the recommended allowance for iron (see Table 5.1).

This section examines the differences between younger and older women, so as to identify features that can be addressed in health and nutrition promotion programmes.

Young women (< 30 yrs) were more likely than older women (30 to 59 years) to:

• achieve a higher education level - secondary as opposed to primary school only;

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

• have lower mean BMIs - 26.5 kg/m² compared with 28.1 kg/m². Nonetheless, a mean BMI of 26.5 is high, and falls in the overweight (pre-obesity) rather than the normal range;

• recognize that they are overweight or obese - 74.3 percent of young women with high BMIs (> 25 kg/m²) stated that they considered themselves to be overweight, compared with 61.7 percent of older women with high BMIs;

• have a lower percentage of energy intake from protein, and a higher percentage from carbohydrates;

• consume greater quantities of cereals, as well as foods and beverages containing calories only - sugar, carbonated beverages;

• consume smaller quantities of starchy roots and tubers, meats and vegetables;

• recognize that they are consuming inadequate amounts of fruits and vegetables;

• have lower micronutrient adequacy scores.

Young women were less likely than older women to:

• be diabetic (4 percent compared with 11.4 percent) or hypertensive (9.7 percent compared with 22.4 percent). This is not surprising.

YOUNG MEN COMPARED WITH OLDER MEN

The prevalence of overweight and obesity among young men (< 30 years), although lower than that among young women, was by no means negligible, at nearly 30 percent (see Figure 2). Young men also exhibited a low prevalence of underweight, at just over 8 percent (see Figure 3). However, no moderate or severe undernutrition was found, and most of the undernutrition fell into the 17 to 18.5 kg/m² range (mild undernutrition).

Young men (< 30 years) were more likely than older men (30 to 59 years) to:

• achieve a higher education level - secondary as opposed to primary school only;

• be unemployed;

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

• use dietary supplements (such as Supligen);

• have lower mean BMIs (23.6 kg/m² compared with 26.7 kg/m²);

• have a lower percentage of their energy intake from protein;

• consume more cereals and items containing mostly calories: sugar, carbonated beverages;

• consume smaller quantities of starchy roots and tubers, meats and vegetables;

• recognize that they are consuming insufficient fruit and vegetables.

Young men were less likely than older men to:

• consume alcohol;

• suffer from hypertension (5.2 percent compared with 15.8 percent);

• be on a diet (this is probably related to the fact that CNCD prevalence is lower in younger men).

YOUNG WOMEN COMPARED WITH YOUNG MEN

Young women were more likely than young men to:

• have inadequate intakes of calcium and iron;

• have lower micronutrient adequacy scores;

• suffer from a CNCD;

• correctly perceive themselves as overweight.

Young men were more likely than young women to:

• have a lower BMI;

• consume meals outside the home;

• consume legumes and foods and beverages containing only calories: sugar, carbonated beverages and alcohol.

SUMMARY

Unless preventive action is taken soon, a generation of Barbadians is emerging that will enter middle age and old age already overweight or obese and with poor dietary practices, such as high consumption of high-calorie fast foods, sugars and carbonated beverages, and 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 an early start to health and nutrition promotion, during adolescence, and the need for collaboration across government sectors, non-governmental agencies and the private sector.