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Changing nutritional patterns in the Caribbean and their implications for health

Dinesh P. Sinha and Curtis E. McIntosh

Abstract

In the last 30 years, the health and nutrition of young children in the English-speaking Caribbean has improved significantly. Infant and child mortality rates and severe cases of PEM have declined. However, among adults obesity has increased and high morbidity and mortality rates due to chronic degenerative diseases have been reported. This paper reports on the food and nutrition patterns of the two countries that are at the upper and lower limits of economic development in the region, Barbados and Guyana respectively. In the last three decades, compared to Guyana, Barbados has made significant progress economically and has increased food availability. It has eliminated malnutrition in children; however, nutrition-related chronic diseases in adults have assumed epidemic proportions. Qualitative as well as quantitative aspects of the diet need to be addressed. Public education programmes need to be developed to encourage low-fat/high-complex-carbohydrate diets. In addition to diet. other lifestyle factors such as exercise, smoking, alcohol consumption. and psychosocial stress need to be addressed among the Caribbean populations.

Editor's note

This paper addresses an important issue and makes a number of useful points. Our reviewers pointed out the probability that reduced physical activity is playing a larger role than is commonly acknowledged in the development of obesity and obesity-related diseases. For example, the data for Barbados given in this article indicate that the prevalence of obesity in men has doubled despite a relatively small increase in dietary fat. The Food and Nutrition Bulletin would be interested in receiving several additional papers from developing countries that provide similar quantitative documentation of a transition from malnutrition and acute infections as the overwhelming health problems requiring attention to an increasing proportion of nutrition-related chronic diseases and obesity.

Introduction

There has been a significant improvement in the health and nutrition of young children in the English-speaking Caribbean countries in the last thirty years. Severe cases of protein-energy malnutrition such as marasmus and kwashiorkor, which were once common, are now not seen frequently. Infant and child-mortality rates and life expectancy are approaching those found in the more developed countries of the world [1]. On the other hand, an increasing proportion of adults are becoming obese. In some countries of the region more than half of the adult females and over a quarter of the male population are reported to be obese (fig. 1) [2, 3]. It is not surprising that these countries also report high morbidity and mortality - in some cases the highest in the world - due to chronic diseases such as diabetes, high blood pressure, coronary heart disease, stroke, and cancer (fig. 2) [4]. Available evidence indicates that these problems are growing rapidly in the region. According to a recent report [5], approximately 30% of adults 35 years old and over are hypertensive and 12%15% suffer from diabetes mellitus (approximately 20% in the population of East Indian origin).

While the death rate from coronary heart disease has been reported to be low, national health and nutrition surveys carried out in some of the countries in recent years reveal that an alarmingly high proportion of the adult population have high levels of serum cholesterol and triglycerides, hyperglycaemia, and low levels of high-density lipoprotein, all of which have been reported to be factors contributing to coronary heart disease [6] (table 1). Thus it is evident that obesity and non-communicable chronic diseases such as hypertension, diabetes, stroke, heart disease, and cancer have become the major health problems in the countries of the English-speaking Caribbean.

FIG. 1. Prevalence of obesity (weight for height >120% of standard) in persons over 15 years of age in selected Caribbean countries

FIG. 2. Age-adjusted rates for mortality due to nutrition-related chronic non-communicable: diseases (Rates for Barbados, Grenada, and Saint Christopher and Nevis not adjusted for age)

Diet, nutrition, and non-communicable chronic diseases

Extensive research in the industrialized countries has substantiated an association between dietary factors and rates of chronic diseases [7, 8]. As the economy of countries improves, there appears to be a tendency towards increased consumption of refined sugar, fats and oils, and foods from animal sources - increasing, in addition to calories, the saturated fat, cholesterol, and salt in the diet. Excesses of these nutrients have been found to be associated with obesity, diabetes, hypertension, and heart disease [9]. High intake of total fat has also been found to be associated with increased risk of cancers of the colon, prostate, and breast [10]. In the changing pattern of diet associated with the above increases, a reduction has been noted in the consumption of complex carbohydrates (mostly plant foods - cereals, roots and tubers, pulses and seeds, and fruits and vegetables). Diets rich in plant foods, especially green and yellow vegetables and citrus fruits, are associated with lower occurrences of cancers of the lung, colon, oesophagus, and stomach [11].

TABLE 1. Percentages of adult population with potentially reversible risk factors for coronary heart disease in Barbados and the Bahamas

a. Adults over 35 years old: 1981
b. Adults over 15 years old; 1988-1989 Data for serum cholesterol, high-density lipoprotein, and blood glucose levels are fur males and females combined.
c. Systolic >160 and or diastolic >90.
d. Weight for height >120% of standard.
e. For Barbados: >125 mg/100 ml. For the Bahamas: > 110 mg/100 ml.

TABLE 2. Intermediate and ultimate nutrient goals for Europe

Source: Ref .8.

a. Values relate to alcohol-free total energy intake.
b. The complex carbohydrate figures arc implications of the other recommendations.
c. Dietary fibre values are based on analytical methods that measure non-starch polysaccharides and the enzyme-resistant starch produced by food processing or cooking.

Although much is still uncertain about how dietary patterns protect or injure human health, enough has been learned about the overall health impact of dietary patterns now prevalent in these societies to recommend significant changes. On the basis of the available evidence, the Surgeon General of the United States has made the following general key recommendations concerning dietary changes [7]:

» Fats and cholesterol: Reduce consumption of fat (especially saturated fat) and cholesterol. Choose foods relatively low in these substances, such as vegetables, fruits, whole grains, fish, poultry, lean meats, and low-fat dairy products. Use food preparation methods that add little or no fat.
» Energy arid weight control. Achieve and maintain a desirable body weight. To do so. choose a dietary pattern in which energy (calorie) intake is consistent with energy expenditure. To reduce energy intake, limit consumption of foods relatively high in calories, fats. and sugars, and minimize alcohol consumption. Increase energy expenditure through regular and sustained physical activity.
» Complex carbohydrates and fibre: Increase consumption of whole-grain foods and cereal products, vegetables (including dried beans and peas). and fruits.
» Sodium: Reduce intake of sodium by choosing foods relatively low in sodium and limiting the amount of salt added in food preparation and at the table.
» Alcohol: To reduce the risk of chronic disease, take alcohol only in moderation (no more than two drinks a day), if at all. Avoid drinking any alcohol before or while driving, operating machinery, taking medications, or engaging in any other activity requiring judgement. Avoid drinking alcohol while pregnant.

A similar set of goals, intermediate and ultimate, have been presented for the European countries in a report by the European Regional Office of WHO [8] (table 2). The World Health Organization, in one of its most recent technical reports on the subject [12i, has recommended a more precise dietary goal for the population and suggested that "the goals proposed are appropriate for developed and developing countries alike" (table 3).

TABLE 3. Nutrient goals - limits for average population intakes

source: Ref 12.

a. Energy intake needs to be sufficient to, allow for normal childhood growth for the needs of pregnancy and lactation. and for work and desirable physical activities and to maintain appropriate body reserves of energy in children and adults Adult populations should have on average a body mass index (body mass in kilograms/height in metres]²) of 20-22.
b. Interim goal for populations with high fat intakes: further benefits would be expected from reducing fat intake towards 15% of total energy
c. A daily minimum of 400 g of vegetables and fruits, including at least 30 g or pulses. nuts. and seeds. should contribute to this component
d. Includes non-starch polysacharides (NSP), the goals for which are based on NSP obtained from mixed sources. Since the definition and measurement of dietary fibre remain uncertain, the goals for total dietary fibre have been estimated from the NSP values
e. Including monosaccharides. disaccharides. find other short-chain sugars produced by refining carbohydrates
f. Not defined.

FIG. 3. Total calorie availability by country, 1984-1986

Food availability patterns in the Caribbean

Food balance sheets produced by the Food and Agriculture Organization show that during 1984-1986 all the countries of the Caribbean except one had an adequate daily per capita calorie availability (fig. 3) [15]. This is a marked improvement over the 19611963 figures, in which seven out of the eleven countries for which data were available showed a shortfall in total calorie availability (fig. 4) [16].

FIG. 4. Changes in per capita calorie availability, 1961-1983

The distribution of calorie availability by food group in the mid-1980s ranged as follows in different countries: 43%-66% from complex carbohydrates, 11%-24% from animal products, 4%-22% from fats and oils? and 14%-17% from simple sugar (fig. 5). Fourteen per cent to 29% of the energy was derived from total available fat from all food sources and 9%-12% from total protein (fig. 6).

While it is encouraging that countries of the Caribbean no longer face a shortfall in available calories. the data reveal some very disturbing trends - ones which the experience of the industrialized countries warns the developing countries to guard against. Most of the increases in energy availability in the Caribbean countries in the last 30 years have been due to increases in food from animal sources and fats and oils. Thus the relative consumption of total fat has been increasing (fig. 7), while that of complex carbohydrates has consistently declined in most countries (fig. 8). The contribution of different sources of complex carbohydrates is shown in figure 9. The majority of the energy in this group came from cereals, which, except in Guyana and Belize, were almost all of imported origin. The contribution of roots and tubers, pulses and oilseeds, and fruits and vegetables, which most countries produce and can increase further, was invariably very poor and has been declining. A higher consumption of these foods is strongly associated with a lower prevalence of some of the chronic diseases.

Two-country case study

The data from Barbados and Guyana, countries at the extremes of, economic development in the region, were analysed further to illustrate some emerging food and nutrition patterns that should be of concern.

FIG. 5. Contribution of different food groups to total calories

FIG. 6. Contribution of fat and protein to total calories

FIG. 7. Changes in availability of calories from total fat, 1961-1983

FIG. 8. Changes in availability of calories from complex carbohydrates. 1961-1983

FIG. 9. Contribution of different sources of complex carbohydrates to total calories

Barbados experienced a strong economic growth between 1960 and 1982, with an average increase in the gross domestic product (GDP) of 4.5%, the highest in the Caribbean [17]. During the same period Guyana's rate was 1.7%. More recently Barbados's per capita GDP rose from US$3,530 in 1970 to US$4,233 in 1988 (at 1988 prices), while Guyana's declined from US$1,111 to US$995.

Between 1961-1963 and 1981-1983, Barbados's per capita daily energy availability increased from 2,595 to 3,131 kcal (39% above its average estimated requirement), whereas in Guyana there was a marginal increase from 2,295 to 2,334 kcal (a mere 4% above the requirement). It should be mentioned that Barbados imports a large proportion of its food supply; it imported 62% of its calories in 1966 and 78.8% in 1986-1988. Guyana, on the other hand, is a major producer of its own food. Its food imports decreased from 34.5% in 1964-1966 to 18.7% in 1986-1988.

While Barbados has made significant progress economically as well as in total food availability in the last three decades compared to Guyana, nutritional improvement is less clear. It is true that Barbados has eliminated malnutrition in children during this period and Guyana continues to fight this problem. From the point of view of adult health, however, the progress in Barbados needs to be examined and improved to prevent nutrition-related chronic diseases which have assumed epidemic proportions.

In Barbados, between 1961 - 1963 and 1985, the proportion of calories from complex carbohydrates declined from 52% to 41%, while that from animal products increased from 18% to 24% and that from fats and oils increased from 12% to 22% (fig. 1()). As a result, the proportion of calories from total fat rose from 20% to 29%. In Guyana, on the other hand, the contribution of complex carbohydrates to total calories increased from 62% to 66%, that of animal products remained at around 11%, and that of fats and oils declined from 8.5% to 4%; and, as a result, the contribution of total fat to energy declined from 18% to 14%.

In Barbados, the contribution of cereals declined from 35% to 31%, and that of roots and tubers declined drastically from 11% to 4%; vegetables and fruits made a poor contribution of 2%-3%, and pulses and nuts remained at 4% (fig. 11). In Guyana, cereals increased from 47% to 50%. and pulses and nuts remained high at 7%-8% of total calories. However, the consumption of fruits, vegetables, roots, and tubers, which was already low in 19611963, declined further (fig. 12). The contribution of protein was also low (9.5%) and remained so during this period.

Given this scenario of food availability, it is not surprising that obesity in Barbados increased between 1968 and 1981 from 7% to 16% in males and from 32% to 38% in females. Unfortunately, the only national figure on obesity available for Guyana is from 1971; it showed 7% of males and 32% of females obese.

Owing to changes in the classification of chronic diseases, limitations of diagnostic capabilities, and reporting problems, comparison over time and between countries during the period is very difficult, but it is reasonable to say that mortality due to different nutrition-related chronic diseases of the non-deficiency type in Barbados is very high and much higher than in Guyana (table 4)[4].

FIG 10. Changes in contribution of different food groups to total calories in Barbados and Guyana. 1961- l985

FIG. 11. Changes in contribution of different sources of complex carbohydrates to total calories. Barbados, 1961-19X5

FIG.12. Changes in contribution of different sources of complex carbohidrates to total calories, Guyana, 1961-1984

Implications

The growing problem of non-communicable chronic diseases in the Caribbean requires that a closer look be taken at the qualitative aspects of the diet in addition to the quantitative aspects which have been the primary focus of concern in the recent past. Public education programmes to adjust eating patterns will have to be developed to decrease the consumption of fats and fat-containing food from animals, cholesterol, and salt and to increase the consumption of complex carbohydrates, particularly fibre-containing fruits, vegetables, roots, and tubers. The supply and demand sides must be addressed simultaneously. Preventing these diseases will also reduce the vast sums of money being spent in managing cases of chronic diseases through expensive medical means. Without these adjustments the epidemic of chronic diseases will not be stopped and premature deaths, disabilities, and their economic consequences will continue.

TABLE 4. Age-adjusted mortality rates per 100,000 population for mortality due to non-communicable chronic diseases in Barbados and Guyana (latest available data)

a. 1987.
b. 1984.

Finally the non-communicable chronic diseases that are increasing in the Caribbean population are multifactorial in origin. In addition to diet, other lifestyle factors such as physical exercise, smoking, alcohol consumption, and psychosocial stress are also important to this epidemic. However, directly or indirectly. diet plays a major role, and dietary adjustments will go a long way towards altering the problem. The problems faced by the countries of the Caribbean due to dietary change will increasingly be experienced by other developing countries.

Acknowledgements

The authors wish to express their thanks to Mrs. V. S. Campbell, nutrition educator, for her technical support in the preparation of this paper and to Dr. A. W. Patterson for reviewing it. The support of Ms. K. Russell in typing the manuscript and preparing the graphs is also gratefully acknowledged.

References

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2. Sinha DP. Obesity and related disease in the Caribbean. Cajanus 1984;17:79-106.

3. Commonwealth of the Bahamas, Ministry of Health. Health and nutrition survey of the Bahamas. Nassau: Ministry of Health, 1991. Mimeo.

4. PAHO. Health conditions in the Americas. Vol. 2. Paho Scientific Publication no. 524. Washington, DC: Pan American Health Organization, 1990:342, 353.

5. Hagley K. An overview of the problem. Cajanus 1990;23:8-13.

6. Sinha DP. The risk factors and lifestyles. Cajanus 1990;23: 14-46.

7. US Department of Health and Human Services, Public Health Service. The Surgeon General's report on nutrition and health. DHHS(PHS) Publication no. 8850210. Washington, DC: US Government Printing Office, 1988.

8. James WPT. Health nutrition: preventing nutrition related diseases in Europe. Copenhagen: WHO Regional Office for Europe, 1988.

9. National Research Council. Diet and health: implications for reducing chronic disease risk. Report of the Committee on Diet and Health, Food and Nutrition Board. Washington, DC: National Academy Press, 1989.

10. National Academy of Sciences, National Research Council. Diet, nutrition and cancer. Report of the Committee on Diet, Nutrition and Cancer. Washington, DC: National Academy Press, 1982.

11. Doll R, Peto R. The causes of cancer. Oxford, UK: Oxford University Press, 1981.

12. WHO. Diet, nutrition and the prevention of chronic diseases. Report of a WHO study group. Technical Report Series. no. 797. Geneva: World Health Organization, 1990.

13. Bengoa JM, Torún B, Béhar M, Scrimshaw NS, eds. Guías de alimentación bases pare su desarrollo en America Latina. Caracas, Venezuela: Fundación Cavendes, 1988.

14. Bengoa JM, Torún B, Béhar M, Scrimshaw NS. Nutritional goals for health in Latin America. Food Nutr Bull 1989;11(1):4-20.

15. FAO. Food balance sheets. Rome: Food and Agriculture Organization, 1990.

16. FAO. Nutrition country profiles. Rome: Food and Agriculture Organization, 1989.

17. World Bank. World development report, 1984. New York: Oxford University Press, 1984.

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