CHILDHOOD OBESITY PREVENTION & THE EDUCATION SECTOR:

A CARIBBEAN PERSPECTIVE

Dr. Fitzroy HenryCaribbean Food and Nutrition Institute

(PAHO/WHO)

Presentation to the PAHO / PAHEF WORKSHOP, ARUBA

JUNE 14-16, 2012

OUTLINE OF PRESENTATION

• CHILDHOOD OBESITY & THE CHALLENGE FOR THE EDUCATION SECTOR

• TARGET 1-4: SCHOOL

• TARGET 5: COMMUNITY

• TARGET 6: PUBLIC

• CRITICAL STRATEGIES FOR THE CARIBBEAN

VICIOUS CYCLE OF EDUCATION & NUTRITION

POOR EDUCATIONAL ACHIEVEMENT

POOR NUTRITION

(UNDERNUTRITION/OBESITY)

OBESITY & LEARNING

Obesity is significantly associated with cognitive impairment, specifically learning and memory

functions.

Trends in under- and over weight (WHZ) among children 0-5 yrs in the Caribbean

0123

4567

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

%

Wasting Overw t

0

5

10

15

underwt overwt

CHANGE (%) IN UNDERNUTRITION AND OBESITY OF CHILDREN (0-5yrs) IN THE CARIBBEAN 2000-2010

2000

2010

NUTRITIONAL STATUS OF CARIBBEAN CHILDREN11-13 YEARS OLD (2008)

BOYSN=812

GIRLSN=1049

% %

THIN<2SD

6 4

NORMAL 67 63

OVERWEIGHT>1SD

14 19

OBESE>2SD

13 14

0

20

40

60

80

(%

)

1970s 1980s 1990s 2000s

Male

Female

ADULT OVERWEIGHT/OBESITY TRENDS IN THE CARIBBEAN

Traditional strategies will continue to fail

Traditional View: Obesity is a personal disorder that needs treatmentCurrent View: (i) Obesity is a normal response to an abnormal Environment (ii) The Environment is complex but mainly obesogenic

The Complexity Of Healthy Eating& Childhood obesity

CHILDHOOD OBESITY

PHYSICAL ACTIVITY SPACES

AVAILABLE, ATTRACTIVE & SAFE

KNOWLEDGE OF WHAT TO EAT /

HOW TO EXERCISE VS

CULTURAL PREFERENCES

AVAILABLE HEALTHY FOODS

MARKET PRESSUREMEDIA,

FRANCHISES PEERS

ACCESSIBLE HEALTHY

FOODS~ COST

.

REDUCING THE COMPLEXITY - FOR INTERVENTION

FOOD PREP P0RTION SIZE

LABELS

WHAT CAN THE EDUCATION SECTOR DO TO COMBAT CHILDHOOD OBESITY?

TARGETS FOR POLICY:1. SCHOOL FEEDING2. SCHOOL VENDING3. PHYSICAL EDUCATION4. CLASSROOM EDUCATION5. COMMUNITY EDUCATION6. PUBLIC EDUCATION

TARGET 1:

SCHOOL FEEDING PROGRAMS

SCHOOL FEEDING - KEY QUESTIONS?• Programs aim to target socio-economically and

nutritionally challenged children- Should this be our main target? • Programs do not have strict targeting criteria (self

selection and perceived needs by teachers)- Are we contributing to the child obesity problem?• Meals usually do not include foods from most of the

food groups- Are we using scientific methods or guesswork?

MAJOR QUESTIONS

Are we using existing resources effectively?Do countries have written policies?

ONLY 47% OF STUDENTS

11-13 yrs old

eat breakfast

every morning

A PARENTAL OR GOVERNMENTAL RESPONSIBILITY?

Nutrient Standards based on Recommended Dietary Allowances

Variable Unit Value Target (mean)

20% 25%

Age years 4-6 4-6

Gender M F

Body Weight kg 19.7 18.6

Energy kcal 1800 1625 342.5 428

MJ 7.53 6.79 1.432 2

Protein g 22 21 4.3 5

Vitamin A REd μg 400 400 80 100

Vitamin De μg 5 5 1 1

Vitamin Ef mg α-TE 7 7 1.4 2

Thiamine mg 0.7 0.7 0.14 0

Riboflavin mg 1.0 0.9 0.19 0

Niacin NEg mg 12 11 2.3 3

Ascorbic Acid mg 60 60 12 15

Pyridoxine B6mg 0.3 0.4 0.07 0

Folacin μg 100 100 20 25

Vitamin. B12μg 0.9 0.9 0.18 0

Calcium mg 500 500 100 125

Magnesium f mg 200 200 40 50

Iron mg 10 10 2 3

Sodium mg 300 300 60 75

Potassium mg 1400 1400 280 350

Zinc mg 10 10 2 3

Notes:

• Use the RDA to determine nutrient requirements / needs

• Help to correct under- and control obesity

• Use culturally appropriate local foods/meals

From Nutrients to MealsReference NutrientsCalories 342.5 kcal

Protein 15 g

Fat 13 g

Vitamin A 80

Vitamin C 20 mg

Iron 4 mg

Calcium 200 mg

Meal Plans

Food Group Exchanges Kcal

Food From Animals 1.5 112.5

Staples 1.5 105

Fruits 0.5 20

Vegetables 0.5 18

Fats & Oils 1 45

Sugar 2 40

Total 342.5

Carbohydrates 49% 42g

Protein 17% 15 g

Fat 34% 13 gAdjusted Meal standard 2 oz meat or substitute

4 oz rice, cereal or provision

2 oz vegetable

1 tsp gravy or substitute

4 oz drink

(2 oz juice & 2 tsp sugar)Average Meal Cost US$ 1.10

CRITICAL STRATEGIES – T1SCHOOL FEEDING PROG’MS

1. Define the target groups and their needs2. Establish nutrient standards and convert to

meal standards3. Organize local farmers to supply food items

to school feeding programs4. Provide adequate budgets to meet these

healthy options5. Implement menu with standard meals and

manage resources accordingly6. Develop Dietary Guidelines for school

nutrition programs7. Monitor and adjust according to evaluation

TARGET 2:

SCHOOL VENDING

TARGETS FOR INTERVENTION

Sources of Lunch (%)

Source CAR

Home 50

School Canteen 15

Tuck Shop 14

Vendors 11

Others (machines, etc)

10

WHAT ARE STUDENTS EATING?

ONE OR MORE PER DAY %

SNACKS 57

MEAT/FISH/EGGS 56

CARBONATED DRINKS 52

MILK/MILK PRODUCTS 35

VEGETABLES 29

FRUITS 27

OTHERS 30

FOOD PRICE & DEMAND

USA – 12 SCHOOLS + 12 WORK 55 Vending Machines - 12 Months

LOW FAT SNACKSPrice

%

Purchasing %

10 ↓ 9 ↑

25 ↓ 39 ↑

50 ↓ 93 ↑

Why a School Vending Machine Policy

• Usually stocked with high fat, sugar and salt foods

• May undermine what children are taught in the classroom about healthy eating

A vending machine policy must be linked to a wider school nutrition policy which takes into account the school community, the school curriculum, health services, access to food that is safe and meets nutrient requirements.

Perspective 1 – Provide Healthy Choices Only

• Research shows that children, especially young children, are less likely to make nutritious choices when other choices are available (USDA, 2005)

• Schools provide clear rules for course of study and dress code and the same should go for meals

Perspective 2 – Allow students to Exercise Choice

• Students learn to make better decisions if they are provided with a wide assortment of food choices

• Concern about the stigma attached to those foods that are labeled as ‘bad’ for health since all foods can fit into a healthy diet

Policies in the Caribbean

• Most countries are yet to develop a policy

• In a draft document for Barbados titled ‘Nutritious and Healthy Foods in Schools – National and Practical Guidelines for Barbados 2009’ it is recommended that ‘schools should ensure that all sales of snacks, foods and drinks, including those sold from vending machines, fit into the whole-school food policy’

Policies in the Caribbean

• The document goes further to provide specific guidelines:

• Drinks-vending machines should be stocked with 100% fruit juices, fresh low fat (1%) or fat free (skimmed) milk and flavoured milks or soy beverages with less than 10% added sugar

• Vending machines at schools should always provide water and fruit as options

Recommended/Policy Initiatives

• All vending machine policies should have as their foundation the FBDGs

• National governments should have an approved policy on school health that includes access to healthy foods at schools including availability of vending machines.

Recommended/Policy Initiatives

• Vending machines should only be included in schools/countries where it is possible to have a variety of healthy options to promote appropriate nutritional status and cognitive development

• Access to the vending machine should be at usual school designated break times – recess times and lunch times

Recommended/Policy Initiatives

• Food items should be nutritious and healthy and meet the nutritional requirements of adolescents without putting them at risk for obesity and other chronic diseases

CRITICAL STRATEGIES - T2SCHOOL VENDING

1. Establish specifications for school canteen tenders.

2. Implement an inspection process to ensure food service providers comply with nutrient-based standards

3. Establish a meal pricing policy to blend nutrients with preferences

4. Integration of school foodservice and nutrition curriculum & training (staff & Students)

5. Regular evaluation with feedback from caterers and students

6. Require vending machines to stock bottled water, appropriate sized fruit juices and low sugar beverages.

TARGET 3:

PHYSICAL EDUCATION

Physical Activity Levels among 13-15 year olds in the CaribbeanGlobal School-based Health Survey

0

5

10

15

20

25

30

35

Countries

Per

cent

Level of Sedentary Activities among Children aged 13-15 Years in the Caribbean

0

10

20

30

40

50

60

70

80

Per

cent

Fitness Test – Flexibility ‘Trunk-lift’

0

5

10

15

20

25

11y 12y 13y 14y 11y 12y 13y 14y

Age (years)

Mea

n di

stan

ce (c

m)

HFZ

Meandistance

Females Males

Fitness Test – Muscular StrengthMean # of Push-Ups

0

5

10

15

11y 12y 13y 14y 11y 12y 13y 14y

Age (years)

# of

pus

h up

s

HFZ

meanpush ups

Females Males

SIT - UPs

Fitness Test – Muscular EnduranceSIT-UPs

0

20

40

60

80

Male Female

Pass Fail

CRITICAL STRATEGIES - T3 PHYSICAL EDUCATION

• Create an environment where play and exercise are actively enabled and encouraged.

• Make compulsory - physical education to enable 60 mins of moderate PA most days of the week

• Introduce innovative & fun-oriented PA programs not only for the athletically gifted

• Encourage children to drink water as the most appropriate rehydration fluid

• Provide incentives to the private sector to invest in swimming pools and safe recreational spaces & facilities

TARGET 4:

CLASSROOM EDUCATION & INFORMATION

INCORRECT ANSWERS (%)Which foods to eat sparingly? 53

Min. time someone my age should exercise?

64

The need to eat breakfast daily? 86

What to do to maintain my right weight? 90

The need to eat a variety of foods daily? 93

A diet with the right variety of foods includes?

95

Why do we need to be physically active? 79

An adequate variety of PA includes? 92

Students Nutrition Information (%)

Source CARIB

PARENTS & RELATIVES

76

SCHOOL 53

BOOKS/MAG’NE 53

FRIENDS 21

INTERNET 20

DOCTOR 9

OTHER (TV etc.) 20

CRITICAL STRATEGIES – T4 EDUCATION / INFORMATION

• Establish in each school zone a qualified dietitian / nutritionist to plan, coordinate, train and monitor activities

• Make mandatory - training for school meal providers and teachers so children will receive consistent information about healthy eating

• Schools should provide guidance to parents on nutritionally appropriate packed lunches

• Train food service providers on innovative ways to offer fat free, and low calorie nutritious meals

• Make school staff positive role models in their own food selection and attitude to physical activity

• Tailor advertisement (media) to change the thinking and practices of children towards healthy diets and food choices

TOWARDS HEALTH PROMOTING SCHOOLS

SCHOOL FEEDING

HEALTHY EATING

HEALTH PROMOTING SCHOOLS

A NEW APPROACH NEEDED

12 LESSONS LEARNT1. Conceptualization2. Design3. Planning Teams4. Project Management5. Teaching methods and

Materials6. Training of Teachers7. Teacher Motivation8. Standards

– Nutrient, meal, menu9. Monitoring & Evaluation10. Resources11. Disruptions12. Policy

• Desired – Ideal, based on

the research

• Reality– What actually

happens

• Suggest– What we would

recommend or do differently

School–based Behavioural

Intervention in Four Caribbean Countries

Specific Project ObjectivesSpecific Project Objectives1. IMPROVED DIET AND

PHYSICAL ACTIVITY PATTERNS

2. SUSTAINABLE LIFESTYLE INTERVENTIONS

KEY PROJECT STRATEGYKEY PROJECT STRATEGYPROMOTE HEALTY LIFESTYLE BEHAVIOURS FOR 3 YRS TO A COHORT FROM GRADES 7-9 (Forms 1-3).

PROJECT GOALPROJECT GOAL REDUCE OBESITY THROUGH BEHAVIORAL INTERVENTION

The WDF-CFNI healthy School

We promote healthy eating and active living

Diet and Physical Activity

Behavioural Curriculum

School wide Promotional

Activities

Supportive Homes and Communities

Supportive School

Environment

Eat Fruits and

Vegetables Daily

Reduce Sugary Snacks & Drinks

Variety of Physical Activity

Daily

1 Hour Moderate Physical Activity daily

Eat a Variety of

Foods Daily

Reduce Salt & Fat

Intake

Eat Breakfast

Daily

Student

Lifestyle Intervention

Project PhasesProject PhasesPhase 1:

Problem Assessment and Awareness Raising

Phase 3:

Implementation of a Lifestyle Intervention (Cohort of Form 1/Grade 7 students followed for three years)

Phase 2:

Development of Programme Materials and Training of Project Teachers

Phase 4:

Evaluation of the Intervention – Process and Outcome.

EVALUATION PLANEVALUATION PLAN• Both qualitative and quantitative data collected• Outcome Evaluation/Indicators: – Knowledge test– Skills development– Classroom and take home assignments/projects done– BMI– Fitness

• Process evaluation/Indicators:– # hours or time spent on sessions– # of concepts taught– Exposure of students (attendance records)– # and details of other intervention strategies carried out

• Impact evaluation/Indicators:– Comparative analysis of behaviour changes pre and post intervention and

control vs. intervention

STUDENTS

PARENTS TEACHERSCANTEEN/VENDORS

CFNI

COUNTRY COORDINATOR

SCHOOL TEAM

COUNTRY TEAM

From Project to Self Management

FOCAL POINT

MOE; MOH; MOS

KEY RECOMMENDATIONS

Education Sector - Education Sector - SchoolsSchools

1. Principles, concepts and skills training about healthy eating and regular physical exercise made mandatory

2. Nutrition education and physical activity incorporated into a healthy lifestyle programme in schools.

3. Policies developed to support healthy diet and lifestyle choices

Education Sector - Education Sector - SchoolsSchools

1. Principles, concepts and skills training about healthy eating and regular physical exercise made mandatory

– Create awareness among policy makers, teachers and curriculum planners

– Ensure that all children participate in a minimum of 30 minutes of moderate to vigorous physical activity during the school day.

– Incorporate in the curriculum of colleges and universities a well designed course on diet, nutrition, health and physical education, and ways to promote behavior change.

Education Sector - Education Sector - SchoolsSchools

2. Nutrition education and physical activity incorporated into a healthy lifestyle programme in schools.

- Conduct nutritional assessment of schoolchildren to (1) determine the trends in nutritional status

and (2) provide information for counselling.– Based on scientific data, plan and implement

healthy lifestyle programmes incorporating nutrition education, exercise and healthy school meal choices.

– Develop incentives for students who make healthy diet and lifestyle choices.

Education Sector - Education Sector - SchoolsSchools

3. Policies developed to support healthy diet and lifestyle choices

- Evaluate current foods offered at the school cafeteria or in lunch programs, whilst also discouraging the excessive use of sugar- and fat-containing foods.

- Introduce competitions as incentives to promote

physical activity for all categories of students, not only the athletically gifted.

- Involve school health services in obesity prevention efforts

TARGET 5:

COMMUNITY EDUCATION

Education Sector - Education Sector - CommunityCommunity

Community-oriented nutrition and lifestyle programs developed

Community workers in health, sports and other sectors should actively promote healthy eating habits and physical activity.

Design and implement programs for the prevention of obesity particularly in high-risk low-income groups.

Identify or provide safe and inexpensive exercise facilities in communities.

Identify and train resource persons in the community to obtain skills in food preparation and healthy eating.

TARGET 6:

PUBLIC EDUCATION

Education Sector – Public Education Sector – Public EducationEducation

1. The public is aware of, and convinced of, the need to develop and maintain healthy lifestyle habits.

Provide support, incentives, and introduce competitions, which challenge the public to seek and obtain information on healthy eating and physical activity.

Education Sector – Public Education Sector – Public EducationEducation

2. The public is provided with consistent educational messages and dietary recommendations

Launch and maintain massive public education campaigns.

Prepare and utilize a resource list of local organizations both public and private that can provide the public with information on food, nutrition, exercise regimes and health.

Develop and disseminate scientific-based nutrition and lifestyle education materials to all audiences.

Review and monitor public educational messages to ensure consistency and accuracy of information

The New Approach

CHANGING THE CHANGING THE ENVIRONMENT ENVIRONMENT

TO TO ENHANCE ENHANCE

BEHAVIOURBEHAVIOUR

CHANGING THE CHANGING THE ENVIRONMENT ENVIRONMENT

TO TO ENHANCE ENHANCE

BEHAVIOURBEHAVIOUR

TOTO FROMFROM

CHANGING CHANGING BEHAVIOUR BEHAVIOUR IN SETTINGSIN SETTINGS

THE OUTCOMEChildren should be

going to …...a healthy

school environment

with improved nutritional

services which can enable

healthy lifestyle behaviors

TAKE HOME MESSAGE

TREATING CHILDHOOD OBESITY AND NOT THE CAUSE WILL BRING

SHORT TERM BENEFITS ONLY

TRAINING MUST BE LINKED TO OTHER IMPORTANT ANTI-

OBESOGENIC ACTIONS INSIDE AND OUTSIDE THE SCHOOL SYSTEM

Summary of Presentation

POLICIES RECOMMENDED FOR:-

• SCHOOLS

• COMMUNITY

• PUBLIC

CRITICAL STRATEGIES FOR EACH

THANK YOU