CHILDHOOD OBESITY PREVENTION &
THE EDUCATION SECTOR:
A CARIBBEAN PERSPECTIVE
Dr. Fitzroy Henry
Caribbean 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
NUTRITION
(UNDERNUTRITION
/OBESITY)
POOR
EDUCATIONAL
ACHIEVEMENT
OBESITY & LEARNING
Obesity is significantly
associated with cognitive
impairment, specifically
learning and memory
functions.
7
6
5
4
3
2
1
0
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
%
Trends in under- and over weight (WHZ)
among children 0-5 yrs in the Caribbean
Wasting
Overw t
CHANGE (%) IN UNDERNUTRITION AND OBESITY OF
CHILDREN (0-5yrs) IN THE CARIBBEAN 2000-2010
15
10
2000
2010
5
0
underwt
overwt
NUTRITIONAL STATUS OF CARIBBEAN CHILDREN
11-13 YEARS OLD (2008)
BOYS
N=812
%
6
GIRLS
N=1049
%
4
67
63
OVERWEIGHT
>1SD
14
19
OBESE
>2SD
13
14
THIN
<2SD
NORMAL
ADULT OVERWEIGHT/OBESITY
TRENDS IN THE CARIBBEAN
80
(%)
60
Male
Female
40
20
0
1970s
1980s
1990s
2000s
Traditional strategies
will continue to fail
Traditional View:
Obesity is a personal disorder that
needs treatment
Current 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
REDUCING THE COMPLEXITY - FOR INTERVENTION
ACCESSIBLE
HEALTHY
FOODS
~ COST
AVAILABLE
HEALTHY
FOODS
MARKET PRESSURE
MEDIA,
FRANCHISES
PEERS
.
CHILDHOOD
OBESITY
PHYSICAL ACTIVITY
SPACES
AVAILABLE,
ATTRACTIVE & SAFE
FOOD PREP
P0RTION SIZE
LABELS
KNOWLEDGE OF
WHAT TO EAT /
HOW TO EXERCISE
VS
CULTURAL
PREFERENCES
WHAT CAN THE EDUCATION SECTOR
DO TO COMBAT CHILDHOOD OBESITY?
TARGETS FOR POLICY:
1. SCHOOL FEEDING
2. SCHOOL VENDING
3. PHYSICAL EDUCATION
4. CLASSROOM EDUCATION
5. COMMUNITY EDUCATION
6. 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
Age
Value
Unit
years
Gender
4-6
4-6
M
F
Target (mean)
20%
25%
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 B6
mg
0.3
0.4
0.07
0
Folacin
μg
100
100
20
25
Vitamin. B12
μg
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 Meals
Meal Plans
Reference Nutrients
Calories
342.5 kcal
Food Group
Exchanges
Kcal
Protein
15 g
Food From Animals
1.5
112.5
Fat
13 g
Staples
1.5
105
Vitamin A
80
Fruits
0.5
20
Vitamin C
20 mg
Vegetables
0.5
18
Iron
4 mg
Fats & Oils
1
45
Calcium
200 mg
Sugar
2
40
Adjusted Meal standard
Total
342.5
Carbohydrates
49%
42g
Protein
17%
15 g
Fat
34%
13 g
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 – T1
SCHOOL FEEDING PROG’MS
1. Define the target groups and their needs
2. Establish nutrient standards and convert to meal
standards
3. Organize local farmers to supply food items to
school feeding programs
4. Provide adequate budgets to meet these healthy
options
5. Implement menu with standard meals and
manage resources accordingly
6. Develop Dietary Guidelines for school nutrition
programs
7. 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 SNACKS
Price
%
10 ↓
Purchasing
%
25 ↓
50 ↓
39 ↑
93 ↑
9↑
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 - T2
SCHOOL 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
nt
Countries
An
d
tig
ua
d
a
a
s
bu
d
t
e
m
ica
an
d
/B
ar
Is
l
in
a
in
om
Su
r
in
id
a
uc
i
Is
.
er
ra
on
ts
D
s
G
uy
an
a
Tr
in
St
.L
ay
m
an
M
C
in
e
na
da
na
d
G
re
G
re
Vi
rg
an
Br
iti
sh
in
ce
St
.V
Percent
Physical Activity Levels among 13-15 year olds in the Caribbean
Global School-based Health Survey
35
30
25
20
15
10
5
0
h
d
Is
l
s
a
Is
.
an
d
ay
m
an
in
C
Vi
rg
bu
d
/B
ar
d
uc
ia
id
a
St
.L
Tr
in
t
an
a
G
uy
er
ra
na
da
e
s
am
in
e
on
ts
M
G
re
rin
na
d
Su
G
re
tig
ua
an
An
nt
Br
iti
s
in
ce
St
.V
Percent
Level of Sedentary Activities among Children aged 13-15 Years in the Caribbean
80
70
60
50
40
30
20
10
0
Mean distance (cm)
Fitness Test – Flexibility ‘Trunk-lift’
Females
25
Males
20
15
HFZ
10
Mean
distance
5
0
11y
12y
13y
14y
11y
Age (years)
12y
13y
14y
Fitness Test – Muscular Strength
Mean # of Push-Ups
Females
# of push ups
15
Males
10
5
HFZ
0
11y
12y
13y
14y
11y
Age (years)
12y
13y
14y
mean
push ups
SIT - UPs
Fitness Test – Muscular Endurance
SIT-UPs
80
60
40
20
0
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?
The need to eat breakfast daily?
64
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?
Why do we need to be physically active?
95
An adequate variety of PA includes?
92
86
79
Students Nutrition Information (%)
Source
CARIB
PARENTS &
RELATIVES
SCHOOL
76
BOOKS/MAG’NE
53
FRIENDS
21
INTERNET
20
DOCTOR
OTHER (TV etc.)
53
9
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 LEARNT
1.
2.
3.
4.
5.
Conceptualization
Design
Planning Teams
Project Management
Teaching methods and
Materials
6. Training of Teachers
7. Teacher Motivation
8. Standards
–
9.
10.
11.
12.
• Desired
– Ideal, based on
the research
• Reality
– What actually
happens
Nutrient, meal, menu
Monitoring & Evaluation
Resources
Disruptions
Policy
• Suggest
– What we would
recommend or
do differently
School–based Behavioural
Intervention in Four
Caribbean Countries
PROJECT GOAL
REDUCE OBESITY THROUGH BEHAVIORAL
INTERVENTION
KEY PROJECT STRATEGY
PROMOTE HEALTY LIFESTYLE BEHAVIOURS FOR 3
YRS TO A COHORT FROM GRADES 7-9 (Forms 1-3).
Specific Project Objectives
1. IMPROVED DIET AND
PHYSICAL ACTIVITY
PATTERNS
2. SUSTAINABLE LIFESTYLE
INTERVENTIONS
Lifestyle Intervention
The WDF-CFNI healthy School
We promote healthy eating and active living
Diet and
Physical
Activity
Behavioural
Curriculum
Eat Fruits
and
Vegetables
Daily
Reduce
Sugary
Snacks &
Drinks
Eat a
Variety of
Foods Daily
Eat
Breakfast
Daily
School wide
Promotional
Activities
Student
Variety of
Physical
Activity
Daily
1 Hour
Moderate
Physical
Activity
daily
Reduce
Salt & Fat
Intake
Supportive
School
Environment
Supportive Homes and Communities
Project Phases
Phase 1:
Problem Assessment and
Awareness Raising
Phase 2:
Development of Programme
Materials and Training of
Project Teachers
Phase 3:
Implementation of a Lifestyle
Intervention (Cohort of Form
1/Grade 7 students followed for
three years)
Phase 4:
Evaluation of the Intervention –
Process and Outcome.
EVALUATION PLAN
•
•
Both qualitative and quantitative data collected
Outcome Evaluation/Indicators:
–
–
–
–
–
•
Process evaluation/Indicators:
–
–
–
–
•
Knowledge test
Skills development
Classroom and take home assignments/projects done
BMI
Fitness
# 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
TEACHERS
CANTEEN/
VENDORS
SCHOOL TEAM
FOCAL
POINT
COUNTRY
TEAM
COUNTRY
COORDINATOR
From
Project to Self
Management
CFNI
MOE;
MOH;
MOS
KEY
RECOMMENDATIONS
Education Sector - Schools
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 - Schools
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 - Schools
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 - Schools
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 - Community
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
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
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
FROM
CHANGING
BEHAVIOUR
IN
SETTINGS
TO
CHANGING THE
ENVIRONMENT
TO
ENHANCE
BEHAVIOUR
THE
OUTCOME
Children 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 ANTIOBESOGENIC ACTIONS INSIDE AND
OUTSIDE THE SCHOOL SYSTEM
Summary of Presentation
POLICIES RECOMMENDED FOR:• SCHOOLS
• COMMUNITY
• PUBLIC
CRITICAL STRATEGIES FOR EACH
THANK YOU