A protocol with an impact

In several Caribbean ministries of health a protocol for nutritional management was already on the drawing board. But a World Diabetes Foundation-supported project, coordinated by Jamaica-based CFNI, allowed them to finalise and coordinate a Caribbean standard protocol for nutritional management of diabetes, obesity and hypertension. The now finalised protocol is a 94-page simple tool kit for health care workers on how to collect relevant data such as height, weight and waist-hip ratio as well as calculating the BMI. Norma Howard, Head of the Nutrition Unit at the Guyanese Ministry of Health is pleased with the project. “Without the CFNI project my department would still be trying to convince health workers that BMI and weight assessment are important tools for assessing and managing the patient and that they are just as important as the medication given to the patient,” she says. 

Simple is good

When CFNI set out to finalise the protocol, the objective was to have trained a nutritional coordinator and diabetes educator in each of the five project countries; Belize, Guyana, Jamaica, Suriname, and St. Vincent & the Grenadines. Furthermore, some 300 to 500 doctors, nurses, nutritionists and diabetes educators should have been trained. By the end of the project period in 2007, the number of participating countries had expanded from five to nine, and 488 health care professionals had been trained. “The simple hands-on approach of the project turned out to be the success factor”, says Programme Coordinator from the World Diabetes Foundation, Mr. Ulrik Uldall Nielsen. “The fact that it was so straightforward made it easy to expand to more countries in the region. In this case, simple has shown to be good.”

But the success does not only show in the geographical expansion. The protocol was also adopted by the Ministries of Health in nine Caribbean countries. And this was far from a coincidence. Arguing that the economic cost of obesity and the related co-morbid conditions are immense, CFNI had long appealed to policy makers for long-term strategies to control obesity in the Caribbean. “With almost half of the adult Caribbean population being overweight and many children at increased risk of obesity, the case for a population approach for obesity control rather than a strategy merely targeting at-risk individuals and groups was strong,” says Dr. Fitzroy Henry, Director of CFNI.

Sugar, fat & politics

While no food consumption data is available for Caribbean countries, the availability of energy gives some indications. An FAO (Food and Agriculture Organisation of the UN) analysis shows an overall insufficiency of calories in the 1960s, which was reflected in the high rates of under-nutrition at that time. However, from the 1970s onwards, the average availability of calories per person increased rapidly. Today, the availability of fats exceeds 160% of the average requirement, while excess sugar comes as high as 250%. Much research has linked growing obesity rates with a growing consumption of snacks, fast foods, soft drinks, and high-energy diets. “Since both global and local market forces drive the excesses in sugar and fat consumption, this is not just a public health issue, but one that has economic and political ramifications,” argues Dr Fitzroy Henry.

And Caribbean policymakers do seem to have realised the seriousness of the problem. Last year at the CARICOM (Caribbean Community Secretariat) Heads of Government Summit, the Port-of-Spain Declaration “Uniting to Stop the Epidemic of Chronic Non-communicable Diseases” was issued. The general objective was to launch a series of ongoing population based physical activities to promote healthy living for the prevention and control of chronic non-communicable diseases. On 13th September 2008, the Caribbean Wellness Day was celebrated under the theme “Love that body” to commemorate the first anniversary of this important declaration.

Change at small scale

Although it may be a while before a drop in overweight and obesity prevalence is seen, health care professionals are implementing the protocol every day. Norma Howard from the Food Policy Unit at the Guyanese Ministry of Health explains that one of the key achievements has been the emphasis on BMI, weight and obesity management: “Before, hardly anyone measured BMI or knew the meaning of the term. Now patients ask for their BMI data when it is taken at the clinic. ”The protocol provides tools for screening and management that can be used by health workers in all primary health care clinics. Ms. Norma Howard is realistic but at the same time optimistic about the impact of the protocol: “Health care workers are aware that there is a protocol. The general public is aware of the health risks of obesity and many individuals are engaging in daily exercise. I see persons walking as part of their exercise routine. Community and church groups are including healthy lifestyle activities as part of their programme and collaborate with the nutrition department to organise and conduct these activities. The most popular sessions at these activities are the calculation of individual BMI and weight management counselling,” says Ms. Norma Howard. 

With en estimated 8-10% diabetes prevalence in most Caribbean countries it will take a while to turn the tide for the 4.75 million people in the nine countries who have adopted the protocol so far.