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Introduction
In the last blog post, the author mentioned that Trinidad and Tobago has a burgeoning obesity problem in which 1 in 2 adults and 1 in 2 children are either overweight or obese.
Being overweight or obese is a significant risk factor in the development of chronic disease and Trinidad and Tobago has one of the highest rates of chronic disease or non-communicable disease (NCDs) in the Caribbean.
Why are Trinis getting bigger?
Well, one will naturally ask, why is this increasing trend of obesity in the population happening?
The present Chief Medical Officer, Dr. Roshan Parasram, gave an answer to a question similar to this by Paul Richards, Chairman of the Joint Select Committee on Social Services And Public Administration On An Examination of the current level of childhood obesity and the State’s interventions to promote a healthy lifestyle among children. Here’s the answer he gave in the video clip below:
Eating too much vs not moving enough
As Dr Parasram mentioned, the increasing obesity trend has been observed worldwide. However, the primary cause of the obesity epidemic worldwide has been a source of much debate.
One school of thought is that ‘unhealthy diets’ are the main driver of the obesity epidemic. The ‘unhealthy diets’ advocates point to:
- Increased food energy supply
- Globalisation of food supply
- Increased availability of obesogenic ultra-processed foods
The ‘decrease in physical activity’ advocates point to:
- Increasing motorisation and mechanization
- Time spent in front of screens
- Increase in motor transport and decrease in pedestrian transport
- Decrease in occupational physical activity
However, there needs to be an agreement, especially from a legislative viewpoint, as to the main drivers of the obesity epidemic so that resources can be optimally allocated to provide the most significant impact to halt and stem the rising obesity levels in the world and more specifically, in Trinidad & Tobago and the Caribbean.
TTMoves - solution or smokescreen?
As of now, the Trinidad & Tobago Ministry of Health has adopted the TTMoves campaign which encourages the population to:
- Get Moving – With recommendations of 30 minutes of exercise a day or making 4000-7000 steps a day.
- Drink Water – At least 8-10 glasses of water a day. Each glass should be at least 250ml.
- Eat Fruits and Vegetables – At least 2-4 servings of fruits daily and eating vegetables with every meal.
If one reads the author’s previous post, this is an approach that the post author believes is a very lukewarm, tepid approach to the obesity and chronic disease burden in the population because it places the emphasis of obesity and NCDs control and prevention on the individual and not on the environment.
To the Government’s credit, it has adopted a more involved approach when addressing childhood obesity and disease. The present Minister of Health talked about this involved approach in the 2023-2024 Budget debate, with the ban on sugar-sweetened beverages in schools being one of the pillars of this approach. Another pillar of the approach is the provision of exercise equipment to schools so that the children can be ‘active’.
Contribution of the Minister of Health, Mr Terrance Deyalsingh to the 2023-2024 Budget Debate (up to 4:28:44)
Therefore, like Dr Parasram, the approach tries to ‘cover all bases’ in terms of diet and exercise. However, in the case of the child, there is an attempt to change the school environment by making sugar-sweetened beverages less accessible to students.
In the post author’s opinion, the prohibition of sugar-sweetened beverages to students is a good starting point. However, more needs to be done to change the dietary environment in the home and in the wider society in order to see a noticeable improvement in the overall health of children in Trinidad & Tobago.
Is it Gluttony or Sloth (or something else)?
Marion Nestle
Marion Nestle is a former senior nutrition policy advisor in the Department of Health and Human Services in the USA. She was also the editor of The Surgeon General’s Report on Nutrition and Health. Her research examines scientific and socioeconomic influences on food choice, obesity and food safety, emphasizing the role of food marketing. She is the author of numerous articles in professional publications and is the author or co-author of numerous books.
Her website is foodpolitics.com
In an interview with Ben Jones, she talks about obesity, gives compelling reasons why the obesity epidemic in the USA is the way it is and also states her solutions to the crisis. She was asked the question, “How do you account for the rise in obesity?”
Part of her answer is quoted below:
“It’s because people are eating more. On the simplest level, people have to be eating more or moving less, or doing both. The evidence is much stronger for eating more than it is for changes in physical activity. Evidence for a decline in physical activity is small, but there is plenty of evidence that people are eating more now than 30 years ago.”
Here are some quotes from various papers that agree with Ms. Nestle
Despite these limitations, our data consistently demonstrate that caloric supply, driven by changing technological and sociodemographic factors, is highly associated with the increase in obesity among the OECD countries.
In conclusion, in high-income countries, observed increases in body weight over recent decades are associated with increased food energy supply. In addition, increases in food energy supply are sufficient to explain increases in average population weight1
Increased energy intake appears to be more than sufficient to explain weight gain in the US population 2.
Our results are consistent with recent U.S. evidence that the increase in adult weight gain is attributable primarily to overconsumption3 .
Our findings suggest that there is an excess of energy available from an increasing national average food energy supply in countries of varying income levels. Therefore, policy efforts need to focus on reducing population energy intake through improving the healthiness of food systems and environments4
Several studies have tested the hypothesis that increases in the food supply are the dominant drivers of the weight gain in populations. Results from these investigations show that the rise in food energy supply was more than sufficient to explain the rise in obesity in the USA from the 1970s and most of the weight increase in the UK since the 1980s5.
So there is a pretty good consensus internationally that increases in caloric food supply have been the biggest driver of the obesity epidemic, especially in the developed world.
But is this the case for us in Trinidad & Tobago and the Caribbean?
Obesity Drivers in the Caribbean
The following is a quote from the document titled “NCDs and Trade Policy in the Caribbean” from the Healthy Caribbean Coalition:
Increased trade liberalisation has resulted in dramatic alterations in the supplies of important commodities which directly and indirectly influences the health of nations.
Trade policy has had a significant impact on access to essential medicines, the availability, affordability and marketing of tobacco and alcohol products, and the transformation of local diets.
Trade liberalization policies have contributed to the “nutrition transition” or rapid changes in food availability and consumption patterns in developing countries that lead to shifts from diets consisting largely of traditional plant-based and home-cooked foods to meat-derived and processed products.
This ‘nutrition transition’ has been accompanied by an epidemiological transition from infectious diseases to chronic, non-communicable diseases such as obesity, diabetes and cardiovascular disease.
In the Caribbean, half of CARICOM countries import more than 80% of what they consume, fueling dramatic changes in diet towards greater consumption of processed foods, contributing to an ‘epidemic’ of obesity and diet-related NCDs.
When it comes to obesity, the picture isn’t pretty according to the document:
Caribbean adults are among the heaviest in the world with Antigua & Barbuda, The Bahamas, Barbados, Belize, Jamaica and Trinidad & Tobago recording staggering rates of adult overweight/obesity: 61.9%, 69%, 62.3%, 53.8%, 59.1%, and 61.4% respectively
Therefore, this particular document has obesity rates of adults in Trinidad & Tobago at 61.4%. This means that 3 out of every 5 adults in Trinidad & Tobago are either overweight or obese.
Food imports and 'the nutrition transition'
Not surprisingly, Trinidad and Tobago has been subjected to the ‘nutrition transition’ made possible due to the increasing influx of food imports. In 2000, the food import bill was just over $300 million US; in 2011, the food import bill ballooned to $833 million US. In 2022, the food import bill crossed $7.3 billion TTD or over $1 billion USD.
A quote from a Food and Agriculture Organisation document on the CARICOM Food Import Bill, Food Security and Nutrition states:
Food imports, particularly of processed foods, are often associated with increasing overweight and higher rates of chronic non-communicable diseases (obesity, diabetes, hypertension, stroke, heart disease, and cancer). This phenomenon of over-nutrition— the increased consumption of animal fats, sugar products and salt—has led to rising obesity, particularly in the over-35 age group.
Mr. Fitzroy Henry, a nutrition professional who has served 18 years as Director of The Caribbean Food and Nutrition Institute (CFNI) and worked in/with 17 Caribbean countries, has a unique perspective of Caribbean dietary patterns and their associated effects. His qualifications include a PhD in Nutritional Epidemiology from the University of London.
In the video below, he shows the link between the food the Caribbean citizens import and thus consume, the origin of the food that is imported and its contribution to the obesity and NCD epidemic.
Dr Rohit Doon shows the nutrition transition in Trinidad and Tobago from a diet rich in fruits and vegetables to an energy-dense diet that is consumed by the majority of the population.
So, in short, why are we as a people growing horizontally? It’s not genetics, not a substantial drop in physical activity…
It’s. The. Food.
Its. The. Food
Proposed Solution to tackle the obesity epidemic in the Caribbean.
Don’t be fooled, this blog post is not to minimise the importance of increasing physical activity, exercise and movement. Increasing physical activity in most individuals is a high-reward, low-risk undertaking for health promotion or maintenance.
The author is of the view that the built environments of communities in the Caribbean should nudge individuals towards physical activity e.g. biking lanes, walking lanes or pathways, decreased access to personal motor vehicles etc.
However, the author believes that poor nutrition quality can cancel out or minimise any beneficial effects of exercise. Therefore, nutrition quality in the population should be of benefit to any population and not a hindrance.
Now that it’s clear that the food consumed is the X factor in the obesity epidemic, one should look at strategies to roll back the crisis and its associated health and economic effects.
To quote from a few research papers:
The author feels if history taught us any lessons from some of these successful public health campaigns, a combination of taxation, regulation and norm changes are needed to successfully address the issue of obesity prevention in the modern world6.
Policy efforts should focus on reducing population energy intake through improving the healthiness of food systems and environments7
The creation of effective (obesity) interventions will require collaboration across a diverse set of stakeholders, including legislators, educators, the food and health industries, media, community organizations, researchers, and public health organizations8.
Whereas ongoing efforts are needed to increase physical activity levels in the population, the priorities for reversing the obesity epidemic should focus on energy intake by addressing the obesogenic food environment drivers of the current energy overconsumption9.
Marion Nestle in her interview with Ben Jones offered this suggestion:
You can tell people that large portions have more calories, but they will still eat more when given a large portion. Everyone does. Education isn’t enough. You have to change the environment to make healthy choices the easy choices.
In the best case scenario, the envisioned environmental change can be realised through a combination of measures such as taxation and lack of access to unhealthy foods and substances, regulation (e.g. front-of-package warning labels), subsidisation of healthy foods e.g. fruits, vegetables, legumes, whole grains and tubers.
Healthy Caribbean Coalition campaign advocating for Front-Of-Package Warning Labels
The next question might be “How to achieve this environmental change to make healthy choices the easier choices?”
There are two ways to go about it (although there is a common theme in the two pathways).
Vote for health
Many people in Trinidad and Tobago may disagree with the author, but the author is of the view that voting matters (well, most of the time). As Dan Buettner says in his book The Blue Zones Solution: Eating and Living like the World’s Healthiest People(affiliate link):
“It sounds like a cliché, but a call or an email to the mayor’s office really does work. Your vote helps determine your community leaders. Are they ones who want to build a town for just cars and commerce or ones who build to favor humans and quality of life? Do they perpetuate the convenience trap of more strip malls and highways or advocate for parks and places for people to connect?”
In other words, the choice that you make for your community leader/mayor/councillor/Member of Parliament is a reflection of you and your desires. What sort of environment do you want to live in and be a part of? Your answer to that question determines your vote.
Then when your representatives are installed, lobby for change to make healthy choices easier e.g. community gardens, farmer’s markets etc.
From the ground up
If your supposed representatives are resistant to making this change possible, then start from the grassroots, like Pekka Puska of Finland. This approach will most likely encounter more resistance, will require a lot more patience and more stakeholders will need to be involved. However, this approach will tend to have a longer-lasting impact. The author has touched on the impact Pekka Puska had on North Karelia and Finland. One can read about it in more detail in Chapter 6 of The Blue Zones Solution: Eating and Living like the World’s Healthiest People.
Feed them!
Ok, I lied. I think there is a 3rd way (cue the shameless plugin)
As a segue to the 3rd way, here is a quote from Dan’s book mentioned earlier:
My lunch companion was Antonia Trichopoulou of the University of Athens, the world’s leading expert on the Mediterranean diet. Thinking of all the research she’d done, I asked her how I could persuade Americans to start eating food as healthy as this. I expected her to tell me I should focus on the dozens of nutritional benefits of the Ikarian diet. Instead, she motioned to the delicious items before us and said, “Feed them!”
And that’s what we at Spencer’s Whole Foods Plant Based Eats and Treats want to do.
We want to feed you food that is tasty and pleasing to the palate, yet will be of benefit healthwise to you.
Foods that are not calorie-dense, yet satiating
Foods that are not high in fat, salt and refined sugar and (refined) carbohydrates but food that is nutrient-dense, rich in vitamins, minerals and other compounds that will aid in normal body functions.
Foods that will lower your risk for chronic disease or if you are unfortunately challenged with a chronic disease, will make it easier to manage.
Foods that will be part of the environment that makes healthier choices easier, thereby helping Trinidad & Tobago and the Caribbean turn the tide of obesity and chronic disease
Food like this…
And this
References
- Bleich, S., Cutler, D., Murray, C., & Adams, A. (2008). Why is the developed world obese?. Annual review of public health, 29, 273–295. https://doi.org/10.1146/annurev.publhealth.29.020907.090954.
- Swinburn, B., Sacks, G., & Ravussin, E. (2009). Increased food energy supply is more than sufficient to explain the US epidemic of obesity. The American journal of clinical nutrition, 90(6), 1453–1456. https://doi.org/10.3945/ajcn.2009.28595
- Bleich, S., Cutler, D., Murray, C., & Adams, A. (2008). Why is the developed world obese?. Annual review of public health, 29, 273–295. https://doi.org/10.1146/annurev.publhealth.29.020907.090954.
- Vandevijvere, S., Chow, C. C., Hall, K. D., Umali, E., & Swinburn, B. A. (2015). Increased food energy supply as a major driver of the obesity epidemic: a global analysis. Bulletin of the World Health Organization, 93(7), 446–456. https://doi.org/10.2471/BLT.14.150565
- Swinburn, B. A., Sacks, G., Hall, K. D., McPherson, K., Finegood, D. T., Moodie, M. L., & Gortmaker, S. L. (2011). The global obesity pandemic: shaped by global drivers and local environments. Lancet (London, England), 378(9793), 804–814. https://doi.org/10.1016/S0140-6736(11)60813-1
- Swinburn, B. A., Sacks, G., Hall, K. D., McPherson, K., Finegood, D. T., Moodie, M. L., & Gortmaker, S. L. (2011). The global obesity pandemic: shaped by global drivers and local environments. Lancet (London, England), 378(9793), 804–814. https://doi.org/10.1016/S0140-6736(11)60813-1
- Vandevijvere, S., Chow, C. C., Hall, K. D., Umali, E., & Swinburn, B. A. (2015). Increased food energy supply as a major driver of the obesity epidemic: a global analysis. Bulletin of the World Health Organization, 93(7), 446–456. https://doi.org/10.2471/BLT.14.150565
- Bleich, S., Cutler, D., Murray, C., & Adams, A. (2008). Why is the developed world obese?. Annual review of public health, 29, 273–295. https://doi.org/10.1146/annurev.publhealth.29.020907.090954.
- Swinburn, B., Sacks, G., & Ravussin, E. (2009). Increased food energy supply is more than sufficient to explain the US epidemic of obesity. The American journal of clinical nutrition, 90(6), 1453–1456. https://doi.org/10.3945/ajcn.2009.28595
