Barbados’s Trident: A Multipronged Approach to Combatting Childhood Obesity through Advocacy, Policy, and Education

Acknowledgments

The completion of this case study would not have been possible without the support of the Barbadian community. We thank every policymaker, health expert, civil society representative, and thought leader who participated in our research. We also expand our gratitude to our partners, the Heart and Stroke Foundation of Barbados, the Healthy Caribbean Coalition, and the University of the West Indies, for their constant and unwavering support. Thank you for trusting us with your story. We notably acknowledge the foundational research conducted by Dr. Natasha Sobers and colleagues out of the George Alleyne Chronic Disease Research Centre at the University of the West Indies regarding the need for a whole-of- society approach to nutrition policy implementation.

Throughout the research process, we have deeply valued the mentorship and leadership we received from Dr. Leanne De Souza-Kenney and the Reach Alliance team. For the numerous people who touched this case study, in known and unknown ways, thank you for your guidance.

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MUNK SCHOOL OF GLOBAL AFFAIRS & PUBLIC POLICY

The Munk School of Global Affairs & Public Policy at the University of Toronto brings together passionate researchers, experts, and students to address the needs of a rapidly changing world. Through innovative teaching, collaborative research, and robust public dialogue and debate, we are shaping the next generation of leaders to tackle our most pressing global and domestic challenges.

Executive Summary

The focal point of the Barbadian Flag, the trident, is said to represent a break away from British colonialism, with the three spokes symbolizing the creation of a government of, by, and for the people. In 2007, against a backdrop of the increasing presence of noncommunicable diseases, the Caribbean community convened at the Port of Spain in Trinidad and Tobago to produce a declaration directly targeted at combatting and preventing such diseases. Barbados has one of the highest levels of commitment to this declaration. This report details the manner in which Barbados was able to achieve success in combatting childhood obesity by using a “trident” of advocacy, policy, and education as well as the challenges it has and will face in the process.

We explore Barbados’s multifaceted approach to combatting childhood obesity and describe the contributors to childhood obesity, initiatives undertaken to combat it, barriers to the success of these initiatives, and strategies for future implementation. Holistic, cross-sectoral, and people-centric policymaking have been crucial to the country’s approach, made possible by an active partnership between government and civil society organization. 

Context: Obesity in Caribbean Countries

Caribbean countries have among the highest obesity rates in the world and in Barbados specifically, two-thirds of the population are either overweight or obese, with one-third of Barbadian children considered obese.¹  A survey of students aged 13 to 15 found that at least 73 per cent consumed at least one carbonated soft drink per day, while over 70 per cent were not achieving WHO-recommended levels of physical activity. ² According to the World Health Organization, childhood obesity is “one of the most serious global public health challenges of the 21st century” and represents a substantial obstacle in the achievement of the Sustainable Development Goals.³ Obesity in childhood increases the risk of other health complications and has been linked to noncommunicable diseases (NCDs) in adulthood such as type 2 diabetes, coronary heart disease, and stroke, making this issue pertinent for policymakers and communities in Barbados. 

In conjunction with other member states of the Caribbean community (CARICOM), Barbados held the world’s first summit dedicated to NCDs in Port of Spain, Trinidad and Tobago, which afterward issued the “Port of Spain Declaration: Uniting to Stop the Epidemic of Chronic NCDs” in 2007.⁴ Member states’ government, civil society, and private sectors committed to preventing and controlling NCDs with recommendations specific to addressing the increasing prevalence of childhood obesity in the region — including mandating and providing incentives/resources for physical education and promoting healthy diets in schools. When compliance with these recommendations was evaluated in 2014, Barbados was found to be among the CARICOM member states with the highest level of commitment to the declarations made in the Port of Spain Declaration. It had introduced a 10 per cent tax on sugar-sweetened beverages (SSBs), a WHO endorsed best-practice aimed at promoting healthy diets.⁵   

Although the government also released guidelines for physical activity and nutritious foods in schools, these guidelines lacked a legal framework, and largely ignored the role of teachers and school workers so implementation and awareness among school administrators were minimal.⁶ Administrators aware of the guidelines were concerned about the cost of nutritious food options, and the continued availability of unhealthy foods for purchase in and near school environments. 

The recognition of childhood obesity as a significant issue across Barbadian society prompted community action. School-level programs enacted to address childhood obesity sought to raise awareness across the entire school community including teachers, students, and parents.⁷ The emergence of programs from different sectors of the community, such as the Heart and Stroke Foundation of Barbados’s Yute Gym, centred interventions on the context and needs of children. However, significant challenges remained because students still packed unhealthy foods and beverages and could buy additional unhealthy snacks at the food vendors at school.

Despite these challenges, the advocacy and program implementation efforts of civil society and individuals spanning healthcare, educational, and religious sectors have recently culminated in significant government action toward reducing obesity rates in Barbados. This included increases in taxation to sugar-sweetened beverages and the introduction of the National School Nutrition program, which represented a significant commitment by government and community to creating a health-promoting school environment.

We examine the development and evolving prevention of childhood obesity in Barbados: factors contributing to its widespread prevalence, the impact of civil-society-led interventions and government action, and the remaining challenges of addressing childhood obesity.

Hardest to Reach

Typically, being “hardest to reach” is conceptualized as a population of individuals who miss out on critical innovation or intervention because of geographic isolation, poverty, or marginalization. Here we consider “hardest to reach” in the context of broader societal issues which are difficult to address because of their multifaceted nature and the complex interplay impacted individuals have with their environment. One such issue is childhood obesity. Traditionally, obesity was solely considered as a consequence of energy imbalance produced by physical inactivity and an unhealthy diet. Now, researchers understand childhood obesity in a socioecological context that recognizes the interwoven relationship between a child’s health and their broader economic, cultural, and physical environment.⁸ Tackling the surface-level contributors of obesity (healthy diet and exercise) won’t adequately address the issue unless the upstream socioeconomic contributors are addressed — posing a complex challenge for Barbados and similar Caribbean countries.

The context of Barbados as a Small Island Developing State (SIDS) subjects it to unique economic, climate-related, and nutritional challenges that create an environment conducive to the development of childhood obesity and may ultimately hinder the development of sustainable solutions to address it.⁹ This is evident in the fact that half of the top 24 countries with the highest prevalence of childhood obesity are small islands.¹⁰  

Composed of an array of scenic islands, the Caribbean is one of the most tourism-dependent regions in the world.  In Barbados specifically, the accommodation and food services sector accounts for approximately 17 per cent of economic activity and 13  per cent of total employment.¹¹

As a result, the nation was particularly vulnerable to the devastating economic effects of the COVID-19 pandemic, which brought almost all tourism to an abrupt halt.  During the height of the pandemic, unemployment claims were submitted by roughly one-third of the entire work force and the number of households earning below the minimum wage in early 2020 more than doubled.¹² Widespread economic challenges left the population vulnerable to poverty, a widely recognized risk factor for the development of obesity, particularly in racialized populations.¹³  

Caribbean SIDS have fragile natural environments that are highly vulnerable to the landscape’s changes produced by climate change. For example, rising sea levels have resulted in salt infiltration into Barbados’s fresh water supply that lies beneath the island.  As a result, it is among the most water-stressed countries in the world and depends on the importation of water from other Caribbean states to meet local demands. The country expects the availability of fresh water to diminish as a result of ongoing saltwater contamination and declining average rainfall in the Eastern Caribbean which will further increase the costs of clean water and worsen related health conditions.

The modern agricultural and nutritional challenges faced by the Barbadian community are intertwined with its history as a British plantation state. Beginning in the 1640s,  sugar was produced using the labour of enslaved Africans. While slavery was abolished in 1807, sugar cane was still the major product on the island.¹⁴ This extractive process focused on maximizing the profit from land through exportable food products, particularly sugar, rather than meeting the dietary needs of its local population. The government has attempted to diversify the agricultural sector and increase local food production of root crops and vegetables. However, the high cost of energy and water, limited financing, and reduced quantities of farmable land has limited domestic agricultural output and food processing. 

Constrained agriculture has led to nutritional insecurity as Barbados depends on international trade to meet its population’s nutritional needs.  In 2020, half of the people in the Caribbean and Pacific SIDS had 80 per cent of their food come from elsewhere.¹⁵ Although the prices of these imports are often cheaper than locally produced foods, this affordability comes at a nutritional cost, with highly processed foods high in calories, sugar, and sodium making up 18 per cent of CARICOM food imports. Ultra-processed imported foods have predominated in Barbadian diets and will continue to as economic development continues and regulation on commercial food producers remains minimal.¹⁶ 

Approaches to childhood obesity prevention in Barbados that operate solely at the level of individual choices fail to address the upstream socioecological factors affecting the accessibility of nutritional foods and the capacity to engage in exercise regularly. We highlight the “hard to reach” nature of adequately addressing childhood obesity in Barbados and the innovative multi-level approaches being undertaken across society to tackle this issue.

About Our Research

While existing literature recognizes the need for a mandatory school nutrition and physical activity policy to tackle the growing rates of childhood obesity in Barbados, there was a gap in knowledge regarding the specific parameters and function of these programs, and how they interact with each other to contribute to the current state of children’s dietary habits and physical activity levels. We also explored existing policies and current guidelines related to lowering childhood obesity (looking at both physical activity and nutrition) so that we were better equipped to pose targeted questions to pertinent stakeholders about how they put these demands into practice in their organization or industry. 

The Interviews

After obtaining research ethics approval from both the University of Toronto and the University of the West Indies, Cave Hill, we formed a partnership with the Heart and Stroke Foundation of Barbados (HSFB) and the Healthy Caribbean Coalition (HCC), who supported us throughout the recruitment and logistics of field research. We recruited participants through purposive and snowball sampling.

We conducted a series of semi-structured interviews that lasted 30 to 60 minutes with 27 stakeholders relevant to a whole-of-society approach to childhood obesity prevention. These stakeholders included government policymakers, secondary school alumni, leaders of civil society organizations and faith-based organizations, healthcare workers, academic experts, and members of the private sector. 

Data Collection

We gave each participant the option for an in-person interview or virtual interview via Zoom. We conducted in-person interviews in Barbados, at a predetermined private location convenient for the participant.  We used the Zoom platform to conduct virtual interviews. With each participant’s consent, we recorded interviews (audio and/or video). One researcher led the interview, communicating directly with the participant following a prepared interview guide. All other researchers present took hand-written notes during the interview. 

We stored audio-video recordings of the interviews on an encrypted and password-protected FIPPA (Freedom of Information and Protection of Privacy Act)-compliant server’s SharePoint folder for a period of 48 hours. All personal identifying information was removed prior to transcription by assigning each interview a number, and removing identifying information provided by the interviewee, such as their current workplace. Before deletion, each recording was transcribed into a separate encrypted SharePoint document. Then using the transcripts as a guide, we developed a codebook that collected overarching themes from across the interviews which became the basis for our findings.

Perceptions of and Contributors to Childhood Obesity in Barbados 

Most people we spoke with expressed concerns about childhood obesity and the potential long-term effects it may have on Barbadians. Health professionals and academics described the link between childhood obesity and other noncommunicable diseases later in life, such as diabetes and cardiovascular diseases, which can lower quality of life and increase costs in the country’s publicly funded healthcare system. Other experts from disciplines such as business, finance, and agriculture were concerned about how the rising rates of noncommunicable diseases stemming from habits built in childhood and adolescence may lead to increased absenteeism and an eventual shortage in the workforce. There are current signs of this burden: Barbados is known as the “amputee capitol of the world” as a result of its high rates of untreated diabetics in the country, especially in adult males.¹⁷  

Most participants felt that there had been an increase in general awareness and concern about childhood obesity over the past couple of years. However, many explained that some parents are unaware of the gravity of the issue. In the words of a health expert we spoke with, “There are parents that when they get the information, they really are appall[ed] — they try to make change. And then there are parents that are — they’re not moved. They see the statistics and they say, ‘well, this doesn’t apply to my child cause my child is slim and I don’t see a problem right now.’” 

Contributors to Childhood Obesity

Numerous factors contribute to the dispropor-tionately high rates of childhood obesity in Barbados, ranging from the micro and personal to the macro and societal levels, and they are frequently interconnected. Many efforts to reduce childhood obesity focus on external factors because, in the words of one interviewee, “[we] can’t look at an issue outside of what is really the whole environment that [the individual] operates within … [We] can’t blame the individual if that individual operated in an environment that is very restrictive to that individual.” 

Four key contributors to the rates of childhood obesity emerged from the interviews: 

1. The Barbadian preference for particular types of dishes, cuisines, and physical appearance;
2. The Western World’s influence of fast-food culture on Barbadian food preferences;
3. Barbados’s high cost of living and lack of understanding about how to maintain healthy eating; 
4. The development of sedentary lifestyles among children as a result of the built environment.

Preferences: Particular Foods and Physical Appearance

Many participants noted that people’s eating habits are unhealthy, with excessive amounts of salt, fat, sugar, and fatty meats, as well as larger-than-necessary portion sizes. “Within Barbados we eat a lot of starch and yes, we eat some fruits and veggies in between, but it’s mainly a very heavy starch diet. [On] the average plate there are two to three starches” one participant said. Another participant told us that,”[Bajan] tradition is to have your breakfast [then] lunch is a big lunch, with rice and peas or macaroni pie or it’s a heavy meat, starch — maybe a little salad or vegetables on the side — but it’s a heavy meal.” Both of these interviewees noted the strong connection between the average diet and poor nutrition.  

Heavily influenced by their colonial background, modern Bajan culture frequently favours a particularly sweet cuisine. “Sugar is a major part of our culture in Barbados. A lot of the national dishes that we hold dear are high in sugar,” said one of the participants. As a result of their exposure to sugary foods, children are destined to crave them throughout their lives, and it would be challenging “to refine [their] palates to remove that sugar.” Many of the participants who work in the health field strongly believed that “sugar-sweetened beverages were the number one source of added sugars in diets in Barbados.” 

People also told us about the inclination to favour a fuller body shape, especially for Caribbean women. This causes problematic eating and inadequate fitness habits because unhealthy weights are favoured. Young girls, in particular, may experience societal pressure to appear fuller, leading them to consume more food than is necessary to attain an appearance that makes them more attractive. “When I was in school, there was this concept that girls who were bigger were more sought after. And that was always a thing. I remember that sort of cultural thing around body and your body shape. It was never like, I [want to] be skinny — it’s always I want to be big.” 

Current Initiatives

Numerous accounts tell a story of Barbados “leading the way in the entire Caribbean” in the health space through policy, innovation, and a people-first approach. Under Prime Minister Mia Motley, the government has rolled out a series of policies aimed at combatting noncommunicable diseases (NCDs) and subsequently improving overall health. These policies include a School Nutrition Policy and a tax on sugar-sweetened-beverages (SSBs). The School Nutrition Policy, implemented early in 2023, is a collaboration between the Ministry of Health and Ministry of Education. It is a comprehensive set of rules and guidelines designed to improve the health of children by completely eliminating sugary beverages (like fizzy drinks and concentrated juices) and unhealthy snack foods from schools. 

The policy’s sudden implementation and perceived extremity caused initial outrage among teachers, parents, canteen vendors, and students alike.  Participants reiterated how teachers expressed concerns that they “can’t spend a whole day policing what the child eats or drinks.” To ease tensions and ensure the policy’s successful implementation, various government ministries, the Heart and Stroke Foundation of Barbados (HSFB), the National Non-Communicable Diseases Commission, the Healthy Caribbean Coalition (HCC), United Youth Leaders of Barbados, and prominent community leaders made significant efforts to sensitize and educate the public on its benefits.

The Sugar-Sweetened Beverage Tax was initially put forward in 2015 as a 10 per cent tax and then increased to 20 per cent in April 2022. Although civil society organizations like the HSFB saw the implementation and subsequent increase of this tax as a victory after years of campaigning and advocacy, reactions to the policy were mixed. While many were overjoyed and point to research that shows decreased sugary beverage consumption after the tax, critics highlight the underlying substitution effect with the tax simply driving consumers to cheaper drinks instead of healthier options. However, everyone agreed that regardless of how much of an impact the tax had on consumption, it served as a tool to raise awareness and educate the public on healthy food choices. 

In addition to major policies, the government has also been actively working to ensure that NCD prevention is at the forefront of people’s awareness. They do this through health fairs, encouraging physical activity in schools through HYPE (Healthy Youth through Physical Education) days, and increased sporting opportunities. The Ministry of Agriculture has been focusing on how food is grown and the nutritional composition of local produce. The Barbados National Standards has labelling regulations for all packaged food and beverages and consistently conducts workshops with the informal sector to ensure labelling uptake. However, civil society is still very vocal about the need for stricter front-of-package labelling requirements. The NCD Commission supports the implementation of the octagonal “high-in” front-of-package warning label for all packaged foods and beverages. Such a label is recommended by WHO/ PAHO and CARPHA and has seen successful implementation in Chile.

The government has also identified a “basket of goods” under the Social Compact Program that consists of goods that are not taxed. The basket includes some of the common staples in Barbadian diet. This zero-tax-rated basket aims to mitigate the rising cost of living on the island, and civil society organizations have been lobbying to expand the program and include a greater number of nutritious food options. 

The Ministry of Education and the Dieticians of Barbados have also organized competitions like essay writing and poster making to make learning about NCDs enjoyable for children. Such gamified nutritional education has also been taking place through social media competitions and events, increasing youth engagement in health.

Collaboration and Civil Society Initiatives

Acting as both the government’s pillars of support and its harshest critics, civil society organizations have played an instrumental role in the fight against childhood obesity. Most notably, the HSFB and its Childhood Obesity Prevention Coalition have taken on mass media campaigns to educate and sensitize the public on making healthy choices as well as to promote certain government policies. The coalition also provided training to vendors and teachers in partnership with the Ministry of Education in the aftermath of the School Nutrition Policy. The HSFB also developed the Model School Program in 2019 which removed sugar-sweetened beverages (SSBs) and unhealthy food choices from six select schools in addition to creating increased physical activity opportunities. The program’s success, documented through extensive monitoring and evaluation, served as the template for the School Nutrition Policy. HSFB also conducted a “drink more water” campaign. To support this, the coalition and the Barbados Muslim Association rolled out a water-cooler program that brought safe drinking water to schools across Barbados. 

Barriers

While a variety of stakeholders have made considerable progress toward preventing childhood obesity and reducing associated preventable disease rates, numerous barriers currently prevent their collective efforts’ further success. Preventing and mitigating obesity often requires changing aspects of inherent cultural practices, such the high amounts of sugar and salt added to traditional dishes. Research participants repeatedly emphasized that changing culture is a rather sensitive and expensive process. Advertising messages through billboards, radio programs, and education within the community about healthy diet and exercise are effective strategies, but organizations often lack the required funding to launch these health-promotion efforts. Reducing the consumption of high-sugar and high-salt food also means healthy alternatives must be made accessible to families.

Some participants described limited human resources as another major hindrance. While the Barbados National School Nutrition Policy has banned sugar-sweetened beverages (SSBs) and unhealthy foods within and around school, participants reiterate that policy enforcement outside school is particularly challenging due to a shortage of staff. Issues with staff shortages are prominent for partnering sectors outside of the nutrition and health promotion sectors, such as education, where resources are already exhausted: “This is particularly relevant for the education sector in which teachers do not have the bandwidth to monitor policy compliance in addition to their other roles.”

Lack of Compliance

Because implementing the National School Nutrition Policy requires changing part of  Barbadian culture, many participants expected pushback. This type of resistance is especially present among parents and school vendors. COVID-19 restrictions may have further contributed to this resistance because people believe that the “government wants to get involved in the home.” Some parents believe that “children should have the right to eat and drink whatever they want,” and find the policy intrusive. As a result, participation in parent teacher association meetings that were planned for the promotion of the policy was low. 

School vendors are also significantly impacted by the nutrition policy since “this is literally what they do to survive.” However, vendors’ reactions to the policy seem to be divided —  some vendors believe “there’s nothing wrong with what [they] are doing, because children could take a little bit [of the unhealthy food and drink].” 

Consequently, some vendors took advantage of staff shortages around the school compound and “still serve the same high-sugar and -salt [food and beverage just outside school].” Meanwhile, other vendors were on board with the policy, according to an HSFB member, but they find selling healthy alternatives challenging, since these products do not entice children as much, negatively impacting their business.

Political Will 

While many civil organizations have participated in the education campaigns to sensitize the public about the dangers of noncommunicable diseases (NCDs) and childhood obesity, with the Barbadian government response through increased taxes on SSBs and the National School Nutrition Policy, some participants emphasized that political will could be further strengthened. One civil society member highlighted that “every single thing is dependent on political will,” especially when “we can have the best campaigns in the world, but if you don’t have the right people pushing the campaigns, it will not work.” 

Another participant believed that the government should intervene. For instance, the government could enforce more strict nutrition labelling in local restaurants. However, as a government official pointed out “[most governments] become reactive,” especially when there are “high cases of NCDs.” Instead, governments should take a more preventive approach to keep issues from becoming severe.

Industry Interference

Interference from companies that promote unhealthy food and beverages is another major barrier to the prevention of childhood obesity, since civil society special interest groups and nonprofits have to diligently counter their messages. This industry influence has infiltrated many aspects of children’s lives. For instance, these companies have created different marketing strategies, such as “posters and giving books with their brand on the back [in schools]” and television. 

An HSFB member stressed that digital marketing is especially powerful to “a mind that is not completely developed” and is particularly challenging to control. Paradoxically, sports events, such as the Barbados Association of Secondary School Championships, often receive sponsorship from food and beverage companies, which often are the companies “that are contrary to the School Nutrition Policy.” An HCC member mentioned that “[the food and beverage industry] is more or less involved in policymaking,” making it quite challenging to minimize their interference in changing the school food environment.

Lack of Information

When it comes to a lack of information, two strands hinder the success of initiatives that target childhood obesity: (1) lack of information or misinformation about nutrition and exercise science and (2) insufficient sensitization about the National School Nutrition Policy.

Participants described lack of information/knowledge of nutrition literacy among teachers and physicians. One HSFB member pointed out that some teachers do not fully understand the harm of added sugar and the value of natural sources of sweetness, such as those from whole fruits. A government official highlighted that physicians need to provide more detailed discussions with patients about nutrition and exercise science. For instance, only telling obese patients to exercise more may not be sufficient, since a moderate amount of exercise may “raise cortisol levels,” and lead to stress eating. They further stated that doctors could suggest that patients incorporate 30 minutes of leisure walking after a workout to lower cortisol levels. They believe that physicians should educate patients more when providing nutrition advice, such as why “avoiding red meat” is important or if there is solid scientific research underlying it. 

Several participants also expressed that sensitization about the National School Nutrition Policy could have occurred earlier. In general, participants believed that the groups (such as children, parents, and school vendors) who are most affected by the policy should be consulted even before the announcement of the policy. As one civil society member pointed out “the problem is always that you consult people who are at the top, but information is not always trickled off to the bottom.” Such disconnection may prevent the successful rollout of the policy.

Partnerships

Although the Healthy Caribbean Coalition (HCC) and the Heart and Stroke Foundation of Barbados (HSFB) collaborate with various civil societies and government sectors, many participants described unequal partnerships among different stakeholders. One civil society member mentioned that “one of the major challenges is communication among organizations,” and when different sectors meet, “the impact is there but the impact is small.” 

The small impact could be reflected in low participation in certain events, likely due to the lack of active promotion by the associated partners. One participant also described how “the government and schools lean heavily on civil society” for hosting activities. Such lack of synergy could be mitigated by keeping consistency in messaging/language across campaigns run collaboratively and individually by partner organizations. For instance, a government official pointed out that communicating with nutrition teachers through WhatsApp facilitated the spread of important announcements.

Strategies for the Future

People we interviewed had a range of ideas and methods to improve current interventions, and key approaches that must be at the forefront in this battle against the childhood obesity epidemic. 

Increased Access to Healthy Foods

A key strategy involves tackling the economic burden that a healthy lifestyle can present. A simple way to do this is by leveraging current systems of access to food. While the government’s zero-rate (tax-free) food basket discounts common and popular foods, it should target healthier food options. As one participant explained: “I think going forward, the food and nutrition security policy should speak to that — a nutritious basket of goods that we are asking for a lower pricing on — to specifically deal with the issues of obesity in Barbados.” 

Simple swaps, such as exchanging salted meats for fresh local, lean cuts and simple carbohydrates for more complex local carbs within the tax-free basket, can create a difference in the types of foods that are accessible. Another aspect to this access is ensuring that healthy foods are available across the country to the entire population. This would ensure that people get the chance to make better choices if they have the options available. 

Creating more equitable access to healthy foods gives people, including children, the opportunity to make wiser choices regarding their health. Otherwise, there’s no point to more sensitization and education if healthy options don’t exist. “In terms of the vendors, they think we need to encourage them to sell the healthier option because they have a big role to play. A child will naturally buy what he sees. So, if all he’s seeing is all unhealthy, he’s going to buy that. If you see — if you ingrain in the culture of fruits and healthier options — then yeah.” 

Targeting Culture 

Another strategy was to highlight local foods that are healthy and make small changes to traditional meals to make them healthier. This strategy lessens the negative polarization that some people may feel when organizations advise them on what to eat. Cultural foods can be appreciated and transformed into a healthier meal without sacrificing taste. As one participant explains:

Simply informing people of healthier options will not produce the desired effect if healthy foods are not infused into mainstream culture and embedded within cultural delicacies. Participants explained how classic Bajan dishes, such as macaroni pie, can be transformed into healthier versions by substituting half of the regular amount of cheese with pumpkin, to preserve the texture and deepen the flavour. “Education is absolutely key when it comes to getting people to do the right thing, even within the culture.” Barbadians shouldn’t be constrained in their food choices, but rather given the ability to make educated choices about their diet.

A Push for Greater Education

Without creating platforms for people to learn about the consequences of poor nutrition and a sedentary lifestyle from early on, there can be no opportunity for change. One aspect of education is sensitization. If a new rule comes into place, such as the National School Nutrition Policy, there is value in informing parents and the children themselves. A participant elaborated: “Even when you take from that child, you explain to the child why you were taking. So, you just don’t do it because, ‘oh, this is not allowed here.’ You do it and you explain to them, ‘Well, this is not allowed because X, Y, Z’.” 

A great way to allow children to engage in conversations about healthier lifestyles is by “gamifying” health. For instance, hosting regular competitions for children could be one strategy to “gamify” learning about healthy lifestyles. In fact, one participant explained that Barbadian culture facilitates healthy competition. “You find a lot of Barbadians will not engage unless it is a competition or something like that.”

Sensitization also involves educating the facilitators of childhood-obesity-prevention programming, such as teachers, and ensuring that all schools have uniform messaging. A participant explained:

With the rise of social media influencers, many participants agreed that invading the digital arena is vital to reach the youth. “We recognize that it can’t just be scientists and healthcare providers telling everybody this — you have to get influencers. You have to get people that young people will listen to and say, ‘okay, you know, what they’re saying— that makes sense,’ not some old guy that’s coming out and saying, ‘well, the science says this’.”

“A lot of our young people are on social media so we need to have a lot more social media presence. You know, TikTok videos and things like that. So if we had the resources, we can put more into that to help spread the message. Get influencers that have large followings to say, you know what, you know, do this.”  They went on to explain a barrier regarding getting major Barbadian celebrities to spread the message. “A number of our influencers, unfortunately, are also influencers for the big brands, so, it’s a conflict of interest if you need to use them. But, you know, but they would, obviously, it’s an economic thing for them. They get money. If you can afford to pay them to not promote big brands and promote [childhood obesity prevention], then that’s fine.” 

Starting at Home

One expert we spoke with said:

Others also recognized that the primary defence against childhood obesity begins in the home. “The school plays a role, but it’s not the primary holder of this responsibility. It also comes down to parents: what snacks, what beverages parents send their children to school with. That’s the first thing.” 

Bringing the Private Sector on Board

The food industry’s involvement in the fight against childhood obesity was central to many discussions. One participant explained how important industry is in the options to consumers, and how interrelated those two things are.

Industries can make a change by altering the way they market to children. A participant explained how bright colours can easily attract children to unhealthy foods. Changing the way the food industry markets their products, such as by removing cartoon characters from packaging, could discourage children from purchasing these unhealthy foods.

An alternative to removing bright colours and mascots would be for the health community to add their own bright colour to the mix in the way of nutritional labelling and warnings on foods high in sugars, fats, and salt. One interviewee explained that “front-of-package warning labels will inform people what they need to put back and leave on the shelf.”  The HSFB and HCC have been advocating for front-of-packaging warning labelling and hope to see the government rolling it out soon.

Shifting Society Advocacy to Government Policy

Our conversations around next steps were often guided by the idea that there is a need for government to increase their role in this fight. Indeed, the government has the power to create policies. Once policies are set in place, all sectors can contribute in one way or another to reduce the number of NCDs in the country. One interviewee pushed for the government to take on the role of regulating the private sector in the health sphere. “The government has now to think outside the box to say, ‘What are these policy tools that we’re going to use to incentivize industry to move in the [right] direction?’” 

Another recognized the vital role of NGOs and grassroots organizations to combat childhood obesity rates, but in the end, it is not the most sustainable solution. “[Barbados] has a strong NGO subsector — the Healthy Caribbean Coalition and stakeholders like that. They’ve been pushing and promoting for years, so I would never understate the value of their work. I just think it is far more enhanced by what and when the government supports and intervenes.” Participants were eager for the government to continue to create policies that would further push for a healthier Barbadian society, such as the advocacy in the context of the school nutrition policy.

Embracing a Holistic Approach 

Several participants recognized the importance of a holistic, all-encompassing approach to tackling childhood obesity. However, they had diverse views on what this approach entails. Some advocated targeted interventions ranging from tackling both nutrition and exercise, to initiatives targeting prevention and the development of potential cures for noncommunicable diseases. For others, embracing a holistic approach means understanding the overall contexts that lead to childhood obesity in order to make informed and appropriate interventions. One participant explained that there is a dire need to “understand the context from where we came, to understand context from where we are, to understand the context for where we’re going.” 

Interviewees saw a holistic approach involving all sectors coming together to accomplish the goal of lowering the rates of childhood obesity. “It’s everybody’s [responsibility] … It’s not strictly the medical professionals’ need to do it, but everyone needs to do it. Whether it’s in the churches, in the mosque, it’s in the rum shops. The message should be there — that you should be responsible, and you should be responsible in how you take care of yourself.” 

Reminiscent of the iconic trident stationed upon the Barbadian flag, one participant highlighted a holistic, multipronged approach: “So with the multipronged approach at the national level, you begin support for international financial agencies to do it. You then have the civil society groups, and industry, trying to tackle this and if you have a central point then everybody is going to [create impact] over time.” Another aspect of the holistic approach is to ensure that government policy is created in a way that affects all of society. “The policy, starting with the nutrition policy, has not only to go with the schools, but it has to go in every theatre of society.” 

The impact of the SSBs tax may not have been as efficient as possible simply because the policy does not attack the psychology behind purchasing SSBs.“Ultimately [the SSB tax] had a revenue impact for the government, but from a lifestyle standpoint, persons paid for [SSBs] because they wanted it. I don’t think you’re going to price people out of drinking those drinks — it has to be a more holistic approach.”

Lessons Learned

People in Barbados view childhood obesity as needing prevention which can help maintain the population they have and lessen the burden on the fragile healthcare system in adulthood. It is a long-term intervention in which the results won’t be seen for another 10 to 20 years. The only way to achieve long-term prevention is through changing the culture, which is what they are doing through policy and advocacy and through education at every age.  

Despite various barriers that have become apparent as Barbadians develop into a healthier society, the following lessons are promising.

• Initiatives that target a health issue such as childhood obesity require a multipronged approach to attack the issue on multiple fronts (i.e., at home, in schools, and in the public).
• Multisectorial initiatives can work to create permanent change (e.g., Barbados National School Nutrition Policy), only if there is ongoing communication and constant public attention.
• The food industry must get on board with developing new healthy foods instead of pumping nutritionally lacking foods into poor communities. Further advocacy for government regulation is necessary.
• Small change is still change. Creating conversation surrounding health, nutrition, and fitness can lead to a greater awareness, and to changing habits in families. Education is the key to developing this long-term change.
• Understanding the implications of colonialism on current health crises is crucial.
• Childhood obesity preventions initiatives cannot be a one-size-fits-all approach. Every country must consider their own culture to create targeted interventions.