Food and Nutrition Security Policy and Action Plan for the Commonwealth of the Bahamas 2017 - 2022

2 1 Table of Contents 2 Abbreviations & Acronyms ............................................................................................. 4 3 Glossary ......................................................................................................................... 6 4 EXECUTIVE SUMMARY .................................................................................................... 8 5 Introduction ................................................................................................................. 12 5.1 Physical and Population Characteristics ............................................................................. 12 5.2 Economic structure ........................................................................................................... 12 5.3 Poverty ............................................................................................................................. 13 6 The Health Profile ......................................................................................................... 14 7 The National Food and Nutrition Situation .................................................................... 16 7.1 Food and Nutrition Security Profile .................................................................................... 16 7.2 Food availability ................................................................................................................ 16 7.3 Food Accessibility and Affordability ................................................................................... 18 7.3.1 Resources to purchase food ................................................................................................ 19 7.3.2 Physical access to food ........................................................................................................ 19 7.3.3 Economic access to food ..................................................................................................... 20 7.3.4 Social safety-net for the vulnerable .................................................................................... 20 8 Food Consumption and Utilization ................................................................................ 21 8.1 Food choice ....................................................................................................................... 21 8.2 Childcare practices ............................................................................................................ 22 8.3 Food safety and quality ..................................................................................................... 23 8.4 Food borne illness ............................................................................................................. 24 8.5 Lifestyle choices ................................................................................................................ 24 9 Food Stability ............................................................................................................... 25 9.1 Economic vulnerability ...................................................................................................... 25 9.2 Natural disasters ............................................................................................................... 25 9.3 Promoting resiliency .......................................................................................................... 26 10 The International and Regional Context ..................................................................... 27 10.1 Regional ............................................................................................................................ 28 10.2 National Context ............................................................................................................... 28 11 THE BAHAMAS FOOD AND NUTRITION SECURITY POLICY ........................................... 29 11.1 The Vision ......................................................................................................................... 29 11.2 The Goal ........................................................................................................................... 29 11.3 The Guiding Principles ....................................................................................................... 29 11.4 Organization of the Food and Nutrition Security Policy ....................................................... 31 11.5 Thematic Area I - FOOD AVAILABILITY ................................................................................ 31 3 11.6 Thematic Area II: FOOD ACCESSIBILITY AND AFFORDABILITY .............................................. 33 11.7 Thematic Area III: FOOD CONSUMPTION AND UTILIZATION ............................................... 34 11.8 Thematic Area IV: FOOD STABILITY .................................................................................... 36 11.9 Thematic Area V: GOVERNANCE AND CAPACITY BUILDING FOR FNSP ................................. 37 11.10 MONITORING, EVALUATION, ACCOUNTABILITY AND LEARNNG ...................................... 38 12 Annex I – The Food and Nutrition Security Action Plan (2017 – 2022) ......................... 40 14 ANNEX II: List of Membership for the National Food and ........................................... 62 15 REFERENCES .............................................................................................................. 63 4 2 Abbreviations & Acronyms AIDS - Acquired Immune Deficiency Syndrome BAIC - Bahamas Agricultural & Industrial Corporation BAMSI - Bahamas Agriculture and Marine Science Institute BEST - Bahamas Environment Science & Technology Commission BLCS - Bahamas Living Conditions Survey BOS - Bureau of Standards CARICOM - Caribbean Community CELAC - Community of Latin American and Caribbean States CNCDs - Chronic Non-Communicable Diseases CPI - Consumer Price Index CNCDs - Chronic Non-Communicable Diseases CPI - Consumer Price Index DEHS - Department of Environmental Health Services DPS - Department of Public Service ECLAC - Economic Commission for Latin America and the Caribbean FAO - Food and Agricultural Organization FBDG - Food-Based Dietary Guidelines FNS - Food and Nutrition Security FNSP - Food and Nutrition Security Policy GDP - Gross Domestic Product HACCP - Hazard Analysis Critical Control Point HAZ - Height for Age Z-scores HIV - Human Immunodeficiency Virus IMF - International Monetary Fund M&E - Monitoring and Evaluation MOA - Ministry of Agriculture and Marine Resources MOE - Ministry of Education MOF - Ministry of Finance MOH - Ministry of Health Abbreviations & Acronyms (cont’d) 5 NCD - Non-Communicable Disease NFNCC - National Food and Nutrition Coordinating Commission NDP - National Development Plan NGO - Non-Government Organization PEM - Protein Energy Malnutrition OAG - Office of the Attorney General RFNSP - Regional Food and Nutrition Security Policy SDG - Sustainable Development Goals SIDS - Small Island Developing State UNDP - United National Development Programme UNICEF - United Nations Children's Fund US - United States WHO - World Health Organization 6 3 Glossary  Exclusive breastfeeding is defined as an infant being solely breastfed or fed expressed breast milk via the spoon-and-cup method; and given no bottle (even if it contains expressed breast milk), water, formula, or baby food.  Food Availability refers to the supply of nutritious food at national and community levels as a result of national food production, food imports, and stocks or stores of food.  Food Accessibility/affordability means that households and individuals have the necessary resources to obtain adequate nutritious food and that there are no physical or economic barriers to accessing the food.  Food Consumption/utilization refers to the attainment of adequate nutrition through wholesome, healthy and diverse food choices and adherence to appropriate and acceptable food quality and safety standards, basic principles of nutrition and child care, adequate levels of physical activity, and complementary medical services and adherence to Food Based Dietary Guidelines (FBDG).  Food Dependence is the ratio of total food imports to total food consumption  Food Stability refers to long-term food and nutrition security and requires that risk management and social protection measures be put in place to protect against physical and economic shocks at national and household levels to ensure availability, livelihood and safety net measures are developed to ensure access and food can be utilized through access to healthcare, clean water and sanitation.  Food price inflation is an increase in the price of a standardized good/service or a basket of goods/services over a specific period of time usually one year.  Iron-deficiency anaemia is a condition in which there are no mobilizable iron stores and in which signs of a compromised supply of iron to tissues, including the erythron, are noted. The more severe stages of iron deficiency are associated with anaemia.  Low birth weight refers to the proportion of newborns weighing less than 2,500g.  Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. The term malnutrition covers 2 broad groups of conditions. One is ‘undernutrition’—which includes stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals). The other is overweight, 7 obesity and diet-related non-communicable diseases (such as heart disease, stroke, diabetes and cancer).  Protein-energy malnutrition is a nutritional deficiency resulting from either inadequate energy (caloric) or protein intake and manifesting in either marasmus or kwashiorkor.  Under nourishment is a measure of the proportion of the population estimated to be at risk of caloric inadequacy.  Under-nutrition is defined as the outcome of insufficient food intake and repeated infectious diseases. It includes being underweight for one's age, too short for one's age (stunted), dangerously thin for one's height (wasted) and deficient in vitamins and minerals (micronutrient malnutrition). 8 4 EXECUTIVE SUMMARY Food and nutrition security refers to a situation where all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life1. The Commonwealth of The Bahamas has made great strides in reducing the prevalence of undernourishment, however it is estimated that 5.6 per cent of the population, about 19,000 individuals, still lack sufficient food for their dietary needs. Similarly, about 5 per cent of children are stunted; which is considered low by global public health standards, but is unacceptably high for our nation. Micronutrient deficiencies, particularly iron deficient anaemia, pose a significant risk for maternal and child health in The Bahamas. By far the most pressing nutritional challenge facing The Bahamas are the burgeoning rates of overweight and obesity, and the accompanying epidemic of chronic non-communicable diseases (CNCDs). It was estimated that 27 percent of adults were overweight and 43 percent were obese in 20052. These levels continued to increase, and in 2012, it was estimated that 80 per cent of adults were overweight and 49 percent were obese. There is also growing concern about obesity rates in children, where the percentage of children who are overweight in grade 1 has increased from 4.8 percent in 2005 to 7.4 percent in 20123. The Bahamas is facing a public health crisis due to poor dietary habits and unhealthy lifestyle choices. The Government of The Bahamas is committed to creating a food and nutrition secure nation. Good nutrition through all phases of the human lifecycle begins with access to healthy diets, but also requires adequate levels of regular physical activity, complementary health care, accurate knowledge and information, good sanitation and reliable protection from natural disasters and economic shocks and a supportive environment. The four pillars that are used to determine food and nutrition security are: food availability, food accessibility/affordability, food consumption/utilization and food stability. An analysis of the first pillar indicates that there is enough food available in The Bahamas from food production, imports and stocks of food. In fact, the amount of food available exceeds the recommended dietary energy supply. The main issues related to food supply are the need for comprehensive policy framework to address productivity and competitiveness constrains in the agricultural sector, and the types of food imported which are calorie dense, nutrient -poor carbohydrates (pastry and flour) and foods high in fats, sweeteners and sodium such as food preparations, meats and beverages The second pillar of food security is accessibility/affordability, which looks at the physical and economic access of households and individuals to adequate supplies of nutritious food. The data suggests that although food is available and physically accessible, there is not equitable access to 1 Food and Agriculture Organization (1996) World Food Summit 2 Ministry of Health (2005) CNCD Prevalence Study and Risk Factor Survey 3 Ministry of Health (2012) Primary Health Report 9 food due to growing levels of poverty and high food prices. Moreover, despite the existence of a range of publically-funded social programmes to address access to food, there is a need for greater coordination of these programmes to prevent duplication of efforts and missed opportunities for economies of scale to impact the vulnerable population. The vulnerable population have been identified as: school-aged children, pregnant women, people living with HIV/AIDS, senior citizens, disabled persons, including mentally and physically challenged persons, and individuals that qualify for government-assistance programmes. The food consumption/utilization pillar refers to the food choices made by individuals and their ability to utilize the food throughout the entire lifecycle. The information for The Bahamas indicates that there is inadequate adoption of exclusive breastfeeding practices among mothers, and complementary feeding is introduced too early. Furthermore, there is low consumption of fruit and vegetables, and a preference for foods that have high fat and sugar content. These food practices coupled with sedentary lifestyles have resulted in rapidly increasing numbers of overweight and obese children and adults. Finally, the stability pillar ensures that measures to ensure long-term food and nutrition security are resilient to political, economic, social and environmental factors. The Bahamas is a stable parliamentary democracy. The economy which is based on tourism and financial services, has recently exhibited lower levels of economic growth resulting in higher levels of unemployment particularly among young people. Although there are sources of environmental susceptibility affecting food security such as land degradation, the greatest sources of vulnerability are the high dependence on imported food and the impact of climate change, which will affect underground water quality, cause salination of water and land resources, and result increasing frequency of weather-related events including hurricanes, droughts and floods. In light of the multi-dimensional factors that influence food and nutrition security, the Government of The Bahamas has prepared a National Food and Nutrition Security Policy (FNSP) that seeks to create synergies between public and private institutions and positively impact the food and nutrition security of the nation. The vision of this Food and Nutrition Security Policy and Action Plan for the Commonwealth of The Bahamas is for all people to have physical and economic access to sufficient, safe and nutritious food, at all times, to meet their dietary needs and food preferences for an active and healthy life. The goal of the Food and Nutrition Security Policy and Action Plan is to improve the food, nutrition and health status of the population with minimum disruption to the ecosystem. The policy will seek to ensure that people have sufficient knowledge about the relationship between dietary practices and physical fitness to protect their health, well-being and the environment. The attainment of the goals will be facilitated by six interrelated guiding principles which are:  National ownership  “All of Government” collaboration  “All of Society” partnership  Continuous Learning and Sharing 10  International, Regional and 'South-South' Cooperation These guiding principles anchor the FNSP Policy and Action Plan in a collaborative, multidisciplinary approach. This requires coordinating the activities of government agencies and partnering with private sector and civil society in mainstreaming good nutrition throughout the entire food system and within all of society (FAO, 2013). This document presents a national Food and Nutrition Security Policy (FNSP) and Action Plan for The Bahamas, for the five year period, 2017 – 2021 and is designed to improve the food and nutrition status of every segment of the population and to serve as a roadmap for attaining the highest level of food and nutrition security within The Commonwealth of The Bahamas. The FNSP Policy and Action Plan are built upon the four pillars of food and nutrition security: Availability, Accessibility/Affordability, Consumption/Utilization, and Stability. The FSNP can be summarized as follows: Food Availability: The Government of The Bahamas will promote the sustainable production of safe, affordable, nutritious, and high quality, local foods through the development of competitive and diverse domestic food production systems and value chains, and will ensure a sustainable level of equally safe, affordable, nutritious, and high quality food imports built upon mutually collaborative links with regional and international countries. It is recognized that The Bahamas is highly dependent on international food trading systems to meet its national food requirements. Therefore, The Bahamas will adopt a strategic dual approach to securing food availability– firstly by actively participating in the functioning of international trade systems; and secondly by strengthening and diversifying national food production systems to enhance sustainable local production. Food Accessibility and Affordability: The Government of The Bahamas will facilitate the sustainable development of human and social capital of the population, monitor national and international food price movements, and provide social protection for vulnerable groups, thereby increasing greater accessibility to safe and nutritious food. Food Consumption and Utilization: The Government of The Bahamas will ensure the improvement of the nutritional status and well-being of the population through the promotion of safe, affordable, nutritious, food while building the capacity of individuals to make healthier consumption choices, improving quality food and food products, and through the provision and promotion of complementary measures such as food safety measures, enhanced health care, nutrition education, sanitation and physical activity. The Government of The Bahamas will also ensure that adequate social services are in place to protect poor and vulnerable people. Food stability: The Government of The Bahamas will strengthen emergency preparedness mechanisms in order to ensure the resilience of national food systems and households to natural disasters and socioeconomic shocks, including those associated with climate change. 11 The National Food and Nutrition Security Policy is based on sixteen Policy Objectives: 1. Creating an enabling environment for agricultural production. 2. Fostering an effective innovation system for agricultural production. 3. Providing targeted value chain development support for agricultural production. 4. Promoting a transparent multilateral and regional trading system for nutritious and high quality food. 5. Enhancing income to facilitate reduction in poverty and unemployment. 6. Addressing price barriers to reduce food and nutrition security. 7. Strengthening social protection for the poor and vulnerable. 8. Encouraging and empowering people to make healthy lifestyle choices. 9. Strengthening food safety and quality systems. 10. Mainstreaming food and nutrition security in social protection and health care programmes. 11. Mainstreaming food and nutrition security learning in education programmes. 12. Strengthening the national capacity for Food and Nutrition Surveillance. 13. Strengthening resilience and disaster management for food and agriculture systems. 14. Institutionalizing a National Food and Nutrition Coordinating Commission. 15. Strengthening human and financial resources in all areas of food and nutrition. 16. Monitoring the progress of food and nutrition impacts, outcomes and activities. 12 5 Introduction 5.1 Physical and Population Characteristics The Bahamas is an archipelago of 700 islands and cays that occupies 124,000 square miles (321,159km2) in the North Atlantic Ocean southeast of the United States of America and northeast of Hispaniola. There are twenty-nine inhabited islands which are relatively flat. The highest point is 206 ft (63km). The population was estimated at 372,300 persons (2016) and is projected to increase to 389,200 by 2020.4 The rate of population growth between 2010 and 2015 was 1.5%. The population is mainly urban with the majority (85 percent) residing on two islands– New Providence and Grand Bahama. The islands of Abaco, Andros and Eleuthera account for nine (9) per cent of the population, followed by Exuma and Long Island which account for three (3) per cent. The remaining Family Islands and inhabited cays account for the remaining there (3) per cent of the population. The population density in The Bahamas was estimated at 27.07 persons per sq. km in 2013, based on World Bank data. 5.2 Economic structure The Bahamas is a small open economy that is driven by tourism and financial services that, along with supporting industries such as construction and wholesale/retail trade, provide the largest proportion of employment and income for the population. The Primary Sectors contributed 2.2 percent to real Gross Domestic Product (GDP) in 1997, but declined sharply to 1.9 percent of GDP in 2013. The relative contribution of the Secondary Sectors to GDP also declined over the same period, from 17.4 in 1997 to 16.8 % in 2013. Historically a service sector economy, the Tertiary Sectors’ relative contribution to GDP in 1997 was 80.9% and increased slightly in 2013 81.3%. These changes reflect noticeable sectoral shifts in The Bahamas economy over the past 16 years from a reduction in primary and secondary sectors to a consolidation of the tertiary sectors: the relative contribution of the primary and secondary sectors’ contribution to GDP declined by 13.6% and 3.4%, respectively, while the tertiary sectors’ contribution maintained its dominance and increased slightly by 0.5% (Table 1). The economic growth of The Bahamas has stalled. The rate of GDP growth was 3.4 percent in 2005 and slowed to 1.5 percent in 2010. The International Monetary Fund5 projected economic growth at 0.5 percent in 2016 due to low air tourist arrivals, contraction in domestic demand and the weak export of goods. The rate of GDP growth is closely linked to unemployment levels which were estimated at 10.2 percent in 2005, 14.7 percent in 2010, and 15.1 percent in 2014. 4 Department of Statistics (2015) Population Projections 2010-2014 5 International Monetary Fund (2016) Article IV Consultation 13 Table 1: Structure of The Bahamas Economy and Sectoral Change, 1997-2012, Selected Years Sector % of GDP (2006=100) Sectoral Change (%) (1997-2013) 1997 2000 2008 2013 Primary Sectors1 2.2 1.9 2.2 1.9 -13.6 Secondary Sectors 2 17.4 17.4 14.0 16.8 -3.4 Tertiary Sectors3 80.9 80.9 83.8 81.3 0.5 Source: Data from Statistical Department, The Bahamas.www.statistics.bahamas.gov.bs. Accessed Sept., 2015. 1Agriculture (crops, livestock), Forestry, and Fishing).2Manufacturing, Mining, Electricity and Water Supply, and Construction.3Wholesale and Retail Trade; Hotels and Restaurants; Transport and Communication; Financial Intermediation; Real Estate, Renting and Business Services; Community, Social and Personal Services; and General Government Services. The GDP per capita was $22,817 (2015). The Bahamas was ranked 58 out of 188 countries in the UNDP Human Development Index, a decrease of 6 in rank when compared to the period 2010 2015. The Bahamas is vulnerable to global economic shocks, particularly those that impact the economy of the United States of America. Recent examples of exogenous shocks and their impacts on The Bahamas include: the 2001 terrorist attack in the United States; the international commodity price volatilities in the 2007-08 fuel financial-food crisis; and the 2008-09 recession in the advanced economies. The United States accounts for 80 per cent of the Bahamas’ total tourist arrivals, and any downturn in the US economy impacts negatively on employment, export earnings, international reserves, the country’s ability to meet debt obligations and ultimately on economic growth (IMF, 2013). In addition, inadequate product and market diversification, high unemployment, estimated at 12.7 percent (2016)6 and crime could negatively affect tourism if not urgently addressed. Moreover, continued low confidence of the private sector due to lack of access to credit (relatively high public-debt crowding-out private-sector borrowing), high taxation and cost of electricity, inadequately educated labour force and trade regulations—all of which could act as a drag on domestic activity. 5.3 Poverty The national poverty rate was 9.3% in 20017 but increased to 12.5% in 2013. The Bahamas Living Conditions Survey (BLCS) in 2001 provided a profile on poverty in The Bahamas which showed that poverty rates were higher in the Family Islands, and that the poor on those islands were poorer than the poor in urban regions, comprising New Providence and Grand Bahama. Poverty rates on the less-populated islands ranged from 13.2 percent in Abaco, Eleuthera and Andros to 6 Department of Statistics, (2016) Labour Force and Household Survey Report 7 Department of Statistics (2004) Bahamas Living Conditions Survey 2001 http://www.statistics.bahamas.gov.bs/ 14 21 percent for the Other Family Islands.8 Nearly half of the poor are under age 15 and the incidence of poverty increases with the size of the household. The poverty gap is also higher in Exuma, Long Island and Other Family Islands. Moreover, poverty rates are also linked to labour market participation. There is a difference in the level of participation rates in the labour market between men (79%) and women (69.5%). Participation rates are also higher for those aged 25 44 years (92.1%) and 45-59 years (83.1%) as compared to those under 25 years (55.5%) and over 59 years (24.1%). However, the probability of participation in the labour market increases with educational and expenditure levels.9 The BCLS also indicated that there were several categories of persons who had poverty rates higher than the national average. These groups included: households headed by Haitian nationals (16%), persons in common-law relationships (13%), widowed persons (8%), while female-headed households, households with more than 5 persons, and households in which the head is 65 or older had poverty levels of seven percent (7%). The Household Expenditure Survey (2013), indicated that women comprised most of the poor (51.8%), and reiterated the findings of the BLCS that people in the Family Island region were more likely to be poor (17.2%) than people living in New Providence (12.4%) or Grand Bahama (9.4%). The results also indicated that people younger than 20 years were over‐represented among the poor. Young people in this cohort represented 33.7% of the population but nearly half of the poor (49.7%). A disaggregation of the data indicated that poverty rates were higher than the national average among children aged 0 to 9 (18.2%) and those aged 10 ‐19 (19.3%). Interestingly, the 60‐69 year old group was the age group that had the lowest poverty rate (6.5%). 6 The Health Profile The Government of The Bahamas allocated 12.7 per cent to the public health sector10 in 2010. It is estimated that average annual expenditure on health care was BSD 1,002 per person – inclusive of health insurance and medicines. The Bahamas provides ambulatory and primary are services through its network of public community health centres, with at least one centre on every main inhabited island. This network consists of ninety-eight (98) polyclinics and satellite clinics scattered throughout the archipelago. These primary care services are undergirded by fourteen (14)11 national programmes that address more than just disease management, but encompass 8 Department of Statistics (2004) Bahamas Living Conditions Survey 9 Report of 2013 Household Expenditure Survey Executive Summary 10Approved Budget Estimates 2010/2011 11 These programmes are: Public Health Nutrition Programme, Dietetics Programme, Maternal and Child Programme, School Health Programme, Medical School Health Services, National School Feeding Programme, Health Education Programme, Healthy Lifestyles Programme ,Education Programme, HIV/AIDS Programme and Non-Communicable Disease Programme 15 health promotion, disease prevention and individual ownership of wellness throughout the life course. According to the World Health Organization (WHO), life expectancy of Bahamians at birth increased from 72 years in 1990 to 76 years in 2013. The infant mortality rate reduced from 13.0 in 2000 to 10.4 in 2013. The Healthy Life Expectancy is 64 years. In pre-school children, 9% were severely stunted and 5% were severely overweight. The average level of stunting was estimated at 10.7 percent12 in children 2-10 years of age, with the highest rate (11.2%) occurring in New Providence and Grand Bahama, and the lowest rate (4.4%) in Other Family Islands. There are about 19,000 persons in The Bahamas that consume an amount of food energy that is insufficient to cover their energy requirement for an active and healthy life. While protein-energy malnutrition (PEM) among children less than five years is not a significant public health problem in the general population, evidence indicates that attention should be given among pockets of the population such as undocumented immigrants, where cases arise periodically. Approximately 14 percent of children (2-10 years) were overweight with Exuma and Long Island having the highest rate (20%) of overweight children. In adolescents (11-20 years), 59 percent were of normal weight, 18 percent underweight and 14 percent were at risk of being overweight. This trend is also observed in the adult population where the 49.2 percent are obese. The growing prevalence of overweight and obese children and adults does not mean that the population is well nourished, in fact the opposite may be true. The large number of calories from processed food may mean that individuals are not getting the vitamins and minerals needed for metabolism and the regulation of sugar which is resulting in the weight gain. Although there is no overt indication of micronutrient deficiencies, other than iron-deficiency anaemia, sub-clinical deficiencies in the Bahamian population may exist. Good nutrition in the first 1,000 days of life, from mother’s pregnancy to the second birthday of the child, is important of for building a functioning immune system, improving chances of survival, and providing protection for the rest of the life of the child. The problem of iron deficiency anaemia is acknowledged as an area for specific intervention, particularly in children and pregnant and lactating women in The Bahamas, where the World Health Organization estimates that that 33 percent of children 6-59 months and 29 percent of pregnant women 15-49 years have a blood haemoglobin concentration ≤110g/L.13 This is of particular concern because iron deficiency has functional repercussions on mental, endocrine, and immunological health, as well as on the capacity to perform physical labour. In addition, anaemia during pregnancy is one of the risk factors of low birth weight. Moreover, the prevalence of low birth weight among neonates is unacceptably high. Low birth weight among neonates in The Bahamas for the period 2009-2013 was 1214 percent compared 12 Department of Statistics (2004) Bahamas Living Conditions Survey 2001 13 World Health Organization (2015) The Global Prevalence of Anaemia in 2011 14 https://data.unicef.org/topic/nutrition/low-birthweight/ 16 to 7 percent for the period 1990-199915. This constitutes another area for specialized medical nutrition therapy because of the link between low birth weight and the development of adult chronic diseases, and its use as an indicator for maternal and child health. There are several challenges which face the healthcare systems. These include providing care to an expanding aging population, along with the growing epidemic of chronic non-communicable diseases (CNCDs). It is estimated that five of the ten leading causes of mortality are linked to CNCDs. Equally worrisome is the high prevalence of the risk factors that lead to CNCDs which cause premature mortality, morbidity and diminished quality of life. Other health challenges that are impacting the growth and development of the nation are the relatively high infant mortality rate and violent death rates, particularly among males where the intentional homicide rate is 29.8 per 100,000 population16. 7 The National Food and Nutrition Situation 7.1 Food and Nutrition Security Profile The levels of poverty, food insecurity and unemployment, particularly among the youth, are cause for concern. These issues are major development challenges for The Bahamas and can be addressed through a food and nutrition security policy which defines food security as a state in which “all people at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life17”. This definition embodies four major pillars: Availability; Accessibility; Utilization/Consumption; and Stability of the previous three components. These pillars offer a useful framework within which to analyze food and nutrition security of The Bahamas. The impact of adequate nutrition throughout the lifecycle is well documented. Proper nutrition during development in the womb of babies allows the brain and immune systems to develop and function fully; well-nourished children learn better; and proper nourishment during adult years results in good metabolism and ability to fight disease and infections. Moreover, improvements in nutrition throughout the lifecycle of the individual are central to the achievement of national development goals on poverty, food, health, education, gender and employment. 7.2 Food availability 15 WHO/UNICEF (2004) Low Birth weight: Country, regional and global estimates 16 http://data.un.org/CountryProfile.aspx?crName=bahamas 17 Food and Agriculture Organization (1996) World Food Summit 17 Food availability refers to the amount of food available at the national level as a result of national food production, food imports and stocks or stores of food. The agricultural sector in The Bahamas is small. There are less than 2,000 registered farmers and the value of agricultural production is about B$50 million, all of which is consumed domestically. The Bahamas has witnessed a steady decline in the productivity and competitiveness of agricultural products, which is attributable to combination of factors. These include the process of trade liberalization, which reduced tariffs on imports and preferences for exports of traditional crops, as well as domestic limitations including agro-climatic, institutional, structural, economic and technological factors. For example, Bahamian farmers’ investment in agricultural capital stock per worker is only slightly higher than it was in 1980 and is less than 10 per cent of the average for other high income countries (FAO, 2012). The Bahamas’ food production index has18 shown modest increases over the period 2005 to 2014. Following a 21 per cent increase in 2010, the index has remained stable thereafter. Despite the low level of agricultural production, there is sufficient food available in The Bahamas. The food requirements for the nation, are therefore met through imports. About 90% of The Bahamas’ food supply is imported.19 The Bahamas has a food dependency ratio (2011) of 0.92 compared to Antigua and Barbuda (0.92), Belize (0.4), Jamaica (0.63) and Trinidad and Tobago (0.85)20. The high dependence on food imports is a cause of concern for a number of reasons. The high level of food imports has negative impacts on agricultural producers and agro-processing industries, not only on the fiscal, but also social domains due to their lack of competitiveness, inadequate infrastructure and investment, low technological adoption, and issues of land tenure, credit availability and investment. From this perspective, the social impact of high food import bills has resulted in loss of employment opportunities, underemployment in rural communities, neglect of rural infrastructure, and increasing rural-urban migration. The heavy dependence on food imports also introduces an element of risk related to potential trade disruptions due to economic or weather shocks. The Bahamas recognizes notable critical challenges to the food production sector, many of which are long standing and complex. There is an urgent need to implement a sustained agricultural development strategy which is coherent with other related policies, such as land-use and water use and which clearly identifies and supports national production priorities. Moreover, consideration needs to given to policies that would address the shortages in skilled and unskilled labour at all levels of the value chain. Other challenges impacting the competitiveness of the sector include coordinated research and technical support for adoption and adaptation of advanced techniques in food production and processing; development of critical post-harvest handling storage; and more inter-sectoral linkages (agriculture, environment, tourism, health, 19 Food and Agriculture Organization (2015) FAOSTAT 20 FAO (2016) State of Food and Nutrition Security in Small Island Developing States (SIDS) 18 trade, education etc.) to foster public-private partnerships, and to strengthen producer organizations. The fisheries sector is the largest primary industry in The Bahamas and is an important source of food, foreign exchange, and livelihood, especially in rural areas. The sector employs about 9,700 persons21. In 2015, 3 million kilograms of marine products from capture fisheries were landed and half of that amount was exported. Fisheries exports valued at B$63 million comprise 28 percent of the total value of domestic export in 2015. Fish is also an important source of protein. Fish consumption in The Bahamas is estimated at 27.3kg per capita compared to 18.9 kg per capita for the world. There are approximately 5.8 million tourist arrivals annually, of which about 1.3 million are stopovers22. This compares to a domestic population of 0.3 million, implying that a significant proportion of imported food is consumed by tourists. The food import bill grew rapidly from US$232.37 million in 1995 to US$ 610 million in 2015. Further, recent estimates suggest that the country’s import bill approaches US$1 billion and is projected to more than double by 2025. The cost of food is borne by consumers where an estimated 40 percent of the cost of food comes from import taxes, transportation and importers mark-up. Perhaps one of the most important concerns regarding food imports is the type of food that is imported. With the exception of fruits and vegetables, which accounts for 19 per cent total food imports, most other food components are calories-dense, nutrient-poor, refined carbohydrates (pastry, flour) and foods high in fats, sweeteners and sodium (food preparations, meats, beverages, other agricultural food imports). The growing reliance on imported, processed foods may have contributed to an overall deterioration in the quality of diets consumed in The Bahamas. As in many countries, market pressures and changing food preferences have caused a shift in diets away from indigenous staples to more convenient high fat, sugar and salt options. 7.3 Food Accessibility and Affordability This dimension of food and nutrition security implies that households and individuals have the necessary resources to obtain supplies of food that are considered adequate and nutritious; and, that there are no physical barriers to accessing food. Accessibility to food is based on two factors: physical access and economic access. Country data supports the fact that there is adequate quantity of food available at the national level in The Bahamas. This adequacy, however, does not necessarily guarantee or translate into equitable access to food at the household level. The critical determinants of household access are physical infrastructure (mainly marketing and storage) and purchasing power, which depends on the ability to generate income from various productive activities, and food prices. The income available to an individual or household, 21 Department of Marine Resources Fisheries Census 22 Central Bank of The Bahamas (2016) Quarterly Economic Review 19 together with the supporting livelihood systems and strategies, are therefore essential factors in determining access to food. 7.3.1 Resources to purchase food There are established inter-relations between education, employment and poverty. The unemployment rate has been increasing. It has grown from 10% in 2000 to 14% in 2015. Further, youth unemployment rate has generally been more than twice that of the national level. The proportion of individuals older than 15 years of age that participate in the labour market is higher in New Providence and Grand Bahama than in the Family Islands, which is likely due to age composition differences in the population between the islands. Economic activity is generally low in many Family Islands and is based primarily on farming and fishing. However, in recent times increased emphasis has been placed on individualizing and strengthening the tourism product on each of the Family Islands. According to FAO23, between 30-77 percent of the poor in the Caribbean are employed. These persons are referred to as “the working poor”. They have wages which are too low to enable them to escape poverty. They typically work part-time or suffer regular periodic layoffs from work and have low take-home pay. An important consideration in accessibility is the cost of food. Food price inflation in The Bahamas averaged 1.89 per cent from 2007 to 2014, less than the rise in the general consumer price index. Food price inflation peaked at 12.18 per cent in February 2009, but dropped thereafter and remains relatively low. The domestic food price index appears to be largely disconnected from the world commodity prices, possibly because commodities make up a relatively small part of the price of processed foods. In The Bahamas, a larger proportion of the budget of the poor (24.7%) was spend on food and non-alcoholic beverages compared to the non-poor (11.9%)24. It is unclear how prices of fresh fruits and vegetables, lean meats, and fish compare with prices of processed foods. The relative prices of fresh versus processed foods could have an important impact on the affordability of more diverse, nutritious diets, especially for the poor. 7.3.2 Physical access to food From a general perspective, physical access to food in The Bahamas is acceptable in the urban areas, the situation in the rural areas is not quantified. Many large supermarkets, smaller convenience stores, and outlets for dry goods and fresh produce exist in New Providence. Smaller outlets exist in almost all communities in the urban areas, and are easily accessible either by walking or driving. 23 Food and Agriculture Organization (2016) State of Food and Nutrition Security in Small Island Developing States (SIDS) 24 Department of Statistics (2013) Household Expenditure Survey 20 7.3.3 Economic access to food Economic access to food is constrained for some households due to high food prices and poverty. World food prices, as measured by the five key commodities in the FAO Real Food Price Index (sugar, meats, oils, cereals and dairy) declined steadily in real terms for several decades prior to the 21st century and remained relatively flat until 2006. The Index began rising in 2006, driven by a combination of bio fuel policies, demand growth, and supply disruptions. By 2011, world food prices were 50 per cent higher than in 2006. Since 2011, the Real Food Price index has been declining but still has not returned to the pre-2006 levels. 7.3.4 Social safety-net for the vulnerable The Bahamas has an extensive social protection system, consisting of both targeted and non targeted transfer programs. Targeted programmes include a cash transfer program for poor households, child allowances, disability grants, school supply grants, and health care services to the poor. There are also a number of policy initiatives that address issues of access to food, such as the National School Feeding Programme that provides standard meals for poor school children in an effort to meet their minimum nutritional requirements. The design of that programme could promote more diverse diets that incorporate locally sourced foods and lead to better nutritional outcomes for children. The Government of The Bahamas also provides a subsidized “breadbasket” of food items for low-income households intended to ensure access to a minimum amount of food items. However, the current composition of the breadbasket is not optimized to ensure access to a nutritionally balanced diet. The current structure of subsidies requires an adjustment to its content to make it more nutritionally sound. The lowest cost food breadbasket provides 2,000 kcal, of which 81.8g is from fat, 23g of which is saturated fat, 180mg cholesterol and 23.6g fibre. This programme and other institutional feeding programmes, such as those disabled persons and senior citizens, should be made more nutrition-sensitive. These social safety net programmes are the primary mechanisms that facilitate access to food by the poor. These programmes are implemented by the Ministry of Social Services and Urban Development, the National Insurance Board and other agencies. The largest programs are executed by the Ministry of Social Services and Urban Development, with the target groups being indigent people, people with disabilities, senior citizens, children and youth. According to the Labour Force and Household Survey Report, there is at least one recipient of food assistance in 10.1% of all households, and males whose mean age was 51.4 years comprised 19.3% of the recipients. Moreover, 23.2 percent of poor households had at least one recipient of this programme and the average amount of food assistance received was $106.4/month or $3.54/day. It is estimated that the least amount needed for an adequate diet of 2,400 kilocalories was $2.64/day.25 25 Department of Statistics (2004) Bahamas Living Conditions Survey 2004 21 The social safety-net programmes which are administered by multiple ministries and agencies which could benefit from improved coordination of safety net priorities. Moreover, there are also a number of faith-based and registered Non-Governmental Organizations (NGOs) that have been playing an increasingly important role in poverty alleviation in The Bahamas. Among the NGOs, there are still deficiencies in effective programme implementation by many groups, and the lack of coordination has caused duplication of efforts and missed opportunities for economies of scale, particularly for reducing inter-generational poverty. The policy reforms in the area of social protection have focused heavily on changing behaviour to promote human capital development through improved educational achievement and healthier lifestyles. In addition to social policy, there have been changes in taxation policies which have resulted in a lower average tariff rate on fresh fruit and vegetables to encourage increased consumption. There are several socio-economic factors that impact the access of the population of The Bahamas to adequate and nutritious foods. These include the high price of food, poverty related to high unemployment particularly among youth, and lack of access to productive resources as well as ineffective safety net programmes with inadequate monitoring and evaluation. 8 Food Consumption and Utilization The food consumption and utilization pillar of food and nutrition security refers to the choices individuals make regarding which foods to consume and the ability of their bodies to utilize the nutrients in the food. Consumption choices are influenced by a range of factors including affordability, culture, advertising convenience, knowledge, information, preferences and tastes and habits. Effective utilization of the nutrients in food depends crucially on complementary factors such as food quality and safety, sanitary conditions, childcare practices, health care, and lifestyle choices. 8.1 Food choice The diet consumed by the average Bahamian is not a healthy one. It is especially high in saturated fats and simple carbohydrates, and low in complex carbohydrates and fibre. In simple terms, Bahamians consume too many highly processed foods, fried foods, fatty meats, and sweet snacks and beverages. The consumptions patterns are similar among poor and non-poor households. Among the poor and non-poor households, the largest proportion of household expenditure (35%) is spent on animal products, followed by cereals (13%), fruits (12%), sugars (10%) and vegetables (9%)26. At the same time, Bahamians consume too few fresh fruits and vegetables, whole grains, pulses and legumes, roots and tubers. According to the STEP Survey (2012), the average level of fruit and vegetable consumption was 1 per day. In addition to consuming calorie dense, nutrient-poor diets, many of which are not labelled in a way that allows consumers to 26 Department of Statistics (2004) Bahamas Living Conditions Survey 2001 22 make informed choices, food preferences and tastes are heavily influenced by the external media and there is a loss in the use of traditional foods. Overweight and obesity are likely to be the most significant health-related nutrition challenge in The Bahamas. There is growing concern in the social, educational and political spheres that the challenge may be related to the production and availability of nutritious foods. It is estimated that 64 per cent of the population is overweight, of which 25 per cent are obese. The rise in overweight and obesity has resulted in increasingly greater prevalence of health risks in the form of chronic non-communicable diseases (CNCDs), especially coronary heart disease, hypertension, diabetes and some forms of cancer. The top five causes of death per 100,000 population are coronary heart disease, HIV/AIDS, stroke, diabetes mellitus and hypertension, many of which are related to CNCDs. Although there are a wide range of programmes aimed at addressing under nutrition, there are less in controlling overweight and obesity and the attendant epidemic of diet-related chronic non-communicable diseases. Moreover, the existing programmes could benefit from better coordination, staffing and funding to help overcome challenges of duplication. The Bahamas has prepared Food Based Dietary Guidelines. There is however, a lack of awareness of these guidelines among the population. Although nutritional guidelines have been prepared for the National School Lunch Programme which is provided to children in public schools, there are no similar guidelines for persons in other publicly-funded programmes including the social protection programmes and public institutions such as orphanages or senior citizens homes. Moreover, there are no nutritional guidelines for the feeding programmes of non-government organizations or for food assistance provided in the event of disasters or emergencies. In addition to improving knowledge on nutrition, attention needs to be given to creating environments at home, school and in the workplace that support healthy food choices. Furthermore, given the rising obesity rates in school-aged children, consideration should be given to limiting advertising, particularly of high-calorie, nutrient- poor foods to children. 8.2 Childcare practices It is estimated that 74 percent of children27 in The Bahamas were breastfed between 0-6 months. The middle quintile of the population had the highest prevalence of breastfeeding (94%) compared to fourth quintile which had the lowest (63%). Interestingly, the highest incidence of breastfeeding nationally was in the more urban areas of New Providence and Grand Bahama compared to the more rural communities. In fact, Long Island and Exuma reported the lowest breastfeeding rate. Moreover, a comparison of the period of exclusive breastfeeding for the first six months showed that the level of persons who exclusively breastfed for the first four months increased from 2 percent in 1998 to 7 percent in 2001. These results may be attributed to the well-recognized National Breastfeeding Campaign, however, complementary feeding is introduced too early. 27 Department of Statistics (2004) Bahamas Living Conditions Survey 23 8.3 Food safety and quality Food quality and safety are indispensable to ensuring community health and national development in that it protects people from the hazards to health and fraud related to the production, distribution, sale and use of foods. Appropriate labelling is also essential to provide consumers with accurate information upon which to base their food choices and in a language that they can understand. The issues of food safety, food standards and labelling are developed by several agencies under authority of several pieces of legislation. The Government enacted the Food and Quality Act, 2016, to regulate food safety and quality throughout the entire food chain from 'farm to fork', for crop and livestock products and to coordinate all the public and private sector agencies involved in food production. The legislation includes a mechanism for collaboration and cooperation between public and private sector institutions. Currently, the legislation needs the development of enabling regulations and capacity-building to ensure adequate policing of the food industry, including the development of Good Agricultural Practices at the farm level and adequate sanitary and phytosanitary procedures to protect against the introduction or spread of pest and diseases at the national level. Moreover, there needs to be public awareness and training to assist food vendors, processors, restaurants and other participants in the food chain to comply with food standards. There is a regulatory requirement under the Food (Seafood Processing and Inspection) Regulations, 2003, for seafood processors to comply with the principles of Hazardous Analysis Critical Control Point (HACCP) which is enforced through a system of fisheries inspectors located on New Providence and the Family Islands. The Bureau of Standards has been undergoing a legislative and capacity strengthening exercise since 2012. The objective of the strengthening exercise to improve the quality of local food products by standardizing labelling requirements of fresh and processed food products for children and adults to protect consumers from inferior products and to prevent “dumping” of imported substandard food onto food markets of The Bahamas and to assist consumers in making good food choices. The Bureau has given priority to the adoption of front-of-package and nutrient labelling standards for all food products in The Bahamas. There are food standards for operators that cater food to airlines which were established by the International Civil Aviation Organization (ICAO). Additionally, the airline catering company must meet the regulations and standards of the Department of Environmental Health of The Bahamas. Furthermore, hotels are restaurants are inspected by the Department of Environmental Health and some are also certified using external auditors. Itinerant vendors selling fresh and cooked food products play an increasingly important role in the development of the economy of the country and in the feeding and nutrition of people. These vendors need to be officially 24 recognized, and at the same time, adequate control must be exercised over their food products and practices. Presently, the place where food is prepared is inspected by the Department of Environmental Health. There is currently a Food Handlers Course operated by the Department of Public Health for food service workers. All food service workers are required to take the course annually. Despite these efforts, there are deficiencies in the food hygiene and protection system throughout the food production and distribution chain, which requires immediate attention and coordination between agencies. An important gap in the food safety system is the under regulation of roadside vendors. Moreover, food safety programmes must address emerging issues such as antimicrobial resistance in foods. 8.4 Food borne illness There have been periodic outbreaks of food borne illnesses, including conch poisoning caused by vibrio parahaemolyticus, which was first recognized and documented in 1991; salmonella; and fish poisoning caused by ciguatera. The prevention of these localized outbreaks is a national priority since they potentially affect not only the Bahamian population but also the tourism industry. The incidence of diarrhoea (7.8 percent) among children five years or younger is the second most common cause of childhood illness. This information suggests that more attention needs to be given to proper food handling and hand washing practices in families, particularly among children. 8.5 Lifestyle choices Many Bahamians lead a comparatively inactive lifestyle with approximately 75% of the population reporting a sedentary lifestyle in 2012. The change in the economic base during the early 1950s toward predominantly service-oriented industries resulted in a decreased level of daily physical activity for most Bahamians. Recent data indicates that the 30 to 30 years old age group exercise the most, while the age group that had the lowest number of days of physical activity was the 10 to 19 year old group (4.3 days)28. Another important lifestyle statistic is the significant amount of money spent on meals away from the home. Average per capita household expenditure on meals away from the home was $252.05 among poor households and nearly five times higher ($1,020.42 ) among non-poor households. This trend suggests that focus needs to be given to making healthy food choices outside the home. Alcohol and tobacco use are lifestyle choices that impact health. The STEPS Survey (2012) indicated that 41 percent of respondents consumed alcohol in the past 30 days. The WHO World Health Statistics 2015 indicates that alcohol consumption per capita for persons over 15 is 4.2 28 Department of Statistics (2004) Labour Force and Household Income Survey , 25 litres in The Bahamas, 5.1 litres in Jamaica and 6.5 litres in Barbados. This combination of changes in diet, activity, and lifestyle patterns may have made a considerable contribution to the increasing rates of NCDs in the population. 9 Food Stability The food stability pillar refers to long-term food and nutrition security. Stability requires that measures are put in place to reduce the risk of adverse effects at the national and household levels on any of the other three pillars arising from natural, social, economic or political factors. 9.1 Economic vulnerability The Bahamas is small and open economy driven by tourism and financial services, and heavily dependent on imported food and fuel, with fuel imports comprising 15% of the value of all imports in 201529. This openness is a major source of economic vulnerability. With food and fuel accounting for a large share of the Consumer Price Index (CPI) consumption basket, any increase in these commodities will lead to higher inflation. The openness also exposes the economy to exogenous shocks. Since The Bahamas is very dependent on food imports, disruptions in transportation links based on natural or the disasters will impact the availability of food. There are no statutory requirements for food reserves and estimates are that there are about eight weeks of food stores in the country at any time. Moreover, many of the inputs for the agricultural sector are also imported. Recent examples of economic disruptions include the 2001 terrorist attack on the United States, and the 2007/2008 financial crisis and food price volatilities, as well as the 2008-2009 recessions in advanced economies including the United States, which accounts for 80 percent of tourist arrivals. Additionally, inadequate product and market diversification for tourism and financial services, high unemployment and crime could affect tourism if not urgently addressed. Other sources of economic vulnerability stem from continued low confidence by the private sector due to lack of access to credit arising from relatively high level of public-debt and crowding out of private sector borrowing, high taxation and cost of electricity, inadequately educated labour force, and trade regulations. These all could all be a drag on the economy resulting in lower levels of economic growth. 9.2 Natural disasters As a Small Island Developing State, climate change is also a major source of vulnerability. The Bahamas is within the Atlantic hurricane system with varying categories of natural disasters occurring annually between June and November. Over the period 1980-2010, the country experienced 13 serious natural disasters, resulting in 19 fatalities, an estimated total economic 2929 Department of Statistics (2016) The 2015 Annual Foreign Trade Statistics Report 26 damage of US$2.6 billion, or economic damage of US$82.3 million annually.30 More recently Hurricane Sandy negatively impacted tourism arrivals in late 2012 and early 2013. Hurricane Joaquin which impacted islands in the south-eastern Bahamas in 2015 caused an estimated $100 million in damage which was estimated at 1.1% GDP. 31 Although the Paris Agreement of 2015 aims to hold global average temperatures at 2 degrees Celsius above pre-industrial levels, a recent study has estimated that the economic losses due to climate change in The Bahamas by 2050 will cost US$16.3-18.3 billion, depending on the climate change scenario. The National Climate Change Policy highlights several consequences of climate change which include: depletion and pollution of potable ground water supplies; loss of agricultural land and reduced agricultural productivity from salinity; introduction of alien pests and diseases and increases in the incidence of pests and diseases of crop plants , introduction of insect vectors of diseases of livestock and humankind, contagious diseases and heat stress-related syndromes and coral reef bleaching. Weather and non-weather related events, which include droughts and fires lead to the depletion of household assets can cause transient insecurity and recovery may require food and non-food assistance. 9.3 Promoting resiliency The Bahamas has made a lot of economic progress since its independence in 1973, however, much more needs to be accomplished to buffer vulnerabilities and advance more resilient responses to them at the national and household levels. Resiliency must also undergird the other pillars of food security including accessibility/affordability and consumption/utilization through the establishing early warning systems and ensuring that food relief meet the dietary requirements of the beneficiaries. Most of the population of The Bahamas lives within five miles of the sea. The climate change scenarios suggest that The Bahamas will be impacted by sea-level rise and more intensive and frequent extreme events. In order to promote longer term resiliency, consideration needs to be given to more climate-proof infrastructure so that households and their assets are protected. Poverty is a main cause of food and nutrition insecurity and focus should be given to improving school completion rates among the vulnerable population to reduce inter-generational poverty. Finally, attention also needs to be given to livelihood resiliency and providing employment opportunities particularly among young people. 30 (www.preventionweb.net). 31 International Monetary Fund (2016) Article IV Consultation 27 10 The International and Regional Context The United Nations General Assembly declared the period 2016–2025 as the Decade of Action on Nutrition. The resolution aims to trigger intensified action to end hunger and eradicate malnutrition worldwide, and ensure universal access to healthier and more sustainable diets. At the Second International Conference on Nutrition (ICN2), co-hosted by the Food and Agriculture Organization of the United Nations and by the World Health Organization in November 2014, the Rome Declaration on Nutrition acknowledged that current food systems are being increasingly challenged to provide adequate, safe, diversified and nutrient-rich foods needed for healthy diets. As an outcome of ICN2, Members and Member Countries committed to “enhance sustainable food systems by developing public policies from production to consumption and across relevant sectors to provide year round access to food that meets peoples’ nutrition and promote safe and diversified healthy diets”. The Framework for Action commits governments to exercise their primary role and responsibility for addressing undernourishment, stunting, wasting, underweight and overweight in children under five years of age, anaemia in women and children, among other micronutrient deficiencies. It also commits governments to reverse the rising trends in overweight and obesity and reduce the burden of diet-related non-communicable diseases in all age groups. The Government of The Bahamas endorsed the outcomes of ICN2 during the 34th FAO Regional Conference for Latin America and the Caribbean held in Mexico City, Mexico in February 2016. The Bahamas has also committed to the achievement of the Sustainable Development Goals (SDG), 2030 Agenda which places nutrition at the centre of meeting SDGs on poverty, food, health, education, gender and employment. Moreover, the World Health Organization has also set six Global Nutrition Targets for 2025 which include: 40 percent reduction in the number of children under 5 who are stunted; 50 percent reduction in women of reproductive age; 30 percent reduction in low birth weight; no increase in child overweight rates; increases in exclusive breastfeeding in the first six months of life to at least 50%; and reduce and maintain childhood wasting to less than 5%. In addition to meeting these targets, the FNSP seeks to incorporate commitments in the WHO Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013-2020, WHO Global Strategy on Infant and Young Child Feeding, WHO Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition 2012-2025 and the Sendai Framework for Disaster Risk Reduction 2015-2030. The Small Island Developing States Accelerated Modalities of Action (S.A.M.O.A Pathway), 2014 has also prioritized several strategies for SIDS, incorporated in this plan, which include sustainable practices relating to agriculture, fisheries and water management to improve food and nutrition security and end malnutrition in all its forms, by securing year-round access to sufficient, safe, affordable, diverse and nutritious food. 28 10.1 Regional At the regional level, The Bahamas is committed to the Community of Latin American and Caribbean States (CELAC) Plan for Food and Nutrition Security and the Eradication of Hunger 2025 and has endorsed the CARICOM Regional Food and Nutrition Security Policy (RFNSP). The RFNSP recognizes that food and nutrition security in the region is compromised not so much by lack of food availability as by inadequate access to nutritious foods and inappropriate dietary patterns that adversely affect nutritional status. The RFNSP recognizes the vulnerability to external shocks, poverty, social exclusion, and a lack of participation in policy-decision making processes are the main structural causes of food and nutrition insecurity. 10.2 National Context The Bahamas has elaborated a National Development Plan (NDP) based on the Sustainable Development Goals (SDGs). The FSNP seeks to be coherent with existing national plans and initiatives and aligns with NDP: Vision 2040 with respect to the following goals: (a) Achieve food security, end hunger and improve nutrition for all; (b) Deliver integrated people-cantered health care, services and programs focused on maintaining healthy individuals within an efficient, well governed system; and (c) Strengthen internal government decision-making processes to deliver results for the people of The Bahamas. Additionally, the FSNP also integrates the objectives of the Agriculture Sector 20 Year Plan32 and the National Climate Change Policy33 as well as incorporating the actions in National Multi Sectoral Non-Communicable Disease Strategy and Plan of Action for The Bahamas (2017-2022) which includes among its objectives the promotion of healthy eating and the promotion healthy and active living throughout life. The FSNP provides an overarching framework which brings together under in single policy issues of health, nutrition, agriculture, social services, education, labour, economy and their integration to address health and wellbeing and food security. 32 Eneas, Godfrey, Rebuilding Bahamian Agriculture: A 20 year plan 33 Bahamas Environment Science and Technology Commission (2005) National Policy for the Adaptation to Climate Change 29 11 THE BAHAMAS FOOD AND NUTRITION SECURITY POLICY The Government of The Commonwealth of The Bahamas subscribes to the philosophy that food and nutrition security is a fundamental right for all citizens and is a primary determinant of health outcomes. The nutritional status of people living in The Bahamas is intrinsically linked to their current and future health and well-being. The recommendations for policy initiatives must therefore have a positive impact that will improve the quality of life and living in The Bahamas. Bahamians need to improve their food choices, become more physically active, and manage their weight to reduce their risk of developing chronic diseases. Proper nutrition, physical activity and weight management are key factors in chronic disease reduction and management. Families and individuals must be empowered with information to better care for themselves. Equally important are the development of standardized care, and the implementation of various programmes by trained health care worker to deliver nutrition related programmes. A comprehensive food and nutrition security policy will ensure that Bahamian households have access at all times to adequate nutritious foods for a healthy diet, and that they have the necessary health, sanitation, education, leisure and social services to empower and encourage them to choose healthy lifestyles. 11.1 The Vision The vision of the Food and Nutrition Security Policy and Action Plan for the Commonwealth of The Bahamas is for all people to have physical and economic access to sufficient, safe and nutritious food, at all times to meet their dietary needs and food preferences for an active and healthy life. 11.2 The Goal The goal of the Food and Nutrition Security Policy and Action Plan to improve the food, nutrition and health status of the population, with minimum disruption to the ecosystem. The policy will seek to ensure that the consumer has sufficient knowledge about the relationship between dietary practices and physical fitness, to protect their health, well-being, and the environment. At the same time, the policy seeks to ensure, through collaboration, that adequate supplies of safe, nutritious foods are available on a continuous basis and accessible to all people to meet the nutritional needs of the population. The policy seeks to empower all people in the Bahamian society, at every stage in the lifecycle to develop healthy lifestyle practices, inclusive of healthy food choices and regular physical activity practices. 11.3 The Guiding Principles It is further envisioned that six major guiding principles of the Food and Nutrition Security Policy and Action Plan will contribute to the attainment of the overall goal. These interrelated principles are: 30  National ownership: Food and Nutrition Security for The Bahamas must be based on national consensus, national priorities and nationally-owned plans aimed at channelling resources to well-designed and results-based programmes and partnerships.  “All of Government” collaboration at inter-ministerial, inter-agency and bipartisan levels. The multidimensional nature of the food and nutrition security challenge facing The Bahamas necessitates a coordinated multisectoral approach that includes activities spanning several Ministerial portfolios, inter alia: health, agriculture, education, trade, social services, emergency management and others. Food and Nutrition Security is the responsibility of all agencies of The Government of The Bahamas and requires the full collaboration of all of Government.  “All of Society” partnerships: Food and Nutrition Security is not only the responsibility of Government, but all of society, and requires full partnerships with civil society, the private sector and individuals.  Sustained Action: Food and Nutrition Security requires sustained action beyond the mandate of a single electoral cycle or planning period. Sustained political will is required to reap the benefits of long term investments in Food and Nutrition Security.  Continuous Learning and Sharing: Best practices in Food and Nutrition Security are constantly evolving and all parties must engage in continuous learning and sharing within and across their respective spheres of responsibility.  International Cooperation: Food and Nutrition Security for The Bahamas can only be achieved in cooperation with regional and international partners, through a strong multilateral system. The Food and Nutrition Security Policy recognizes that the health of the population is an intrinsically desirable goal as well as an important investment in the economic development process. A healthy population is more productive, better able to learn and acquire skills, and more apt to engage in positive activities, which contribute to individual and national development goals. There is a close interrelationship between food, nutrition, levels of physical fitness and health status. Good nutrition ensures proper growth and development, protects against diseases and reduces health care costs. The health and well-being of a population are dependent upon a food supply system that is accessible, affordable, available and sustainable. These fundamental elements of food security contribute significantly to quality of life. Low levels of physical fitness and lack of exercise are considered independent risk factors for many of the CNCDs, including hypertension, diabetes mellitus type 2, coronary heart disease and some cancers. The Ministry of Health and the Ministry of Agriculture and Marine Resources recognize this important relationship and the need for a comprehensive policy on food and nutrition. In 31 collaboration with other government ministries, a multi-sectoral committee was established to review the current food, nutrition and health situation, and set guidelines for improving food and nutrition security for all segments of the population and the many visitors to the country. 11.4 Organization of the Food and Nutrition Security Policy The Food and Nutrition Security Policy is organized into five Thematic Areas. The first four are built upon the four pillars of food and nutrition security, while the fifth thematic area refers specifically to the mechanisms for harnessing the political will and building the institutional capacity required for attainment of a food and nutrition secure nation. This organization reflects the international best practice which is a coordinated, multidisciplinary, inter-sectoral approach that includes activities spanning several Ministerial portfolios, inter alia: agriculture, fisheries, health, education, trade, social services finance, environment and emergency management, private sector and other stakeholder organizations. The Food and Nutrition Security Policy draws heavily from the 2008 and 2010 Policy and Action Plan but with significant modifications. First, the document brings to bear the critical importance of food and nutrition security in the context of national well-being. Second, data are updated to include the most recent information that is available. Third, the main food and nutrition security challenges are now organized under the pillars of food and nutrition security with a focus on mainstreaming nutrition throughout the food system and complementary interventions. There is also an emphasis in the FNSP governance, inter sectoral and integrated approaches, and capacity building for implementing food and nutrition security actions. 11.5 Thematic Area I - FOOD AVAILABILITY The Government of The Bahamas will promote the sustainable production of safe, affordable, nutritious and high quality local foods through the development of competitive and diverse domestic food production systems and value chains, and will ensure a sustainable level of equally safe, affordable, nutritious, and high-quality food imports built upon mutually collaborative links with regional and international countries. Objective 1: The Government of The Bahamas will create an enabling environment for agricultural production Legal, institutional, and policy environments for diversified crop, livestock, and fisheries production and value chains will be strengthened through the following actions: a Develop and implement a strategy to prioritize and support local agricultural production in the context of a nutritionally sensitive food importation reduction plan. b. Review and promote policy coherence across sectors to ensure that nutritionally sensitive food production has a fully supportive enabling environment. 32 c. Develop legal and regulatory measures to increase investments (public and private) to ensure access to, and effective management of land, water, marine, and other productive resources. . Objective 2: The Government of The Bahamas will foster an effective innovation system for agricultural production To ensure that all food system participants are able to contribute to increased production and productivity within the sector, with particular emphasis on mainstreaming nutrition throughout the food system, the following actions are to be implemented: a. Develop human resource capacity to ensure that producers, processors, extension workers, technicians and value chain participants are fully equipped to innovate and to sustainably increase production and productivity within the sector. b.. Build research partnerships, knowledge exchange platforms, agricultural education curricula and technical training to prioritize nutrition throughout the food system. c. Ensure marginalized groups, especially women and youth, will participate in all aspects of the value chain. Objective 3: The Government of The Bahamas will provide targeted value chain development support for agricultural production Appropriate value chain and food system development methodologies will be applied to crops, livestock and fishery products to promote increased sustainable production, processing and marketing of more diversified, high quality, nutritious, foods based on current national dietary guidelines through the following actions: a. Promote diversified food crop value chains, such as indigenous fruits, vegetables, roots and tubers. b. Revitalize selected high value product value chains for domestic, tourism and export markets. c. Promote sustainable management of fisheries and aquaculture value chains. Objective 4: The Government of The Bahamas will promote a strong, transparent, robust, reliable multilateral and regional trading system for nutritious and high-quality food and agriculture The Bahamas will actively participate in the deliberations of relevant international bodies to ensure that the national interests of the country are well represented and that the international system remains robust, for example, through the following actions: a. Improve food labelling regulations to clarify nutritional content and to restrict unverified health claims. 33 b. Review taxes on foods including fresh fruit and vegetables and processed food and beverages containing added salts and sugars. c. Encourage international and regional organizations to identify opportunities to achieved food and nutrition targets through trade and investment policies. 11.6 Thematic Area II: FOOD ACCESSIBILITY AND AFFORDABILITY The Government of The Bahamas will facilitate the sustainable development of human and social capital of the population, monitor national and international food price movements, and provide social protection for vulnerable groups, thereby increasing greater accessibility to safe and nutritious food. Food accessibility and affordability at the country level is most often looked at from the perspective of physical and economic access to food. . Objective 5: Through efforts to enhance income, The Government of The Bahamas will facilitate the reduction of poverty and unemployment The following actions will be implemented to support the achievement of this objective: a. Strengthen human capital development to improve employment and entrepreneurial skills, especially among women and youth. b. Facilitate employment and income-generating opportunities to diversify the economy, including in the food, fisheries, forestry, and agriculture system. Objective 6: The Government of The Bahamas will address food prices to reduce food and nutrition insecurity Actions to be taken towards the achievement of this objective include: a. Improve monitoring of domestic and international food prices, including monitoring for the exercise of market power (monopoly pricing) within the food marketing system. b. Improve marketing and distribution infrastructure (especially for fresh fruit, vegetables, fish, and lean meats) to enhance efficiency and nutritional quality and to reduce relative prices. c. Adjust content of the subsidized consumer “food basket” to conform with national Food Based Dietary Guidelines. Objective 7: The Government of The Bahamas will strengthen social protection for the poor and vulnerable Building on existing mechanisms, the following actions will be taken: a. Strengthen monitoring of food and nutrition status and poverty indicators for vulnerable groups. . 34 b. Enhance school feeding and other supplemental feeding programmes to reduce stigma and promote consumption of nutritionally balanced diets. c. Increase food transfer programmes for vulnerable populations to improve diets through better access to food. 11.7 Thematic Area III: FOOD CONSUMPTION AND UTILIZATION The Government of The Bahamas will improve the nutritional status and well-being of the population through the promotion and consumption of safe, affordable, nutritious, quality food and food products, and through the provision and promotion of complementary measures such as food safety measures, health care, nutrition education, sanitation and physical activity. Objective 8: The Government of The Bahamas will encourage and empower people to make healthy lifestyle choices The need to adopt healthy eating practices and engage in regular physical activity must be inculcated by every individual. Sustained actions that promote the adoption of these types of activities are needed in order to achieve a more tangible measure of success. Actions to improve consumer awareness and choices will include: a. Promote good nutrition through the universal application of The National Food Based Dietary Guidelines. b. Develop community awareness programmes on healthy nutrition and lifestyle practices. c. Develop and promote programs to increase physical activity. e. Strengthen school nutrition and education programmes. f. Increase connections between farm/fishers and food service providers to ensure greater availability of local fruit and vegetables. g. Raise awareness on iron-deficiency in pregnant woman and school -aged children. h. Improve public education on food choices of foods containing sodium, sugar, saturated and trans fats. Objective 9: The Government of The Bahamas will ensure that food safety and quality systems are strengthened Consistent with international standards and obligations, the following actions will contribute to the achievement of this objective: a. Revise and amend existing legislation and guidelines related to food safety and food quality from farm to fork. 35 b. Strengthen and expand the food production and food control infrastructure system. c. Develop food labelling standards including Nutrition Facts for The Bahamas. d. Promote nutritional education to consumer body to serve as a watch dog. Objective 10: The Government of The Bahamas will ensure that food and nutrition security are mainstreamed and coordinated in social protection and health care programmes Under this objective, actions will address the need to improve the nutritional status of infants, pregnant and lactating women, children, adolescents, the elderly, persons with HIV/AIDS, the poor and others at risk groups. At the same time, complementary actions will also be undertaken to mainstream nutrition throughout the healthcare system. These actions include: a. Promote and support breastfeeding. b. Enhance nutritional information and care for antenatal and post-natal women. c. Enhance programmes for children and adolescents at nutritional risk of stunting and wasting. d. Improve accessibility, availability, and stability of healthy foods to senior citizens. e. Promote healthy lifestyles and nutrition practices among vulnerable groups. f. Enhance the capacity of healthcare professionals to care for persons with HIV/AIDS. g. Strengthen the nutrition component of HIV/AIDS programmes. h. Increase technical cooperation and assistance to NGOs, community agencies, religious, and civic organizations involved in feeding programmes to enhance the quality of nutrition services provided to the poor. i. Improve management of nutrition-related chronic non-communicable diseases. j. Enhance health care services by including nutrition services as part of everyday community-based and hospital health services. Objective 11: The Government of The Bahamas will ensure that food and nutrition security learning are mainstreamed and coordinated in education programmes Recognizing the critical role that the education system, and in particular, the school feeding programme, play in changing harmful consumption patterns in children, and in promoting 36 lifelong healthy eating habits, the following actions will be taken to mainstream nutrition education in schools: a. Implement the Healthy Schools Initiative in all school districts. b. Integrate Health and Family Life Education (HFLE) components into other subject areas in all schools; Integrate nutrition into all subject areas in all schools. c. Strengthen the National School Feeding Programme. d. Increase availability of more healthy food choices at school cafeterias, tuck shops, and school lunch vendors. e. Integrate all components of Agriculture in the 4-H Programmes. f. Strengthen the Physical Education Curriculum/Programme. g. Increase partnerships among government agencies, private sector, and NGOs to avoid duplication of programmes. 11.8 Thematic Area IV: FOOD STABILITY The Government of The Bahamas will strengthen emergency preparedness mechanisms in order to ensure the resilience of the nation to socio-economic shocks and natural disasters, including those associated with climate change. The Government of The Bahamas will also ensure that adequate social services are in place to protect the population during emergencies. Objective 12: The Government of The Bahamas will strengthen national capacity for Food and Nutrition Surveillance The following actions will be undertaken to achieve this objective: a. Establish sentinel sites to monitor nutritional status within various populations; including expansion of surveillance of school aged children in the public and private schools. b. Strengthen evidence based health and nutrition information into decision making. c. Improve nutritional data and indicators among vulnerable groups. Objective 13: The Government of The Bahamas will strengthen resilience and disaster risk management for food and agriculture systems The following actions will be undertaken to contribute to the achievement of this objective: a. Strengthen the resilience of food systems, for example through maintenance of appropriate levels of food stocks. 37 b. Develop and implement a Disaster Risk Management Plan for food and agriculture, including for transboundary pests and diseases, weather-related shocks, and climate change. c. Enhance household resilience in response to disasters, hazards and shocks. 11.9 Thematic Area V: GOVERNANCE AND CAPACITY BUILDING FOR FNSP The Government of The Bahamas will establish coordination mechanisms to ensure that all relevant parts of the Government and all of society are fully engaged in supporting the achievement of this National Food and Nutrition Security Policy and Action Plan. The implementation of this policy will require active cooperation among many sectors, agencies, and individuals in the Bahamian community. The mechanism for sustaining and building upon the initiative requires the involvement of all partners and stakeholders. Objective 14: The Government of The Bahamas will appoint a National Food and Nutrition Coordinating Commission The coordination of the policies and programmes will be facilitated by the establishment of a National Food and Nutrition Coordinating Commission (NFNCC) jointly chaired by the Ministers of Health and Agriculture respectively and comprising of representatives from the key public and private sector institutions and NGOs concerned with food and nutrition The NFNCC would be a Cabinet-appointed Commission which would report to the Cabinet through the Minister of Health or the Minister of Agriculture. The NFNCC will be empowered to conduct the following functions: a. Promote inter-sectoral collaboration in programme planning and implementation with particular reference to food and nutrition. b. Provide regular information and advice on the Food and Nutrition situation to policymakers on the national implementation strategy. c. Advocate for the implementation of corrective measures to improve the nutrition and health status of vulnerable groups. d. Create an enabling environment for the scaling-up of Food and Nutrition Security specific interventions. Objective 15: The Government of The Commonwealth of The Bahamas will strengthen human and financial resources in all areas of food and nutrition It is recognized that the successful implementation of the policies and programmes is greatly dependent upon the existence of adequate and effective human resources at all levels. The need for suitably trained and qualified professionals in all the relevant sectors in which this policy and agenda for action will operate is paramount. Human resources capacity of Ministries will be assessed and appropriately strengthened through the following actions: 38 a. Assess manpower needs for appropriate leadership, governance and delivery of nutritional policy and programmes. b. Support education/training in Nutrition and Agricultural Science at the tertiary level though the development of programmes or scholarships. c. Strengthening of the national capacity of the Food Technology Unit in the Ministry of Agriculture and Marine Resources to conduct food research and testing. Objective 16: The Government of The Bahamas will ensure that the progress towards a food and nutrition secure nation is financed and monitored Sustained action is best achieved when those involved are provided with feedback on their progress. The foundation of the success of the Food and Nutrition Policy is clearly strong partnership of committed agencies, groups, and individuals. Working together in such partnership is a key step in promoting coordinated, inter-sectoral action for good nutritional health. a. Establish a budget in the Ministry of Health or the Ministry of Agriculture to finance the Food and Nutrition Security Policy. b. Develop a framework to monitor the international commitments. c. Organize and strengthen civil society and consumer advocacy groups to participate in funding and monitoring food and nutrition security planning, funding, and monitoring. 11.10 MONITORING, EVALUATION, ACCOUNTABILITY AND LEARNNG The Government of The Bahamas will appoint a National Food and Nutrition Security Coordinating Commission to track the progress of the implementation of the FSNP. This Cabinet-appointed committee would be co-chaired by the Ministry of Health and the Ministry of Agriculture would report to Cabinet through the Minister of Health and will be empowered through a participatory process to conduct the following functions: a. To promote inter-sectoral collaboration in programme planning and implementation with particular reference to food and nutrition. b. Provide regular assessments on the Food and Nutrition situation to policy makers and advice on the national implementation strategy. c. To promote the full diagnosis of the food and nutrition status of the population and the maintenance of adequate food and nutrition surveillance. d. Advocate for the implementation of corrective measures to improve the nutrition and health status of vulnerable groups. 39 e. To perform such other functions related to food and nutrition that the government may from time to time deem necessary. The National Food and Nutrition Security Coordinating Commission will: a. Have access to all necessary information regarding the planning and implementation of projects relevant to food and nutrition. b. Collate and disseminate data for effective decision making in food and nutrition. c. Co-op resource personnel and mobilize resources (physical and financial) for the advancement of food and nutrition in The Bahamas. d. Develop national food and nutrition plans and act as the advisory body on the interface of food and nutrition. e. Promote the coordination of the implementation of projects and programmes of the various agencies and ministries influencing food and nutrition. f. Monitor the implementation of projects and programmes and redefine policies and strategies. g. Identify research and training needs and make recommendations for satisfying such needs. Membership in the National Food and Nutrition Coordinating Commission will consist of representatives from a wide cross-section of government ministries, agencies and organizations, as well as representatives of civil society, health specialist groups, and food retailer’s organizations. Each Government Ministry shall identify a focal point to the Commission. The list of recommended groups is provided in Annex I. The United Nations Decade of Action on Nutrition and the Sustainable Development Goals represent global commitments with an international framework for the monitoring of and reporting on progress on a range of relevant food and nutrition security indicators. The Government of The Bahamas will align its monitoring efforts with these international commitments and frameworks to achieve the status of a food and nutrition secure nation as outlined in the Plan of Action. 40 12 Annex I – The Food and Nutrition Security Action Plan (2017 – 2022) FOOD AND NUTRITION SECURITY ACTION PLAN (2017-2022) 41 Introduction Without good nutrition, the mind and body cannot function well. When that happens, the foundations of economic, social and cultural life are undermined34. Patrick Webb The Government of The Bahamas is committed to ensuring that people at all times have physical and economic access to sufficient, safe, and nutritious foods to meet their dietary needs and food preferences for an active and healthy life. The Food and Nutrition Security Policy (FNSP) analysed the four pillars of food and nutrition security and concluded that while there is enough food available in The Bahamas, maintaining food availability will depend on increasing domestic production and ensuring access to international markets for a sustainable supply of food. The FNSP indicates that with respect to the second pillar, food accessibility and affordability, that while food is generally accessible, the food is not equitably distributed and healthy food is expensive particularly for poor households. Moreover, the FNSP suggests that using the four pillars of food security as a reference point, the third pillar, food consumption and utilization pillar, would represent the most the effective focus of activities to effect long lasting changes on behaviours since food choice and healthy lifestyle decisions in the population, among very similar amongst poor and non-poor groups. Finally, the food stability pillar which looks at the resiliency of the three pillars highlights the vulnerability of The Bahamas to exogenous factors, particularly due to the impact of climate change on weather patterns and natural ecosystems, particularly the marine ecosystem which is important for food, livelihoods and foreign exchange. Importantly, there are endogenous sources of vulnerability emanating from poverty and unemployment particularly among young people and vulnerable groups who are children, pregnant women, physically and mentally disabled, senior citizens, and persons receiving government assistance that require the development of programmes to address resiliency at the community and household levels. The FNSP Action Plan covers an implementation period of five years (2017-2021). The implementation and coordination of the FNSP Action Plan is the responsibility of the National Food and Nutrition Coordinating Commission which operates under the Ministry of Health. The FNSP Action Plan requires collaboration with public, private, and Non-Governmental 34 Webb, Patrick (2014) Nutrition and the Post 2015 Sustainable Development Goals: A Technical Note 42 Organizations (NGOs) and will be implemented at national and community levels to deliver results to everyone in The Bahamas, including persons in the Family Islands. Food and nutrition security is at the centre of our national development and the FNSP Action Plan has a national system of monitoring and evaluation (M&E) to ensure that there is sustained progress in meeting the objectives of the FNSP. Many of the monitoring indicators are collected by the Ministry of Health and are based on national targets, and those established by the United Nations Sustainable Development Goals (SDGs); the World Health Organization (WHO) Nutrition Targets 2025; the Community of Latin American and Caribbean States (CELAC) Plan for Food and Nutrition Security and the Eradication of Hunger 2025; and CARICOM Regional Food and Nutrition Security Action Plan. Efforts have been made in the Action Plan to ensure that regional indicators for food and nutritional security are used which would allow data to feed into the decision-making process, and allow for monitoring the effectiveness of the actions taken. Furthermore, under the governance pillar, attention is given to the evaluation of programmes related to the FNSP Action Plan by a wide range of stakeholders from the public and private sectors as well as the NGO community. The budget for the implementation is $952,000 which is distributed among the components as follows: Information, Knowledge and Training on Proper Nutrition $296,000 (31%) Promotion of Production, Consumption and Storage of Foods $137,000 (14%) Strengthening legislative, institutional and policy environment $165,000 (17%) Strengthening partnerships $129,000 (14%) Strengthening evidence-based decision-making $225,000 (24%) Food and Nutrition Security Action Plan (2017-2022) The global agricultural system needs to produce about 50 percent more food to feed the population of the world, estimated at 9 billion people by 2050. The global and national agricultural system needs to provide adequate nutrition to raise the incomes and employment of persons in the sector and be resilient to climatic and non-climatic factors. Despite contributing about 10 percent of the food requirements, the agriculture sector has a role in absorbing more carbon and protecting biodiversity, and using land and water resources more efficiently. The Action Plan focuses on improving family farmer productivity with particular emphasis on women and youth to produce increases in food production. The Ministry of Health conducted a Chronic Non-communicable Disease Prevalence and Risk Factor Survey in 2005, which indicated that 71 percent of the population was overweight or 43 obese, with higher rates on Grand Bahama (74%) and the Family Islands (77%). Nearly half of the population (43%) was obese. The 2012 STEPS Survey indicated that the prevalence of overweight and obesity increased to 80 percent and 40 percent of the population respectively. Poor food choice and sedentary lifestyles are major factors contributing to increase in non-communicable diseases. The 2012 STEPS Survey indicated that 90 percent of Bahamian did not eat 5 or more servings of fruit and vegetables per day, and 73 percent had a sedentary lifestyle. Moreover, the impact of poor diet is seen in the health indicators. According to the Ministry of Health, Non-Communicable Diseases (NCDs), which include cardiovascular disease, neoplasms, diabetes, and respiratory diseases account for four of the six leading causes of death in The Bahamas. Ischemic heart disease is the leading cause of death with a mortality rate of 28.7 per 100,000 inhabitants. The impact of NCD is seen in nearly every age cohort and is particularly alarming in adults ages 25 to 44 where 121.4 per 100,000 died as a result of NCDs and/or complications. The incidence increases to 354.2 per 100,000 in persons aged 45-64, and is 2,327.6 per 100,000 in persons 65 years and older.35 As outlined in the FNSP, the issue of food security goes beyond indicators in food production and health, and must also incorporate targeting social programmes, livelihood enhancing programmes, and resilience to disaster. The FNSP Action Plan therefore provides a holistic strategy that addresses the food and nutrition of the entire population with particular attention being given to the nutrition needs of young children, pregnant women, persons who are disabled, persons living with HIV/AIDS, elderly persons, and persons who are beneficiaries of Government assistance programmes. Purpose of the Food and Nutrition Security Action Plan The Food and Nutrition Security Action Plan serves to guide the coordinated implementation of the Food and Nutrition Security Policy by public sector and private sector stakeholders as well as Non-Governmental Organizations, who comprise a National Food and Nutrition Coordinating Committee during the period 2017-2022. Strategic Objectives The Action Plan identifies five strategic objectives to achieve the objective of FNSP which is to ensure that the population has sufficient, safe, and nutritious food to meet their dietary requirements and food preferences for a healthy and active life. 1) Improve information, environment, knowledge and training on proper nutrition throughout the lifecycle Food Consumption and Utilization 35 Ministry of Health (2017) The National Multi-Sectoral Non-Communicable Disease Strategy and Plan of Action for The Bahamas (2017-2022) 44 2) Promote safe, production, consumption and storage foods Food Production 3) Integration of food and nutrition into the legislative, institutional and policy environment Food affordability 4) Strengthen the coordination and partnerships among public and private sector institutions and non-governmental organizations Governance 5) Strengthening evidence-based decision making, surveillance, monitoring and evaluation Food Stability The Strategic Objectives which have been identified to implement NFSP are: 1. Improve information, environment, knowledge, and training on proper nutrition throughout the lifecycle The ability to make good food choices based on accurate information is a key component in efforts to address the issues related to malnutrition in our society and to improve the nutritional situation of the population throughout the lifecycle. Through advocacy and public awareness, a communication strategy will be developed and implemented at the community and individual levels using traditional and non-traditional methods with the objective of providing nutrition information in an easily readable and understood format that would influence life-long changes in dietary practices. Additionally, training on proper nutrition will be provided to a wide range of stakeholders that will include healthcare providers, teachers, parents, care givers, agricultural extension personnel, social workers, and members of Non-Governmental Organizations. Moreover, nutrition information will be targeted to specific vulnerable groups such as pregnant women and children, where research has shown that investments yield an average benefit-cost ratio of 1:5. Specific interventions will be made to address stunting and wasting, particularly among children and anaemia during pregnancy. Anaemia among pregnant women is one of the risk factors that contribute to low birth weight babies who are, in turn, more susceptible to infectious diseases as infants, and chronic diseases like diabetes and heart disease in later life. Priority areas  Develop and implement nutrition advocacy and communication campaign throughout the lifecycle  Provide training to target groups to change attitudes and practices to target groups such as pregnant women, children, elderly, physically and mentally disabled, and recipients of government assistance  Assess knowledge, environment, attitudes, and practices among the population  Increase number of children who are exclusively breastfed within first six months 45 Expected outcome: Improved nutritional knowledge, environment, attitudes and practices in the population 2. Promote the safe production, consumption and storage of root crops, fruit and vegetables Domestic food production of fresh and processed root crops, fruit, and vegetables as well as fish will be encouraged. There will be particular emphasis on family farming systems that involve women and youth which will be strengthened to produce food that is nutritious and culturally sensitive. Programmes will also be established to diversify farming system to encompass more value-added production and innovation. There will be programmes to enhance efficient food marketing systems. Moreover, all foods, including imported foods will adopt the highest food standards from production through to consumption, and food will be properly labelled to assist the population in meeting their nutritional needs as outlined in the Food Based Dietary Guidelines. Priority areas:  Develop root crop value-chains  Support backyard and community gardens  Train farmers, extensions and community leaders  Improve efficiency of food markets  Promote food safety from 'farm to fork' Expected outcome: Increased availability of safe local nutritionally-sensitive foods 3. Support an enabling legislative, institutional and policy environment for FNSP The FNSP advocates an inclusive approach that encompasses an ‘All of Government’ and ‘All of Society’ approach to implementation. Every ministry of Government and their agencies have a role in food and nutrition security. Priority areas:  Strengthen FNSP -related legislation  Integrate FNSP in policies  Increase awareness of FNSP among policymakers  Implement nutrition interventions in schools and other institutions Expected outcome: Strengthen legislative and policy framework for FNSP 4. Strengthen coordination, collaboration and partnerships among public and private sector institutions and non-governmental organizations 46 The issues in the FNSP are cross-sectoral, and non-traditional partnerships will be important to ensuring the results of the programmes in an “All of Society” approach to engaging a wide cross section of partners in sensitization and the delivery of programmes.  Promote dialogue with stakeholders  Strengthen coordination in healthy diet, wellness, and lifestyle programmes  Involve partners in delivering food and nutrition activities  Expand monitoring activities outside the public sector Expected outcome: Stakeholders are engaged in implementation of food and nutrition programmes 5. To enhance evidence-based decision-making through surveillance monitoring and evaluation systems There is a wide range of information required to design food and nutrition programmes and to ensure their impact on the intended beneficiaries. This will be obtained through evidence-based data and research and through regular reporting through monitoring and evaluation systems throughout the lifecycle. An important role for the surveillance and monitoring systems is to prevent the deterioration in nutritional status of vulnerable groups and the population in emergencies.  Maintain the nutritional status of the population in emergencies  Improve knowledge on macro- and micronutrient deficiencies  Improve timeliness and quality of nutrition information, particularly for vulnerable populations  Strengthen monitoring and evaluation of nutrition interventions in schools and other institutions Monitoring and Evaluation The FNSP is based on building and strengthening inter-sectoral linkages within the public sector and with non-governmental stakeholders to build synergies and to add value to existing programmes. The implementation framework seeks to link programmes with partners in a realistic way that would contribute to long term impacts and sustainability. Monitoring The FNSP Action Plan will be implemented by government ministries with particular emphasis on including partners such as non-governmental organizations, local communities, and the media in the monitoring of activities. Monitoring of the programme will have to be integrated into the 47 existing health information system, and regular reports will be provided by the NFNCC to the Cabinet through the Ministry of Health and disseminated as widely as possible. Evaluation There should be an evaluation of the FNSP Action Plan at the end of the five year period. Since the FNSP Action Plan seeks to address food and nutrition security issues in a holistic manner, funds are provided for the NFNCC to undertaken evaluations of existing programmes to identify gaps and to ensure that interventions address these gaps or strengthen existing policies and programmes. FOOD AND NUTRITION SECURITY RESULTS FRAMEWORK Level Objectives Indicators/Targets Means of Verification Critical Assumption Outcome Improve the food, nutrition, and health status of Bahamians with minimum disruption to the ecosystem No increase in childhood and adult obesity 10% relative reduction in age standardized prevalence of raised blood pressure Ministry of Health Reports Ministry of Health Reports Political will is maintained Line of Action 1 Information, knowledge and training on proper nutrition throughout the lifecycle Population adopts healthy food choices throughout the lifecycle 50% increase in children who are exclusively breastfed in first six months by 2022 to 10.5% 50% reduction in pregnant women with anaemia by 2022 to 12%1 Consumption of fruit/vegetables per day increases from 1 to 3 by 2022 Ministry of Health Reports Ministry of Health Reports Ministry of Health STEPS Survey Population is receptive to message Funds are available for nationwide programmes 49 Level Objectives Indicators/Targets Means of Verification Critical Assumption Line of Action 2 Production, consumption and storage of safe foods Increased availability of nutritious food Increase production of root crops by 10% by 2022 At least 2 fresh foods grown locally that conform to international food safety standards by 2022 Ministry of Agriculture Report There is inter-ministerial and private sector cooperation Line of Action 3 Legislative, institutional and policy environments strengthened Integration of nutrition in national legislation and policies At least 2 pieces of nutrition sensitive legislation enacted by 2022 At least 3 sectors apart from health sector collaborate in development of multi-sectoral nutrition-sensitive policies National Food and Nutrition Security Commission (NFNCC) established and funded by 2017 Government Gazette Published policy documents Ministry of Finance 2017-2018 budget Nutrition-sensitive proposals are included in legislative agenda Policymakers are receptive to integration of policies 50 Level Objectives Indicators/Targets Means of Verification Critical Assumption Line of Action 4 Partnerships among public and private sector and non governmental organizations strengthened Expand collaboration with non-traditional partners 5 non-traditional stakeholders actively participate in NFNCC by 2018 NFNCC Annual Report Stakeholders agree to work together to avoid duplication of effort Line of Action 5 Evidence-based decision making, surveillance monitoring and evaluation systems established Improved information for decision-making among public, private, and NGO stakeholders Dietary Diversity Assessment undertaken by 2019 Ministry of Health published documents Funds and technical resources are available for surveillance and monitoring Support is given to strengthen and expand existing systems 51 Strategic Line of Action 1: Information, knowledge and training on proper nutrition throughout the lifecycle Strategies Activities Performance Indicators Lead Agency Budget Public awareness Undertake media campaign to promote National Food Based Dietary Guidelines (FBDGs) Develop and implement national nutritional advocacy, communication and social mobilization media campaign for the period 2017-2022 NFNCC $50,000 Promote awareness on breastfeeding, iron-deficiency to ante-natal and post natal women Support provided annually to National breastfeeding campaign for areas of low breastfeeding adoption MOH $5,000 Public awareness campaign on iron-deficient in pregnant women and school aged children implemented annually between 2017-2022 MOH $10,000 Expand nutritional counselling on NCDs at community clinics and workplace Nutritional counselling takes place once per month at 50% of community clinics, 1 clinic in Family Island and 2 workplaces MOH Promote awareness and sensitization material on childhood obesity for children, parents/guardians and care givers Awareness campaign designed and implemented by 2019 MOH $10,000 Implement public awareness campaign on sodium, sugar, saturated and transfats Public awareness campaign developed and implemented between 2018 – 2022 NFNCC $10,000 52 Strategies Activities Performance Indicators Lead Agency Budget Undertake community awareness programmes on healthy nutrition and lifestyle practices Public awareness campaign on food choices containing sodium, sugar, saturated and transfats NFNCC $10,000 Enhance household resilience and response to disasters, hazards and shock Public awareness campaign on disaster resilience directed at households NEMA $5,000 Training and capacity building Provide training to health professions, social workers teachers, agricultural professionals, and community organizations on FBDGs 3 training sessions take place annually. One training must be in a FI communities MOH $15,000 Provide training to community organizations to deliver awareness programmes on nutrition to elderly and disabled 3 training programmes for community organizations take place annually. One training must be in a FI community by 2020 MOH $15,000 Develop nutrition training guidelines for healthcare workers and caregivers dealing with HIV/AIDS Nutrition guidelines prepared and validated by 2019 MOH $3,000 Assess human resource requirements for food and nutrition security Review of salary and working condition for public service nutritionists and dieticians undertaken by 2019 Education scholarship provided for student in area of food and nutrition security DPS MOE $3,000 $160,000 53 Strategic Line of Action 2: Promote production, consumption and storage of foods Strategies Activities Performance Indicators Lead Agency Budget Encourage increased local production of foods Support increase in local production of root crops Acreage of root crop production increases by 5% MOA $3,000 Increase Backyard gardening programme support increased Number of households with backyard gardening in 3 constituencies increases by 10% MOA $3,000 Support product clusters and value chains Strengthening of one nutrition-sensitive value chain by 2020 MOA $3,000 Support investment in agriculture Incentives and enabling environment for agriculture and agro-processing evaluated for effectiveness by 2019 MOA $5,000 Support agro-processing of root crops At least two new agro-processed root crop products developed by FSTL by 2021 MOA $12,000 Support linkages between producers and consumers Develop national policies and programmes on government purchases from family farms Develop procurement policies for purchases from 3 nutrition-sensitive crops by 2020 MOF $3,000 Facilitate local purchases of food in education and public -funded institutions at national and local level 3 contracts signed for local purchase of food by public-funded institutions by 2020 MOF $5,000 Improve marketing and distribution infrastructure (fresh fruit, vegetables, Improve Packing House infrastructure to improve storage, delivery, and nutritional quality of root crop by 2019 MOA $30,000 54 Strategies Activities Performance Indicators Lead Agency Budget fish and lean meat) to enhance efficiency and nutritional quality Develop of food standards and guidelines Regional Food and Nutrition Security Policy Document and disseminate Good Agricultural Practices for crop/livestock Develop Good Agricultural Practice for one root crop by 2019 MOA $15,000 Prepare guidelines on sanitation and hygienic practices in households, healthcare facilities, restaurants, etc. 5 guidelines on hygiene and sanitation practices prepared by 2020 DEHS $15,000 Prepare guidelines on food safety in school cafeterias, tuck shops and lunch vendors Guidelines and fines for food safety revised by 2019 DEHS $3,000 Develop food labelling standards for salt, sugar and trans fats in foods Labelling standards for salt, sugar and transfats prepared by 2020 BOS $15,000 Establish nutritional labelling on the front of packaged food products based on Codex Alimentarius Front of package labelling standard established by 2019 BOS $5,000 Training and capacity building Training and continuous extension to farmers and backyard gardeners on root crop production 3 training events provided annually to farmers and backyard gardeners on root crop production MOA $15,000 55 Strategies Activities Performance Indicators Lead Agency Budget Short training and exchange visits to other countries on research and technology for root crops At least one academic research report published on root crops by 2020 At least one exchange visit/short course visit for young persons involved in root crop production by 2021 MOA MOA $10,000 $10,000 Strategic Line of Action 3: Strengthen legislative, institutional and policy environment Strategies Activities Performance Indicators Lead Agency Budget Advocacy Undertake sensitization awareness activities for policymakers on FNSP Annual public awareness programme for senior policymakers (Ministers, Permanent Secretaries and Directors) undertaken NFNCC $10,000 Undertake sensitization campaign to non-traditional partners/stakeholder Sensitization campaigns undertaken to 2 non traditional stakeholders annually NFNCC $10,000 Undertake sensitization campaign on FNSP to public sector agencies Undertake annual sensitization campaign to public sector agencies NFNCC $5,000 Strengthening legislative framework Review legislation to determine right to food Report on legal right to food determined by 2018 OAG $5,000 Limit or control advertising of ultra processed food products of low nutritional quality directed at children Regulation to limit advertising to children enacted by 2020 OAG $30,000 56 Strategies Activities Performance Indicators Lead Agency Budget Include legislation that supports breastfeeding for women in the workplace Undertake amendment to relevant labour legislation to support breastfeeding in the workplace by 2021 OAG $30,000 Promoting inter-sectoral collaboration Establish inter-sectoral polices that incorporate nutrition Prepare Sustainable Consumption and production National Action Plan by 2020 MOA $10,000 Review taxes on foods including processed food and beverage containing added salts and sugars by 2019 MOF $5,000 Develop a nutritionally sensitive food production strategy that promotes local production by 2018 MOA $10,000 Develop sustainable water management plans for the agriculture sector MOA $10,000 Develop sustainable management plan for marine resources by 2019 MOA $10,000 Develop Disaster Risk Management Plan for food and agriculture sectors by 2018 MOA $10,000 Integrate climate awareness and mitigation strategies into agriculture and fisheries policies by 2018 MOA $10,000 Review nutritional balance and presentation of National School Lunch Programme MOH $10,000 57 58 Strategic Line of Action 4: Strengthen partnerships among public and private institutions and Non-Governmental Organizations Strategies Activities Performance Indicators Lead Agency Budget Facilitate joint planning and implementation of programmes Encourage civil society to participate in monitoring FNSP indicators 2 civil society groups participate in monitoring indicators by 2019 NFNCC $10,000 Encourage non-traditional public sector institutions to participate in monitoring FNSP indicators 2 public sector groups participate in monitoring indicators by 2019 NFNCC $10,000 Strengthen partnerships with education sector CELAC Plan for Nutrition Security Link School Feeding Programmes to Public Procurement At least 4 family farms (1 in New Providence and 3 in Family Islands have contracts to supply School Feeding Programme) by 2021 MOE $40,000 Promote health food environments within school Prepare guidelines on healthy food choices for school cafeterias, tuck shops and school lunch vendors by 2020 MOH $3,000 Incorporate nutrition education in school curriculum Nutrition education integrated in pre-school, primary and high school curriculum by 2022 MOE $30,000 Establish healthy varied menus within National School Food Programme Develop healthy menu guidelines for pre-school, primary school, high school and special schools by 2019 MOH $12,000 Strengthen Physical Education Programme Promote physical education to two target group (adolescent girls) by 2019 MOE $10,000 59 Strategies Activities Performance Indicators Lead Agency Budget Strengthen partnerships with Ministry of Social Services Sensitize public officials on nutrition in Government funded social programmes Undertake annual awareness promotion campaign to public and private sector senior officials on nutrition MOH $3,000 Strengthen partnership with non-traditional stakeholders Promote nutritional education to Consumer Protection Body Undertake awareness campaign to Consumer Protection Body by 2018 NFNCC $3,000 Provide nutritional education and awareness to NGO feeding programmes Prepare nutritional guidelines for NGO feeding programmes by 2018 MOH NFNCC $3,000 $5,000 Provide annual seminar to NGO feeding programme 2018-2021 60 Strategic Line of Action 5: Strengthen evidence-based decision-making surveillance, monitoring and evaluation Strategies Activities Performance Indicators Lead Agency Budget Strengthen nutritional information Survey to collect baseline data on salt intake using WHO Took Kit for salt reduction Undertake baseline survey in New Providence and one other region by 2020 MOH $30,000 Conduct survey on population dietary patterns Diet Diversity Survey undertaken by 2019 MOH $30,000 Conduct a survey of healthy food availability and choice in public and private schools Undertake survey in 8 schools in New Providence and 4 schools in Family Islands by 2018 MOH $30,000 Undertake survey to determine knowledge of FBDG Survey on FBDG takes place by 2019 NFNCC $10,000 Undertake nutrition survey in vulnerable populations Nutritional data collected for 2 vulnerable populations by 2020 NFNCC $10,000 Strengthen national information/surve illance systems Develop and map food insecurity and poverty based on existing information Database for food insecurity mapping developed by 2019 NFNCC $30,000 Strengthen monitoring of domestic and international food prices Database developed for monitoring food prices NFNCC $10,000 Investigate exercise of monopoly pricing in food marketing system Undertake food market structure and pricing study by 2020 NFNCC $10,000 61 Strategies Activities Performance Indicators Lead Agency Budget Improve targeting of social protection programmes Undertake study on targeting of social protection programmes in two communities by 2020 NFNCC $20,000 Expand nutritional surveillance in public and private schools Nutritional information collected from 5 new schools by 2020 MOH $25,000 Strengthen evaluation systems Undertake evaluation of targeted programme At least one programme evaluated annually NFNCC $10,000 14 ANNEX II: List of Membership for the National Food and Nutrition Coordinating Commission Ministries and Agencies  Ministry of Health (including Maternal and Child Health, Chronic Non Communicable Disease, Health/Health Promotion and Healthy Bahamas Coalition)  Ministry of Agriculture and Marine Resources  Ministry of Education, Science and Technology  Ministry of Finance  Ministry of Youth, Sports and Culture  Ministry of Labour and National Insurance  Ministry of Environment and Housing  Ministry of Public Works and Urban Development  Ministry of National Security  Ministry of Tourism  Ministry of Foreign Affairs and Immigration  Ministry of Transport and Aviation  Ministry of Social Services and Community Development  Attorney General and Ministry of Legal Affairs  The University of The Bahamas  Bureau of Standards Non-Government Organizations:  Bahamas Cancer Society  Bahamas Heart Association  Pan American Health Organization/  Food and Agriculture Organization  Inter-American Institute for Cooperation on Agriculture  Diabetic Association  Wholesalers and Retailers Association  The Bahamas Red Cross  The Salvation Army  Doctors Hospital  Primary Principals Association  Bahamas Association of Nutritionists and Dieticians  The Medical Association  The Dental Association  The Bahamas Chamber of Commerce  The Association of Farmers and Producers  Bahamas Marine Exporters Association  Hands for Hunger  Great Commission Ministries  Bahamas Christian Council  Media 15 REFERENCES  Central Bank of The Bahamas (2016) Quarterly Economic Review  CARICOM Secretariat (2010). CARICOM Region: CARICOM Regional Food and Nutrition Security Policy.  Georgetown. Guyana.  CARICOM Secretariat (2011). CARICOM Region: Regional Food and Nutrition Security Action Plan.  Georgetown. Guyana  Economic Commission for Latin America & the Caribbean (ECLAC) (2011).Preliminary Overview of  Caribbean Economies, 2010-2011.ECLAC Sub regional Headquarters for the Caribbean. Port of  Spain. Trinidad and Tobago.  Department of Statistics (2004) Bahamas Living Conditions Survey 2001, Nassau. Bahamas  Department of Statistics (2015) Population Projections 2010-2814, Nassau, Bahamas  Department of Statistics (2016) Labour Force and Household Survey, Nassau, Bahamas  Department of Statistics (2016) Household Expenditure Survey 2013, Nassau, Bahamas  Food and Agriculture Organization, 1996. World Food Summit, Rome  Food and Agriculture Organization. 2012. The State of Food and Agriculture 2012: Investing in  agriculture for a better future. Rome.  Food and Agriculture Organization. 2013. The State of Food and Agriculture 2013: Food systems for  better nutrition. Rome.  Food and Agriculture Organization (2016) State of Food and Nutrition Security in Small Island Developing States (SIDS), Rome  FAOSTAT. www.fao.org. 2015.  International Monetary Fund (IMF) (2013). Country Report, 2013. IMF. Washington, DC. USA.  International Monetary Fund (2016) Article IV Consultation Report 2016, IMF Washington, DC, USA  Ministry of Finance (2012) Approved Budget Estimates, Nassau. Bahamas  Ministry of Health (2005) Chronic Non-Communicable Disease Prevalence Study and Risk Factory Survey. Nassau. Bahamas  Ministry of Heallth (2012) STEPS Survey, Nassau. Bahamas  Ministry of Health (2012) Primary Health Report, Nassau, Bahamas  WHO/UNICEF (2004) Low Birthweight: Country, regional and global estimates,  WHO (2014) 2014 Global Nutrition Report: Actions and Accountability to Accelerate the World's Progress on Nutrition