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1 STEPS Report CD Surveillance 21/08/2007 Page 1 of 94

2 Table of Contents 1. FOREWORD AD SUMMARY Foreword from MOH Foreword from WHO Executive Summary ACKOWLEDGMETS AD KEY COTACTS Acknowledgments WHO Contact American Samoa Contact Monash University Contact ITRODUCTIOI Background to the CD STEPS The ational Context Geography Population Economy Government Social Services and Health Status CDs in American Samoa ational Health Plan and Priorities SURVEY METHODS AD OPERATIOS Survey Rationale and Objectives Survey Sampling Methodology Sample Size Survey Structure Survey Administration Data Analysis RESULTS Description of the Sample Survey sample characteristics Level of Education Behavioural Measures Tobacco Use Alcohol Consumption Diet Physical Activity Physical Measures Obesity Blood Pressure and hypertension Biochemical Measures Blood Glucose and Diabetes Blood Cholesterol Combined risk factors /08/2007 Page 2 of 94

3 6. COCLUSIOS RECOMMEDATIOS APPEDIX 1 DETAILED RESULTS Demographic Information Tobacco Use Alcohol Consumption Diet Physical Activity Obesity Blood Pressure And Hypertension Blood Glucose And Diabetes Blood Cholesterol Data Quality Indices APPEDIX 2 QUESTIOAIRE (EGLISH VERSIO) APPEDIX 3 QUESTIOAIRE (SAMOA VERSIO) APPEDIX 4 Detailed equipment list REFERECES...92 Lists of tables, graphs and figures Table 3.1 Ten leading causes of mortality in American Samoa in Figure 4.1 Survey sampling methodology Table 4.2 List of Villages Selected Figure 4.3 The WHO STEPwise approach to surveillance of CDs Table 5.1 Demographic Description of Study Sample and Sampling Frame Figure 5.1 and gender distribution of American Samoa Population and Survey Sample Table Current smoking status of the study population Figure Percentage of current daily smokers among total smokers Figure Mean age of starting smoking, for current daily smokers Table Mean number of years of smoking, for current daily smokers Table umber of manufactured cigarettes smoked per day by current smokers of manufactured cigarettes Table Smoking prevalence in American Samoa Figure Percentage of male and female current consumers of alcohol across age groups Figure Percentage of current consumers of alcohol who binge drink* on at least one day in the last week across age groups Figure Daily frequency of binge drinking amongst current consumers of alcohol Table Servings of fruit consumed per day Table Mean number of servings of fruit consumed per day Table Servings of vegetables consumed per day Table Mean number of servings of vegetables consumed per day Table Combined servings of fruit & vegetables consumed per day /08/2007 Page 3 of 94

4 Table Percentages of the study population that are physically inactive Table Total physical activity (hours/week) by age group Figure Total physical activity by domain (METminutes/week) Figure Total physical activity in the work domain amongst participants reporting physical activity in the work domain across age groups (METminutes/week) Figure Total physical activity in the leisure domain amongst participants reporting physical activity in the leisure domain across age groups (METminutes/week) Table Involvement in physical activity for less than 150 minutes per week by age group Table a Mean height (inches) of the study population across gender and age groups Table a Mean weight (pounds) of the study population across gender and age groups Table Mean body mass index (kg/m 2 ) Figure Mean body mass index across gender and age groups Table Risk categories for body mass index (kg/m 2 ) Table a Mean waist circumference (cm) Table Mean resting systolic and diastolic blood pressure (mmhg) Figure Percentage of study population with a diagnosis of hypertension in the past 12 months across gender and age group Table Percentage of the study population previously diagnosed with high blood pressure receiving drug treatment for it Table Prevalence of high blood pressure Figure Total prevalence* of high blood pressure across age and gender groups Table Fasting blood glucose (mg/dl) Figure Percentage o fthe study population with a previous diagnosis of diabetes across gender and age group. 44 Table Prevalence of diabetes (110 mg/dl cut-off)...44 Figure Total Prevalence of diabetes (110 mg/dl cut-off) by gender across age groups...45 Table Prevalence of diabetes (120 mg/dl cut-off) by gender across age groups..45 Table b Type of blood glucose treatment for diabetes Table Precentage of study participants with impaired fasting blood glucose ( mg/dl)...47 Figure Percentage of study participants with impaired fasting blood glucose ( mg/dl) by age group and gender..47 Table Mean total blood cholesterol levels (mg/dl) Figure Percentage of study population with high risk total blood cholesterol levels Table Mean and average total cholesterol levels in American Samoans /08/2007 Page 4 of 94

5 1.1 Foreword In American Samoa, as in all other Pacific Island Countries, noncommunicable diseases (CDs) or lifestyle diseases are responsible for a high proportion of death and disability. These common diseases include mainly diabetes, heart disease, stroke and cancer. Throughout the Pacific, the burden of CDs is increasing rapidly with significant social, economic and health consequences. If we are going to effectively address this growing problem, we must have accurate information regarding the risk factors that contribute to the development of CDs. Risk factors refer to any characteristic or exposure that increases a person s likelihood of developing a CD, and include smoking, alcohol use, physical inactivity, obesity, high blood pressure, a raised level of blood glucose or cholesterol, and an unbalanced diet. The American Samoa CD STEPS survey, 2004 was specifically designed to assess the prevalence of the common CDs and risk factors in our population. The information from this survey provides an important platform for the development and implementation of strategic plans and programs to address the growing epidemic of CDs in American Samoa. Furthermore, the implementation of this important survey in American Samoa provides a firm foundation for an ongoing surveillance for CDs and their various risk factors. The Department of Public Health is sincerely grateful to the World Health Organization (WHO), the Fiji School of Medicine and Monash University in Australia for the technical assistance provided that helped guide the survey from inception to implementation, analysis and interpretation. We are also most appreciative of the funding from AusAID and WHO that allowed us to undertake this important activity. While available data has clearly indicated an increasing burden of CDs in American Samoa, there has been no population-based information on the prevalence of the CD risk factors that are common to many of the CDs affecting our population. It is this risk approach to CD surveillance and control that is one of the most notable features of the STEPwise surveillance process with a shift in emphasis from individual to community health. Implementing the American Samoa CD STEPS survey required intensive work, long days, and persistence and dedication from the American Samoa team that undertook the survey. Indeed, it is the hard work of the STEPS team that allowed this vital activity to take place and we owe each of them our sincere appreciation. The American Samoa CD STEPS and this report is a landmark in our efforts to address the increasing CD epidemic affecting our people. It marks an increased commitment by the American Samoa health system to tackle the CD challenge and will serve us well in the further development, monitoring and evaluation of effective health policies and programs appropriate to our context, and to our ongoing efforts in CD and CD risk factor surveillance. Indeed, it is our hope that we will now move forward in the formulation of a comprehensive and feasible CD strategic action plan in American Samoa. Finally, I expect that this report will provide its readers with the opportunity to understand the magnitude of the CD burden and the vital role of CD risk factors in the epidemic. I also encourage you to participate in concrete actions to promoting healthier lifestyles within our communities as we work collectively to address the CD challenge. MOH, American Samoa 21/08/2007 Page 5 of 94

6 1.2 Foreword The World Health Organisation is proud to be part of this collaborative efforts among Ministry of Health of American Samoa, Monash University in Australia, the Fiji School of Medicine and AusAID. WHO Offices in Suva, Apia, Manila and Geneva have had effective and efficient cooperation in working with American Samoa during the whole process of STEPS Survey and Report. The STEPSwise Approach is a simple, standardized method for collecting, analyzing and disseminating data for CD risk factors in WHO member countries. The publishing of the oncommunicable Diseases STEPSwise Approach Risk Factor (CD STEPS) Report marks a milestone in American Samoa as it provides critical and updated data that will assist the Ministry of Health in addressing the escalating issue of CDs. By using the standardized instruments and protocols, member states can use STEPS information not only for monitoring within country trends, but for making comparisons between and among countries as well. The approach encourages the collection of small amounts of useful data information on a regular and continuing basis adopting standard methodology and sample size to detect trends in age and sex group. STEPS risk factors is a sequential process, starting with gathering information on key risk factors by the use of interviewer administered questionnaires (STEP 1), then moving to simple physical measurements (STEP 2), and only then recommending the collection of blood samples for biochemical assessment (STEP 3). The baseline data provided by CD STEPS will ensure that the right emphasis is placed on the risk factors that need to be addressed in the efforts to control obesity, high blood pressure, diabetes, and physical inactivity. The results showed that 29.9% of both genders reported smoking daily. Manufactured cigarettes were 96.3% of tobacco used, thus manufactured cigarettes were the most frequent form of tobacco use in the country, though Tobacco: Deadly in any form or disguise, the theme of World o Tobacco Day % of the study population consumed fewer than 5 of combined servings of fruit and vegetables per day. It indicated a physically active population (61.7%). Majority of the study population (93.5%) was overweight or obese, it was indeed too big to ignore. WHO has newly developed the summary of combined risk factors. We have selected 5 common and critical risk factors for CDs, including current daily smokers, overweight or obese (BMI 25kg/m 2 ), raised Blood Pressure (SBP 140 and/or DBP 90 mmhg or currently on medication for raised BP), less than 5 servings of fruit and vegetables per day and low level of activity (<600 MET-minutes). By this comprehensive assessment, only 0.4% of the study population in American Samoa were low risk to CD (i.e., none of the 5 risk factors). 71.2% of the population aged 45 to 64 years old were raised risk (at least three of the risk factors included above). What should be paid more attention to was 60.9% of the population were raised risk since their ages were 25 to 44 years old only. The importance of the results given by the STEPS survey cannot be emphasized more. These figures show that there is a need for urgent intervention measures to be put into place by the countries to counter the growing threat of CDs. 21/08/2007 Page 6 of 94

7 WHO is grateful to AusAID for their financial assistance, Monash University in Australia and the Fiji School of Medicine for their technical assistance, and the staff of Ministry of Health of American Samoa who travelled the length and breadth of the country to obtain this much-needed data. WHO congratulates you all on this tremendous effort as we continue to work together to tackle the concerning issue of CDs which is very severe in most Pacific Island Countries. World Health Organization 21/08/2007 Page 7 of 94

8 1.3 Executive Summary The American Samoa CD-STEPS survey was a population-based nation-wide cross-sectional assessment of key chronic diseases and their risk factors in adults aged years. It was carried out from June to August 2004 using the WHO STEPS surveillance methodology and questionnaires. The main objectives were: To investigate the prevalence of key noncommunicable diseases (CDs) in American Samoa. To determine the prevalence of the major risk factors for common CDs in American Samoa. Using stratified cluster sampling, data were obtained from 2072 individuals. Summary prevalence data for behavioural measures The percentage who currently smoke tobacco daily was 29.9%. Looking at a gender difference, 38.1% of American Samoan males and 21.6% of females were current daily smokers. Manufactured cigarettes were the most frequent form of tobacco used (96.3%). The overall prevalence of current alcohol consumption in the population was 28.0% with 45.3% of males and 10.5% of females classified as current consumers of alcohol. There were 49.6% of male consumers of alcohol in the study population and 33.9% of current female consumers of alcohol had participated in binge drinking. Male binge drinkers had consumed 5 or more standard drinks on at least one day in the previous week while female binge drinkers had consumed 4 or more standard drinks on at least one day in the previous week. The mean number of servings of fruit eaten per day was 1.9 for males and 2.0 for females. The mean number of servings of vegetables eaten per day was 2.5 for males and females. Overall, 62.1% of the study population consumed fewer than 5 of combined servings of fruit and vegetables per day. 63.0% of the male and 61.2% of the female consumed fewer than 5 of combined servings of fruit and vegetables per day, there was no significant difference between men and women on this. Starchy vegetables are not counted in this statistic. Overall, 61.7% of the study population was classified to be physically inactive (57.8% of males and 65.7% of females). For both males and females the majority of physical activity was undertaken during work time. Males undertook significantly more physical activity than females. For males, the amount of physical activity undertaken decreased with increasing age, while for females it remained constant. Out of the three areas activity was reported from (work, transport and leisure), the transport area was the one in which the least physical activity was undertaken. Summary prevalence data for physical measures The overall proportion of overweight or obese (defined as BMI 25kg/m 2 ) in the survey population was 93.5% and for obesity (BMI 30kg/m 2 ) 74.6%. For males, 92.7% were classified overweight or obese and among them 69.3% were obese. For females, 94.4% were overweight or obese and 80.2% were classified as obese. Mean waist circumferences for both males and females were 104.7cm and 104.8cm respectively; both of these exceed the values of 94cm (males) and 80cm (females) that are considered to infer increased risk of cardiovascular disease. 21/08/2007 Page 8 of 94

9 The total prevalence of high blood pressure amongst males in the survey population was 20.6%. The total prevalence of high blood pressure amongst females was 12.3%. The mean systolic and diastolic blood pressure was / 83.5 mmhg in men and / 80.0 mmhg in women. Summary prevalence data for biochemical measures The mean fasting blood glucose level in the study population was mg/dl (123.0 mg/dl in males and mg/dl in females). Overall, the total prevalence of diabetes in the study population was 47.3%. For males, the total prevalence of diabetes was 52.3% and for females the total prevalence of diabetes was 42.4%. The total prevalence includes the known, or previously diagnosed diabetics, and newly diagnosed diabetics (those with blood glucose levels greater or equal to 110 mg/dl). The mean total blood cholesterol level for the study population was mg/dl (183.3 mg/dl in men and mg/dl in women). Overall, 23.4% of the study population had cholesterol levels greater than 200 mg/dl or 5.2 mmol/l, which indicates a high risk of coronary artery disease. 23.1% of males and 23.7% of females were in the high risk category as determined by blood cholesterol levels >200 mg/dl or 5.2 mmol/l. Summary of combined risk factors There are 5 common and critical risk factors for CDs were selected, including current daily smokers, overweight or obese (BMI 25kg/m 2 ), raised Blood Pressure (SBP 140 and/or DBP 90 mmhg or currently on medication for raised BP), less than 5 servings of fruit and vegetables per day and low level of activity (<600 MET-minutes). Only 0.4% of the study population were low risk to CD (i.e., none of the 5 risk factors). 71.2% of the population aged 45 to 64 years old were raised risk (at least three of the risk factors included above). What should be paid more attention to was 60.9% of the population were raised risk (at least three of the risk factors included above) since their ages were 25 to 44 years old only. Opportunities for intervention and action The survey data indicate that both non-communicable diseases such as diabetes and hypertension as well as their risk factors are very common in American Samoa. CDs such as diabetes, cardiovascular disease and cancer are already leading the mortality statistics of American Samoa. But the high level of risk factors observed in the survey such as obesity, elevated blood pressure and blood lipids, physical inactivity and a lack of fresh fruit and vegetable intake together with widespread consumption of tobacco and alcohol can only result in more disability and reduced quality of life if preventive measures are not succeeding. Therefore, intervention should be created at multiple levels in the American Samoan community. In particular, the American Samoan public need to be informed and educated about the major risk factors for CDs, and should be given all possible support to prevent, reduce or eliminate individual risk factors. They should be made aware that many of the adverse health consequences of these risk factors could be reduced or eliminated by adopting a healthier lifestyle. Specific recommendations are: To inform through educational means the American Samoan public about: the health risks associated with smoking and of the health benefits of smoking cessation. the adverse health effects of excessive alcohol consumption and the health benefits of decreasing alcohol consumption, particularly targeted towards younger males and females. 21/08/2007 Page 9 of 94

10 the health benefits of increasing fruit and vegetable consumption and decreasing consumption of fatty foods. the contributions of overweight and obesity to chronic diseases such as type 2 diabetes, cardiovascular disease, stroke and some cancers. the health benefits of reducing and preventing overweight and obesity. ways of achieving weight reduction through modification of diet and physical activity. the health risks of hypertension, diabetes and cardiovascular disease and the health benefits of preventing or controlling them. lifestyle factors contributing to hypertension, diabetes and cardiovascular disease the importance of appropriately monitoring and treating hypertension and diabetes, particularly amongst older age groups. To develop, introduce and strengthen environmental, behavioural and policy strategies to decrease the prevalence of lifestyle risk factors among American Samoans, including the following: measures to prevent younger Samoans from taking up smoking measures to encourage and support current smokers to quit smoking measures to discourage younger Samoans from participating in binge drinking measures to encourage current consumers of alcohol to decrease their level of alcohol consumption To develop and introduce programmes that support the prevention and control of hypertension, diabetes and cardiovascular disease including the following: an increase in efforts to encourage healthy eating habits across all age groups by promoting the availability and consumption of greater levels of fruit and vegetables. instigating strategies that support and promote weight reduction. This should include increased access to healthy foods and options for physical activity. Increasing levels of physical activity during leisure and transportation could be targeted specifically. ensuring that the health system adequately performs monitoring and treatment of hypertension, diabetes and cardiovascular disease 21/08/2007 Page 10 of 94

11 2. Acknowledgments and Key Contacts 2.1 Acknowledgments This report follows the WHO standard format for reporting results from STEPS surveys. The support of the personnel Dr Maximilian de Courten and Dr Andrea Curtis (Monash University), Dr Li Dan, Mr Raj Shalvindra (WHO Office in Suva), Ms Leanne Riley, Dr Gauden Galea and Ms Jacklynn Lippe (WHO Office in Geneva), Ms ancy Macdonald (WHO Office in Samoa), Ms Elaine Chung (Australia) during the STEPS process is gratefully acknowledged. This study would not be possible without the leadership of the American Samoa Department of Health team, the team from the Fiji School of Medicine and the participation of the STEPS survey team, who managed and implemented all aspects of the survey activities, from participant recruitment to data collection and data entry. We thank the American Samoa Department of Health for providing staffing, laboratory facilities and office space for the survey. The contribution made by the people of American Samoa through their participation and support of the survey is gratefully acknowledged. We owe special thanks to the following persons: Elize Gershater (Health Project, Apia), Vizo Halavatau (FSMed), Steven Kaplan (Biostatistician, Department of Health), Fuata'i Kava (Statistical Analyst, Department of Health), La'aloi F. Lili'o (Statistician, Department of Health), Aso Maga (STEPS Project Manager, Deputy Director of Health), Shakila aidu (FSMed), Dr Jan Pryor (FSMed), Dr Sivia Sunia (STEPS Assistant Project Manager, Assistant Director, Department of Health), Fale Uele (Health Information Systems Administrator, Department of Health), etc. Analyses of the survey data, interpretation of the results and preparation of the report were carried out as a collaborative effort between staff from the American Samoa Department of Health, staff from the WHO offices in Suva and Apia, and the Department of Epidemiology and Preventive Medicine (DEPM), Monash University in Melbourne, Australia. In this process we gratefully acknowledge the statistical support provided by Mr Shalvindra Raj, Ms Jacklynn Lippe, Ms Leanne Riley and Ms Elaine Chung who made a substantial contribution to the timely completion of data analyses. The finalization, reviewing and publication of this STEPS Report were greatly contributed by Dr Li Dan, Ms Leanne Riley, Dr Maximilian de Courten, Dr Chen ken (WHO Representative in the South Pacific) and Mr Shalvindra Raj The American Samoa -STEPS survey was funded by WHO through budgetary allocations and funds received from AusAid, and the American Samoa Department of Health provided funding-in-kind, and the Fiji School of Medicine and the DEPM, Melbourne and WHO provided technical support. 2.2 WHO Contact Dr Li Dan Medical Officer oncommunicable Diseases WHO Office for the South Pacific PO Box 113, Suva, Fiji Tel.: (679) Fax: (679) LiD@sp.wpro.who.int 21/08/2007 Page 11 of 94

12 2.3 American Samoa Department of Health Contact Mr. Uto ofili Aso Maga Director Department of Health American Samoa Telephone: Monash University Contact Dr Maximilian de Courten Associate Professor Clinical Epidemiology Department of Epidemiology and Preventive Medicine Monash University Melbourne, Australia Telephone: max.decourten@med.monash.edu.au 21/08/2007 Page 12 of 94

13 3. Introduction 3.1 Background to the CD STEPS surveillance oncommunicable diseases (CDs) are the major cause of death and disability globally and are of great concern to the World Health Organization (WHO) and countries alike. Recent trends indicate that CDs are responsible for almost 60% of deaths and 43% of disease burden and predict that they will be responsible for 73% of deaths and 60% of the global burden of disease by Recent WHO Western Pacific Regional office analyses of CDs in the Western Pacific Region highlighted the very high mortality already noted in Pacific Islands 1 and associated economic burden2. WHO is assisting countries by implementing the WHO STEPwise approach 3 - a surveillance program that could help control and prevent growing CDs. The recent meeting of the Ministers of Health in Tonga has recommended the WHO STEPwise approach for CD surveillance 4. Surveillance is essential for guiding policy development; for effective allocation of health care resources; to improve capability of countries to respond to emerging disease trends; and to underpin the development of intervention programs and evaluating prevention programs. The framework of STEPS is the distinction between the different levels of risk-factor assessment into: health risk behaviours; physical measurements; and blood samples. Key premises for implementing STEPS are: to establish a surveillance system that produces comparable, reliable, valid and timely risk factor prevalence estimates to utilise the modular approach leading to appropriate STEPS according to country needs and resources, thereby focussing on essential information and ensuring enough statistical power to detect risk factor trends to contribute to comparable data. The local focus for implementing STEPS is: to build local capacity for surveillance to understand surveillance as information for public health policy to strengthen baseline systems with plans for continuity to link to existing systems where feasible. The WHO global surveillance strategy contains provision of technical materials and tools to support the application of surveillance packages; effective communication strategies for providing data to policy and intervention programme planners, decision-makers, potential funding sources, as well as to the general public; and the use of state-of-the-art technology to share information both between and within countries. 21/08/2007 Page 13 of 94

14 3.2 The ational Context Geography American Samoa is group of islands located in Oceania, in the South Pacific Ocean, about half way between Hawaii and ew Zealand. Its total land area comprises 199 sq km. The climate is tropical marine, moderated by southeast trade winds with annual rainfall averages about 3 m. The rainy season is around ovember to April, and a dry season from May to October with little seasonal temperature variation. Its terrain comprises five volcanic islands with rugged peaks and limited coastal plains, and two coral atolls (Rose Island, Swains Island) Population In 2004, American Samoa had an estimated population of , with around 40% below 15 years of age. Almost 4% were above 65 years of age. The average age was estimated at 21.3 years. About onehalf of the population resides in urban areas. American Samoans are US nationals and the 2000 census listed ethnic groups as 92.9% native Pacific islander, 2.9% Asian, 1.2% white, 2.8% mixed, and 0.2% other Economy American Samoa is considered a small developing economy that depends on two main sources of income: the United States Government and tuna canning. Federal expenditures and the canning business together account for 93% of the economy. The remaining 7% results from a small tourism industry and service sector. Transfers from the United States Government add substantially to American Samoa s economy. The United States is the main trading partner. Gross domestic product (GDP) per capita (purchasing power parity) was estimated at US$ 8000 in Government The political entity of the Territory of American Samoa was defined in 1899 by a treaty between the United States of America, the United Kingdom of Great Britain and orthern Ireland, and Germany, which gave the United States of America control of American Samoa. American Samoa is a territory of the US, administered by the Office of Insular Affairs, US Department of the Interior. In 1978, the first popularly elected Samoan governor was inaugurated. There is a bicameral legislature (Fono), consisting of a senate (18 members chosen by county councils) and a house of representatives (20 members elected by popular vote, plus one non-voting member from Swains Island). There is also an independent judiciary Social Services and Health Status As of the latest census in 2000, life expectancy at birth for men is 69 years, while for women it is 76 years. Based on 2004 estimates, there are 104 males for every 100 females. The crude birth rate was per 1000 population in 2002, and the crude death rate was 3.9 per 1000 population in The infant mortality rate is estimated at 8.50 per 1000 live births, and the under-five mortality rate at 4.90 per 1000 live births. The total fertility rate for women aged years is 4.50, and the maternal mortality ratio was 123 per live births in In 2000, 33% of women in the reproductive age group were using modern contraceptive methods 6. 21/08/2007 Page 14 of 94

15 There has been considerable progress in primary health care in recent years. Water supplies and sanitation systems are well organized and maintained, and 99% of the population has access to safe water. Water is increasingly supplied from deep bores, with a smaller portion from reservoirs, and is chlorinated. Although 99% of the population have adequate excreta disposal facilities, solid waste disposal is still a problem. Waste collection systems have improved significantly, but adequate space for solid waste landfill operations is limited CDs in American Samoa The morbidity pattern has shifted significantly over the past three decades. Where infectious diseases were previously the major cause of morbidity, noncommunicable diseases related to modernization and lifestyle changes now predominate. Enumerated data on the leading causes of morbidity are currently unavailable 7. However, based on the observations of senior health officers, the following are assessed as the leading communicable diseases presently affecting the population: respiratory infectious diseases, filariasis, dengue, hepatitis, tuberculosis, leprosy and intestinal worm infestations. For noncommunicable diseases, obesity, diabetes and complications (including hypertension, heart disease and stroke), chronic disabling conditions (including asthma, gout, osteoarthritis and osteoporosis), tobacco-related obstructive pulmonary disease, cancer and oral health are the leading causes of morbidity. The most serious health issues are related to the increase in chronic diseases associated with lifestyle, with their roots in improper nutrition and physical inactivity. Significant increases in the prevalence of obesity, in both sexes and at increasingly younger ages, are associated with a number of these conditions. Hypertension, cardiovascular diseases, cerebrovascular diseases, Type 2 diabetes mellitus and its complications, arthritis, gout and some forms of cancer are among these important chronic diseases. The ten leading causes of mortality also show a predominance of noncommunicable diseases 7 (Table 3.1) Table 3.1 Ten leading causes of mortality in American Samoa in 2001 Cause of mortality Total Rate per number population 1. Heart disease eoplasms Diabetes Cerebrovascular disease Accidents Prenatal condition ephritis / nephrosis Chronic obstructive pulmonary disease Septicaemia Pneumonia / influenza /08/2007 Page 15 of 94

16 3.2.7 ational Health Plan and Priorities Recognizing the burden of chronic diseases and the imperative for prevention, the territorial health priorities listed by the Department of Health are as follows: 1. Increase the capacity of the health system to meet the health challenges of the 21st century through: improving health policy development mechanisms, developing the health workforce, improving management processes at all levels, and strengthening long-range health planning and programme planning. 2. Identify emerging and re-emerging diseases and implement effective interventions. 3. Implement effective interventions to decrease the burden of chronic diseases related to unhealthy lifestyles, especially cardiovascular disease, cancer and diabetes mellitus. 4. Actively implement the Healthy Islands concepts of health promotion, health protection and primary health care in priority settings, particularly through community health centres and school-linked programmes. 5. Increase the effectiveness of public investment in health through development of decision-oriented information systems, applied research, effective deployment of the health workforce, application of appropriate technology, and increased allocation of funding for health promotion, health protection and primary health care. 21/08/2007 Page 16 of 94

17 4. Survey Methods and Operations 4.1 Survey rationale and objectives The overall objective of the survey was to investigate the prevalence of key CDs and their associated risk factors, which include smoking, alcohol consumption, physical inactivity, obesity, hypertension, raised blood glucose and lipids. As of mid 2006 STEPS surveys have been conducted in over 41 countries globally, ten of which are in the Pacific. Data collected from this survey will contribute to the Global Database on CD risk factors 8. This survey will help the government in improving the health of the people of American Samoa by: 1. Keeping track of the magnitude and trends of CD risk factors. 2. Assisting planning and evaluation of health promotion and preventative campaigns. 3. Predicting likely future demands for health services. 4.2 Survey Sampling Methodology The American Samoa STEPS survey is a population-based nation-wide survey of adults aged The survey employed a stratified cluster sampling design (stratified by cluster size i.e. large villages and small villages) to obtain a nationally representative sample of adults aged Large villages were defined as those villages with a population greater than or equal to 350 in the target population (i.e. adults aged 25 64). Small villages were defined as those villages with a population of less than 350 in the target population. Villages with a target population of less than 50 were excluded from the survey. Tafuna, a village with a population of over 3000 was also excluded due to logistical reasons. Hence, the sampling frame consisted of 57 villages, covering 83.6 % (19,628 out of 23,479) of the total American Samoa adult population aged 25 to 64 years. Five villages were randomly selected from the two stratums (i.e. Large villages and Small villages) using probability proportional to size (PPS) to village size. For selected villages in the Small Village stratum, everyone in each selected village between the ages of was invited to participate in the survey. For selected villages with a population size of greater than or equal to 350, households were selected using simple random sampling until a target of 254 in the target age group was reached. 21/08/2007 Page 17 of 94

18 Figure 4.1 Survey sampling methodology. Total population (based on 2000 Census) Population < 50 or logistically infeasible villages excluded 73 Villages SAMPLIG FRAME 57 Villages RADOM PPS Sampling Every eligible person in the village or subsampled area 10 Villages 5 large, 5 small Participants years Sample size American Samoa adopted the STEPS guidelines, which require a minimum sample size of 2000 participants, with at least 250 participants in each of the 8 age-sex categories (25-34, 35-44, 45-54, years for males and females). After sample selection, the total targeted sample size was 2,188. This was designed so that if 80% participation in the 5 smaller villages and 100% of the sub-samples of the larger villages were achieved, this would provide a sample of Table 4.2 List of Villages Selected Villages Target sample size (age 25-64) Large Villages Leone Malaeimi Pagopago Malaeloa Pavaiai Small Villages Utulei Olosega Faganeanea Fagasa Asili Total Actual sample size (after data cleaning) 21/08/2007 Page 18 of 94

19 4.2.2 Survey Structure The STEPS approach moves along a sequential three-step process (Figure 4.3). Figure 4.3 The WHO STEPwise approach to surveillance of CDs. STEP 1: STEP 2: STEP 3: A simple questionnaire-based survey on selected major health risk behaviours (smoking, alcohol consumption, physical inactivity) plus additional issues deemed to be of importance in the individual country. A basic field survey including additional basic physiological measures of health risks (blood pressure, height, weight, and waist). A comprehensive field survey adding analysis of blood samples (total cholesterol, and fasting glucose). 4.3 Survey Administration The survey was conducted from June 21, 2004 through August 14, 2004 after staff training was held by Dr. Jan Pryor, Fiji School of Medicine on June 14 17, 2004 and a pilot survey at the village of Aua on June 18, The survey received an approval from the American Samoa IRB on June 15, 2004 after receiving an expedited review as specified in CFR American Samoa used the same questionnaire used by Western Samoa with few changes that were translated in-house. All equipment used for measurement of weight, height, waist, and blood pressure were the same recommended by WHO, and purchased through the WHO, Apia Office. Measurement of blood glucose and blood cholesterol was performed using an Accutrend GCT (Bayer Corp). Details on all equipment used can be found in the Appendix. The results from the survey were reported to participants following completion of physical measurements and blood tests. 21/08/2007 Page 19 of 94

20 Processing of questionnaires: At the end of each day of data collection, questionnaires were checked for completeness and accuracy. The questionnaires were then packed in a labeled envelope and given to data entry personnel. Team leaders tracked the number of completed questionnaires on a master log sheet. Double data entry using a data entry protocol was done on computers that had EpiInfo and Epidata software 9 for double data entry installed. The database was saved daily in a different drive as backup so that data would not be lost. After each round of data entry, the data entry personnel indicated this accordingly on the front sheet of each questionnaire along with any indication of irregularities. 4.4 Data analysis To take into account the complex design of the American Samoa STEPS Survey, a weighting factor was applied to each participant record to adjust for varying probabilities of selection and nonrepresentativeness in the stratum 10-year age sex groups. Data analyses were conducted using EpiInfo for Windows 9. Weighted percentages, means and 95% confidence intervals for these percentages and means were computed. 21/08/2007 Page 20 of 94

21 5. Results 5.1 Description of the sample The targeted sample size was 2188 from 10 villages. Data were obtained from 2076 individuals with the data being reduced to 2072 following the data cleaning process. Details of the sample characteristics are outlined in Table 5.1 and Figure 5.1 below Survey sample characteristics Table 5.1 Demographic Description of Study Sample 10 and Sampling Frame Demographic Characteristic umber Unweighted Proportion Study Sample Weighted Proportion Sampling Frame 95% CI umber Proportion Gender Males ±4.1 9, Females ±4.1 9, Total ,634 group years ±3.2 7, years ±3.9 6, years ±3.1 3, years ±1.9 2, Total ,634 Table 5.1 describes the age and gender breakdown of the surveyed population and its relation to the overall sampling frame. Figure 5.1 shows that males were slightly over-sampled in the and year age groups and under sampled in the and year age groups. Females were slightly oversampled in the 35-44, and year age groups and under sampled in the year age group. Figure 5.1 and gender distribution of American Samoa Population and Survey Sample Males Females Proportion Survey Sample American Samoa population as per /08/2007 Page 21 of 94

22 5.1.2 Level of Education The survey indicated that American Samoa has a well-educated population with the mean number of years spent in school as 12.1 (±0.2) (Table Appendix 1). There was no statistically significant difference in the mean number of years spent in school between males (12.1 years ±0.2) and females (12.2 years ±0.2). As expected, the mean number of years spent in school was slightly reduced in the older age groups. 5.2 Behavioural measures (Detailed tables in Appendix 1 Tables ) Tobacco Use Tobacco use was assessed according to participant responses in the questionnaire. The following smoking status definitions were used: Current smokers those who have smoked any tobacco products (such as cigarettes, cigars or rolled tobacco) in the past 12 months. These are further subdivided into: Daily smokers those who smoked any tobacco product every day. on-daily smokers those who have smoke any tobacco product in the past 12 months but not every day. Result tables Table Current smoking status of the study population AGE on-daily Smokers Daily Smokers Total Current Smokers % CI n % CI n % CI n Males Total Females Total /08/2007 Page 22 of 94

23 Figure Percentage of current daily smokers among total smokers % of current smokers in the study population who are daily smokers Males Females Group (years) Figure Mean age of starting smoking, for current daily smokers started smoking (years) Group (years) males females Table Mean number of years of smoking, for current daily smokers Males Females Mean CI Mean CI Total Table umber of manufactured cigarettes smoked per day by current smokers of manufactured cigarettes Males Females Mean CI Mean CI Total /08/2007 Page 23 of 94

24 Result description The survey indicated that 29.9% of the study population were current daily users of tobacco. 60.6% do not smoke (Table , Appendix 1). A gender difference was observed, with 49.0% and 29.7% of males and females respectively, being current smokers (Table ). There was also a higher proportion of male daily smokers 38.1% (±4.6) than female daily smokers 21.6% ±3.3). Figure shows the percentage of current smokers who are daily smokers. There was no significant difference across age groups or gender, with 76.8% (±7.0) of male and 72.7% (±7.5) of female smokers being daily smokers (Table , Appendix 1). For all current daily smokers, the mean age of starting smoking was 20.6 (± 0.6) years (Table , Appendix 1). Male current daily smokers began smoking at a mean age of 20.1 (± 0.9) years, while females current daily smokers began smoking at a mean age of 21.3 (± 1.3) years (Table , Appendix 1). There was no significant difference in the mean age of starting smoking for current male smokers across age groups (Figure ). Current female smokers in the youngest age group started smoking at a significantly lower mean age than current female smokers in the three older age groups (Figure ). The mean number of years of smoking for the total study population was 19.0 (± 1.1) years (Table , Appendix 1). Male current daily smokers had been smoking for a mean of 19.9 (± 1.6) years, while female current daily smokers had been smoking for a mean of 17.4 (± 1.1) years (Table ). All current male smokers smoked manufactured cigarettes (Table , Appendix 1). A small proportion of male smokers also smoked hand rolled cigarettes (3.8% ±16.5), and cigars, cheroots or cigarillos (3.7% ±20.9). All of the surveyed current daily female smokers smoked manufactured cigarettes only. For daily smokers of manufactured cigarettes the mean number of cigarettes smoked per day was 13.5 (± 1.1) (Table , Appendix 1; Male smokers 14.2/day (± 1.2), Female smokers 12.4/day (± 1.3). There was no significant difference in the number of cigarettes smoked per day between the genders at each age group level. 21/08/2007 Page 24 of 94

25 Comparison with previous data Table Smoking prevalence in American Samoa Publication Survey year Gender groups (years) Current Smoking Prevalence Dwyer et.al Males 20 41% (1999) 11 (Household survey of smoking) Females % 1994 (Tobacco or Health in the Males 15 41% Western Pacific Region, 1997) Females 15 16% McGarvey 1994 (2001) 12 Mishra et.al. Males & (2005) 13 Females Males % Males % Females % Females % 28% Table lists previous surveys of current smoking prevalence for American Samoa. In general prevalence of smoking amongst females has been lower than that amongst males. Comparisons with the results of the present survey are limited since most of the other surveys do not specify if the current or current daily smoking prevalence was measured. In the present survey 39.4% of the survey population were current smokers. The prevalence of daily smoking for males 25 years was 38.1% and the prevalence of daily smoking for females 25 years was 21.6%. This indicates that smoking prevalence for males has remained relatively stable over almost two decades. For females the prevalence of smoking has probably undergone a slight increase over the same period. 21/08/2007 Page 25 of 94

26 5.2.2 Alcohol Consumption Prevalence of alcohol consumption was assessed by asking study participants questions on alcohol consumption. The consumption behaviour of binge drinking was specifically assessed due to its cardiovascular and associated risks. The definitions used were as follows: Ever drinkers those who have ever consumed a drink that contains alcohol Current drinkers those who have consumed a drink containing alcohol in the past 12 months Binge drinkers (for males) those who have consumed 5 or more drinks per day on at least one day in the past week. For females those who have consumed 4 or more drinks per day on at least one day in the past week. Result tables Figure Percentage of male and female current consumers of alcohol across age groups 100 % of the study population who are current consumers of alcohol Group (years) Male Female 21/08/2007 Page 26 of 94

27 Figure Percentage of current consumers of alcohol who binge drink* on at least one day in the last week across age groups % of current consumers of alcohol who binge drink on at least one day in the last week Male Female group (years) *5 or more standard drinks per drinking day for males and 4 or more standard drinks per drinking day for females Figure Daily frequency of binge drinking amongst current consumers of alcohol % of current consumers of alcohol who binge drink Mon Tues Wed Thurs Fri Sat Sun Male Female Result description The survey results indicate that 57% of the study population had never consumed alcohol and 43% (±7.8) had consumed alcohol at some time (Table Appendix 1). A significant gender difference was observed, with 61.4% (±6.5) of males having consumed alcohol at some time compared with 24.3% (±9.2) of females. This gender difference persisted across all age groups. 38.6% of males and 75.7% of females in the study population had never consumed alcohol. There was also a slight decrease with age in the percentage of ever consumers of alcohol. This was observed for both genders but was more pronounced for females, where 26.8% of years olds had consumed alcohol compared with 15.7% of years olds. In the previous 12 months 28.0% (±4.2) of the study population had consumed alcohol (Table Appendix 1). There was a significant gender difference with 45.3% (±5.9) of males and 10.5 % (±3.6) of 21/08/2007 Page 27 of 94

28 females having consumed alcohol in the previous 12 months. This gender difference persisted across age groups (Figure ). The only statistically significant age difference was between the and age groups for both males and females, with a smaller proportion of those in the oldest age group having consumed alcohol in the previous 12 months. Figure (and Table Appendix 1) shows the percentage of current consumers of alcohol who participated in binge drinking on at least one day in the previous week. For females binge drinking was defined as having 4 or more standard drinks on at least one day in the previous week. For males binge drinking was defined as having 5 or more standard drinks on at least one day in the previous week. A higher proportion of males (49.6% (±6.4)) being binge drinkers compared to females (33.9% (±11.5)). The gender difference was significant and persisted across all age groups, except for the year age group. There was a higher proportion of binge drinkers in the younger age groups for both males and females (Figure ) The daily pattern of binge drinking for current consumers of alcohol is shown in Table (Appendix 1). Overall Saturday was the day on which the greatest percentage (28.0% ±7.7) of current consumers of alcohol participated in binge drinking. Binge drinking was most common amongst the year age group. In general there was a trend for participation in binge drinking to decline with increasing age, and this was observed for both males and females. Figures show participation in binge drinking by males and females, across each day of the week. Comparison with previous data There are no previous survey data available on the prevalence of alcohol consumption in American Samoa. However the WHO Global Status Report on Alcohol (2004) 14 states that the Western Pacific Region is on of the two WHO regions showing recent and continuing increases in alcohol consumption. 21/08/2007 Page 28 of 94

29 5.2.3 Diet To assess the eating pattern of the surveyed population related to cardiovascular disease risk, the study participants were asked how often they ate fruit and vegetables and the number of servings of each that they ate each day. Study participants were shown a card with illustrations of fruit and vegetables to assist them in answering these questions. For the purposes of the survey, fruit included paw-paw, orange, guava, pineapple, passion fruit, apple, jackfruit, mango, banana, lemon, lime, pear, etc. Coconut and coconut juices were not included. A single serving of fruit was defined as follows: ½ cup of chopped, cooked or canned fruit 1 medium whole fruit (e.g. orange, apple, banana, pear) ¾ cup (180ml) of 100% fruit juice Vegetables included the following: Dark green leaves: green leafy vegetables (e.g. lettuce, pinapi), rukau, rukau viti, pumpkin leaves, kumara leaves, spinach, etc. Yellow/red/orange vegetables: corn, carrot, tomatoes, pumpkin Other vegetables: cabbage, green beans, cucumber, beets, eggplant, broccoli, cauliflower, onion, capsicum, chilli A single serving of vegetable was defined as follows: 1 cup of raw leafy vegetables ½ cup of cooked or chopped raw vegetables Result tables Table Servings of fruit consumed per day Total population < 1 serving per 2-4 servings per 5 or more servings 1 serving per day day* day per day % CI n % CI n % CI n % CI n Male Females * Includes Don t eat fruit at all Table Mean number of servings of fruit consumed per day Males Females Mean CI Mean CI Total /08/2007 Page 29 of 94

30 Table Servings of vegetables consumed per day Total population 5 or more servings < 1 serving per day* 1 serving per day 2-4 servings per day per day % CI n % CI n % CI n % CI n Males Females *Includes Don t eat vegetables at all Table Mean number of servings of vegetables consumed per day Males Females Mean CI Mean CI Total Table Combined servings of fruit & vegetables consumed per day Total population <5 servings % CI n Male <5 servings % CI n Female <5 servings % CI n Result description The survey indicated that fruit and vegetable consumption by the majority of the study population in American Samoa was lower than the WHO recommended intake of 400g per day (equivalent of 5x 80g servings per day) 15. Fruit was consumed only on an average of 2.4 days per week (± 0.1) and there was significant difference in the number of days per week that males (2.1 ± 0.2) and females (2.6 ± 0.2) consumed fruit (Table Appendix 1). 21/08/2007 Page 30 of 94

31 Among the total study population, 77.0% (± 2.7) of people consumed less than 1 serving of fruit per day, while only 0.8.6% (± 0.5) consumed 5 or more servings per day (Table ). There was a significant difference between the percentage of males and females who consumed <1 serving of fruit per day, which was due to a difference between the genders in the year age group. In this age group 83.6% (±5.4) of males and 66.5% (±6.1) of females consumed less than 1 serving of fruit per day. Amongst other age groups there were no significant differences between genders. Overall the mean number of servings of fruit consumed per day was 2.0 (±0.1) (Table , Appendix 1). There was no significant gender difference, with males consuming a mean of 1.9 (±0.2) servings of fruit per day and females consuming a mean of 2.0 (±0.1) servings of fruit per day (Table ). There was no significant difference by age. Vegetables were consumed on an average of 4.2days per day (± 0.4) and there was no significant difference in the number of days per day that males (3.7 ± 0.3) and females (4.2 ± 0.4) consumed vegetables (Table Appendix 1). Again, there was no significant difference across age groups. Among the total study population, 50.4% (± 8.7) of people consumed less than 1 serving of vegetables per day, while 2.8% (± 1.8) consumed more than 5 servings per day (Table ). The results were not significantly different for males and females. There were no significant differences across age groups for either gender. Overall the mean number of servings of vegetables consumed per day was 2.5 (±0.2) (Table , Appendix). There was no significant gender difference, with males consuming a mean of 2.5 (±0.2) servings of vegetables per day and females consuming a mean of 2.5 (±0.2) servings of vegetables per day (Table ). There was no significant difference by age. In summary, Table shows that 62.1% (± 3.0) of the total study population consumed less than 5 servings of fruit and vegetables in combination per day. There was no gender difference with 63.0 % (± 4.0) of males and 61.2 % (± 3.3) of females consuming less than 5 servings of fruit and vegetables per day. There was also no difference observed across age groups. Overall, in this survey population, the level of consumption of vegetables was higher than that for fruit. Comparison with previous data There are no previous data available on specific levels of fruit and vegetable consumption in American Samoa. However, the traditional diet of Samoans (both American and Western Samoans) based mostly on taro, yams, coconut, bananas and breadfruit has moved to one in which imported and purchased foods including white rice, flour and sugar are more prominent A similar situation, where traditional foods and local diets have been progressively replaced with Spanish, Japanese and American influenced and imported foods, has occurred in Micronesia and is comprehensively reviewed in Cassels /08/2007 Page 31 of 94

32 5.2.4 Physical Activity Physical activity participation was measured by asking survey participants to report on the amount of time they spend doing different types of physical activity in their employment, transport and leisure time. Study participants were shown a card with illustrations of various types of physical activity to assist them in answering these questions. For the purposes of the survey, moderate activity was defined as more than 10 minutes at a time of any of the following: painting gardening cleaning plastering swimming climbing stairs cycling farming Vigorous physical activity was defined as more than 10 minutes at a time of any of the following: heavy construction carrying heavy loads digging running strenuous sport sawing wood shovelling For the purposes of this report physical activity was converted to METminutes. The term MET is an abbreviation for metabolic equivalent and is used to reflect the intensity of the specific physical activity. A MET is defined as the ratio of the associated metabolic rate for a specific activity divided by the resting metabolic rate. The resting metabolic rate is approximately 1 MET and reflects the energy cost of sitting quietly. The MET values for the three PA domains are as follows: Moderate PA (work and leisure domain) = METS Vigorous PA (work and leisure domain) = 8.0 METS Transport related walking/cycling = 3.0 METS In terms of METminutes the following levels of activity were defined: Inactive - <600 METminutes Moderately active METminutes Vigorously active - >1500 METminutes 21/08/2007 Page 32 of 94

33 Result tables Table Percentages of the study population that are physically inactive Males Females AGE Inactive Inactive % CI n % CI n ± ± ± ± ± ± ± ± Total ± ± Table Total physical activity (hours/week) by age group Males Females Mean CI Mean CI ± ± ± ± ± ± ± ± Total 25.7 ± ± Figure Total physical activity by domain (METminutes/week) total physical activity by domain (metminutes/week) Work Transport Leisure Male Female Total 21/08/2007 Page 33 of 94

34 Figure Total physical activity in the work domain amongst participants reporting physical activity in the work domain across age groups (METminutes/week) Total physical activity in the work domain (metminutes/week) Total population Male Female Group (years) Figure Total physical activity in the leisure domain amongst participants reporting physical activity in the leisure domain across age groups (METminutes/week) Total physical activity in the leisure domain (metminutes/week) Total population Male Female Group (years) Table Involvement in physical activity for less than 150 minutes per week by age group Males Females AGE Yes Yes % CI n % CI n ± ± ± ± ± ± ± ± Total ± ± /08/2007 Page 34 of 94

35 Result description The survey results indicated that 61.7% (±6.3) of the study population was low level of physical activity in their work, transport or leisure time (Table ). There was no significant difference between males and females with 57.8% (±6.9) and 65.7% (±5.9) of females being physically inactive. There was also no evident difference in the proportions of physically inactive participants across age groups. For study participants who reported engaging in physical activity during their work, transport or leisure time, Table shows total activity in hours per week. There was a significant gender difference with males engaged in physical activity for a mean of 25.7 (±3.5) hours per week and females for a mean of 12.6 (±3.4) minutes per week. There was a significant difference between the youngest and oldest male age groups, with those in the youngest age group engaged in more physical activity than the older group. There was no difference in activity levels across age groups for females. Figure (and Table Appendix) shows the total physical activity (metminutes/week) by domains of activity (work, transport and leisure) for study participants who reported engaging in physical activity. The results indicate that both male and females undertake the majority of their physical activity during work time. Male undertake a significantly greater amount of physical activity during their work time than females. Figure shows the total amount of physical activity undertaken in the work domain across age groups. The results show that total physical activity undertaken at work by male declines with age. There was no significant difference in the level of work-related physical activity across age groups for females. The activity domain accounting for the least amount of physical activity was the transport domain, and there was no difference between male and females for this domain (Figure ). The amount of physical activity undertaken during leisure time was smaller than that during work time for both male and females (Figure ). Male participated in more physical activity during leisure time than females; however the difference was not significant. There was also no significant difference in the amount of work undertaken during leisure time across age groups for both males and females (Figure ). It is notable that although the greatest amount of physical activity was undertaken in the work domain, the domain in which the greatest numbers of participants were physically active was the transport domain (Table Appendix). Table shows that there is no significant difference in the proportion of the population involved in less than 150 minutes per week across age groups or gender. Comparison with previous data There are no previously reported data on levels of physical activity in American Samoans. However it is repeatedly asserted that declining levels of physical activity across the Pacific region result from increasing economic and lifestyle modernisation. Studies carried out in Western Samoa found that lower male BMI (but not females) was associated with increased physical activity 19. More recently Keighley et. al. (2006) 20 described an association between participation in farm work and significantly lower BMI in older American Samoan females and American Samoan males of all ages. 21/08/2007 Page 35 of 94

36 5.3 Physical measures (Detailed tables in Appendix 1 Table ) Obesity Height and weight Height and weight was measured for each participant as described in the Survey Operational Manual 21. Waist circumference The waist circumference was measured for each participant (excluding pregnant females). Results for height, weight and waist circumference are presented in the text using U.S. customary units (inches and pounds). In the Appendix results tables both U.S. customary units and SI (metric) measurements are presented. Body Mass Index (BMI) and risk factor categories Body mass index* (BMI) was calculated for each participant as the weight in kilograms over the height in metres 2. Risk categories for BMI were defined as follows: Underweight BMI <18.5 ormal BMI 18.5 to 25.0 Overweight BMI 25.0 and < 30.0 Obese BMI 30.0 *BMI can also be calculated by the following formula with U.S. customary units: BMI = 703x [weight (inches)/height (inches) x height (inches)] Results Tables **MEA HEIGHT AD WEIGHT STILL TO BE RECEIVED FROM LEAE** Table a Mean height (inches) of the study population across gender and age groups Total population Males Females Mean CI Mean CI Mean CI ± ± ± ± ± ± ± ± ± ± ± ± Total 67.5 ± ± ± Table a Mean weight (pounds) of the study population across gender and age groups Males Females* Mean CI Mean CI ± ± ± ± ± ± ± ± Total ± ± *Missing = 65; pregnant = 35 Pregnant females excluded 21/08/2007 Page 36 of 94

37 Table Mean body mass index (kg/m 2 ) Males Females* group Mean CI Mea CI n Total *Missing = 65; pregnant = 35 Pregnant females excluded Figure Mean body mass index across gender and age groups Mean body mass index (kg/m 2 ) Men Women Group (years) Table Risk categories for body mass index (kg/m 2 ) Total Population* Overweight ( ) Obese ( 30.0) % CI n % CI n Total Males Total Females* Total * Pregnant females excluded 21/08/2007 Page 37 of 94

38 Table a Mean waist circumference (CM) Total population* Males Females* Mean CI Mean CI Mean CI Total * Pregnant females excluded Results Description The mean height of the study population was 67.5 (±0.2) inches and the mean weight was (± 1.4) lbs (Tables a and a). For males the mean height was 69.6 (±0.3) inches and the mean weight was (±4.4) lbs. For females the mean height was 65.5 (±0.3) inches and the mean weight was (±3.8) lbs (Tables a and a). The mean BMI for the study population was 34.9 (±0.2) kg/m 2 (Table ). Table and Figure show the mean BMI by gender and age group. A significant gender difference was observed with the mean BMI for males being 33.7 (±0.5) kg/m 2 and for females being 36.2 (±0.3) kg/m 2. The gender difference was significant for all age groups except the year group. Table (Appendix 1) shows the proportion of the study population in each BMI risk category by gender and age. Table shows the same information across age groups for the overweight and obese BMI categories. The percentage of the total study population that was obese (BMI 30 kg/m 2 ) was 74.6% (±1.5). 69.3% (±2.0) and 80.2% (±3.3) of males and females respectively were obese. In combination, 92.7% and 94.4% of males and females respectively were overweight or obese. There was no significant gender difference in waist measurement, with the mean waist circumference of males being (±0.6) CM and that of females being (±0.7) CM (Table ). For males there was a small increase in waist circumference observed with increasing age; however the only significant difference was between the and year age groups. Mean waist circumferences for both genders were above the values of 102 cm (approx. 40 inches) for males and 88cm (approx. 35 inches) for females that are considered to infer high risk of cardiovascular disease 22. Comparison with previous data Previous survey data regarding the prevalence of overweight and obesity in American Samoa has been reviewed by Coyne (2000) 23. Recent prevalence data on obesity in American Samoans has been cited by Keighley et al (2006) 24. For males living in American Samoa the prevalence of obesity was estimated to rise from 32.2% in 1976 to 63.1% in For females living in American Samoa, the prevalence of obesity in 1976 was 58.0% and 75% in In an earlier study using different BMI cut-offs (overweight BMI 27.8 for males, overweight BMI 27.3 for females) McGarvey etal (1993) 25 found that prevalence of overweight in1990 was 83.6% for males and 87.6% for females. This is a significant increase over the prevalence of overweight for males in While the prevalence of overweight in the female population did not rise over this period, it was speculated that this was because females already had a higher prevalence of overweight in The current (2004) WHO CD-surveillance data indicate that the prevalence of 21/08/2007 Page 38 of 94

39 obesity continues to rise, with 69.3% of males and 80.2% of females in the study population having a BMI of 30 kg/m Blood Pressure and hypertension Diastolic and systolic blood pressure measurements were taken for all study participants using an Omron digital automatic blood pressure monitor (DABPM). Two readings were taken for each participant. If the difference between the first and second readings was 10mm Hg or more, then a third reading was taken. Study participants were also asked about aspects of their medical history relating to high blood pressure. A diagnosis of high blood pressure was recorded if, during the past 12 months, a doctor or health worker had told the participant that they had elevated blood pressure or hypertension. Those participants with a diagnosis of hypertension or elevated blood pressure were asked if they had taken any blood pressure drugs during the past two weeks that were prescribed by a doctor or health worker. For the purposes of this report, high blood pressure is defined as: Systolic blood pressure greater than or equal to 140 mmhg and/or Diastolic blood pressure greater than or equal to 90 mmhg and/or Receiving treatment for high blood pressure. Results Tables Table Mean resting systolic and diastolic blood pressure (mmhg) Systolic Blood Pressure Diastolic Blood Pressure Mean CI Mean CI Males Total Females Total /08/2007 Page 39 of 94

40 Figure Percentage of study population with a diagnosis of hypertension in the past 12 months across gender and age group % of study population with a confirmed or new diagnosis of hypertension in the past 12 months male female group (years) Table Percentage of the study population previously diagnosed with high blood pressure receiving drug treatment for it Males Females Yes Yes % CI n % CI n ± ± ± ± ± ± ± ± Total ± ± /08/2007 Page 40 of 94

41 Table Prevalence of high blood pressure Previously Diagnosed With Hypertension and on Medication Total population All Individuals OT Diagnosed Previously but with BP >= 140/90* Total Prevalence of High Blood Pressure % CI % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± *All Individuals OT diagnosed previously but with BP >= 140/90 mmhg also includes individuals not previously diagnosed but with BP >= 160/100 mmhg Figure Total prevalence* of high blood pressure across age and gender groups Total prevalence of high blood pressure Male Female group (years) * Total prevalence of high blood pressure is defined as the % of the study population with a previous diagnosis of high blood pressure and on medication plus the % not previously diagnosed but with blood pressure measured 140/90 mmhg Results Description Table shows that the mean systolic blood pressure for males in the study population was (±1.5) mmhg and the mean diastolic blood pressure was 83.5 (±1.7) mmhg. The mean systolic blood pressure for females was (±1.4) mmhg and the mean diastolic blood pressure was 80.0 (±1.1) mmhg. There was a statistically significant overall gender difference in both systolic and diastolic blood 21/08/2007 Page 41 of 94

42 pressure with males having higher blood pressure readings than females. For diastolic blood pressure this gender difference was observed in the two younger age groups, while for systolic blood pressure the difference was only observed in the year age group. There was also a significant increase in systolic blood pressure with increasing age. This was observed for both males and females, although the magnitude of the increase was greater for females. There was also a trend for increasing diastolic blood pressure with increasing age, although this was only significant for females. As shown in Table (Appendix 1), only 11.4% (±1.6) of the study population had a diagnosis of high blood pressure by a health worker in the previous 12 months. There was no gender difference with 12.3% (±2.8) of males and 10.6% (±2.1) of females being diagnosed with high blood pressure in the preceding 12 months (Table ). However there was a pronounced increase in the proportion of the study population diagnosed with hypertension with increasing age. This trend was apparent for both males and females but there was no significant gender difference (Figure ). Amongst the group of study participants with a diagnosis of high blood pressure in the previous 12 months, 59.1% (±8.4) were on anti-hypertensive medication (Table ). There was no significant gender difference with 62.0% (±11.4) of male and 55.8% (±11.1) of female hypertensives on medication respectively. However, for both males and females there was an increase in the proportion of hypertensives on medication with increasing age. Table shows the total prevalence of high blood pressure in the study population. Total prevalence was defined as the sum of those participants with a diagnosis of high blood pressure who were taking blood pressure medication and those who have not previously been diagnosed with high blood pressure but who have BP >= 140/90 mmhg. The prevalence of high blood pressure amongst males in the study population was 42.3% (±6.0) while the prevalence amongst females was 29.0 % (±4.6). When stratified by age and gender groups, it was apparent that there was a significantly higher prevalence of high blood pressure amongst younger males compared to younger females. There was no significant gender difference in high blood pressure prevalence in the older age groupings. (Figure ). Comparison with previous data Coyne (2000) 26 has summarized previous investigations of blood pressure undertaken in Samoa and American Samoa. In general, blood pressure increased with age for both males and females. The prevalence of hypertension for Samoan males in 1994 was greater than 35% and for females it was approximately 18%. The current survey data indicated that the prevalence of hypertension for American Samoan males is 43.9% (±6.5) and for females is 30.7 %. (±4.4). The extent to which this can be compared with previous data is limited since the previous surveys incorporate information from both Western Samoa and American Samoa; however, it may indicate that the prevalence of hypertension is increasing. 21/08/2007 Page 42 of 94

43 5.4 Biochemical measures (Detailed tables in Appendix 1 Table ) Blood Glucose and Diabetes **STILL BEIG AALYSED** Whole blood capillary glucose was measured for each participant using an Accutrend (Bayer Corp) as described in the operational manual. Elevated blood glucose was defined as being 110mg/dL or 6.1 mmol/l and impaired fasting glucose levels were defined as being 100 mg/dl and <110 mg/dl ( 5.6 and <6.1 mmol/l) 27. The participants were also asked questions about their history of diabetes and treatment for diabetes. A reported diagnosis of diabetes was recorded if, during the past 12 months, a doctor or health worker had told the participant that they had diabetes. Participants with a reported diagnosis of diabetes were asked if they were currently receiving insulin, oral drugs or special dietary treatments as prescribed by a doctor or health worker. To assess the diabetes status of the surveyed population, the total diabetes prevalence was calculated and was defined as including the following two groups of participants: Known or previously diagnosed diabetes if they were currently receiving anti-diabetes medication and/or insulin prescribed by a health worker, OR Having fasting blood glucose greater than or equal to 110 mg/dl (6.1 mmol/l) without having known diabetes or being on treatment. These were called ewly Diagnosed Diabetics. Result tables Table Fasting blood glucose (mg/dl) Males Females Mean CI Mean CI ± ± ± ± ± ± ± ± Total ± ± /08/2007 Page 43 of 94

44 Figure Percentage of the study population with a previous diagnosis of diabetes across gender and age group % of the study population with a diagnosis of diabetes in the past 12 months Group (years) Male Female Table Prevalence of diabetes (110mg/dL cut-off) Previously Diagnosed With Diabetes and on Medication Total population All Individuals OT diagnosed previously but with Glucose >= 110mg/dL Total Prevalence % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± /08/2007 Page 44 of 94

45 Figure Total Prevalence* of diabetes (110 mg/dl cut-off) by gender across age groups Total prevalence of diabetes (%) Male Female group (years) * Total prevalence of diabetes is defined as: the % of the study population previously diagnosed with diabetes who are on diabetes medication and those newly diagnosed with diabetes. Table Prevalence of diabetes (120mg/dL cut-off)* Total Population All Individuals OT Previously Diagnosed diagnosed previously With Diabetes and on but with Treatment Glucose >= 120 mg/dl Total Prevalence % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± *The 120mg/dL glucose cut-off was used for classification until 1999 and is provided here for comparison with older studies. 21/08/2007 Page 45 of 94

46 Table b Type of blood glucose treatment for diabetes Insulin Only Insulin & Drugs Diet Only (includes insulin & (includes drugs, diet (includes drugs & Drugs Only o treatment diet) & insulin) diet) % CI n % CI n % CI n % CI n % CI n Total ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± ± /08/2007 Page 46 of 94

47 Table Percentage of study participants with impaired fasting blood glucose ( mg/dl) Total Population Males Females % CI % CI % CI ± ± ± ± ± ± ± ± ± ± ± ± Total 25.7 ± ± ± Figure Percentage of study participants with impaired fasting blood glucose (100mg/dL -110mg/dL) by age group and gender % of the study population with impaired fasting blood glucose levels Male Female Group (years) Result description The mean fasting blood glucose level of the study population was (±3.6) mg/dl (Table Appendix 1). There was no significant difference between males (122.6 (±4.4) mg/dl) and females (120.9 (±5.2) (Table ). Mean blood glucose levels increased with increasing age for both males and females. As indicated in Table (Appendix 1), 10.4% (±8.4) of the study population had been diagnosed with diabetes by a health worker in the previous 12 months. There was no significant difference between males and females, with 9.3% (±3.0) and 11.5% (±2.9) of males and females being diagnosed with diabetes in the last 12 months, respectively. The proportion of participants with a recent diagnosis of diabetes was observed to increase with increasing age (Figure ). This was evident for both males and females. For the most senior age grouping, 29.3% (±10.3) of males and 30.4% (±10.0) of females had been given a diagnosis of diabetes within the previous 12 months. As shown by Table , the prevalence of diabetes in the total study population using a blood glucose level of 110 mg/dl as a cut-off was 47.3% (±3.4). The prevalence of diabetes in males from the study population was 52.3% (±3.7) and for females it was 42.4% (±4.1). Figure shows prevalence of diabetes by gender and age group. The prevalence of diabetes amongst males was higher than that amongst females for each age group; however the differences were not significant. In general, for both males and females the prevalence of diabetes increased with increasing age, such that approximately 70% of males and females in the year age group were diabetic. 21/08/2007 Page 47 of 94

48 Prior to 1999, a blood glucose level of 120 mg/dl was the accepted cut-off value used to diagnose diabetes. To enable comparison with older studies, the prevalence of diabetes in the current survey was also calculated using this higher cut-off. Table shows that the prevalence of diabetes in the total study population using the 120 mg/dl cut-off was 29.6% (±3.7). The prevalence of diabetes amongst males and females using the 120 mg/dl cut-off was 31.1% (±5.9) and 28.1% (±4.4) respectively. There was no significant difference in the prevalence of diabetes between males and females using the higher blood glucose cut-off. There was a trend for prevalence of diabetes to increase with increasing age for both males and females. Table b shows the proportions of diagnosed diabetics receiving various prescribed diabetes treatments in the past 2 weeks. This table is a condensed version of the table shown in the appendix (Table a) in which some of the treatment categories are collapsed. Treatment categories from Table a were collapsed into the following treatment categories for Table b: Insulin and Diet (Table a) = Insulin Only (Table b) All (Drugs, diet and insulin) (Table a) = Insulin & Drugs (Table b) The results indicate that the majority of the diabetics in the study population were taking oral drugs (47.8% (±15.7)). 48.6% (±22.6) of males and 47.2% (±16.5) of females were taking oral drugs. Overall, 28.4% (±8.0) of the study population was not being treated for their diabetes. The remainder of the population were on a special diet (13.2% (±5.4), insulin (5.9% (±5.8), or various combinations of therapy. There were no significant differences between the percentages of men and women on the different therapies. Table shows the percentage of the study population with impaired fasting blood glucose levels. This percentage takes into account only those participants who had not been previously diagnosed with diabetes and whose blood glucose levels were mg/dl. The results indicate that overall 25.7% (±1.5) of the population who were not diabetic but had impaired fasting glucose levels. There was no significant gender or age difference (Figure ). Comparison with previous data A previous 1990 study cited by Coyne (2000) 28 indicated the prevalence of diabetes in American Samoa to be 13.1% for males and 7.8% for females. Using a fasting glucose level of 126 mg/dl as a cut-off, McGarvey (2001) 29 found the 1995 prevalence of diabetes to 11% and 36% for males aged and years, respectively. Prevalence of diabetes was 15% for females in and year age groups. There have been no other reports on prevalence of diabetes in American Samoa. In the current survey the prevalence of diagnosed diabetes in the study population was 10.45% (±8.4), with 9.3% (±3.0) and 11.5% (±2.9) in males and females respectively. The total prevalence of diabetes takes into account those participants with a diagnosis of diabetes as well as those with no new diagnosis but with elevated blood glucose levels. Prevalence of diabetes was estimated using two different blood glucose concentrations as cut-offs. Using a glucose cut-off of 110mg/dL the prevalence of diabetes in the total study population was 45.7% (±4.4). The prevalence of diabetes was 49.3% (±5.0) for males and 42.0% (±5.7) for females. Using a glucose cut-off of 120 mg/dl, overall prevalence in the study population was 29.6% (±3.7). The prevalence for males was 31.1% (±5.9) and for females was 28.1% (±4.4). 21/08/2007 Page 48 of 94

49 5.4.2 Blood Cholesterol 22 Total blood cholesterol was measured for each participant as described in the operational manual using an Accutrend GCT. Elevated total blood cholesterol was defined as being >200mg/dL (5.15 mmol/l) 30. The measurement range of the Accutrend GC is from 150 mg/dl (3.88 mmol/l) to 300 mg/dl (7.76 mmol/l) with a stated accuracy of ± 5 % compared with CHOD-PAP method 31. The instrument indicated values outside the measurement range but not zero as either low or "high". During statistical analyses these "low" values were set to the lowest readable value (150 mg/dl) and the high values were set at the highest readable value i.e. 300 mg/dl for further statistical analysis. Result tables Table Mean total blood cholesterol levels (mg/dl) Males Females Mean CI Mean CI Total Figure Percentage of study population with high risk total blood cholesterol levels % of study population with high risk cholesterol levels Male Female group (years) 21/08/2007 Page 49 of 94

50 Result description The mean blood total cholesterol level of the total population was (±1.8) mg/dl (Table Appendix 1). There was a significant gender difference with the mean cholesterol level for males and females being (±2.4) mg/dl and (±2.2) mg/dl, respectively (Table ). For both males and females mean cholesterol level increased with age. Females tended to have a slightly higher cholesterol level in each age group than males. However this difference was only significant for the age group with a mean cholesterol level of (±4.3) mg/dl for females and (±7.5) for males. The mean total cholesterol level for each participant was used to determine the proportion of individuals at high risk for coronary artery disease as determined by levels of cholesterol >200mg/dL (Table ). For all age groups except the year group, the proportion of females in the high risk category was greater than for males (Figure ). However the differences were not statistically significant and the overall proportion of females and males in the high risk group were 23.7% (±3.0) and 23.1% (±2.2), respectively, indicating no gender difference. For both males and females the proportion of participants in the high risk category increased with increasing age, such that 34.7% (±10.4) and 39.5% (±7.3) of males and females from the year age group, respectively were in the high risk category (Figure ). Comparison with previous data Publication Table Mean and average total cholesterol levels in American Samoans Survey Year umber of participants Gender groups (years) Cholesterol level (mg/dl) WHO CD-STEPS (current Males study) Females Crews et.al Males= Females = 149 Kamboh et.al Males = Females = 216 McGarvey et.al Males Males Pelletier & Hornick Males = 50 Females = ot available A Table shows previously reported average total blood cholesterol levels for American Samoans. In each case the levels are higher than the mean total blood cholesterol determined in the current survey (172.8 mg/dl). The current survey measured blood cholesterol in 2062 individuals while the previously reported mean cholesterol levels were all determined from fewer than 400 individuals. 21/08/2007 Page 50 of 94

51 The prevalence of high cholesterol levels (>200 mg/dl) in a 1994 study in American Samoa was reported to be above 48% for males aged years and 39% for males aged years 35 For females the prevalence of high cholesterol levels was 32% for those aged years and 57% for those aged 44-60%. These prevalence figures are significantly higher than those assessed in the current survey (15.2% for males and 16.7% for females). Some of this difference might be attributable to the age difference between the participants in the different studies (with the current survey probably having the lowest mean age) and some due to methodological differences. 5.5 Combined risk factors There are 5 common and critical risk factors for CDs were selected, including current daily smokers, overweight or obese (BMI 25kg/m 2 ), raised Blood Pressure (SBP 140 and/or DBP 90 mmhg or currently on medication for raised BP), less than 5 servings of fruit and vegetables per day and low level of activity (<600 MET-minutes). Only 0.4% of the study population were low risk to CD (i.e., none of the 5 risk factors). 71.2% of the population aged 45 to 64 years old were raised risk (at least three of the risk factors included above). What should be paid more attention to was 60.9% of the population were raised risk (at least three of the risk factors included above) since their ages were 25 to 44 years old only. 21/08/2007 Page 51 of 94

52 6. Conclusions and Discussion The American Samoa CD-STEPS survey indicated that noncommunicable disease risk factors are highly prevalent in the population. Tobacco Smoking Tobacco smoking is the major risk factor for heart disease, stroke and chronic respiratory disease. It causes cancer of the lungs, oesophagus, mouth, bladder, and larynx and contributes to cancer of the cervix, kidney and pancreas. It is the single largest preventable cause of disease and premature death. Although smoking prevalence has declined in many developed nations, it has increased in many less developed countries, including those in the Western Pacific region. The current data indicate that smoking prevalence has not declined in nearly two decades in American Samoa. The risk of smoking related chronic disease therefore remains high for a large proportion of American Samoans. Alcohol Consumption Excess alcohol consumption is a leading cause of preventable death and illness. It is a contributing cause of liver cirrhosis, mental illness, pancreatitis, foetal alcohol syndrome and cardiovascular disease. It also is a contributing cause of cancers of the oral cavity, pharynx, oesophagus, liver and breast. In addition, excess alcohol consumption has adverse social consequences, including road traffic injuries and suicide. Although it is not known if alcohol consumption in American Samoa is increasing, alcohol consumption in the Western Pacific region shows an upward trend. Together with information from the current survey that more than 66% and 53% of male and female current consumers of alcohol in the year age bracket, respectively, participate in binge drinking, it indicates a need for an increased awareness of the health implications of excess alcohol consumption, particularly amongst younger American Samoans. Fruit and vegetable intake Evidence reviewed by the FAO/WHO Joint Workshop on Fruit and Vegetables for Health (2004), strongly suggests that fruit and vegetable consumption has a potential role in reducing the risk of type 2 diabetes mellitus (Fruit and Vegetables for Health: Report of a Joint FAO/WHO Workshop, 2004). It was also reported that diets rich in fruit and vegetables could significantly reduce the risk of ischaemic heart disease and stroke. The report also noted that consumption of fruit and vegetables might have a role in obesity, weight management, and cancer prevention. The WHO recommendations are for 400g daily of fruit and vegetable consumption (assuming 80g/ serve). Assuming a serving size of 80g, 90% of the total study population in American Samoa consumed less than this recommended amount. Obesity BMI has an established association with overweight and obesity. A BMI of greater than 25 kg/ m 2 and less than 30 is defined as overweight and one of greater than or equal to 30 kg/ m 2 is defined as obese. Waist circumference, which can be used as an indication of excess abdominal fat, is closely correlated with BMI and is independently associated with overweight and obesity. The WHO currently specifies that waist circumferences of >80cm for females and >94cm for males infer increased risk of cardiovascular disease. Both BMI and waist circumference are therefore important in predicting risk for the various co morbidities associated with obesity. Overweight and obesity are related to a range of serious chronic conditions that reduce overall quality of life and may lead to premature death. Obesity is associated with a greatly increased relative risk for type 2 diabetes, gallbladder disease, and sleep apnoea, with a moderately increased relative risk for coronary heart disease, hypertension and osteoarthritis, and with a slightly increased risk for impaired fertility, and some cancers (postmenopausal breast cancer, endometrial cancer, colon cancer) (WHO 1997). In the current survey, 69.3% of males and 80.2% of females in the study population had BMIs of >=30 kg/m 2. The mean waist circumferences of males and females were greater than those that infer increased 21/08/2007 Page 52 of 94

53 risk of cardiovascular disease. These characteristics place the majority of the study population in high risk categories for serious obesity-related chronic diseases such as type 2 diabetes, cardiovascular disease, hypertension, stroke and some cancers. Physical Activity Physical inactivity is a major preventable risk factor for noncommunicable diseases and has been estimated by the WHO to cause 10-16% each of breast cancer, colon cancer and diabetes, and about 22% of ischaemic heart disease. About 60% of the world s population do not achieve the minimum recommended physical activity each day (about 30 minutes of moderate intensity physical activity). In the current American Samoan survey, it was found that 61.7% of the study population was physically inactive. Along with other risk factors, such as smoking, excessive alcohol intake, and inadequate fruit and vegetable intake, this places a large proportion of the population at risk for the above-mentioned noncommunicable diseases. Hypertension Hypertension is a major risk factor for cardiovascular disease, stroke, renal damage and heart failure. The prevalence of hypertension in the current study was found to be 20.6% for males and 12.3% for females thus placing a large proportion of the population at risk of these serious diseases. The prevalence of hypertension amongst young American Samoan males was significantly higher than that amongst females of similar age, indicating a pressing need to target this group with information about the health risks of hypertension and interventions to prevent and control it. Diabetes Diabetes is a serious condition that is a risk factor for renal failure, blindness, stroke and ischaemic heart disease. In the current survey it was found that the prevalence of diabetes was 52.3% and 42.4% for males and females, respectively. Additionally, prevalence of diabetes was more than 68% for American Samoans in the year age group. More than 23% of diabetics were not currently receiving any treatment. Together with the high prevalence of risk factors for diabetes, such as obesity and physical inactivity, in American Samoa, this data suggests that a large proportion of the population are at risk of serious diabetes-related illnesses. Cholesterol Overall, 23.4% of the study population were in the high risk category for cholesterol levels. Although the majority of the study population is clearly not in the high risk category, the proportions in the high risk category increased with age, so that in the age group, over 30% of the participants had cholesterol levels of above 200 mg/dl. When considered with other risk factors common in the older population, such as obesity, elevated blood pressure, inadequate dietary fruit and vegetable intake and physical inactivity this may indicate that this group needs special attention. 21/08/2007 Page 53 of 94

54 7. Recommendations To inform the American Samoan public about: Implementation of WHO Framework Convention on Tobacco Control (FCTC) The health risks associated with smoking and of the health benefits of smoking cessation. The adverse health effects of excessive alcohol consumption and the health benefits of decreasing alcohol consumption, particularly targeted towards younger males and females. Increasing of production and importation of fruit and vegetables The health benefits of increasing fruit and vegetable consumption and decreasing consumption of fatty foods. The contributions of overweight and obesity to chronic diseases such as type II diabetes, cardiovascular disease, stroke and some cancers. The health benefits of reducing and preventing overweight and obesity Ways of achieving weight reduction through modification of diet and physical activity. The health risks of hypertension, diabetes and cardiovascular disease and the health benefits of preventing or controlling them. Lifestyle factors contributing to hypertension, diabetes and cardiovascular disease The importance of appropriately monitoring and treating hypertension and diabetes, particularly amongst the older age groups. To develop and introduce strategies to decrease the prevalence of lifestyle risk factors including tobacco use, excessive alcohol consumption among American Samoans, including the following: Measures to prevent younger Samoans from taking up smoking Measures to encourage and support current smokers to give up smoking Measures to discourage younger Samoans from participating in binge drinking Measures to encourage current consumers of alcohol to decrease their level of alcohol consumption To develop and introduce programmes that support the prevention and control of hypertension, diabetes and cardiovascular disease, including the following: An increase in efforts to encourage healthy eating habits across all age groups by promoting the availability and consumption of greater levels of fruit and vegetables. 21/08/2007 Page 54 of 94

55 Instigating strategies that support and promote weight reduction. This should include increased access to healthy foods and options for physical activity. Increasing levels of physical activity during leisure and transportation could be targeted specifically. Ensuring that the health system adequately performs monitoring and treatment of hypertension, diabetes and cardiovascular disease 21/08/2007 Page 55 of 94

56 8 Appendix 1 - Detailed Results 8.1 Demographic Information Table Mean number of years spent in school Total Population Males Females Mean CI Mean CI Mean CI ± ± ± ± ± ± ± ± ± ± ± ± Total 12.1 ± ± ± Tobacco Use Table Current smoking status of the study population Total population Total Current Daily Smokers on-daily Smokers Smokers on Smokers % CI n % CI n % CI n % CI n Total Males Total Females Total Table Percentage of daily and non-daily smokers amongst current smokers Total Population Daily Smokers on-daily Smokers % CI % CI ± ± ± ± ± ± ± ± /08/2007 Page 56 of

57 Total 75.3 ± ± Males ± ± ± ± ± ± ± ± Total 76.8 ± ± Females ± ± ± ± ± ± ± ± Total 72.7 ± ± Table Mean age of starting smoking, for current daily smokers Total Population Males Females Mean CI Mean CI Mean CI ± ± ± ± ± ± ± ± ± ± ± ± Total 20.5 ± ± ± Table Mean number of years of smoking, for current smokers Total Population Males Females Mean CI Mean CI Mean CI Total /08/2007 Page 57 of 94

58 Table Percentage of current smokers smoking various types of cigarettes Total Population Manufactured Hand-rolled Pipes full Cigars, cheroots, cigarettes cigarettes of tobacco cigarillos Other % CI n % CI n % CI n % CI n % CI n ± ±0 0 - ±0 0 - ± ± ±0 0 - ±0 0 - ± ± ±0 0 - ±0 0 - ± ± ± ± ± Total 99.9 ± ± ± ± Males ± ±0 0 - ±0 0 - ± ± ±0 0 - ±0 0 - ± ± ±0 0 - ±0 0 - ± ± ± ± ± Total 100 ± ± ± ± Females ± ± ± ±0 19 Total 99.7 ± Table Consumption of manufactured cigarettes/day by current smokers of manufactured cigarettes Total Population Males Females Mean CI Mean CI Mean CI Total /08/2007 Page 58 of 94

59 8.3 Alcohol Consumption Table Alcohol consumption status of the study population Total population Males Females AGE Ever Consumed Ever Consumed Ever Consumed % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Table Consumers of alcohol during the past 12 months Total population Males Females AGE Current Consumers Current Consumers Current Consumers % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ±2.5 3 Total ± ± ± Table Percentage of current consumers of alcohol who binge drink* on at least one day during the past week Total population Males Females AGE Binge Drinking >=5 Drinks on One >= 4 Drinks on One Day Day % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ±0.0 0 Total ± ± ± *5 or more standard drinks per drinking day for males and 4 or more standard drinks per drinking day for females 21/08/2007 Page 59 of 94

60 Table Frequency of binge drinking amongst current consumers of alcohol Total Population Monday Tuesday Wednesday Thursday Friday Saturday Sunday % CI n % CI n % CI n % CI n % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±9.2 4 Total ± ± ± ± ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±9.7 4 Total ± ± ± ± ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.0 0 Total ± ± ± ± ± /08/2007 Page 60 of 94

61 8.4 Diet Table umber of days fruit is consumed per week Total population Males Females Mean CI Mean CI Mean CI Total Table Servings of fruit consumed per day Total population 5 or more servings < 1 serving per day* 1 serving per day 2-4 servings per day per day % CI n % CI n % CI n % CI n Total Males Total Females Total * Includes Don t eat fruit at all Table Mean number of servings of fruit consumed per week Total population Males Females Mean CI Mean CI Mean CI Total /08/2007 Page 61 of 94

62 Table umber of days vegetables are consumed per week Total population Males Females Mean CI Mean CI Mean CI Total Table Servings of vegetables consumed per day Total population 5 or more servings < 1 serving per day* 1 serving per day 2-4 servings per day per day % CI n % CI n % CI n % CI n Total Males Total Females Total * Includes Don t eat vegetables at all Table Mean number of servings of vegetables consumed per week Total population Males Females Mean CI Mean CI Mean CI Total /08/2007 Page 62 of 94

63 Table Servings of fruit & vegetables consumed per day Total population Males Females <5 servings <5 servings <5 servings % CI n % CI n % CI n Total /08/2007 Page 63 of 94

64 8.5 Physical Activity Table Percentage of the study population that is physically inactive Total population Males Females AGE Inactive Inactive Inactive % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Table Total physical activity (hours/week) by age group Total population Males Females Mean CI Mean CI Mean CI Total Table Total physical activity by domain (METminutes/week) and age group Total population Work Transport Leisure Mean CI n Mean CI n Mean CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ote: The term MET is an abbreviation for metabolic equivalent and is used to reflect the intensity of the specific PA. A MET is defined as the ratio of the associated metabolic rate for a specific activity divided by the resting metabolic rate. The resting metabolic rate is approximately 1 MET and reflects the energy cost of sitting quietly. The MET values for the three PA domains are as follows: * Moderate PA (work and leisure domain) = 4.0 METS * Vigorous PA (work and leisure domain) = 6.0 METS * Transport related walking/cycling = 3.0 METS 21/08/2007 Page 64 of 94

65 Table Levels of physical activity at work by age group Total population Inactive Moderate only* Vigorous* % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± * Moderate only: Metminutes * Vigorous: >1500 Metminutes Table Levels of physical activity during transportation by age group Total population Inactive Moderate only* Vigorous* % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± * Moderate only: Metminutes * Vigorous: >1500 Metminutes 21/08/2007 Page 65 of 94

66 Table Levels of physical activity during leisure time by age group Total population Inactive Moderate only* Vigorous* % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± * Moderate only: Metminutes * Vigorous: >1500 Metminutes Table Involvement in physical activity for less than 150 minutes per week by age group Total population Males Females Yes Yes Yes % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Obesity Table a Mean height (inches) of the study population across gender and age groups Total population Males Females Mean CI Mean CI Mean CI ± ± ± ± ± ± ± ± ± ± ± ± Total 67.5 ± ± ± /08/2007 Page 66 of 94

67 Table b Mean height (cm) of the study population across gender and age groups Total population Males Females Mean CI Mean CI Mean CI ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Table a Mean weight of the study population (pounds) of the study population across gender and age groups Total population* Maless Females* Mean CI Mean CI Mean CI ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± * Pregnant females excluded Table b Mean weight of the study population (kg) of the study population across gender and age groups Total population* Males Females* Mean CI Mean CI Mean CI Total Table Mean body mass index (kg/m 2 ) Total population* Males Females* Mean CI Mean CI Mean CI Total * Pregnant females excluded 21/08/2007 Page 67 of 94

68 Table Risk categories for body mass index (kg/m 2 ) Total Population* Underweight (<18.5) ormal weight ( ) Overweight ( ) Obese ( 30.0) % CI n % CI n % CI n % CI n Total Males Total Females* Total * Pregnant females excluded Table a Mean waist circumference (inches) of the study population across gender and age groups Total population* Males Females* Mean CI Mean CI Mean CI ± ± ± ± ± ± ± ± ± ± ± ± Total 42.1 ± ± ± * Pregnant females excluded Table b Mean waist circumference (cm) of the study population across gender and age groups Total population* Males Females* Mean CI Mean CI Mean CI Total * Pregnant females excluded 21/08/2007 Page 68 of 94

69 8.7 Blood Pressure and Hypertension Table Resting blood pressure (mmhg) Total Population Systolic Diastolic Mean CI Mean CI Total Males Total Females Total Includes persons taking medication for high blood pressure Table Diagnosis of hypertension by health worker in past 12 months Total population Males Females HT* HT* HT* % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± * HT = Hypertension or high blood pressure Table Percentage of the study population with high blood pressure receiving drug treatment Total population Males Females Yes Yes Yes % CI n % CI n % CI n Total /08/2007 Page 69 of 94

70 Table Prevalence of high blood pressure Total Population Previously Diagnosed With All Individuals OT Individuals OT Diagnosed All Previously Diagnosed Total Prevalence of High Hypertension and on Diagnosed Previously but Previously but With BP >= with Hypertension Blood Pressure Medication With BP >= 140/90 160/100 % CI n % CI n % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± ± /08/2007 Page 70 of 94

71 8.8 Blood glucose and diabetes Table Fasting status Total population Males Females Fasted Fasted Fasted % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± Step 3 participants only Table Fasting blood glucose (mg/dl) Total population Males Females Mean CI Mean CI Mean CI Total Table Diagnosis of diabetes during the past 12 months Total population Males Females Diabetes Diabetes Diabetes % CI n % CI % CI n ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± /08/2007 Page 71 of 94

72 Table Prevalence of diabetes 110 mg/dl (6.1 mmol/l) cut-off All Previously Diagnosed with Diabetes Total Population Previously Diagnosed With Diabetes and on Treatment All Individuals OT diagnosed previously but with Glucose >= 110mg/dL Total Prevalence % CI n % CI n % CI n % CI n Males ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± /08/2007 Page 72 of 94

73 Table Prevalence of diabetes 120 mg/dl (6.7 mmol/l) cut-off All Previously Diagnosed with Diabetes Previously Diagnosed With Diabetes and on Treatment Total Population All Individuals OT diagnosed previously but with Glucose >= 120 mg/dl Total Prevalence % CI n % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± Females ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± /08/2007 Page 73 of 94

74 Table a Type of blood glucose treatment for diabetes Total Population All (Drugs, Diet & Insulin Only Insulin & Drugs Diet Only Drugs Only o treatment Insulin & Diet Drugs & Diet Insulin) % CI n % CI n % CI n % CI n % CI n % CI n % CI n % CI n ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± ± ± ± ± Males ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±4.3 1 Total ± ± ± ± ± ± ± ±5.7 3 Females ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Total ± ± ± ± ± ± ± ± /08/2007 Page 74 of 94

75 Table Percentage of study participants with impaired fasting blood glucose ( mg/dl) Total Population Males Females % CI % CI % CI ± ± ± ± ± ± ± ± ± ± ± ± Total 25.7 ± ± ± Blood cholesterol Table Mean total cholesterol levels (mg/dl) Total population Males Females Mean CI Mean CI Mean CI Total Table Total blood cholesterol risk categories Total population Males Females 200 mg/dl 200 mg/dl 200 mg/dl % CI n % CI n % CI n Total Data quality indices Table umber of pregnant females Pregnant % CI n ± ± ± ±0.0 0 Total /08/2007 Page 75 of 94

76 Table umber of blood pressure measurements taken One Two Three % CI n % CI n % CI n Systolic 100 ± ± ± Diastolic 100 ± ± ± Table Out-of-range biochemistry results % Low High CI n % CI n Glucose ±0.7 4 Total cholesterol ± ±0.3 7 As indicated by laboratory diagnostic testing equipment. Percentages based on total number of persons with biochemical measures 21/08/2007 Page 76 of 94

77 9 Appendix 2 Questionnaire (English Version) Check if the following are completed (to be checked by:) Yes o Fasting status (Step 2&3 Registration Station) Checkout (Step 2&3 Check-out Station) EpiData data entry (Data entry personnel) EpiInfo data entry (Data entry personnel) Data entry irregularities (Data entry personnel) V 1 I 2 1 Identification Information: Is the respondent on the participation list for the survey? Village name: GOVERMET OF AMERICA SAMOA DEPARTMET OF HEALTH & WORLD HEALTH ORGAIZATIO The WHO STEPwise approach to Surveillance of noncommunicable diseases (STEPS) Yes, on the original list Yes, on the replacement list o (if o, then ED) I 3 Village code: (SEE OTE BELOW) I 4 Interviewer code I 5 Date of completion of the questionnaire //2004 Month Day Year Respondent ID umber Consent I 6 Consent has been read out to respondent Yes 1 o 2 If O, read consent I 7 I 8 Consent has been obtained (verbal or written) Interview Language Yes 1 o 2 If O, ED English 1 Samoan 2 I 9 Time of interview (24 hour clock) : I 10 I 11 I 12 Family ame First ame Contact phone number where possible 21/08/2007 Page 77 of 94

78 I 13 Specify whose phone Work 1 Home 2 eighbor 3 Other 4 ote: Identification information I6 to I12 should be stored separately from the questionnaire because it contains confidential information. Please note: village code is required as part of main instrument for data analyses. Date of interview is required to calculate age. Step 1 Demographic Information C1 Sex (Record Male / Female as observed ) C2 What is your date of birth? If Don t Know, See ote* below and Go to C3 C3 How old are you? Years C4 In total, how many years have you spent at school or in full-time study (excluding pre-school)? Coding Column Male 1 Female 2 Month Day Year19 Years Step 1 Behavioural Measures Tobacco Use (Section S) ow I am going to ask you some questions about various health behaviours. This includes things like smoking, drinking alcohol, eating fruits and vegetables and physical activity. Let's start with smoking. Response Coding Column S 1a Do you currently smoke any tobacco products, S 1b S 2a S 2b S 3 Yes 1 such as cigarettes, cigars or pipes? o 2 If o, go to (OTE: Currently = past 12 months) ext Section If Yes, Yes 1 If o, go to Do you currently smoke tobacco products daily? o 2 ext Section How old were you when you first started smoking (years) If Known, go daily? Don t remember to S 3 DK Do you remember how long ago it was? In Years Years OR in Months Months OR in Weeks (CODE DK FOR DO T KOW OR DO T REMEMBER) Weeks On average, how many of the following do you smoke each day? Manufactured cigarettes (RECORD FOR EACH TYPE) Hand-rolled cigarettes (CODE DK FOR DO T KOW OR DO T REMEMBER) Pipes full of tobacco Cigars, cheroots, cigarillos Other (please specify): Alcohol Consumption (Section A) The next questions ask about the consumption of alcohol. A 1a Have you ever consumed a drink that contains alcohol such as beer, wine, spirit, or fermented cider? Response Yes o Coding Column 1 2 If o, Go to 21/08/2007 Page 78 of 94

79 USE SHOWCARD or SHOW EXAMPLES A 1b Have you consumed alcohol within the past 12 months? Yes o 1 2 ext Section If o, Go to ext Section OTE: The Date of Birth (C2) or the age (C3) or both (C2 and C3) have to be filled. CODE DK FOR DO T KOW or DO T REMEMBER. Code DK for DO T KOW or DO T REMEMBER except for where answers are mandatory such as Village code, date of interview and either date of birth or age. A 2 A 3 A 4 In the past 12 months, how frequently have you had at least one drink? (READ RESPOSES) USE SHOWCARD When you drink alcohol, on average, how many drinks do you have during one day? During each of the past 7 days, how many standard drinks of any alcoholic drink did you have each day? (RECORD FOR EACH DAY USE SHOWCARD) 5 or more days a week days per week days a month 3 Less than once a month 4 umber Don t know DK Monday Tuesday Wednesday Thursday Friday Saturday Sunday Diet (Section D) The next questions ask about the fruits and vegetables that you usually eat. I have a nutrition card here that shows you some examples of local fruits and vegetables. Each picture represents the size of a serving. As you answer these questions please think of a typical week in the last year. D 1a D 1b D 2a D 2b In a typical week, on how many days do you eat fruit? USE SHOWCARD How many servings of fruit do you eat on one of those days? USE SHOWCARD In a typical week, on how many days do you eat vegetables? USE SHOWCARD How many servings of vegetables do you eat on one of those days? USE SHOWCARD umber of days umber of servings umber of days umber of servings If Zero days, go to D 2a If Zero days, go to P1 Physical Activity (Section P) ext I am going to ask you about the time you spend doing different types of physical activity. Please answer these questions even if you do not consider yourself to be an active person. Think first about the time you spend doing work. Think of work as the things that you have to do such as paid or unpaid work, household chores, harvesting food, fishing or hunting for food, seeking employment. P 1 Does your work involve mostly sitting or standing, with walking for no more than 10 minutes at a time? Yes o 1 2 If Yes, go to P6 21/08/2007 Page 79 of 94

80 P 2 Does your work involve vigorous activities, like heavy lifting, digging or construction work for at least 10 minutes at a time? Yes o 1 2 If o, go to P4 ISERT EXAMPLES & USE SHOWCARD In a typical week, on how many days do you do P 3a Days a week vigorous activities as part of your work? ote: Code DK for DO T KOW or DO T REMEMBER except for where answers are mandatory such as Village code, date of interview and either date of birth or age. P 3b On a typical day on which you do vigorous activities, how much time do you spend doing such work? In hours and minutes hrs : mins OR in Minutes only or minutes P 4 P 5a P 5b P 6 Does your work involve moderately intense activities, like brisk walking or carrying light loads for at least 10 minutes at a time? ISERT EXAMPLES & USE SHOWCARD In a typical week, on how many days do you do moderately intense activities as part of your work? On a typical day on which you did moderately intense activities, how much time do you spend doing such work? How long is your typical work day? Yes o 1 2 Days a week In hours and minutes hrs : mins OR in Minutes only or minutes umber of hours hrs Other than activities that you ve already mentioned, I would like to ask you about the way you travel to and from places. For example to work, for shopping, to market, to church etc P 7 P 8a Do you walk or use a bicycle (pedal cycle) for at least 10 minutes continuously to get to and from places? In a typical week, on how many days do you walk or bicycle for at least 10 minutes to get to and from places? Yes o Days a week If o, go to P6 1 2 If o, go to P9 How much time would you spend walking or bicycling P 8b for travel on a typical day? In hours and minutes hrs : mins OR in Minutes only or minutes The next questions ask about activities you do in your leisure time. Think about activities you do for recreation, fitness or sports. Do not include the physical activities you do at work or for travel mentioned already. P 9 P 10 P 11a P 11b P 12 Does your leisure time involve mostly sitting, reclining, or standing, with no physical activity lasting more than 10 minutes at a time? In your leisure time, do you do any vigorous activities like running or strenuous sports, weight lifting for at least 10 minutes at a time? ISERT EXAMPLES & USE SHOWCARD If Yes, In a typical week, on how many days do you do vigorous activities as part of your leisure time? How much time do you spend doing this on a typical day? In your leisure time, do you do any moderateintensity activities like brisk walking, cycling or swimming for at least 10 minutes at a time? ISERT EXAMPLES & USE SHOWCARD Yes o Yes o Days a week In hours and minutes OR in Minutes only Yes o hrs : mins or minutes 1 2 If Yes, go to P 14 If o, go to P 12 If o, go to P 14 21/08/2007 Page 80 of 94

81 P 13a If Yes In a typical week, on how many days do you do Days a week moderately intense activities as part of leisure time? P 13b How much time do you spend doing this on a typical day? In hours and minutes hrs : mins OR in Minutes only or minutes ote: Code DK for DO T KOW or DO T REMEMBER except for where answers are mandatory such as Village code, date of interview and either date of birth or age. The following question is about sitting or reclining. Think back over the past 7 days, to time spent at work, at home, in leisure, including time spent sitting at a desk, visiting friends, reading, or watching television, but do not include time spent sleeping. P 14 Over the past 7 days, how much time did you spend sitting or reclining on a typical day? In hours and minutes hrs : mins OR in Minutes only or minutes History of High Blood Pressure H 2 H 3a During the past 12 months have you been told by a doctor or other health worker that you have elevated blood pressure or hypertension? During the last 2 weeks, have you taken any drugs (medication) for high blood pressure prescribed by a doctor or other health worker? Yes o Yes o If o, skip to H7 History of Diabetes H 7 H 8 During the past 12 months, have you been told by a doctor or other health worker that you have diabetes? Yes o 1 2 Are you currently receiving any of the following treatments for diabetes prescribed by a doctor or other health worker? (OTE: Currently = past 2 weeks) H 8a Insulin Yes o H 8b Oral drug (medication that you have taken in the last 2 weeks) H 8c Special prescribed diet Yes o Yes o If o, skip to V3 Comments: Step 1 V 2 Are there any irregularities or problems with the interview? (to be answered by Interviewer) Yes o 1 2 If yes, please state the irregularities or problems in the space provided below. 21/08/2007 Page 81 of 94

82 Step 2 Physical Measurements Height and weight M 1 M 2a & 2b M 3 M 4 Technician ID Code Device IDs for height and weight Height (in Centimetres) Coding Column (1a) height (1b) weight (2a) height (2b) weight. Weight If too large for scale, use TWO scales (in Pounds). 1 2 M 5 (For women) Are you pregnant? Yes o Waist M 6 M 7 M 8 Technician ID Device ID for waist Waist circumference (in Centimetres). If Yes, go to M9 Blood pressure M 9 M 10 Technician ID Device ID for blood pressure M 11 Cuff size used Standard Large X-Large (Manual) Coding Column M 12a Reading 1 Systolic BP Systolic mmhg M 12b Diastolic BP Diastolic mmhg M 13a Reading 2 Systolic BP Systolic mmhg M 13b Diastolic BP Diastolic mmhg M 14a Reading 3 Systolic BP Systolic mmhg M 14b Diastolic BP Diastolic mmhg 21/08/2007 Page 82 of 94

83 Step 3 Biochemical Measurements Blood glucose B 1 B 2 B 3 B 4 B 5 Blood Lipids B 6 B 7 B 8 Since 10 o clock last night, have you had anything to eat or drink, other than water? Technician ID Code Device ID code Time of day blood specimen taken (24 hour clock) Blood glucose Technician ID Code Device ID code Total cholesterol Yes o Low High Unable to assess Low High Unable to assess Coding Column hrs : mins mg/dl. mg/dl. Comments: Step 2 and 3 V 3 Are there any irregularities or problems with the measurements? (to be answered by any Step 2 or 3 technician) Yes 1 o 2 If yes, please state the irregularities or problems in the space provided below. 21/08/2007 Page 83 of 94

84 10. Appendix 3 Questionnaire (Samoan Version) 21/08/2007 Page 84 of 94

85 GOVERMET OF AMERICA SAMOA DEPARTMET OF HEALTH & World Health Organization Suesuega o Faama i Le Pipisi ma Mafua aga i Samoa I 1 I 2 I 3 I 4 I 5 uu/ Alalafaga: (name) Faamatalaga o le sui auai: Ioe 1 Leai 2 uu (code): (SEE OTE BELOW) Mo Pagopago, Malaeimi, Malaeloa, Leone ma Pavaiai: Does the participant live within the area defined on the map? umera o le sui suesue Aso na mae a ai le suesuega // Aso Masina Tausaga I 6 I 7 I 8 I 9 I 10 Consent Pepa o maliega Gagana faaaogaina Taimi o le suesuega (24 hour clock) Faaiu Igoa Muamua umera a le tagata o loo suesueina Ioe 1 Leai 2 Gagana Peretania Gagana Samoa 2 : I 11 Telefoni I 12 Telefoni i le Fale faigaluega 1 Aiga 2 Tua oi 3 Se isi tagata (o ai?) 4 ote: Identification information I5 to I11 should be stored separately from the questionnaire because it contains confidential information. Please note: village code is required as part of main instrument for data analyses. Date of interview is required to calculate age. 21/08/2007 Page 85 of 94

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