Survey on Non Communicable Disease Risk Factors Maldives, 2004

Transcription

1 Survey on Non Communicable Disease Risk Factors Maldives, 24 Table of Contents EXECUTIVE SUMMARY... 2 INTRODUCTION AND BACKGROUND TO STEPS SURVEILLANCE... 9 STUDY RATIONALE... 9 STUDY OBJECTIVES... 1 SURVEY METHODS AND OPERATIONS RESULTS TABLES RESPONSE RATES DEMOGRAPHIC AND RESPONDENTS PROFILES BEHAVIOURAL MEASURES Tobacco Use Diet Physical Activity PHYSICAL MEASURES BIOCHEMICAL MEASURES IMPLICATIONS AND RECOMMENDATIONS REFERENCES APPENDICES COPY OF ACTUAL QUESTIONNAIRES (ENGLISH AND DHIVEHI) ACKNOWLEDGMENTS

2 Executive summary Introduction With the recommendation of the World Health Organisation that countries implement non communicable disease surveillance with a focus on a few major risk factors for prevention and control of non communicable diseases, the Maldives joined its member countries of the South East Asia region to carryout the STEP Survey to collect risk factor surveillance data for non communicable diseases. Limited data is available on the risk factors that contribute to non communicable diseases in the Maldives. Sporadic surveys have found out on the situation of tobacco use, nutritional status of mothers and children. Little or nothing is known about the physical activity, dietary habits and other lifestyle related behaviour that may have accounted for the increasing number of cardiovascular diseases, hypertension, diabetes and cancers in the country. Cardiovascular diseases have become the major cause of death in the adult population of the Maldives accounting for 25 3% of all deaths every year. This survey on the risk factors is a landmark study for knowing the situation among the livelihood of the people living in the capital, Male, where almost 28% of the countries population reside. The STEPs instrument developed by WHO has been utilised for the data collection and the standard generic guidelines were followed throughout the process of data collection and data processing. All the three STEPs were covered which includes data on behavioural measures, physiological and biochemical measures. Questions on alcohol consumption were omitted from the study due to the reason that it is prohibited by religion as well as its very low known use. 2

3 Summary prevalence data for behavioural measures Smoking The proportion of persons smoking daily accounted for 24.7% of the study population Percentage Daily Smokers, and who are men and women aged 25 to 64 years. Among men 35% reported currently smoking 35 1 daily; and among women 1% reported currently smoking daily. Those who smoke daily on average started to smoke at the age of 18 years (18.4 for men and 18.1 for women). The average duration of smoking is 23.7 years. Average duration of smoking for men is 24 years and for women is 15 years. Majority (73.6%) of those reported daily smoked manufactured cigarettes. Around eighty nine percent (88.6%) of men smoke manufactured cigarettes while this proportion among women is 38.6 %. The average number of manufactured cigarettes smoked per day is found to be 14 (14.8 for men and 8.3 for women). Among men the highest proportion of current daily smokers (38%) are between the ages years. Similar proportion of men years and years (35%) smoke daily. The lowest proportion of daily smokers among men is between the ages years (28%). Comparatively, women daily smokers are more among the older age groups 17% and 15% respectively of the ages years and years. The younger ages years and years are at 4% and 9% respectively. Diet People on average consumed fruits and vegetables 3.5 days and 3.4 days respectively per week. consume slightly more days than women (3.7 and 3.5 days respectively for men; 3.3 days for women). Majority of those who consumed fruits and vegetables (84%) consumed less than 5 servings per day. A serving is measured here as the amount of % Percent of persons who eats < 5 servings of fruits and vegetables per day All 3

4 content in a cup. Majority of persons reported that they eat about 1 serving of fruit per day (56% among men and 57% among women). Eighteen percent (18%) of men and 22% of women eat less than 1 serving or do not eat fruit at all. Those who consume less than 1 serving of vegetables per day or do not eat at all are 13.5% among men and 16.2% among women. One serving of vegetables per day is eaten by 59% men and 6% women. Almost none eat fruits and vegetables of more than 5 servings a day. Majority eat meals prepared at home - 99% women and 83% men. Physical Activity Ninety one percent (91%) men and 95% women reported physically inactive at work. Only 6% men and 4% women reported moderate activity at work. A mere 3% of men and 1% of women are vigorously active at work. Summary prevalence data for physical measures BMI The average weight of persons aged 25 to 64 years BMI(kg/m 2 ) - and is 61kg. The average weight of men and women separately are 64.5kg and % kg respectively. The < >=4 average body mass index is 25.2kg/m 2 (24.5kg/m 2 for men and 25.8kg/m 2 for women). About half of the men (54%) have normal body mass index (between 18.5 and 24.9kg/m 2 ). The proportion of women (excluding pregnant women) who have BMI in this normal range is 43%. The proportion of men and women who have BMI less than 18kg/m 2 are 5.3% and 4.8% respectively. More women than men have BMI above the normal range. The total proportion who are obese (>=3kg/m 2 ) is 13.4%. Obesity is twice higher in women than men 8.7% among men and 17.4% among women. Percent of persons who 4

5 are overweight (>=25kg/m 2 ) is 46.7%, with 4.6% of men and 51.9% of women. Proportions of men and women who are grade 1 overweight (BMI between 25 and 29.9 kg/m 2 ) are 31.9% and 34.3% respectively. Grade 2 overweight (BMI between 3 and 39.9 kg/m 2 ) proportions are 8.2% men and 16.7% women. Those who have BMI 4kg/m 2 or higher (Grade 3 overweight) are.5% men and 1.2% women. Persons with normal BMI decreases with age in both men and women while those with BMI higher BMI increases with age. The percentage who are underweight (BMI lower than 18.5kg/m 2 ) is 5% - 5.2% among men and 4.8% among women. Lower BMI (lower than the normal range) is more prevalent among younger persons 9.9% for men and 7.7% for women of age years. Risk categories for body mass index (kg/m 2 ): and Age Underweight Normal weight Grade 1 Grade 2 Grade 3 (<18.5) ( ) overweight overweight overweight (%) (%) ( ) ( ) ( 4.) (%) (%) (%) Waist (/Hip) The average waist girth is 84.9cm 85.1 for men and 84.7cm. The mean waist circumference increases with age with very slight differences between men and women. The mean waist circumference (cm) Age 5

6 Blood Pressure The average systolic blood pressure is Proportion of men and women confirmed or newly diagnosed of hypertension last 12 mmhg and the average diastolic blood months pressure is 78.3mmHg. For men this 25 2 measure is 127.5mmHg and 78.4mmHg. For 15 1 women, the average systolic pressure is age 125.7mmHg and diastolic is 78.2mmHg. The proportion of people with high BP(SBP>=14 and/or DBP>=9mmHg) is 26.5% with no difference between men and women. Among men 9.5% reported having confirmed or newly diagnosed of hypertension in the past 12 months. Among women the proportion reporting new diagnosis or confirmation of hypertension is 11.5%. Proportion of persons diagnosed of hypertension increases with age and is highest among the older ages. Altogether, 71% of men and 69% of women had their blood pressure measured within the last 12 months. The older the person, it is more likely that blood pressure is measured within the last year. Mean SBP (mmhg) percentage Age Specific Rates of Systolic Blood Pressure, and Age Summary prevalence data for biochemical measures Fasting Blood Glucose The average fasting blood glucose level is found to be 92.2 mg/dl (92.8 for men and 91.8 for women). Blood glucose levels of 7% men and women participants show diabetes (blood glucose Blood glucose levels, men and women (%) % persons Normal Ins. resistance Diabetics Glucose level 6

7 levels >121 mg/dl. Tweleve percent (12%) of years and 21% of year old men are diabetic. Among women diabetics in these ages are 8.2% and 15.6% respectively. More than 2 percent (2.5%) men and over 3% women have their blood glucose levels at insulin resistanct diabetes (11 12 mg/dl). Seventy one percent(71%) of both men and women reported that their blood glucose was measured in the last 12 months. Younger persons than older are more likely to have blood glucose levels measured in the last 12 months. Proportion of persons measured their blood sugar within last 12 month s % Age Total cholesterol The average total Mean Mean Mean cholesterol levels of total cholesterol level tryglycerides level hdl cholesterol level Age both men and women are around 5mmol/L The fasting tryglyceride levels are at 1.4mmol/L for men and 1.2mmol/L for women. The Percent of persons in total cholesterol risk fasting hdl cholesterol levels are at (>=5.2mmol/L), and 1 1.1mmol/L for men and 1.3mmol/L for women. 8 6 More than half of the respondents have cholesterol levels higher than 5.2mmol/L 4 2 which is considered as the cholesterol risk category. For men, 55.2% belong in this category. For women, 58.4% belong in this category. Older women than older men are found to be under cholesterol risk. Percent(%) Age 7

8 Opportunities for intervention and action The risk factor indicators found from the survey open up new opportunities for intervention to prevent the incidence of non communicable diseases at both individual/societal level and at the level of public health programmes. The situation of tobacco use, high levels of physical inactivity, low consumption of fruits and vegetables, prevalence of obesity and excess body fat are important prevention areas that can be easily striken with concerted effort for increasing awareness for health conciousness and self action for improved health. All the above risk factors together lead to conditions of cardiovascular diseases, hypertension, stroke, cancer and diabetes. The two major areas that need priority attention is physical inactivity and low fruit and vegetable intake. The population of Male, due to the nature and type of work available for people to engage in, a sedentary life style is undoubtedly unavoidable. Most people, due to the high cost of living carry out part time and odd but inactive jobs to earn for life. Most are commercial retail work or desk work that hardly involve physical movement. Physical activity is low also because, despite the short distances to travel on land, almost every one prefers a vehicle for mobility. As this is the persistant condition for almost all of the Male residents, people hardly can meet the the adult minimum requirement of 15 minutes per week of physical activity. Low intake of fruits and vegetables in the diet also have necessary implication that availability and accessibility reflect use. As many families are large, considering the cost of the fruits and vegetables that are available, it is difficult for many families to purchase and eat fruits and vegetables to the amount they need to consume or like to consume. Therefore, in addition to health promotion and awareness creation for behaviour change, these two areas specifically require policy development and change in things such as creating environments for physical recreation in the workplace and legislative action on the removal of import tax on fruits and vegetables. 8

9 Introduction and background to STEPS surveillance Surveillance is essential for control and prevention of diseases. Unlike communicable diseases non communicable diseases have a relatively long timeframe between exposure to causal agent and disease, making it extremely difficult to carryout monitoring and surveillance of chronic diseases such as heart disease stroke and cancer. Due to these limitations, the WHO developed the framework for risk factor surveillance giving focus on the major modifiable risk factors. They are selected for surveillance because they are among the leading causes of the disease burden and relatively easy to measure in population(who, 22). The framework for surveillance which uses a STEPwise approach, therefore advocates for small amount of good quality data, emphasising on the benefit of monitoring a few modifiable NCD risk factors that reflect the larger part of future NCD burden. Study Rationale The Republic of Maldives, during recent few decades has been experiencing rapid social and economic development. The country s population growth has been declining steadily through the period. The national population and housing census conducted every 5 years in the country shows that the growth rate declined from as high as 3% per annum in 199 to as low as 1.9% per annum in 2. The country s population which currently stands at a total of 27,11 (Census 2), characterise a young age structure. With success achieved in the control of communicable diseases, the life expectancy of the people has increased from around 48 in the 198s to the present level of around 7 years. Coupled with these changes in demography, social and economic development, the country is also experiencing a period of morbidity transition from communicable to non communicable diseases. Non communicable diseases such as diseases of the circulatory system, cancers and diabetes have emerged as major health concerns for the Maldives. Cardiovascular diseases are highest among all the NCDs and they account for more than a third of all mortality in the country. With the increasing trend in the morbidity of chronic non communicable diseases, the country s resources for health care are over 9

10 burdened. Strategic action need to be taken to implement effective prevention programmes to control and reduce the incidences of non communicable diseases. In order to take effective prevention measures, identification of the risk factors is an essential prerequisite. Little is known about the prevalence of the risk factors. A study conducted on tobacco use in 1997 and 21 reveals that the risk of tobacco consumption is high among the adult population. There is no data available on the dietary habits, physical activity and other life-style associated factors. With the development in the service sectors, and with the improvement in the quality of life of the people, more and more people are seen to fall into a largely sedentary lifestyle. It is with these concerns, that an assessment of risk factors is given priority attention. The STEPs Approach on NCD risk factor surveillance is considered an efficient tool to be used for assessing the risk factor situation in the country. Male, the capital city is chosen for the study area instead of the whole country mainly due to the limitation on the resources available for the study. The high cost of transportation between the islands raises the cost of the study many folds. The study, when conducted in Male has the valid reasons that it consists of almost 28% of the total population of the country. The results of the analysis of data will be used to build capacity for NCD surveillance activities through out the country. Study Objectives The overall objective of the STEPs survey is to identify the major risk factors of noncommunicable diseases among the population living in Male. Specific objectives are: Assess the prevalence of behavioural factors that contribute to non communicable diseases Assess the prevalence of physiological factors that contribute to noncommunicable diseases. Assess the prevalence of bio-chemical factors that contribute to non communicable diseases. 1

11 Survey Methods and Operations Study population and exclusions The study population was persons aged 25 to 64 years, both men and women living in the capital, Male. The following exclusion criteria were used in recruiting participants: - those who refuse to participate - disabled persons - those who consented but failed to be met at appointment times after 3 consecutive attempts in 3 consecutive days - those who agree to participate only in Step 1 Sampling design The sampling method used for selecting the sample was systematic random sampling from a given list of sampling units, the households. Household was considered as the primary sampling unit. Household listing of the 4 different wards of Male, Henveiru, Galolhu, Machchangolhi, and Maafannu, from the Census 2 was the sampling frame used for selecting households. Households from each ward were systematically selected from the listing of each ward, and selection was based on population proportionate to size. In order to make a more distributed sample, the criterion of 1 person from 1 household was used for selection of participants. One person one household criterion was followed to select equal proportions of men and women participants as well as equal number of persons from each of the 1 years age groups (25 34), (35 44), (45 54), and (55 64) years in both men and women. However, the above sampling criteria were not met completely for men and women due to men usually not available at home during the survey hours. Meeting the requirement of equal numbers of participants in different age groups was also found to be difficult. There are fewer persons available in the older age groups than the younger age groups. Sample size A sample size of 2 respondents was selected based on the recommendation by the STEPS survey guideline of WHO as an adequate sample for making age and sex 11

12 comparisons. The 2 sample of respondents is distributed among 25 persons of each of the four 1 year age groups of men and women aged years. The 1 person 1 household selection criterion made selection of households to exceed the 2 household requirement because persons of the needed age group or the sex were not available. The survey teams followed participant selection guideline to recruit equal number of participants in each age group and each sex in a given time. Thus an approximate total of 4 households were approached by the teams in order to obtain the total of 2 participants. Survey dates 1. The pilot test of the survey questionnaire for STEP1 and STEP2 was carried out during end of 23, through a consultancy assignment of WHO Consultant Dr. Anand (member of the RSSG for STEPS Surveillance in SEAR). 2. The generic STEPs instruments developed by WHO was translated and adapted for the country situation by the Principal Investigator and the staff of the Health Information and Research Section, Ministry of Health during January February 24. The translated questionnaire was pre-tested for its use for the survey and was printed in March Training for field data collection enumerators and technical or clinical workers for STEPS 2 and STEPS 3 was conducted during the later part of March The field data collection was carried out from 1 April 24 till 3 October 24. Data collection was continued until the required number of participants was obtained. Training for enumerators was also carried out 3 times during the data collection period as new enumerators were recruited due to the discontinuation of some enumerators who were unable to continue for the lengthened duration of the data collection time. 12

13 Methods of data collection Data collection on all the 3 steps of STEPs instrument was done by visiting households or the place of respondent s convenience. STEP 1: Enumerator teams select and conduct interview for STEP 1 questionnaire, set appointment times for the data collection teams STEP 2 &STEP 3: the clinical workers (nurses teams) visit respondent s place at the times appointed for taking physical measurements and collecting blood samples. Biochemical investigation at the biochemical laboratory of Indhira Gandhi Memorial Hospital (IGMH): The biochemical investigations of the blood samples were carried out using the standard procedures at the hospital laboratory Staff, training and pilot survey A 5-day training session was conducted for enumerators. Training was provided on various aspects of survey data collection and specific to data collection of the survey. Training included details for consistency of selecting respondents, consistency in questioning and questioning techniques, respondent s rights and conveniences, and on various other ethical considerations. They were also informed with the details of the purpose and objectives of the study. Importance was also given on the administrative procedures, maintenance and updating of participant logs for obtaining the relevant and required number of participants as well as on the selection of households and specific details of selecting the respondents. Every team of enumerators was allocated one supervisor who participated in all the trainings and was given additional responsibility of managing the administrative arrangements of the data collection, including maintenance of log books for participant selection and requirements. Implementation of STEP 2 and 3 were contracted out to the NGO, Diabetics and Cancer Society of Maldives (DSCM). The DCSM carries out screening and information services for patients as their routine work. Thus, the involvement of the NGO was considered a a strong technical input. The physical measurements required for STEP 2 and blood 13

14 collection for the STEP 3 biochemical investigations were taken by the trained nursing staff employed by the DCSM. The nurses were given training for the specific implementation of the STEPS survey including the specific guidelines of the STEPS instruments for taking the physiological measurements and the use of equipment. In addition specific administrative arrangements and protocols were laid for them to follow in line with the pace of data collection by enumerator teams. Ethical Approval of survey The survey proposal and the STEPS survey protocol were passed on to the Health Research Committee for review and approval. The Committee approved the implementation of the survey with few amendments. The participants of the survey were explained of the aim and the process of the survey and their written informed consent was obtained for participation in each of the three components of the STEPS survey STEPS 1, STEPS 2, and STEPS 3. Only consenting persons were chosen to be interviewed and other measurements taken. Questionnaire, language (and translation) The STEPS instrument was adapted for the survey. Apart from a few deletions as per adjusting to the country context, the generic questionnaire was used for data collection. The same question codes were used. Except for the section on alcohol consumption, the entire STEPs instrument was used including both the core and expanded questions. The questionnaire was translated into the local language, Dhivehi for use by local data collection. Physical measurements and equipment used The physical measurements taken for assessment were height, weight, waist circumference, and blood pressure. The hip circumference was omitted for the reason it is inappropriate to take measurements in the venue of household. The measurements are taken using the standard equipment provided by WHO for the implementation of the 14

15 STEPS survey. The clinical data collection personnel were given specific training for use of this equipment. Processing and analysis of biochemical measures Blood samples for biochemical measurements were collected at the household and were sent to the laboratory for processing within 2 hours of collection. The biochemical analysis for blood glucose and lipid profile was conducted at the laboratory using the standard routine procedures of wet chemistry. The questionnaires with the ID information and matching ID information marked on the collected blood sample is handed over to the responsible staff at the laboratory by the sample collecting personnel of the DCSM at the end of the data collection time every day. The results of the analysis were filled in the relevant spaces in the questionnaire by the lab technicians, who then pass the filled questionnaires to the survey administration section, Health Information Research Section at the Ministry of Health. Reporting of results to participants At the site of the data/blood collection, the participants are given a slip to be produced at the laboratory if they chose or wish to obtain the results of the analysis. Thus reporting of results was given a voluntary approach. However, if the results of the analysis were found to be abnormal, the laboratory informs the sample collection personnel who then inform the respective participant to seek medical advice. The decision that reporting of abnormal results to be done by the sample collection staff was taken with the consideration that participants feel more at ease when they hear the results from the same personnel who provided pre-sample counselling. Processing of questionnaires The processing of questionnaires, data entry, and data cleaning were carried out by the staff at the Health Information Research Section, Ministry of Health under the guidance of the principal investigator. Data entry was done using the Epi Info Programme. Double entry of data was done on 25% of the questionnaires. The data was then transferred to SPSS for further processing and data cleaning. 15

16 Data Analysis Data analysis of the survey was done by the WHO consultant, Dr. RM Pandey (member of RSSG) on his consultancy visit to Maldives during June 25. Further cleaning of data was done before data analysis. The Statistical Package, STATA was used for the data analysis. 16

17 Results Tables Response Rates Table 1.1 Step 1 response percentages: and Age Participated Participated n % n % Table 1.2 Step 2 response percentages: and Age Participated Participated n % n % Table 1.3 Step 3 response percentages: and Age Participated Participated n % n %

18 Demographic and respondents profiles Table 1.4 Years spent in school: and Age N Mean N Mean Table Highest level of education: Age No Basic Primary Secondary Higher University Post grad Others education literacy Secondary n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) (1.3) 2(6.85) 9(3.82) 121(41.44) 33(11.3) 17(5.82) 7(2.4) 1(.34) (3.17) 73(25.7) 92(32.39) 67(23.59) 17(5.99) 18(6.34) 7(2.46) 1(.34) (3.56) 86(38.22) 72(31.56) 43(19.11) 8(3.56) 2(.89) 7(3.11) (.) (5.3) 72(54.55) 27(2.45) 18(13.64) 3(2.27) 3(2.27) 2(1.52) (.) (2.89) 251(26.9) 28(3.1) 249(26.69) 61(6.54) 4(4.29) 23(2.47) 2(.22) Table Highest level of education: Age No Basic Primary Secondary Higher University Post grad education literacy Secondary n (%) n (%) n (%) n (%) n (%) n (%) n (%) (3.22) 43(13.83) 118(37.94) 112(36.1) 14(4.5) 12(3.86) 2(.64) (.93) 125(38.94) 13(4.5) 5(15.58) 8(2.49) 3(.93) 2(.62) (2.49) 177(62.99) 72(25.62) 19(6.76) 1(.36) 2(.71) 3(1.7) (2.23) 132(73.74) 33(18.44) 8(4.47) 1(.56) 1(.56) (.) (2.2) 477(43.68) 353(32.33) 189(17.31) 24(2.2) 18(1.65) 7(.64) 18

19 Table Main employment: Employment Categories Age n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) (46.92) (38.38) (36.) (39.39) (4.62) 84 (28.77) 82 (28.87) 46 (2.44) 19 (14.39) 231 (24.76) 56 (19.18) 82 (28.87) 75 (33.33) 33 (25.) 246 (26.37) () 1 (.35) 1 (.44) (.) 2 (.21) 3 (1.3) (.) 1 (.44) (.) 4 (.43) 4 (1.37) 8 (2.82) 9 (4.) 11 (8.33) 32 (3.43) (.) (.) 2 (.89) 3 (2.27) 5 (.54) 7 (2.4) 2 (.7) 3 (1.33) 3 (2.27) 15 (1.61) 1 (.34) (.) 7 (3.11) 11 (8.33) 19 (2.4) 1=Government employee, 2=Non-government employee, 3=Self-employed, 4=Non-paid, 5=Student, 6=Homemaker, 7=Retired, 8=Unemployed (able to work), 9=Unemployed (unable to work) Table Main employment: Employment Categories Age n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) (29.29) (19.31) (11.3) (11.24) (18.7) 32 (1.29) 13 (4.5) 7 (2.49) 4 (2.25) 56 (5.13) 32 (1.29) 29 (9.3) 3 (1.68) 9 (5.6) 1 (9.17) (.) 1 (.31) 2 (.71) (.) 3 (.27) 2 (.64) (.) 3 (1.7) (.) 5 (.46) 153 (49.2) 29 (65.11) 23 (72.24) 137 (76.97) 72 (64.34) (.) (.) (.) (.) (.) (.) 2 (.62) 1 (.36) (.) 3 (.27) 1=Government employee, 2=Non-government employee, 3=Self-employed, 4=Non-paid, 5=Student, 6=Homemaker, 7=Retired, 8=Unemployed (able to work), 9=Unemployed (unable to work) 1 (.32) 5 (1.56) 4 (1.42) 8 ( (1.65) 19

20 Table 1.6 Number of persons more than 18 years in household Age N Mean N Mean Table 1.7 Reported household earnings (MRf): and Age N Mean N Mean Table Estimated household earnings(mrf): < , - > =15 <5 <1, <15, Age n (%) n(%) n(%) n (%) n (%) (.42) 6(25.32) 61(25.74) 6(25.32) 55(23.21) (.48) 57(27.54) 78(37.68) 38(18.36) 33(15.94) (.) 54(3.51) 65(36.72) 25(14.12) 33(18.64) (.92) 32(29.36) 35(32.11) ) 21(19.24) (.41) 23(27.81) 239(32.74) 143(19.59) 142(19.45) Table Estimated household earnings(mrf): <1 1 <5 5-1, 1, -<15, > =15 Age n (%) n(%) n(%) n (%) n (%) (.82) 67(27.35) 96(39.18) 46(18.78) 34(13.88) (.4) 74(29.48) 96(38.25) 44(17.53) 36(14.34) (1.23) 72(29.63) 89(36.63) 47(19.34) 32(13.17) (2.) 38(25.33) 55(36.67) 34(22.67) 2(13.33) (1.1) 251(28.23) 336(37.8) 171(19.24) 122(13.72) 2

21 Behavioural measures Tobacco Use Table Current smoking status: Age Daily smokers Non-daily Smokers Non-smokers N n (%) n (%) n (%) (35.27) 13(4.45) 176(6.27) (39.79) 9(3.17) 162(57.4) (35.56) 5(2.22) 14(62.22) (27.82) 4(3.1) 92(69.17) (35.65) 31(3.32) 57(61.3) Table Current smoking status: Age Daily Smokers Non-daily Smokers Non-smokers N n (%) n (%) n (%) (3.54) 4(1.29) 296(95.18) (9.35) 7(2.18) 284(88.47) (14.59) 11(3.91) 229(81.49) (17.32) 2(1.12) 146(81.56) (1.35) 24(2.2) 955(87.45) Table 2.2 Age started smoking, for current smokers: and Age N Mean N Mean

22 Table 2.3 Years of smoking, for current smokers: and Age N Mean N Mean Table Percentage smoking various types of cigarettes, for current smokers: Age Manufactured Hand-rolled Pipes full of Cigars, Other cigarettes cigarettes tobacco cheroots, cigarillos n (%) n (%) n (%) n (%) n (%) (31.9) (34.7) 2 (4) (23.5) 1 (2) 1 (1) 1 (1) (9.9) 2 (4) (1) 5 (1) 1 (1) 1 (1) Table Percentage smoking various types of cigarettes, for current smokers: Age Manufactured Hand-rolled Pipes full of Cigars Other cigarettes cigarettes (bidi) tobacco n (%) n (%) n (%) n (%) n (%) (13.) (34.8) (37) 1 (25) (15.2) 3 (75) 1 (1) (1) 4 (1) () 1 (1) 22

23 Table Consumption of manufactured cigarettes/day, for current smokers of manufactured cigarettes: and Age N Mean N Mean Table Smoking status: Age Current Current Ex-daily Never Daily Non-daily n (%) n (%) n (%) n (%) (34.9) 9(3.1) 5(1.7) 176(6.3) (38.4) 4(1.4) 9(3.2) 162(57.) (35.1) 3(1.3) 3(1.3) 14(62.2) (27.8) 2(1.5) 2(1.5) 92(69.2) (35.) 18(1.9) 19(2.) 57(61.) Table Smoking status: Age Current Current Ex-daily Never Daily Non-daily n (%) n (%) n (%) n (%) (3.2) 2(.6) 3(1.) 296(95.2) (9.) 5(1.6) 3(.9) 284(88.5) (14.6) 9(3.2) 2(.7) 229(81.5) (16.8) (.) 3(1.7) 146(81.5) (1.1) 16(1.5) 11(1.) 955(87.4) 23

24 Table Types of smokeless tobacco used, for current smokers: Oral Snuff Nasal Snuff Chewing Betel n n n n Table Types of smokeless tobacco used, for current smokers: Oral Snuff Nasal snuff Chewing Betel n n n n

25 Diet Table 3.1 Number of days fruit is consumed per Week: and Age N Mean N Mean Table Servings of fruit consumed per day: Age N < 1 serving per day* 1 serving per day 2-4 servings per day 5 or more servings per day n (%) n (%) n (%) n (%) (18.8) 167(57.2) 64(21.9) 6(2.1) (17.6) 153(53.9) 78(27.5) 3(1.) (12.4) 141(62.7) 55(24.4) 1(.5) (25.6) 66(49.6) 32(24.1) 1(.7) (17.9) 527(56.4) 229(24.5) 11(1.2) * Includes Don t eat fruit at all Table Servings of fruit consumed per day: Age N < 1 serving per day* 1 serving per day 2-4 servings per day 5 or more servings per day n (%) n (%) n (%) n (%) (19.3) 183(58.8) 66(21.2) 2(.6) (16.8) 189(58.9) 76(23.7) 2(.6) (29.5) 149(53.1) ) 2(.7) (26.8) 11(56.4) 29(16.2) 1(.6) (22.4) 622(57.) 218(2.) 7(.6) * Includes Don t eat fruit at all 25

26 Table 3.3 Number of days vegetables are consumed per week: and Age N Mean N Mean Table Servings of vegetables consumed per day: Age N < 1 serving per day* 1 serving per day 2-4 servings per day 5 or more servings per day n (%) n (%) n (%) n (%) (14.7) 167(57.2) 81(27.6) 1(.3) (13.) 161(56.7) 85(29.9) 1(.4) (1.2) 142(63.1) 59(26.2) 1(.5) (17.3) 8(6.2) 29(21.8) 1(.7) (13.5) 55(58.9) 254(27.2) 4(.4) * Includes Don t eat vegetables at all Table Servings of vegetables consumed per day: Age n < 1 serving per day* 1 serving per day 2-4 servings per day 5 or more servings per day n (%) n (%) n (%) n (%) (13.2) 187(6.1) 82(26.4) 1(.3) (16.2) 196(61.1) 73(22.7) () (17.8) 169(6.1) 61(21.7) 1(.4) (19.) 15(58.7) 39(21.8) 1(.5) (16.2) 657(6.2) 255(23.3) 3(.3) * Includes Don t eat vegetables at all 26

27 Table 3.5 Servings of fruit & vegetables consumed per day: and Age N <5 >=5 N <5 >= (84.3) 46(15.7) (85.9) 44(14.1) (85.9) 4(14.1) (83.5) 53(16.5) (89.3) 24(1.7) (81.1) 53(18.9) (81.2) 25(18.8) (8.5) 35(19.5) (85.6) 135(14.4) (83.1) 185(16.9) Table 3.6 Subject prepares meals: and Age N n (%) N n (%) (8.1) (98.7) (79.9) (1) (87.1) (98.9) (91.7) (97.8) (83.4) (99) Table Type of oil or fat used, if subject prepares meals: Age N n (%) n (%) n (%) n (%) n (%) n (%) (79.5) 1(.4) () 12(5.1) 35(15.) () (83.7) () 1(.4) 14(6.2) 2(8.8) 2(.9) (74.) () () 23(11.7) 23(11.7) 5(2.6) (85.3) 1(.8) () 6(4.9) 1(8.2) 1(.8) (8.2) 2(.3) 1(.1) 55(7.1) 88(11.3) 8(1.) 1=vegetable oil, 2= butter or ghee, 3= margarine, 4=other, 5=none in particular, 6=none used 27

28 Table Type of oil or fat used, if subject prepares meals: Age N n (%) n (%) n (%) n (%) n (%) (8.8) 2(.6) 19(6.2) 38(12.4) () (79.1) 3(.9) 18(5.6) 46(14.3) () (77.7) 1(.4) 14(5.) 41(14.7) 6(2.2) (81.2) () 1(5.7) 2(11.4) 3(1.7) (79.6) 6(.6) 61(5.6) 145(13.4) 9(.8) 1=vegetable oil, 2= butter or ghee, 3= margarine, 4=other, 5=none in particular, 6=none used Physical Activity Table 4.1 Levels of physical activity at work: and Age Inactive Moderate Vigorous Inactive Moderate Vigorous only only n (%) n (%) n (%) n (%) n (%) n (%) (92.4) 18(75.) 6(25.) 297(96.1) 13(92.9) 3(23.1) (93.3) 12(6.) 1(5.) 299(93.4) 16(84.2) 6(31.6) (89.6) 14(6.9) 9(39.1) 268(96.4) 6(75.) 2(25.) (86.5) 9(56.3) 2(12.5) 16(91.4) 6(46.3) 3(23.) (91.2) 53(63.9) 27(32.5) 124(94.6) 41(75.9) 14(26.4) 28

29 Physical Measures Blood Pressure Table 5.1 Time elapsed since most recent blood pressure measurement: and Age N <12 Months 1-5 Years Never in last 5 years N <12 Months 1-5 Years Never in last 5 years n (%) n (%) n (%) n (%) n (%) n (%) (64.9) 68(23.4) 34(11.7) (58.5) 95(3.6) 34(1.9) (69.5) 6(21.3) 26(9.2) (66.9) 69(21.6) 37(11.5) (74.7) 39(17.3) 18(8.) (74.7) 55(19.6) 16(5.7) (8.5) 24(18.) 2(1.5) (8.4) 27(15.1) 8(4.5) (7.9) 191(2.5) 8(8.6) (68.7) 246(22.6) 95(8.7) Table 5.2 Confirmed or new diagnosis of hypertension by health worker in past 12 Months: and Age N HTN* N HTN n (%) n (%) (2.1) 37 5(1.6) (6.) 316 3(9.5) (15.3) (16.1) (22.7) (24.7) (9.5) (11.5) * HTN = Hypertension or high blood pressure Table Type of blood pressure treatment for hypertension: Age drugs diet weight smoking exercise n (%) n (%) n (%) n (%) n (%) (14.3) 4(66.7) 3(5.) 2(33.3) 2(33.3) (4.) 5(33.3) 5(66.7) 5(35.7) 8(53.3) (75.8) 13(4.6) 17(53.1) 12(4.) 18(56.3) (85.2) 1(37.) 15(55.6) 6(22.2) 17(63.) (67.1) 32(4.) 4(5.) 25(32.5) 45(56.3) Hypertensives only 29

30 Table Type of blood pressure treatment for hypertension: Age drugs diet weight smoking exercise n (%) n (%) n (%) n (%) n (%) (2.) 1(25.) 2(5.) 1(25.) () (62.1) 16(55.2) 13(44.8) 3(1.3) 18(62.1) (67.4) 23(51.1) 29(64.4) 2(4.8) 29(64.4) (8.) 21(47.7) 25(55.6) 2(4.9) 21(46.7) (68.8) 61(5.) 69(56.1) 8(6.9) 68(55.3) Hypertensives only Table 5.4 Currently on anti-hypertensive treatment with drugs prescribed by a health professional: and Age N n (%) N n (%) (9.2) 36 51(16.7) (12.4) (18.5) (26.9) (35.1) (5.8) (49.2) (2.4) (27.4) Table Resting blood pressure (mmhg): Systolic Diastolic Age N Mean N Mean Includes persons taking medication for high blood pressure Table Resting blood pressure (mmhg): Systolic Diastolic Age N Mean N Mean Includes persons taking medication for high blood pressure 3

31 Table Resting blood pressure (mmhg): (Reading 2) Systolic Diastolic Age N Mean N Mean Excludes persons taking medication for high blood pressure Table Resting blood pressure (mmhg): (Reading 2) Systolic Diastolic Age N Mean N Mean Excludes persons taking medication for high blood pressure BMI Table 6.1 Height (m): and Age N Mean N Mean Table 6.2 Weight (kg): and * Age N Mean N Mean * Pregnant females excluded 31

32 Table 6.3 Body mass index (kg/m 2 ): and * Age N Mean N Mean * Pregnant females excluded Table Risk categories for body mass index (kg/m 2 ): Age N Underweight (<18.5) Normal weight ( ) Grade 1 overweight ( ) Grade 2 overweight ( ) Grade 3 overweight ( 4.) n (%) n (%) n (%) n (%) n (%) (9.9) 171(58.6) 76(26.) 14(4.8) 2(.7) (3.5) 153(53.9) 98(34.5) 23(8.1) () (2.2) 123(54.7) 75(33.3) 22(9.8) () (3.8) 58(43.6) 49(36.8) 18(13.5) 3(2.3) (5.3) 55(54.1) 298(31.9) 77(8.2) 5(.5) Table Risk categories for body mass index (kg/m 2 ): * Age N Underweight (<18.5) Normal weight ( ) Grade 1 overweight ( ) Grade 2 overweight ( ) Grade 3 overweight ( 4.) n (%) n (%) n (%) n (%) n (%) (7.7) 167(53.7) 88(28.3) 26(8.4) 6(1.9) (3.1) 134(41.7) 113(35.2) 58(18.1) 6(1.9) (4.3) 15(37.4) 95(33.8) 69(24.6) () (3.4) 64(35.8) 79(44.1) 29(16.2) 1(.6) (4.8) 47(43.) 375(34.3) 182(16.7) 13(1.2) * Pregnant females excluded 32

33 Table 6.5 Waist circumference (cm): and * Age N Mean N Mean * Pregnant females excluded Biochemical Measures Table 7.1 Fasting status: and Age N Fasted n (%) N Fasted n (%) (79.1) (74.9) (76.) (82.9) (79.6) (74.) (69.9) (75.4) (77.) (77.1) Step 3 participants only (N is those who took part in Step2 percentage as per participants of Step 2) Table Diabetes: Blood glucose level (mg/dl)- Age N 1 Normal 2 Ins. resistance 3 Diabetics n (%) n (%) n (%) (98.3) 2(.9) 2(.9) (94.4) 4(1.9) 8(3.7) (82.6) 1(5.6) 21(11.8) (76.3) 2(2.2) 2(21.5) (9.4) 18(2.5) 51(7.1) 1:Normal = 37-19; 2: Ins resistance = 11-12; 3: Diabetics = >121 33

34 Table Diabetes: Blood glucose level (mg/dl) - Age N 1 Normal 2 Ins. resistance 3 Diabetics n (%) n (%) n (%) (94.8) 7(3.) 5(2.2) (91.7) 8(3.) 14(5.3) (88.) 8(3.9) 17(8.2) (79.3) 7(5.2) 21(15.6) (89.6) 3(3.6) 57(6.8) Table 7.3 Fasting blood glucose (mg/dl): and Age N Mean N Mean Table 7.4 Total cholesterol (mmol/l): and Age N Mean N Mean

35 Table 7.5 Total cholesterol risk categories: and Age N Elevated ( 5.2 mmol/l) N Elevated ( 5.2 mmol/l) n (%) n (%) (42.9) (46.8) (61.6) (54.) (58.7) (62.3) (64.5) (8.7) (55.2) (58.4) Table 7.6 Fasting triglycerides (mmol/l): and Age N Mean N Mean Table 7.7 Fasting HDL cholesterol (mmol/l): and Age N Mean n Mean

36 Table 7.8 Fasting HDL cholesterol risk categories: and Age N Low (.9 mmol/l) N Low (.9 mmol/l) n (%) n (%) (43.) 23 44(19.1) (38.7) 26 56(21.5) (4.7) 27 46(22.2) (38.7) (15.7) (4.6) (2.1) 36

37 Implications and Recommendations Opportunities and needs for action In its efforts to control and Risk factors, health indicators, and their associated health conditions prevent the overwhelming Key Risk Factor Indicator Condition growth of non Tobacco use Proportion of adults smoking cigarettes daily Cancer, cardiovascular diseases communicable diseases in Physical Inactivity Proportion of adults meeting recommended Cardiovascular diseases, cancer, diabetes levels of activity the world, the WHO focuses Diet Proportion of adults Cancer, obesity, on the major risk factors eating less than 5 cardiovascular diseases servings a day Excess Body Fat Proportion of adults Obesity, Cardiovascular overweight disease, diabetes, that contribute to the hypertension, stroke incidence of these diseases. Blood Pressure Proportion of persons Hypertension, stroke with high blood pressure Blood Lipids Proportion of persons Cardiovascular disease The 8 risk factors tobacco with hypercholesteraemia Blood Glucose Proportion of persons Diabetes with diabetes use, alcohol consumptions, Source: STEPS: A Framework for Surveillance The WHO STEPwise physical inactivity, low fruit Approach to surveillance of Non Communicable Diseases, WHO, 22 and vegetable intake in diet, excess body fat, raised blood pressure, higher amounts of blood lipids and higher levels of blood glucose, as indicated in the above table, are the major contributors causing the major chronic non communicable diseases. All these factors commonly are the reasons for cardiovascular diseases, hypertension, stroke, obesity, cancers and diabetes. The recommendation of WHO to conduct population based surveillance of the major common risk factors is aimed for countries to plan primary prevention programmes and for evaluation of their success. The Maldives being a developing country in a rapid transition stage of increased burden of non communicable diseases, is obligated for this surveillance in order to carryout effective prevention measures in the area. Non communicable diseases have taken the major threshold of the disease burden and the major cause of mortality in the country taking up a large portion of the health care resources. This survey on the risk factors among the population of Male, can be considered a strong evidence base for taking appropriate interventions to reduce the risks elsewhere in the country as behavioural patterns and changing life styles are simultaneously occurring in the homogenous population. The prevalence of the risk factors evident from the survey 37

38 suggests action need to be taken to address all the 7 risk factors which are discussed below. Addressing these modifiable risk factors at a population level will prove cost effective in controlling the incidences and reduce the future burden of health care costs of treating the sick. Tobacco use Tobacco use is causally linked to a number of chronic diseases several cancers, chronic obstructive pulmonary diseases, and cardiovascular diseases. The prevalence of daily smoking among the population is 25%. Smoking is started at an early age and the longer duration of continuous smoking poses a greater risk for the above conditions. It is found that regular smokers have been smoking for an average duration of 24 years. As seen from previous studies conducted on tobacco use, most people are aware of the health risks associated with smoking and tobacco use. It is the habit and addiction as well as the stressful living that many people continue smoking. As this is the case for the adult population, it is time to consider the increasing use of the tobacco by the youth for there is relevant future implication that the largest portion of the population will fall in the trap. As Maldives is a sole importer of tobacco products for its consumption, placing a ban or control on its importation can be a plausible measure for controlling use. Physical Inactivity Physical inactivity was found to be a difficult one to measure in the survey. However, the little information it was able to collect and analyse shows that people live a very sedentary life. More than 9% of the respondents reported that they are physically inactive at work (including housework). As WHO reports, regular physical activity has health benefits including the regulation of body weight and strengthening of the cardiovascular system. A comparative risk assessment project (CRA project) carried out in 2-21 to estimate and compare the burden of disease and injury in world s population resulting from previous exposure to 38

39 risks [cited in SuRF Report (WHO, 25)], found that overall physical inactivity accounted for 21% of ischaemic heart disease, 11% of stroke, 14% of diabetes, 16% of colon cancers, and 1% breast cancers. Knowledge creation as well as creation of physical fitness environment at workplace can be a helpful measure for the stressed out population of Male to earn enough for their high living costs. Diet Low intake of fruits and vegetables The theoretical minimum requirement distribution of fruit and vegetable consumption was estimated as followed (SuRF Report (WHO, 25): Adults 6g/day Children aged g/day Children aged 4 33g/day Not having a diet sufficient in fruits and vegetables is an independent factor for cardiovascular diseases and cancers, including lung, stomach, colorectal and oesophageal cancers (SuRF Report (WHO, 25). It has been epidemiologically shown that increasing the amount of fruits and vegetables in the diet can reduce the risk of certain cancers and cardiovascular diseases. Considering the low intake of fruits and vegetables shown by the present study, this area clearly needs priority attention. Let alone the minimum requirement, more than half of the respondents reported little or no fruit and vegetable consumption per day. With regard to the availability and affordability of fruits and vegetables in the market, it is not wrong to believe that the minimum requirement cannot be met by the people. A policy change for reducing the price can be a credible intervention for increasing the use of fruits and vegetables in the regular diet of the common people. Increasing the amount of vegetables and fruits in the diet will reduce the fat consumption which leads to overweight and obesity, thereby reducing the risk of diabetes, cardiovascular diseases, 39