Kingdom of Tonga NCD Risk Factors STEPS REPORT (2014)

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2 Kigdom of Toga NCD Risk Factors STEPS REPORT (2014) Prited i Suva, Fiji October,

3 Ackowledgemets The Kigdom of Toga NCD Risk Factors STEPS REPORT (2014) (referred as the Report ) is a record of a combied effort ad cotributio of several orgaizatios ad may idividuals. The Report was compiled by: Dr Cathy Latu Tekiteki (MOH, Toga), Dr Philayrath Phogsava (Uiv. of Sydey), Dr Li Da (WHO, Nuku alofa), Ms Leae Riley, Ms Melaie Cowa (WHO, Geeva), Ms Fusi Kaho, Dr Siale Akau ola (MOH), Mr Shalvidra Raj (Australia) ad Ms Latu Fusimalohi (MOH). Appreciatio is exteded to the Ho. Miister for Health, Lord/Mr Tu i afitu, the Chief Executive Officer, Dr Siale Akau ola for their leadership ad support of the NCD STEPS work i Toga. A special thak is made to the STEPS field survey staff, icludig Dr Cathy Latu Tekiteki, Ms Kalesita Fotu (Australia DFAT, Toga), Dr Paula Vivili (Secretariat of the Pacific Commuity) ad Dr Malakai Ake (MOH, Toga) (see Appedix 3 of the Report). Grateful ackowledgemet is made to Dr Liu Yuguo (Director, Pacific Techical Support ad Represetative, South Pacific, WHO, Suva) ad Dr Susa P. Mercado (Director, Divisio of NCD ad Health through the Life-Course, WHO, Maila) for their great support. We ackowledge the statistical support ad result geeratio provided by Ms Melaie Cowa, Ms Leae Riley, Ms Regia Guthold (WHO, Geeva), Mr Shalvidra Raj, Mr Viliami Koifeleisi Fifita, Mr Ata ata M. Fiau (Departmet of Statistics, Toga) ad Ms Nola Vaualailai (WHO, Suva) who made substatial cotributio to the data aalysis. Ms Katalia Palu, Ms Siutaisa L. Toumoua, Mr Okalai Kaloihea (WHO, Nuku alofa), Mr Saula Volavola, Ms Temalesi Vakaotia-Fracis, Ms Fraces Loloma, Ms Mato Irava (WHO, Suva) ad Ms Poaki Totau (MOH, Toga) provided admiistrative support to the fializatio of the Report. The Toga STEPS survey ad the Report were fuded by the Departmet of Foreig Affairs ad Trade (DFAT), Australia ad WHO. The Miistry of Health, Toga provided i-kid cotributio. Dr Philayrath Phogsava drafted the first versio of the Report. Dr Susa P. Mercado, Dr Li Da, Dr Hai-Rim Shi (WHO, Maila), Dr Cheria Varghese (WHO, Suva), Mr James Rarick, Dr Carme Audera-Lopez (WHO, Maila), Mr Shalvidra Raj, Dr Stefa Savi (WHO Geeva) ad Ms Melaie Cowa have coducted techical reviews for the Report. The coutry cosultatio held i Nuku alofa, Toga was atteded by Dr Siale Akau ola, Dr Sioe Latu ad Ms Fusi Kaho (MOH, Toga), Ms Kathlee Bombell (DFAT, Australia High Commissio, Toga), Dr Li Da ad Ms Siutaisa L. Toumoua (WHO, Nuku alofa). Dr Li Da, Dr Philayrath Phogsava ad Dr Cheria Varghese are the fial techical ad editorial reviewers of the Report. WHO Nuku alofa ad Suva Offices arraged the pritig, o behalf of the Miistry of Health, Kigdom of Toga. 2

4 CONTENTS FOREWORD 8 EXECUTIVE SUMMARY INTRODUCTION The burde of NCDs i Toga is substatial Prevetig ad cotrollig NCDs i Toga is a priority The atioal cotext Geography ad populatio Govermet, educatio ad the ecoomy OBJECTIVES METHODOLOGY Samplig frame ad sample size Data collectio procedures Step 1 - Behavioural risk factors iterviews Step 2 - Physical measuremets Step 3 - Biochemical measuremets Data maagemet ad statistical aalysis RESULTS Demographic characteristics of survey populatio Tobacco use Alcohol cosumptio Fruit ad vegetable itake Physical activity Measuremets Aalysis Levels of physical activity Overweight ad obesity 40 3

5 4.6.1 Height ad weight Body Mass Idex Categories Waist circumferece Blood pressure ad hypertesio Total cholesterol Fastig blood glucose ad diabetes Combied risk factors Cardiovascular disease risk COMPARISON WITH 2004 STEPS SURVEY Tobacco use Alcohol cosumptio Fruit ad vegetable itake Physical activity Overweight ad obesity Combied risk factors DISCUSSION AND CONCLUSIONS RECOMMENDATIONS 59 APPENDICES 61 Appedix 1 Kigdom of Toga STEPS Survey Questioaire 62 Appedix 2 The Data Book of the Kigdom of Toga STEPS Survey 74 Appedix 3 List of STEPS Field Survey Staff from the Kigdom of Toga 133 Appedix 4 Group Photos of the High-level Multi-sectoral Natioal NCD 135 Appedix 5 Workshops Held i Toga sice 1 Jue, 2012 Refereces 140 KEY CONTACTS 4

6 LIST OF FIGURES Figure 1 The WHO STEPwise approach to surveillace of NCD risk factors 21 Figure 2 Percetages of the populatio cosumed less tha five combied servigs of fruit ad vegetables per day betwee ad 2012 surveys Figure 3 Low physical activity levels betwee 2004 ad 2012 surveys 53 LIST OF TABLES Table 1 Demographic descriptio of study populatio 26 Table 2 Mea umber of years of educatio by geder ad age group 27 Table 3 Percetage of curret smokers i the study populatio 27 Table 4 Curret smokig status amog me i the study populatio by age group 28 Table 5 Curret smokig status amog wome i the study populatio by age group 28 Table 6 Curret smokig status amog both sexes i the study populatio by age group 28 Table 7 Mea age started smokig amog curret daily smokers 29 Table 8 Mea umber of years of smokig amog curret daily smokers 29 Table 9 Percetage of curret daily smokers who smoke maufactured cigarettes 30 Table 10 Percetage of tobacco use amog youth ages Toga Global Youth Tobacco Survey 2010 (=sample size) 30 Table 11 Table 12 Table 13 Table 14 Curret tabacco use compariso betwee the 2010 GYTS ad 2012 STEPS surveys i Toga 31 Percetage of alcohol cosumptio amog me durig the past moths by age group Percetage of alcohol cosumptio amog wome durig the past 12 moths by age group 32 Percetage of alcohol cosumptio amog both sexes durig the past 12 moths by age group 32 Table 15 Frequecy ad quatity of driks for me cosumed i the last 7 days by curret (last 30 days) drikers, grouped ito three categories Table 16 Table 17 Table 18 Table 19 Table 20 Table 21 Table 22 Frequecy ad quatity of driks for wome cosumed i the last 7 days by curret (last 30 days) drikers, grouped ito three categories Number of driks per day amog me who are curret drikers by age group 33 Number of driks per day amog wome who are curret 34 drikers by age group Number of driks per day amog both sexes who are curret drikers by age group 34 Mea umber of days i a week that fruits are cosumed by geder ad age group 34 Mea umber of days i a week that vegetables are cosumed by geder ad age group 35 Mea umber of servigs of fruits cosumed o a day whe fruits were eate 35 Table 23 Mea umber of servigs of vegetables cosumed o a day

7 whe vegetables were eate Table 24 Mea umber of combied servigs of fruit ad vegetables cosumed per day of the week 36 Table 25 Percetage who cosumed less tha five combied servigs of fruit ad vegetables per day of the week 36 Table 26 Categories of overall physical activity amog me by age group 37 Table 27 Categories of overall physical activity amog wome by age group 38 Table 28 Categories of overall physical activity amog both sexes by age group 38 Table 29 Level of Total physical activity (mea MET miutes per day) by geder ad age group 39 Table 30 Level of Work-related physical activity (mea MET miutes per day) by geder ad age group 39 Table 31 Level of Trasport-related physical activity (mea MET miutes per day) by geder ad age group 39 Table 32 Level of Recreatio-related physical activity (mea MET miutes per day) by geder ad age group 40 Table 33 Mea height by geder ad age group 40 Table 34 Mea weight by geder ad age group 41 Table 35 Mea body mass idex (kg/m 2 ) by geder ad age group 41 Table 36 BMI classificatios amog me by age group 42 Table 37 BMI classificatios amog wome by age group 42 Table 38 BMI classificatios amog both sexes by age group 42 Table 39 Percetage of obesity (BMI 30kg/m 2 ) by geder ad age group 42 Table 40 Mea waist circumferece (cm) by geder ad age group 43 Table 41 Mea restig systolic blood pressure (mmhg) by geder ad age group 44 Table 42 Mea restig diastolic blood pressure (mmhg) by geder ad age group 44 Table 43 Percetage with hypertesio (SBP 140 ad/or DBP 90 or curretly o medicatio for raised blood pressure) 44 Table 44 Mea levels of total blood cholesterol (mmol/l) by geder ad age group 45 Table 45 Percetage with raised blood cholesterol ( 5.0 mmol/l or mg/dl) or curretly o medicatio by geder ad age group Table 46 Mea fastig blood glucose i mmol/l by geder ad age group 46 Table 47 Prevalece of Impaired Fastig Glycaemia by geder ad age group Table 48 Percetage of diabetes by geder ad age group 46 Table 49 Percetage of NCD risk categories amog me by age group 47 Table 50 Percetage of NCD risk categories amog wome by age group 47 Table 51 Percetage of NCD risk categories amog both sexes by age group 48 Table 52 Percetage of the populatio with a 10-year CVD risk 30 or with existig CVD 48 Table 53 Curret smoker comparisos for me 49 Table 54 Curret smoker comparisos for wome 49 6

8 Table 55 Curret smoker comparisos for both sexes 50 Table 56 Past 12-moths alcohol cosumptio compariso for me 50 Table 57 Past 12-moths alcohol cosumptio compariso for wome 50 Table 58 Past 12-moths alcohol cosumptio compariso for both sexes 51 Table 59 Less tha five combied servigs of fruit ad/or vegetables per day of the week compariso for me 52 Table 60 Less tha five combied servigs of fruit ad/or vegetables day) per day of the week compariso for wome 52 Table 61 Less tha five combied servigs of fruit ad/or vegetables per day of the week compariso for both sexes 52 Table 62 Low physical activity compariso for me 53 Table 63 Low physical activity compariso for wome 54 Table 64 Low physical activity compariso for both sexes 54 Table 65 Overweight compariso for me 54 Table 66 Overweight compariso for wome 54 Table 67 Overweight compariso for both sexes 55 Table 68 Obesity compariso for me 55 Table 69 Obesity compariso for wome 55 Table 70 Obesity compariso for both sexes 55 Table 71 Percetage of NCD risk categories amog me by age group 56 Table 72 Percetage of NCD risk categories amog wome by age group 56 Table 73 Percetage of NCD risk categories amog me by both sexes 57 LIST OF ABBREVIATIONS BMI BP CHD CI CVD DBP DFAT DM FBS HTN MET mg/dl mmhg mmol/l NCDs PICs SBP WHO Body Mass Idex Blood Pressure Coroary Heart Disease Cofidece Iterval Cardiovascular Diseases Diastolic Blood Pressure Departmet of Foreig Affairs ad Trade Diabetes Mellitus Fastig Blood Sugar Hypertesio Metabolic equivalet Milligrams per decilitre (uit of blood chemistry values) Millimetres of mercury (uit of blood pressure measuremet) Millimoles per litre (uit for blood chemistry values) Nocommuicable diseases Pacific islad coutries ad areas Systolic Blood Pressure World Health Orgaizatio 7

9 FOREWORD I most of the coutries i the world, Nocommuicable diseases (NCDs), icludig cardiovascular diseases, diabetes ad cacer have become a high disease burde. I order to address this growig problem, accurate iformatio about the risk factors that cotribute to the developmet of NCDs is eeded. A risk factor is ay characteristic or exposure that icreases a perso s likelihood of developig a NCD. Risk factors of NCDs iclude tobacco use, alcohol use, physical iactivity, uhealthy diet, overweight ad obesity, high blood pressure, a raised level of blood glucose or cholesterol. To icrease our capacity to udertake populatio risk surveillace, the Miistry of Health ad WHO udertook joitly the 2 d -roud atioal NCD Risk Factors STEPS Survey. The STEPS survey has bee specifically desiged by WHO to assess the prevalece of the commo NCDs ad risk factors i a populatio. The iformatio from the survey provides importat iformatio to develop ad implemet NCD plas ad programs to address the growig epidemic of NCDs. Furthermore, the survey provides a firm foudatio for a ogoig surveillace for NCDs ad their various risk factors. This report is the result of the 2 d -roud STEPS survey carried out i Toga by It shows still high prevalece of NCDs ad their risk factors amog our populatio ad suggests actios to: cotrol ad prevetio NCDs; provide a supportive physical eviromet ad ifrastructure, ad improved health service delivery, etc. This is the first atiowide 2 d -roud NCD STEPS survey report to be published across the PICs. It represets a historical milestoe i our efforts to address the NCD epidemic affectig our people ad marks a icreased commitmet by the Miistry of Health ad other govermetal ad ogovermet agecies to tackle the NCD challege. The survey results ad recommedatios will eable us to develop more effective health policies ad programs i primary ad secodary NCD prevetio ad i moitorig ad evaluatig our ogoig efforts i NCD prevetio ad cotrol. 8

10 The Toga STEPS survey ivolved itesive work, persistece ad dedicatio from the Toga STEPS field survey team. We owe each of them our sicere appreciatio. We also wish to thak all the support staff i the Miistry of Health. We wish to thak the WHO CLO/Toga Office ad other WHO Offices for their strog techical guidace, excellet coordiatio ad fiacial support. The fiacial assistace from the Departmet of Foreig Affairs ad Trade, Australia is also appreciated. This report is dedicated to the hard work ad commitmet of all those ivolved from the iceptio to the completio of the NCD Risk Factors STEPS survey i Toga. The fidigs ad recommedatios i this report will guide our actios for prevetig ad cotrollig NCDs ad improvig health for all i our coutry. Lord/Mr Tu i afitu Miister for Health Miistry of Health Kigdom of Toga Dr Siale Akau ola Chief Executive Officer Miistry of Health Kigdom of Toga 9

11 We are pleased to see the 2 d -roud Toga NCD STEPS report has bee completed. The extremely high prevalece of NCDs i Pacific islad coutries ad areas (PICs) accouts for 75 of all deaths ad cotributes to sigificat log term illess ad disability. Miisters at the 9th Health Miisters' Meetig held i Jue, 2011 declared a NCD crisis i the Pacific requirig urget attetio ad actio. The WHO STEPwise Approach to Surveillace of NCD Risk Factors (STEPS) is the WHO recommeded surveillace tool for chroic disease risk factors ad chroic disease-specific morbidity ad mortality at atioal level. To date, majority of coutries ad areas throughout the world have utilized WHO STEPS to coduct atioal surveys o risk factors ad prevalece of NCDs. Some of the key results of the STEPS survey i 2012, reported i 2014 i the Kigdom of Toga iclude the followig: 26.7 of the populatio smoked tobacco daily. 9.3 of the populatio was curret alcohol drikers of the populatio cosumed less tha five combied servigs of fruit ad vegetables per day of the populatio was with low level of physical activity. The prevalece of overweight i the populatio was 90.7, the prevalece of obesity was The prevalece of hypertesio was The prevalece of raised blood glucose i the populatio was The prevalece of raised blood cholesterol i the populatio was of the populatio was at high risk or moderate risk of NCDs. These results clearly documet that NCDs are the No. 1 disease i Toga. Amog the 22 PICs, Toga is the first PIC havig published the 2 d -roud atioal NCD STEPS Report, which marks a milestoe as they have provided the scietific, atioal, updated NCD data. With a specific importace, they have provided comparable data over time, which have show the improvemets ad outcome of the NCD itervetio i Toga. 10

12 The compariso betwee 2004 ad 2012 STEPS surveys has show that the improvemets i may NCD idicators i Toga, icludig prevalece of curret tobacco use, curret alcohol cosumptio, fruit ad vegetable cosumptio, low physical activity, overweight, obesity, combied NCD risk factors; amog the above improved idicators, the prevalece of low physical activities has bee reduced from 43.9 i 2004 to 23.7 i 2012 sigificatly, the percetage cosumed less tha five servigs of fruit ad vegetables per day has bee decreased from 92.2 i 2004 to 73.1 i 2012 sigificatly. Thak for the efforts ad cotributio from all the stakeholders. The applicatio of this Kigdom of Toga NCD Risk Factors STEPS REPORT (2014) iclude updatig the atioal NCD strategy, idetifyig evidece-based prioritized itervetio for NCD prevetio ad cotrol, providig atioal data of NCDs for compariso over time ad betwee coutries, cotributig the scalig up of the implemetatio of the Milleium Developmet Goals, ad coductig evaluatio agaist the global NCD targets ad idicators amog others. Future priorities eed to be give to both primary ad secodary prevetio activities to prevet ad cotrol NCDs, icludig cardiovascular diseases, diabetes, cacer, ad their risk factors icludig tobacco use, harmful use of alcohol, uhealthy diet ad physical iactivity. WHO is hooured to be a critical part of the collaborative efforts amog the Toga Miistry of Health, Australia Departmet of Foreig Affairs ad Trade to complete the Toga 2 d - roud STEPS survey ad report. WHO is proud to collaborate with the Miistry of Health i publishig this ew Kigdom of Toga NCD Risk Factors STEPS REPORT (2014), ad will cotiue to work with health authorities, health workers, other key stakeholders ad the public to address the issues raised i this report ad achieve further improvemets. Dr Liu Yuguo Director, Pacific Techical Support Represetative, South Pacific World Health Orgaizatio Dr Li Da Coutry Liaiso Officer for the Kigdom of Toga World Health Orgaizatio 11

13 EXECUTIVE SUMMARY The WHO STEPS survey for NCD risk factors is a valuable atioal data resource for Toga. As a moitorig ad surveillace system, the surveys provide a evidece-based ad a stadardised methodological framework which the govermet ad o-govermet agecies ca use to systematically idetify ad prioritise o-commuicable disease (NCDs) issues for policy ad public health itervetios. I 2012, the Govermet of Toga coducted its 2 d -roud atioal STEPS survey; this survey repeated the 2004 atioal STEPS survey (N=849; years) but ivolved a relatively larger sample populatio (N=2,457; years). The key objectives of the 2012 STEPS survey were to: documet the prevalece ad magitude of major modifiable risk factors for NCDs, icludig tobacco use, alcohol cosumptio, fruit ad vegetable cosumptio, physical activity, overweight ad obesity, blood pressure, blood glucose ad cholesterol levels documet the prevalece of key NCDs amog adults i Toga moitor treds i major NCD risk factors ad key NCDs across age groups ad geder. A total of 2,599 aged years coseted ad participated i the survey, the respose rate was About 62.1 of wome ad 37.9 of me took part i the survey. The sampled data has bee coducted populatio weightig, takig referece to the atioal populatio structure. Step 1: Behavioural risk factors For tobacco use, the survey foud that amog those aged years: 29.3 had curretly smoked ay tobacco product (such as cigarettes, cigars or rolled tobacco): 46.4 of me ad 13.4 of wome 26.7 were daily smokers: 42.1 me, 12.4 wome Smokig uptake amog daily smokers started at a mea age 18.6 years: me 17.5 years, wome 22.2 years Daily smokers had smoked o average 22 years: me 23.9 years, wome 15.9 years 85.2 of daily smokers smoked maufactured cigarettes. For alcohol cosumptio, the survey foud that amog those aged years: 9.3 drak i the past 30 days (curret drikers): 16.4 of me, 2.8 of wome More respodets i years age group tha those i age groups drak i the past 30 days: 11.6 ad 4.6, respectively 46.9 adults drak 6+ stadard driks o a drikig day: 51 me, 24.2 wome. For fruit ad vegetable itake, the survey foud that amog those aged years: 73.1 cosumed less tha five combied servigs of fruit ad/or vegetables per day: 72.4 me, 73.7 wome Respodets cosumed a average of 3.9 servigs of fruit ad/or vegetables o a typical day: a average of 1.8 serves of fruit, ad 2.1 serves of vegetables. For physical activity, the survey foud that amog those aged years: 23.7 had low level of total physical activity (<600 METmiutes per week): 15.1 of me, 31.7 of wome 12

14 Respodets spet a average of METmiutes per day o total physical activity: METmiutes for me, METmiutes for wome Respodets i years age group had higher mea METmiutes tha those i years age group: METmiutes ad METmiutes, respectively Work-related physical activities cotributed the largest portio of all total physical activity (mea METmiutes per day), followed by trasport (42.8 METmiutes per day) ad recreatio (19.4 METmiutes per day). Step 2: Physical risk factors For body weight ad waist circumferece, the survey foud that amog those aged years: 90.7 were overweight (BMI 25kg/m 2 ): 87.3 of me, 94 of wome 67.6 were obese (BMI 30kg/m 2 ): 57.2 me, 77.6 wome By years, 89.9 were overweight (BMI 25kg/m 2 ): 86.5 me, 93.4 wome Average waist circumfereces were: 103.3cm for me, 106.7cm for wome; both values exceed the cut-off values where the risk of cardiovascular disease icreases (me: 102cm; wome: 88cm) By years, me had a mea waist circumferece of 102.2cm, wome 105.1cm. For hypertesio, the survey foud that amog those aged years: 27.6 had hypertesio (defied as havig SBP 140 mmhg ad/or DBP 90 mmhg or o medicatio for raised blood pressure): 28.2 of me, 27.1 of wome By years, 22.1 of me ad 14.3 of wome had elevated blood pressure By years, 41.3 of me ad 52.9 of wome had elevated blood pressure. Step 3: Biochemical risk factors For total blood cholesterol, the survey foud that amog those aged years: 48.8 had raised blood cholesterol (defied as havig >5.0 mmol/l or 190 mg/dl or curretly o medicatio for raised cholesterol): 49.3 of me, 48.2 of wome By years, 44.1 of me ad 38.2 of wome had raised blood cholesterol By years, 60.3 of me ad 67.5 of wome had raised blood cholesterol. For fastig blood glucose, the survey foud that amog those aged years: 34.4 had diabetes (defied as havig capillary whole blood value 6.1 mmol/l or 110mg/dl or curretly o medicatio for diabetes): 29.7 of me, 38.6 of wome By years, 24.5 of me ad 29.4 of wome had diabetes By years, 40.7 of me ad 56.9 of wome had diabetes 23.8 had impaired fastig glycaemia (defied as havig capillary whole blood value 5.6 mmol/l (100 mg/dl) ad <6.1 mmol/l (110 mg/dl): 23.9 of me, 23.8 of wome By years, 22.1 of me ad 24.7 of wome had impaired fastig glycaemia By years, 27.5 of me ad 22.2 of wome impaired fastig glycaemia. 13

15 Combied NCD risk factors For combied risk factors (curret daily smokers, overweight/obese, cosumed less tha five serves of fruit/vegetables, low total physical activity, raised blood pressure), the survey foud that amog those aged years: 57.1 had 3-5 risk factors ad were cosidered as havig High Risk of NCDs: 56 me, 60.2 wome By years, 52.8 were at High Risk: 51.7 me, 55.4 wome By years, 66.9 were at High Risk: 64.7 me, 75 wome. Cardiovascular disease risk 16.6 of me ad 7 of wome i the age group years had a 10 year cardiovascular risk of more tha 30. Compariso with Toga 2004 STEPS Survey I 2004, Toga coducted its first STEPS survey also coverig three islad groups of Togatapu, Ha apai ad Vava u. This sectio presets a sapshot of treds of major NCD risk factors: tobacco use, alcohol cosumptio, fruit ad vegetable cosumptio, physical activity, overweight, obesity ad combied high risk factors amog the same age group i the two atioal STEPS surveys i Toga. Tred aalysis at a glace NCD Idicators for years Low physical activity (<600 METmiutes per week) Fruit ad vegetable cosumptio (Less tha 5 serves of fruit/vegetables per day) Alcohol cosumptio (i past 12 moths) Smoke ay tobacco product (such as cigarettes, cigars or rolled tobacco) Toga STEPS Survey i 2004 Toga STEPS Survey i Tred 43.9 ± ±2.2 Sigificatly Improved 92.2 ± ±3.0 Sigificatly Improved 8.9 ± ±1.3 Improved 29.8 ± ±2.6 Margially Improved Overweight 92.1 ± ±1.8 Improved Obesity 68.7 ± ±2.9 Margially Improved Combied high NCD risk factors (with 3-5 risk factors) * Both survey data has bee weighted 60.7 ± ±4.6 Improved 14

16 Coclusios Nocommuicable diseases ad associated modifiable risk factors cotiue to preset a major public health issue i Toga. Ecouragigly, the umber of Togas who reported egagig i NCD health risk behaviours decreased betwee 2004 ad For these promisig treds to cotiue existig public health efforts eed to be sustaied ad expaded, before Toga ca expect to see ay further slowig dow i the icidece of NCDs. Uderlyig reasos for NCD health risk behaviours are liked to "uhealthy eviromets" these require modificatio through regulatios, policies, legislatios ad chagig of social orms. Maagemet of people with NCD risk factors i health services is also a critical compoet to chage the NCD risk profile i Toga. 15

17 Recommedatios These recommedatios uderscore the importace for the Toga health systems ad parters to promote ad stregthe primary ad secodary prevetio of NCD risk factors ad NCD-related diseases through whole of-govermet ad whole-of-society approaches: Cotiue comprehesive tobacco cotrol ad ati-smokig programmes, like Tobaccofree workplaces ad Tobacco-free Hospital, to reduce smokig rates, i particular esure comprehesive bas o smokig i all public places ad provide cessatio support i all health facilities. Cotiue to icrease tobacco taxes which have bee showig to reduce tobacco prevalece. Tobacco cotrol i childre, like Tobacco-free Schools, eed to be further stregtheed sice the majority of adult tobacco users begi their tobacco use as teeagers, ad the icreased price ad tax of tobacco products should decrease the prevalece of tobacco use amog childre effectively. Cotiue comprehesive public health programmes ad regulatios to reduce harmful alcohol cosumptio with a emphasis o prevetig youth cosumptio, regulatio of retail ad marketig ad developig public awareess programmes o the likages betwee alcohol use ad health outcomes. Alcohol cosumptio is also resposible for violece ad road traffic ijuries. Cotiue comprehesive healthy eatig programmes to icrease fruit ad vegetable itake, ad udertake policies ad regulatios to reduce excessive cosumptio of highfat, high-salt ad high-sugar foods icludig the ba of sale of sugar sweeteed beverages ad uhealthy foods iside schools. Cotiue comprehesive ad culturally-appropriate programmes to modify eviromets i order to promote daily physical activity such as walkig ad cyclig. Develop a system of commuity-based, outreached lifestyle support for the maagemet of idividuals at risk of NCDs or with diagosed NCDs focused o families ad chagig eatig ad dietary patters i homes. Promote the use of total cardiovascular risk estimatio ad provide maagemet as per atioal agreed protocols. Equip health workers ad health facilities with appropriate techology ad drugs ad medicies to maage ad treat hypertesio ad diabetes ad provide rehabilitatio services that are liked to commuity resources for survivors of heart attacks or strokes ad for amputatios. Develop facility-based targets for reductio of umbers of patiets who smoke, cosume too much salt, are hypertesive or diabetic. Itroduce iovative medical records systems that track idividuals with multiple risks for NCDs, through patiet-cards or family booklets that are moitored over by the health facility, like hospitals ad health cetres, over time. Coduct itesive aalyses ad extesive applicatio of the comparable Toga STEPS data to better uderstad the associatios betwee behavioural, physical ad biochemical risk factors ad chroic disease status over time. 16

18 Cosider repeat STEPS surveys to further moitor treds at 6-8 year itervals, addig expaded quatitative questios (e.g., salt, sugar, fat itake). These surveillace data would provide evidece of et gais i NCD prevetio ad cotrol efforts across Toga ad over time. 17

19 1. INTRODUCTION 1.1 The burde of NCDs i Toga is substatial The four major o-commuicable diseases (NCDs), as defied by the World Health Orgaizatio (WHO), are diabetes, cardiovascular disease, cacer, respiratory diseases, ad diabetes 1. Oce cosidered as diseases of affluece affectig high-icome societies, NCDs have ow affected may low- ad middle-icome coutries 2-3. It is ow widely ackowledged that the risig NCDs ad their associated morbidity ad premature mortality are posig a sigificat threat to coutries achievig sustaiable developmet, ad iteratioally agreed developmet goals 2,4. I Toga, data compiled over the past two decades have idicated the cotiuig rise of NCDs; for example, i 2002 the prevalece of diabetes amog Toga me ad wome was reported at 15.1 (Colagiuri et al, 2002), ad a 2004 study put the prevalece rate amog those aged years at 16.4 (WHO, 2012a). I 2010, NCDs accouted for four out of five leadig causes of mortality i Toga, 10 of hospitalisatio ad 20 of govermet health spedig 5. The icrease i behavioural-related risk factors such as poor diet, harmful alcohol itake, physical iactivity, ad smokig are ackowledged as the major cotributig factors to the rise i NCDs i Toga 6. These are all strogly liked to "uhealthy eviromets"-- that are best addressed through policies, regulatios ad legislatio. Oe of the key behavioural-related risk factors for NCDs, the icrease i overweight ad obesity rates i pose a sigificat NCD cotributor i Toga. Amog Toga adults, a 2000 study reported a mea body mass idex (BMI) of 32.3kgm 2 amog Togas aged 15+ (Colagiuri et al, 2002). I 2004, overweight/obesity rates for those aged years were documeted at 33.3kgm 2 (WHO, 2012). The high prevalece of overweight ad obesity is also evidet amog Toga adolescets, with 36.0 of boys ad 53.8 of girls aged years were overweight or obese usig the iteratioal cut-off poits for childre ad adolescets 7, Prevetig ad cotrollig NCDs i Toga is a priority The Govermet of Toga led the way as the first Pacific islad coutry to lauch a Natioal Strategy to Prevet NCDs ( ); this set the foudatio for a rage of systems ad strategic developmets i Toga some of these are listed below. I 2009, Toga reaffirmed its commitmets to addressig NCDs, by placig NCDs as oe of the seve priority areas for the govermet 6. I recet years, Toga has bee implemetig a rage of systems ad policy iitiatives to comprehesively tackle its NCD challeges, some of these iitiatives iclude: Startig from 1 Jue, 2012, WHO CLO/Toga Office ad Miistry of Health, Toga iitiated to joitly co-orgaize five (5) high-level multi-sectoral atioal workshops/meetigs o NCD prevetio ad cotrol i Toga, coverig physical activity ad healthy eatig, tobacco taxatio, Lauch of STEPS Report (2012), traiig ad review o the Package of Essetial NCD (PEN) itervetio, etc. Therefore, the high-level multi-sectoral platform o NCD prevetio ad cotrol i Toga has bee set up (see the Appedix 4 of the Report). 18

20 I the past 2 years, Toga has received 2 WHO Awards o NCD prevetio ad cotrol: (1) O 31 May, 2014, Mr Siosifa Tuitupou Tu utafaiva, Ho. Miister of Reveue ad Customs, Toga ad Lord/Mr Tu i afitu, Ho. Miister of Health, Toga wo the 2014 World No Tobacco Day Award Medals ad Certificates siged by Dr Margaret Cha, Director Geeral, WHO. Uder the leadership ad ifluece of the above two Miisters ad their officials ad staff, the tobacco tax has bee successfully icreased by 19 i both imported ad local maufactured tobacco i Toga with effect from 13 Aug., (2) I 2013, Healthy Islads Recogitio-Best Practice 2013 issued by Dr Shi Youg-soo, Regioal Director, WHO to the Physical Activity ad Sports Project collaborated by Miistry of Iteral Affairs, Toga ad Miistry of Health, Toga. MOH, Toga ad WHO coducted the first WHO STEPwise Approach to Surveillace of Risk Factors for NCDs to collect ad documet the magitude ad patters of the four major NCD risk factors i 2004 (WHO, 2012). Toga Natioal Strategy to Prevet ad Cotrol No Commuicable Diseases ( ) or Hala Fooga ki ha Toga Mo uilelei, Toga s PATH (Physical activity, Alcohol harm reductio, Tobacco cotrol ad Healthy eatig) to Health. The Strategy set a rage of measurable NCD risk factor targets to be achieved by The Healthy Eatig ad Physical Activities for the School Childre i Toga Project was collaborated betwee WHO, MOH ad Miistry of Educatio ad Traiig, Toga i The Commuity Based Nutritio ad Cookig Educatio for Local Wome i the Three Commuities i Togatapu was collaborated by Miistry of Agriculture ad Food, Forests ad Fisheries, Toga, WHO CLO/Toga Office ad MOH, Toga i I 2009, Toga Health Promotio Foudatio was established; iitiated through the Health Promotio Foudatio Act 2007 to support commuity- ad policy-based iitiatives tacklig NCDs. Toga Health Promotio Foudatio has bee stregtheed sice The Toga Health Systems Support Program ( ), a bilateral program betwee DFAT, Australia ad MOH, Toga, is dedicated to haltig the risig prevalece of NCDs risk factors. It focuses o primary ad secodary prevetio ad takes a comprehesive approach i stregtheig commuity health services, implemetig health promotio ad behaviour chage campaigs ad legislative reform. Establishmet of Advaced Nursig Diploma i the Prevetio, Detectio ad Maagemet of No-Commuicable Diseases. Commeced i 2013, the program graduated its first 20 locally-traied urses i February 2014 with specialised skills i NCD prevetio, detectio ad maagemet. 1.3 The atioal cotext Geography ad populatio The Kigdom of Toga is a islad sovereig atio located i the South Pacific Ocea. As a Polyesia archipelago, Toga s 170 islads (with approximately 718km 2 of lad) are scattered over approximately 800,000km (500miles), of which oly 36 are ihabited. The 19

21 coutry cosists of five mai islad groups: Togatapu, Ha apai, Vava u, Eua ad Niuas. Toga is the official laguage of the islad, but Eglish is also widely spoke. Based o the 2011 Cesus, two thirds of the 104,000 ihabitats live o the mai islad, Togatapu, particularly aroud the capital city of Nuku alofa. Toga has a youg populatio with approximately 38 of the populatio beig uder 15 years of age, ad 8 aged 60 years ad older. While the official data have Togas experiecig a relatively high life expectacy at 72.5 years of age, a recet study foud that life expectacy i Toga has plateaued or declie; with risig NCDs ad premature mortality beig cosidered as the key driver of this chage Govermet, educatio ad the ecoomy Toga is a costitutioal moarchy, with goverace power vested i the Cabiet of Miisters, headed by the Prime Miister. Legislative Assembly Members are elected by popular vote. Local villages or group of villages are govered by tow or district officials, respectively. The educatio is structured ito primary, secodary ad post-secodary. Toga govermet fuds the majority of primary schools ad approximately oe third of secodary schools; the rest are fuded by various [religious] deomiatios. Togas have a average of 10 years of schoolig, ad ejoy a 99 adult literacy rate 10. The Uited Natios classifies Toga i the medium huma developmet category, with Toga's Huma Developmet Idex (HDI; the Uited Natios composite measure of health, educatio ad icome) at 0.710, givig it a rakig of 95 out of 186 coutries with comparable data 10. The HDI of East Asia ad the Pacific as a regio is 0.683, placig Toga above the regioal average. However, this developmet gai is potetially uder threat uless Toga reverses the risig icidece of diabetes ad cardiovascular diseases. As a small islad atio Toga has limited huma ad fiacial resources. I 2012, Toga s Gross Natioal Icome (GNI) per capita stood at US$4, The coutry s ecoomy is agricultural-based icludig fishig ad root crops, with very limited export base. Toga relies substatially o import products, ad remittaces from Togas livig overseas. Toga s ecoomic growth ad ability to attract foreig ivestmet is limited by high trasportatio costs ad fragile ecosystem ad weather. 2. OBJECTIVES The key objectives of the 2012 Toga STEPS survey iclude: documetig the prevalece ad magitude of major modifiable risk factors for NCDs, icludig tobacco use, alcohol cosumptio, fruit ad vegetable cosumptio, physical activity, overweight ad obesity, blood pressure, blood glucose ad cholesterol levels; documetig the prevalece of key NCDs amog adults i Toga, ad; moitorig treds i major NCD risk factors ad key NCDs across age groups ad geder. This STEPS survey will provide withi-coutry tred data for atioal policy ad health promotio iitiative developmet. 20

22 STEPS survey structure A cross-sectioal populatio-wide survey, Toga STEPS survey followed the stadardised sequetial three-step process (Figure 1) recommeded by WHO 9, 12. This is to esure comparable data withi- ad betwee coutry. Core STEPS data are collected across all three steps, specifically: Step 1: A questioaire-based (iterview) survey o tobacco use, alcohol drikig, fruit ad vegetable cosumptio, physical activity, medicatio use, history of elevated blood pressure or hypertesio ad diabetes. Step 2: Physiological ad physical measures of blood pressure, height, weight, ad waist circumferece. Step 3: Biochemical measures of fastig blood glucose ad total cholesterol. Step 3 Step 2 Biochemical measuremets Step 1 Physical measuremets Self report iformatio Miimum Expaded Optioal Figure 1 The WHO STEPwise approach to surveillace of NCD Risk Factors 3. METHODOLOGY 3.1 Samplig frame ad sample size While the origial samplig protocol covered those aged years, due to limited fiacial support, a decisio was made to cofie the samplig to those aged years oly, thus the data for the age group was missig. The survey covered the residets i Togatapu, Vava u, Ha apai, Eua ad Niuas. The samplig frame was household lists from the Populatio Cesus, supplemeted by the additioal households iformatio. A total of 337 Cesus blocks were actually surveyed. A total of 3,446 were radomly draw from the samplig frame; 518 were excluded because they either had severe metal health problems, workig or livig abroad, resultig i the fial sample size of 2,928 eligible Togas ivited to take part i the survey. 21

23 3.2 Data collectio procedures Toga field survey staff received 1-week traiig i the STEPS survey methodology ad data collectio protocol facilitated by WHO staff experieced i STEPS surveys. At the completio of traiig, field staff participated i a brief pilot to familiarise with the survey implemetatio procedures, practice iterview techiques ad coduct physical measures. The Toga 2012 STEPS survey employed a had-held (Persoal Digital Assistats) PDAbased electroic system to collect, verify ad maage data collectio. Steps 1-2 data collectio took place at participatig households, ad Step 3 data collectio took place i dedicated STEPS survey cetres. Traied field staff coducted all data, icludig household iterviews, physical ad biochemical measuremets. Household iterviews were coducted i Eglish ad/or Toga, supported by locally-adapted show cards to facilitate questioaire comprehesio. Siged iformed cosets to participate i Steps 1, 2 ad/or 3 measuremets were obtaied from all participats; the STEPS survey was coducted from September 2011 to August Step 1 - Behavioural risk factors iterviews All cosetig participats completed the face-to-face iterview i which questios were asked about years of formal educatio, tobacco use, alcohol cosumptio, fruit ad vegetable cosumptio, physical activity, medicatio use, ad history of elevated blood pressure or hypertesio ad diabetes. 22

24 3.2.2 Step 2 - Physical measuremets For blood pressure, the OMRON Digital Automatic Blood Pressure Moitor was used to measure restig blood pressure three times; the first readig followed by two measuremets take with 2-3 miute itervals, with the third readig recorded ad used i the aalysis. 23

25 The Seca Leicester Height Measure was used to measure height ad measuremet recorded to the exact cetimetre, ad the Siltec PS500L used to measure weight to the exact kilogram. Participats were measured wearig oly light clothig ad without shoes. Costat tesio tape was used to measure waist circumferece ad recorded to the earest 0.1cm. Height, weight ad waist circumferece were measured oce. Pregat female pregat participats did ot have their waist circumferece, height ad weight measured. Step 2 measuremets followed Step 1 iterviews at the respodets residece. 24

26 3.2.3 Step 3 - Biochemical measuremets This Step assessed respodets fastig blood glucose ad fastig total cholesterol level by drawig capillary whole blood usig figer prick method. Participats who fasted at least 12 hours before their cliic appoitmet i the morig had their capillary blood samples draw. Respodets with diagosed diabetes were asked to take their tablets ad/or isuli after the measuremets were completed. Step 3 measuremets took place at dedicated STEPS survey cliics. 25

27 3.3 Data maagemet ad statistical aalysis The data of this STEPS survey were etered ad stored o the PDA by the coutry staff i Toga. WHO Office i Geeva coducted data cleaig ad weightig ad produced the data book. Data were weighted to accout for the probability of selectio ad these weights were the adjusted to correct for over- or uder- represetatio of each of the age-sex groups icluded i the results. All aalyses were performed usig Epi Ifo. Aalyses for this report were descriptive, comprisig of frequecies, meas ad cross tabulatios. Frequecies were calculated for categorical variables, ad meas were computed for cotiuous variables. For both frequecy ad mea estimates, 95 cofidece itervals were reported by two 20-year age groups (25-44 years ad years) ad by geder. To examie treds over time, tobacco use, alcohol cosumptio, fruit ad vegetable itake, ad physical activity outcomes from the Toga STEPS 2004 were re-aalysed by two 20- year age groups to facilitate compariso with the Toga STEPS 2012 survey. These comparative data are preseted i Sectio 5 of this report. 4. RESULTS 4.1 Demographic characteristics of survey populatio The demographic characteristics of those who took part i the STEPS survey are preseted i this sectio. A total of 2,599 idividuals participated (respose rate of 88.8), of these 2,490 idividuals took part i Steps 1, 2 ad 3; 49 took part i Step 1 oly, ad 60 took part i Steps 2 ad 3 oly. Table 1 shows that across a higher proportio of wome tha me participated i the survey (62.1 ad 37.9, respectively). This patter was similar across the two age groups. The study populatio comprised a slightly higher proportio of participats aged years (57.1), compared to 42.9 who were i the age group. Table 1 Demographic descriptio of study populatio Age Group Age group ad sex of respodets Me Wome Both Sexes N Both me ad wome ad age groups reported similar mea years of educatio (me: 11.2 years; wome: 11.0 years). Overall, the older age group (45-64 years) reported relatively lower mea years of educatio (10.4 years) tha the youger age group (25-44 years, 11.5 years). 26

28 Table 2 Mea umber of years of educatio by geder ad age group Mea umber of years of educatio Me Wome Both Sexes Mea Mea Mea Age Group 4.2 Tobacco use Survey participats were asked a umber of questios relatig to tobacco use, ad based o their resposes were classified ito the followig smokig status: Curret smokers those who curretly smoke ay tobacco product (such as cigarettes, cigars or rolled tobacco). Daily smokers those who smoke ay tobacco product every day. No-daily smokers those curret smokers who do ot smoke o a daily basis. Approximately 29.3 (±2.6) of those surveyed were classified as curret smokers, with sigificatly more me (46.4 ±4.0) tha wome (13.4 ±2.4) beig curret smokers at the time of the survey (Table 3). Although the proportio of male curret smokers i the older age group (45-64 years) was slightly higher (47.8 ±5.5) tha the youger age group (25-44 years, 45.8 ±5.1), this differece was ot statistically sigificat. Amog wome, 15.6 ±2.9 of wome i the years were curret smokers, compared to 9.0 ±3.1 i the years age group. Table 3 Percetage of curret smokers i the study populatio Percetage of curret smokers Me Wome Both Sexes Curret N Curret Curret smoker smoker smoker ± ± ± ± ± ± ± ± ± (±3.9) of all me were smokig o a daily basis (Table 4). Me aged years reported slightly higher proportio of daily smokig (44.6 ±5.3) tha me aged years (40.9 ±4.8). Of the Toga me, 39.0 (±4.0) ever smoked, while 14.6 (±3.4) were former smokers (Table 4). 27

29 Table 4 Curret smokig status amog me i the study populatio by age group Smokig status Me Age Curret smoker No-smokers Group Nodaily Daily Former Never smoker smoker ± ± ± ± ± ± ± ± ± ± ± ± (±2.2) of wome smoked o a daily basis, with 14.5 (±2.8) i the youger age group smokig daily compared to a sigificatly lower daily smokig rate of 8.0 (±3.0) i the older age group years (±2.9) of wome reported that they ever smoked, while 8.0 (±1.8) were defied as former smokers. Table 5 Curret smokig status amog wome i the study populatio by age group Smokig status Wome Age Curret smoker No-smokers Group Nodaily CI 95 Daily Former Never smoker smoker ± ± ± ± ± ± ± ± ± ± ± ±2.9 Table 6 presets the distributios of curret smokers ad o-smokers for me ad wome combied (±2.5) were smokig daily, with the daily smokig rates ot markedly differet betwee youger ad older age groups (±2.7) reported that they ever smoked, with the older age group years reportig the highest proportio of ever smokers (62.7 ±3.7) compared to the youger age group years (58.0 ±3.3). Table 6 Curret smokig status amog both sexes i the study populatio by age group Smokig status Both Sexes Age Curret smoker No-smokers Group Nodaily CI 95 Daily Former Never smoker smoker ± ± ± ± ± ± ± ± ± ± ± ±2.7 28

30 Table 7 shows that amog daily smokers i the survey populatio, the mea age Togas started smokig was 18.6 (±0.5) years old, with those i the youger age group reportig smokig uptake at a slightly youger age (18.4 years ±0.7) tha their older couterparts (45-64 age group: 19.0 years ±0.9). Toga me were sigificatly youger tha wome whe they first started smokig (me: 17.5 years ±0.6; wome: 22.2 ±1.2). For wome, youger age group reported a lower mea age of smokig uptake tha the older age group (25-44 years: 21.1 years ±1.3; years: 26.1 years ±2.1). For me, the mea startig age was similar across both age groups. Table 7 Mea age started smokig amog curret daily smokers Mea age started smokig Me Wome Both Sexes Mea Mea Mea age age age ± ± ± ± ± ± ± ± ±0.5 Table 8 shows that curret daily smokers had bee smokig a average of 22.0 ±1.1 years. Me reported a sigificatly higher mea duratio of smokig tha wome (me: 23.9 ±1.3 years; wome: 15.9 ±1.7 years). As expected, both older me ad wome reported loger smokig duratio tha their youger couterparts. Table 8 Mea umber of years of smokig amog curret daily smokers Mea duratio of smokig Me Wome Both Sexes Mea Mea Mea age age age ± ± ± ± ± ± ± ± ±1.1 Table 9 shows that maufactured cigarettes were smoked by the majority of Toga daily smokers: 85.2 ±3.3. A higher proportio amog wome (95.9 ±3.1) smoked maufactured cigarettes tha me (81.8 ±4.2). Amog me, a relatively higher proportio of youger me reported smokig maufactured cigarettes tha older me (25-44 years: 86.3 ±4.8; years: 72.7 ±7.9). 29

31 Table 9 Percetage of curret daily smokers who smoke maufactured cigarettes Age Group Maufactured cigarette smokers amog daily smokers Me Wome Both Sexes Maufacturefacturefactured Mau- Mau- cigarette cigarette cigarette smoker smoker smoker ± ± ± ± ± ± ± ± ±3.3 Toga s 2012 STEPS survey data ad the 2010 Global Youth Tobacco Survey (GYTS) survey data have bee compared. This compariso provides importat evidece for measurig progress towards the tobacco cotrol i Toga ad the global target -- a 30 reductio of tobacco use prevalece by The Toga 2010 GYTS survey shows that the curret cigarette smokig prevalece for studets aged as 37.5 for boys, ad 18.9 for girls (Table 10). Table 10 Percetage of tobacco use amog youth ages Toga Global Youth Tobacco Survey 2010 ( = sample size) Age Group Sample size Percetage of curret cigarette smokers Boys Girls Both Sexes Curret Sample Curret Sample Curret cigarette size cigarette size cigarette smoker smoker smoker (=50) 47.2 (=41) 38.4 (=93) (=84) 62.1 (=42) 22.7 (=130) (=75) 41.4 (=53) 22.7 (=129) (=209) 47.7 (=136) 20.8 (=352) 33.2 Table 11 shows a compariso betwee curret tobacco use amog youth with curret ay tobacco smokig amog adults i Toga. This compariso idicates the prevalece of ay tobacco use amog Toga boys that is early as high as ay tobacco smokig amog me; for girls the prevalece of ay tobacco use is more tha twice the prevalece of ay tobacco smokig amog wome. 30

32 Table 11 Curret tobacco use compariso betwee the 2010 GYTS ad 2012 STEP surveys i Toga Compariso of Curret Tobacco Use () betwee 2010 Childre GYTS Survey ad 2012 Adult STEPS Survey i Toga Boys i GYTS Me i STEPS Girls i GYTS Wome i STEPS Both Sex i GYTS Both Sex i STEPS A focus o addressig the high smokig rates amog Toga youth will be importat i reducig future smokig prevalece amog Toga adults. To date, three Tobacco Free Schools have bee lauched by WHO ad MOH i Toga. Tobacco Free School Iitiative eeds to be further developed i Toga. The tobacco tax i Toga has bee successfully icreased by 19 sice 13 Aug., Icreased price of tobacco products should be oe of the most effective strategies for prevetig iitiatio of tobacco use amog youth. 4.3 Alcohol cosumptio To examie distributios of alcohol cosumptio, survey respodets were asked if they ever cosumed alcohol, ad the frequecy ad quatity of alcohol cosumed. Based o their resposes, alcohol cosumptio status was classified ito: curret drikers or those who have cosumed a alcoholic drik i the last 30 days; those who had drak alcohol i the past 12 moths, but ot defied curret drikers; those who had abstaied from drikig i the past 12 moths, ad; those who were lifetime abstaiers. Overall, 9.3 (±1.7) of survey respodets reported havig cosumed alcohol i the past 30 days (Table 14). There was a sigificat geder differece, with 16.4 (±3.2) of me reported havig cosumed alcohol i the past 30 days compared with just 2.8 (±1.1) of wome (Tables 12 ad 13). For both me ad wome, the highest proportios of curret drikers occurred i the youger age group years (me 19.7 ±4.3; wome: 3.9 ±1.6) compared to the older age group years (me: 9.3 ±3.3; wome: 0.5 ±0.6). Coversely, 72.8 ±2.7 of survey respodets were classified as lifetime abstaiers, with the majority of Toga wome (86.5 ±2.5) ad just over half of Toga me (58.1 ±4.6) ot havig ever cosumed alcohol. 31

33 Table 12 Percetage of alcohol cosumptio amog me durig the past 12 moths by age group Age Group Curret driker (past 30 days) Alcohol cosumptio status Me Drak i past 12 moths, ot curret Past 12 moths abstaier Lifetime abstaier ± ± ± ± ± ± ± ± ± ± ± ±4.6 Age Group Table 13 Percetage of alcohol cosumptio amog wome durig the past 12 moths by age group Curret driker (past 30 days) Alcohol cosumptio status Wome Drak Past i past moths, moths ot abstaier curret Lifetime abstaier ± ± ± ± ± ± ± ± ± ± ± ±2.5 Age Group Table 14 Percetage of alcohol cosumptio amog both sexes durig the past 12 moths by age group Curret driker (past 30 days) Alcohol cosumptio status Both Sexes Drak i Past past moths, moths ot curret abstaier Lifetime abstaier ± ± ± ± ± ± ± ± ± ± ± ±2.7 Tables preset results o the frequecy ad quatity of stadard driks cosumed i the last 7 days amog curret drikers. Amog male curret drikers (last 30 days), early 1 i 5 Toga me reported drikig 20+ driks i the 7 days precedig the survey (19.1 ±8.8). Amog wome, 17.5 ±17.9 reported drikig 15+ driks. These fidigs eed to be iterpreted with cautio due to the small sample sizes. 32

34 Table 15 Frequecy ad quatity of driks for me cosumed i the last 7 days by curret (last 30 days) driker, grouped ito three categories N Frequecy ad quatity of driks cosumed i the past 7 days Me Drak o 4+ driks o driks i 7 days ay day days ± ± ± ± ± ± ± ± ±8.8 Table 16 Frequecy ad quatity of driks for wome cosumed i the last 7 days by curret (last 30 days) driker, grouped ito three categories Frequecy ad quatity of driks cosumed i the past 7 days Wome Drak o 4+ driks o driks i 7 days ay day days ± ± ± ± ± ± ± ±17.9 Overall, the mea umber of stadard driks cosumed o a drikig day by curret drikers i Toga was 7.7 ±1.7 driks (Table 19); me cosumed a average of 8.5 ±2.0 (Table 17), ad wome a average of 3.6 ±0.9 driks (Table 18). Table 17 idicates that amog male curret drikers, about half (51.0 ±11.0) reported drikig 6 or more driks o a drikig day, compared to 12.9 ±6.8 drikig 4-5 stadard driks, 21 ±7.6 drikig 2-3 stadard driks, ad 15.1 ±8.6 drikig just 1 drik o a drikig day. While o wome aged reported drikig 6 or more stadard driks, oe quarter (25.7 ±18.6) of wome aged years reported drikig this amout. However, a meaigful examiatio of these fidigs is difficult due to the very small umbers of survey respodets respodig to these measures. Table 17 Number of driks per day amog me who are curret drikers by age group Age Group 1 drik Number of stadard driks cosumed o a drikig day 2-3 driks Me 4-5 driks 6+ driks Mea # of stada rd driks ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±2.0 33

35 Table 18 Number of driks per day amog wome who are curret drikers by age group Age Group 1 drik Number of stadard driks cosumed o a drikig day 2-3 driks Wome 4-5 driks 6+ driks Mea # of stadard driks ± ± ± ± ± ± ± ± ± ± ± ± ±0.9 Table 19 Number of driks per day amog both sexes who are curret drikers by age group Age Group 1 drik Number of stadard driks cosumed o a drikig day 2-3 driks Both Sexes 4-5 driks 6+ driks Mea # of stad ard driks ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Fruit ad vegetable itake O the whole reported mea umber of days fruit cosumed was similar across age groups (Table 20). Table 20 Mea umber of days i a week that fruit are cosumed by geder ad age group Mea umber of days fruit cosumed i a typical week Me Wome Both Sexes Mea Mea Mea umber umber umber of days of days of days ± ± ± ± ± ± ± ± ±0.2 For vegetable cosumptio, wome reported margially higher mea umber of days cosumig vegetables i a typical week tha me (wome: 4.4 days ±0.2; me: 3.9 days ±0.2) (Table 21). Table 21 shows that both geders reported a mea 4.2 ±0.1 days of vegetables cosumed i a typical week. Each of the age groups reported the same mea days of vegetable cosumptio i a typical week (4.2 days ±0.2). 34

36 Table 21 Mea umber of days i a week that vegetables are cosumed by geder ad age group Mea umber of days vegetables cosumed i a typical week Me Wome Both Sexes Mea Mea Mea umber umber umber of days of days of days ± ± ± ± ± ± ± ± ±0.1 O the day whe fruits were cosumed, survey respodets reported cosumig a average of 1.8 (±0.2) serves of fruits, with me reportig slightly higher mea servigs tha wome (me: 2.0 ±0.3; wome: 1.7 ±0.1) although this differece was ot statistically sigificat. Reported servigs of fruits remaied costat from youger to older age group (Table 22). Table 22 Mea umber of servigs of fruits cosumed o a day whe fruits were eate Mea umber of servigs of fruit o average per day Me Wome Both Sexes Mea Mea Mea umber umber umber of of of servigs servigs servigs ± ± ± ± ± ± ± ± ±0.2 O a day whe vegetables were cosumed, respodets reported cosumig a average of 2.1 (±0.1) serves of vegetables (Table 23). Wome reported cosumig margially more serves of vegetables but this differece did ot reach statistical sigificace (wome: 2.2 ±0.2; me: 2.0 ±0.2). Both youger ad older age groups reported the same mea umber of servigs of vegetables per day. Table 23 Mea umber of servigs of vegetables cosumed o a day whe vegetables were eate Mea umber of servigs of vegetables o average per day Me Wome Both Sexes Mea Mea Mea umber umber umber of of of servigs servigs servigs ± ± ± ± ± ± ± ± ±0.1 35

37 Table 24 presets results for the mea itake of fruit ad vegetables servigs combied per day o a typical week. Overall, survey respodets reported a average of 3.9 ±0.2 combied servigs of fruit ad vegetables, with o differece observed betwee me ad wome. The mea umber of servigs reported was also similar across both age groups. N Table 24 Mea umber of combied servigs of fruit ad vegetables cosumed per day of the week Mea umber of servigs of fruit ad/or vegetables o average per day Me Wome Both Sexes Mea Mea Mea umber umber umber of of of servigs servigs servigs ± ± ± ± ± ± ± ± ±0.2 Proportios of those who reported cosumig less tha the recommeded five servigs of fruit ad/or vegetables per day of the week are summarised i Table 25. Overall, 73.1 (±3.0) of Togas cosumed less tha the recommeded fruit ad/or vegetables servigs per day i a typical week; there was o differece betwee me ad wome (72.4 ±4.5, 73.7 ±3.1, respectively). Age Group Table 25 Percetage who cosumed less tha five combied servigs of fruit ad/or vegetables per day of the week N Less tha five servigs of fruit ad/or vegetables o average per day Me Wome Both Sexes < five < five < five servigs servigs servigs per day per day per day ± ± ± ± ± ± ± ± ± Physical activity Measuremets Physical activity was asked usig the Global Physical Activity Questioaire (GPAQ) 11. Respodets were asked how ofte (days or sessios) ad how log (miutes or hours) they participated i physical activity i a typical week defied as part of: work, (active) trasport ad leisure, commoly referred to as the three physical activity domais. For work ad leisure, respodets were asked how may days per week ad how may hours/miutes per day they participate i moderate ad vigorous itesity activities. For 36

38 trasport, respodets were asked how ofte ad how log they either walk ad/or cycle to ad from places Aalysis The three physical activity domais were first examied together ad the separately ad respectively, reported as either total physical activity (combiig work, recreatio ad trasport) or i three separate domais. For each domai, three activity levels were defied: low, moderate, ad high (see below defiitio). I each domai, the total time participats spet i a activity per 5 day week was computed by multiplyig the umber of days by the duratio of the activity. To accout for the differet levels of eergy expediture required for the activities (i.e. low, moderate or high), the daily duratio of activity was coverted ito METmiutes per day. The term MET (metabolic equivalet) is used as a idicatio of the itesity of physical activity. A MET is the ratio of the associated metabolic rate for a specific activity divided by the restig metabolic rate. The eergy cost of sittig is equivalet to a restig metabolic rate of 1 MET. I this report ad for cosistecy across all STEPS reports, the followig MET values were allocated to the three physical activity domais (Armstrog & Bull, 2006; WHO, 2005b): Moderate physical activity (work ad leisure domai) = 4.0 METS High physical activity (work ad leisure domai) = 8.0 METS Travel-related walkig/cyclig = 4.0 METS The followig levels of activity i terms of METmiutes were: Low activity: <600 METmiutes per week Moderate activity: METmiutes per week High activity: >1500 METmiutes per week Levels of physical activity To examie total activity levels, physical activity doe as part of work, trasport ad leisure was combied ad categorised ito low (<600 METmiutes per week), moderate ( METmiutes per week) ad high activity levels (>1500 METmiutes per week) for Toga me are summarised i Table 26. Approximately, 15.1 ±2.8 of me reported a low level of total physical activity. Moderate physical activity was reported by 15.2 ±2.8. High level of physical was reported by 69.7 ±3.8, with the highest proportio reported by those aged years (74.0 ±4.6) but declied to 60.1 ±6.5 i the older age group years. Table 26 Categories of overall physical activity amog me by age group Level of total physical activity Me Low High Moderate ± ± ± ± ± ± ± ± ±3.8 37

39 I cotrast to me, Toga wome demostrated differet levels ad patters of total physical activity Table 27). There were similar proportios of wome reportig egagig i low (31.7 ±3.8), moderate (32.1 ±3.1) ad high (36.3 ±3.5) total physical activity. Withi each category of total physical activity, there were o marked differeces i the proportios observed betwee age groups. For example, high total physical activity was reported by 37.4 ±4.0 of those i years age group compared to 34.0 ±5.6 of those i years age group. Table 27 Categories of overall physical activity amog wome by age group Level of total physical activity Wome Low High Moderate ± ± ± ± ± ± ± ± ±3.5 For the etire survey sample, 23.7 ±2.2 were classified as havig low level of total physical activity, with miimal differece betwee the two age groups (Table 28). Moderate physical activity was reported by 23.9 ±2.3 ad high level of physical activity reported by 52.4 ±2.7 of the sample. Overall, youger Togas aged years were more likely to egage i high level of total physical activity (55.4 ±3.4), but this proportio geerally declied to 46.2 ±4.5 by age years. Table 28 Categories of overall physical activity amog both sexes by age group Level of total physical activity Both Sexes Low High Moderate ± ± ± ± ± ± ± ± ±2.7 The mea miutes (defied as METmiutes) of egagig i total physical activity per average day across all three domais by geder separately ad combied are preseted i Table 29. Overall, survey respodets reported spedig a average of ±11.2 METmiutes per day i total physical activity. Toga me reported a sigificat higher mea miutes tha wome (me: ±17.2 METmiutes per day; wome ±9.4 METmiutes per day). For both me ad wome, the average time spet i total physical activity was highest i the years age group ad declied thereafter i the years age group. 38

40 Table 29 Level of Total physical activity (mea MET miutes per day) by geder ad age group Mea miutes of total physical activity o average per day Age Me Wome Both Sexes Group Mea Mea Mea miutes miutes miutes ± ± ± ± ± ± ± ± ±11.2 Tables report o mea METmiutes per day respodets egaged i work, trasport ad recreatio-related physical activity, respectively. Across both geders, egagig i workrelated physical activity accouted for the largest portio (106.6 ±8.7 METmiutes/day) of all physical activity followed by trasport (42.8 ±3.5) ad recreatio (19.4 ±2.9). Table 30 clearly idicates that me spet sigificatly more time o work-related physical activities tha wome (144.1 ±13.6 METmiutes/day ad 71.5 ±8.5 METmiutes/day, respectively). Across all age groups me also reported egagig i more METmiutes of work-related physical activity tha wome. Table 30 Level of Work-related physical activity (mea MET miutes per day) by geder ad age group Mea miutes of work-related physical activity o average per day Me Wome Both Sexes Mea Mea Mea miutes miutes miutes ± ± ± ± ± ± ± ± ±8.7 For trasport-related physical activities, me spet a average of 54.2 ±5.6 METmiutes/day compared to wome who reported 32.1 ±3.2 METmiutes/day, a statistically sigificat geder differece. Mea miutes spet i trasported-related physical activities did ot differ sigificatly betwee youger ad older age groups. Table 31 Level of Trasport-related physical activity (mea MET miutes per day) by geder ad age group Mea miutes of trasport-related physical activity o average per day Me Wome Both Sexes Mea Mea Mea miutes miutes miutes ± ± ± ± ± ± ± ± ±3.5 39

41 Table 32 shows that o average me spet sigificatly higher amout of time o recreatiorelated physical activities tha wome, about 31.4 ±5.3 METmiutes/day for me compared to 8.2 ±1.7 METmiutes/day for wome. While me geerally egaged i more METmiutes/day of recreatio-related physical activity tha wome i both age groups, me oetheless experieced a declie as they aged: from 36.0 ±7.0 METmiutes/day i age group to 21.3 ±7.2 METmiutes/day i age group. Table 32 Level of Recreatio-related physical activity (mea MET miutes per day) by geder ad age group Mea miutes of recreatio-related physical activity o average per day Me Wome Both Sexes Mea Mea Mea N miutes miutes miutes ± ± ± ± ± ± ± ± ± Overweight ad obesity Height ad weight The height ad weight of each participat was measured followig the stadardised STEPS protocol as described i Sectio 3. The body mass idex (BMI) of each participat was the computed by dividig the weight (kilograms) by the square of the height (metres 2 ), ad the BMI risk categories defied as follows: Uderweight BMI < 18.5 Normal weight 18.5 BMI 24.9 Overweight BMI 25.0 Obese BMI 30.0 Tables 33 ad 34 show that Toga me were sigificatly taller (177.9 cm ±0.7) tha wome (167.0cm ±0.7) ad me were slightly heavier (99.4kg ±1.8) tha wome (97.7kg±1.2). Table 33 Mea height by geder ad age group Mea height (cm) Me Wome Mea Mea ± ± ± ± ± ±0.7 40

42 Table 34 Mea weight by geder ad age group Mea weight (kg) Me Wome Mea Mea ± ± ± ± ± ± Body Mass Idex categories Table 35 presets the mea BMI for me ad wome, ad combied. The overall mea BMI was 33.1kg/m 2 ±0.4; wome had a higher mea BMI (34.8kg/m 2 ±0.4) tha me (31.3kg/m 2 ±0.5) ad this patter was observed across youger ad older age groups. Table 35 Mea body mass idex (kg/m 2 ) by geder ad age group Mea BMI (kg/m 2 ) Me Wome Both Sexes Mea Mea Mea ± ± ± ± ± ± ± ± ±0.4 Tables summarise the distributios of three BMI classificatios: uderweight, ormal ad overweight/obese for me, wome ad both geders, respectively. Amog me, 87.3 ±3.0 were classified as overweight; amog wome, 94.0 ±1.7 were classified as overweight. Table 36 BMI classificatios amog me by age group BMI classificatios Me Age Group Uderweight weight weight Normal Over- < ± ± ± ± ± ± ± ± ±3.0 41

43 Table 37 BMI classificatios amog wome by age group BMI classificatios Wome Age Group Uderweight weight weight Normal Over- N < ± ± ± ± ± ±1.7 Table 38 shows that overall 90.7 ±1.8 of the survey populatio were overweight, while 9.2 ±1.8 had a ormal BMI. Table 38 BMI classificatios amog both sexes by age group BMI classificatios Both Sexes Age Group Uderweight weight weight Normal Over- N < ± ± ± ± ± ± ± ± ±1.8 Table 39 presets obesity rates (BMI 30 kg/m 2 ) separately for me ad wome, ad combied. The overall prevalece of obesity i Toga was 67.6 ±2.9. The obesity rate was sigificatly higher amog wome (77.6 ±2.9) tha amog me (57.2 ±4.4). Table 39 Percetage of obesity (BMI 30 kg/m 2 ) by geder ad age group Percetage of respodets who are obese (BMI 30 kg/m 2 ) Me Wome Both Sexes N ± ± ± ± ± ± ± ± ± Waist circumferece Cetral obesity was assessed by measurig waist circumferece of participats followig the STEPS stadardised protocol as outlied i Sectio 3. Wome had a sigificatly larger mea waist circumferece (106.7cm ±1.0) tha me (103.3cm ±1.3). Wome i the older 42

44 age group years had sigificatly higher mea waist circumferece (109.7cm ±1.5) tha youger wome aged years (105.1cm ±1.2). For me, the mea waist circumferece i the youger age group years icreased from 102.2cm ±1.6 to ±1.7 i the older age group years. Table 40 Mea waist circumferece (cm) by geder ad age group Waist circumferece (cm) Me Wome Mea Mea ± ± ± ± ± ± Blood pressure ad hypertesio All survey respodets had their blood pressure measured, were asked if they ever had their blood pressure measured i the last 12 moths or whether they had ever bee told i the last 12 moths by a health worker that they had high blood pressure, ad if they were curretly receivig ay medical treatmet for high blood pressure. Based o self-report ad measured blood pressure data, the followig STEPS classificatios were set out: a mea systolic pressure of SBP 140 mmhg, whether or ot they had previously bee told by a health worker that they had high blood pressure, OR a mea diastolic pressure of DBP 90 mmhg, whether or ot they had previously bee told by a health worker that they had high blood pressure, OR ormal mea systolic ad diastolic pressures (i.e. ormotesive) AND who were curretly receivig ati-hypertesive medicatio, whether or ot they had previously bee told by a health worker that they had high blood pressure. Those participats who reported havig bee previously told by a health worker that they had high blood pressure, but who were ormotesive ad NOT o ati-hypertesive medicatio, were NOT icluded amog those cosidered to have hypertesio. Tables 41 ad 42 preset mea restig systolic blood pressure ad mea restig diastolic blood pressure, respectively, for me ad wome separately, ad combied. Toga me idicate a statistically higher mea systolic blood pressure tha wome (131.2mmHg ±1.2 ad 127.3mmHg ±1.2, respectively). For both geders, systolic blood pressure icreased with age. For restig diastolic blood pressure, both me ad wome idicate similar mea levels (78.2mmHg ±0.9 ad 78.3mmHg ±0.6, respectively), ad icreasig with age across both geders. 43

45 Table 41 Mea restig systolic blood pressure (mmhg) by geder ad age group Mea systolic blood pressure (mmhg) Me Wome Both Sexes Mea Mea Mea ± ± ± ± ± ± ± ± ±0.9 Table 42 Mea restig diastolic blood pressure (mmhg) by geder ad age group Mea diastolic blood pressure (mmhg) Me Wome Both Sexes Mea Mea Mea ± ± ± ± ± ± ± ± ±0.6 Table 43 summarises the prevalece rates of hypertesio for both geders ad combied. Hypertesio was idicated for 27.6 ±2.4 of the survey sample. A lightly higher proportio of Toga me had hypertesio compared to wome, although this differece was ot statistically sigificat (28.2 ±3.6 ad 27.1 ±2.9, respectively). Amog wome, hypertesio rate icreased sigificatly from 14.3 ±2.7 (25-44 years) to 52.9 ±5.3 (45-64 years). Amog me, the rise was less dramatic but still substatial: from 22.1 ±4.3 (25-44 years) to 41.3 ±5.9 (45-64 years). Table 43 Percetage with hypertesio (SBP 140 ad/or DBP 90 or curretly o medicatio for raised blood pressure) SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised blood pressure Me Wome Both Sexes ± ± ± ± ± ± ± ± ± Total cholesterol I this sample, the overall mea total blood cholesterol was 5.1mmol/L ±0.0, with both me ad wome recordig similar mea cholesterol levels (5.2mmol/L ±0.1 ad 5.1mmol/L ±0.1, respectively) (Table 44). Icreased cholesterol levels with age i me, the mea levels for wome icreased highly with age (25-44 years: 4.9 mmol/l ±0.1; years: 5.5 mmol/l ±0.1). 44

46 Table 44 Mea levels of total blood cholesterol (mmol/l) by geder ad age group Mea total cholesterol (mmol/l) Me Wome Both Sexes Mea Mea Mea ± ± ± ± ± ± ± ± ±0.0 Raised blood cholesterol, defied as havig 5.0 mmol/l or 190 mg/dl or reported curretly o medicatio, was idicated by 48.8 ±2.9 of the survey sample (Table 45). Both me ad wome recorded similar proportios of havig raised blood cholesterol (49.3 ±4.1 ad 48.2 ±3.5, respectively). High proportios of raised blood cholesterol were already evidet i the youger age group years for both me (44.1 ±5.1) ad wome (38.2 ±4.5), with these rates icreasig sigificatly i the older age group years (me: 60.3 ±5.9; wome: 67.5 ±4.9). Table 45 Percetage with raised blood cholesterol ( 5.0 mmol/l or 190 mg/dl) or curretly o medicatio by geder ad age group Total cholesterol 5.0 mmol/l or 190 mg/dl or curretly o medicatio for raised cholesterol Me Wome Both Sexes ± ± ± ± ± ± ± ± ± Fastig blood glucose ad diabetes Respodets were asked if they had bee told by a health worker that they had diabetes i the previous 12 moths, ad whether they were curretly receivig medical treatmet for diabetes. Estimates of diabetes prevalece were computed based o the WHO guidelies for defiig ad classifyig diabetes mellitus: elevated fastig capillary whole blood value of glucose 6.1 mmol/l ( 110 mg/dl) AND whether or ot they had previously bee told by a health worker that they had diabetes, OR ormal capillary whole blood value of glucose <6.1 mmol/l (<110 mg/dl) AND who were curretly receivig ati-diabetes medicatio prescribed by a health worker. Those participats who had bee advised by a health worker that they had diabetes but who had ormal fastig blood glucose, ad who were NOT o ati-diabetes medicatio or o a special diet prescribed by a health worker, were NOT icluded amog those cosidered as havig diabetes. 45

47 The overall mea fastig blood glucose amog the survey respodets was 6.5mmol/L ±0.1 (Table 46). Wome reported a margially higher mea fastig blood glucose level (6.7mmol/L ±0.2) tha me (6.2mmo/L ±0.2). For wome, mea fastig blood glucose levels icreased with age, from 6.3mmo/L ±0.2 (25-44 years) to 7.5mmo/L ±0.3 (45-64 years). A similar patter was also recorded for me. Table 46 Mea fastig blood glucose i mmol/l by geder ad age group Mea fastig blood glucose (mmol/l) Me Wome Both Sexes Mea Mea Mea ± ± ± ± ± ± ± ± ±0.1 Table 47 Prevalece of Impaired Fastig Glycaemia by geder ad age group Impaired Fastig Glycaemia* Me Wome Both Sexes ± ± ± ± ± ± ± ± ±2.2 * Capillary whole blood value 5.6 mmol/l (100 mg/dl) ad <6.1 mmol/l (110 mg/dl) The overall diabetes prevalece of those aged years, measured as raised blood glucose or reported as curretly o medicatio for diabetes, was 34.4 ±2.9. Diabetes prevalece was sigificatly higher amog wome (38.6 ±3.3) tha me (29.7 ±4.1). By age years, early oe third of the survey populatio (27.1 ±3.3) had hypertesio, ad by age years this rate rose to about half of the survey sample (49.3 ±4.4). Table 48 Prevalece of diabetes by geder ad age group Raised blood glucose or curretly o medicatio for diabetes Me Wome Both Sexes ± ± ± ± ± ± ± ± ±2.9 46

48 4.10 Combied risk factors The followig five NCD risk factors were summed to idicate the overall NCD risk: curret daily smokers, overweight (BMI 25 kg/m 2 ), raised blood pressure (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio), cosumed less tha five combied servigs of fruit ad vegetables per day, ad low level of activity (<600 METmiutes per week). Based o these combied risk factors, three levels of the overall risk for NCDs were created: Low Risk: 0 risk factor Moderate Risk: 1-2 risk factors High Risk: 3-5 risk factors Table 49 shows that 56.0 ±5.6 of Toga me were at High Risk of NCDs, with at least 51.7 ±7.2 of those aged years already had 3-5 risk factors. Just uder half or 42.4 ±5.4 of me had Moderate Risk. Table 50 shows that 60.2 ±6.9 of Toga wome were at High Risk of NCDs, with more tha half or 55.4 ±8.3 already had 3-5 risk factors by age years. Overall, 57.1 ±4.6 of Togas were deemed to be at High Risk of NCDs (Table 51), ad 41.6 ±4.4 at Moderate Risk. By age years, more tha half those surveyed were at High Risk (52.8 ±5.6) ad icreased with age to 66.9 ±6.4 i the age group. Table 49 Percetage of NCD risk categories amog me by age group Summary of Combied Risk Factors Me with 0 with 1-2 risk risk factors factors with 3-5 risk factors ± ± ± ± ± ± ± ±5.6 Table 50 Percetage of NCD risk categories amog wome by age group Summary of Combied Risk Factors Wome with 0 with 1-2 risk risk factors factors with 3-5 risk factors ± ± ± ± ± ± ± ±6.9 47

49 Table 51 Percetage of NCD risk categories amog both sexes by age group Summary of Combied Risk Factors Both Sexes with 0 with 1-2 risk risk factors factors with 3-5 risk factors ± ± ± ± ± ± ± ± Cardiovascular disease risk Percetage of respodets aged years with a 10-year cardiovascular disease (CVD) risk* 30 or with existig CVD has bee calculated. Istrumet questios: combied from Step 1, 2 ad 3 of the STEPS survey Geder, age Curret ad former smokig History of diabetes, CVD Systolic blood pressure measuremets Fastig status, glucose ad total cholesterol measuremets. Aalysis of the CVD risk factors of the curret smokers, raised blood pressure, total cholesterol ad diabetes were udertake to assess the CVD risk status of the populatio for NCDs. Table 52 shows that oe-sixth (16.6) of year-old me i Toga had a high risk ( 30) of developig CVD i the ext 10 years, which eeds to pay more attetio. The CVD risk icreased with age as would be expected ad this was show from years to with a sigificat icreased from 0.8 to 11.3, show i Table 52. Overall, higher percetages of me were at risk tha wome with CVD risk of 16.6 ad 7.0, respectively, with o sigificat differece. Table 52 Percetage of the populatio with a 10-year CVD risk 30 or with existig CVD Percetage of respodets with a 10-year CVD risk* 30 or with existig CVD Me Wome Both Sexes * A 10-year CVD risk of 30 is defied accordig to age, sex, blood pressure, smokig status (curret smokers OR those who quit smokig less tha 1 year before the assessmet), total cholesterol, ad diabetes (previously diagosed OR a fastig plasma glucose cocetratio >7.0 mmol/l (126 mg/dl)). 48

50 5. COMPARISON WITH 2004 STEPS SURVEY I 2004, Toga coducted the first STEPS survey coverig three islad groups of Togatapu, Ha apai ad Vava u (WHO, 2012). This secod 2012 STEPS survey provide Toga s first populatio-wide treds data i behavioural ad biochemical risk factors for NCDs. Both surveys followed the WHO stadardised survey samplig ad data collectio methodology, ad both survey data weighted to the Toga populatios. To facilitate compariso, oly data for years are preseted here. I this age bad, a sample of 849 participats took part i the 2004 survey, ad 2,457 took part i the 2012 survey. This sectio reports o the treds of four major NCD risk factors: tobacco use, alcohol cosumptio, fruit ad vegetable cosumptio ad physical activity. The prevalece of combied NCD risk categories i 2004 ad 2012 is also preseted, ad the majority of the descriptive results preseted graphically by age group, geder ad overall. 5.1 Tobacco use Overall, the proportios of curret smokers (had smoked ay tobacco products) declied margially over time, with 29.8 i 2004 compared to 29.3 i 2012 (Table 55). Amog Toga me the rates also remaied stable: 46.2 i 2004 ad 46.4 i There was, however, a 2 decrease i smokig prevalece amog the age group, from 49.8 i 2004 to 47.8 i 2012 (Table 53). The rates of smokig amog Toga wome, however, decreased slightly from 14.3 i 2004 to 13.4 i A 1.2 poit decrease i smokig prevalece was oted for wome i the age group (Table 54). Table 53 Curret smoker comparisos for me Curret Smoker ± ± ± ± ± ±4.0 Table 54 Curret smoker comparisos for wome Curret Smoker ± ± ± ± ± ±2.4 49

51 Table 55 Curret smoker comparisos for both sexes Curret Smoker ± ± ± ± ± ± Alcohol cosumptio I cotrast to tobacco use, self-reported alcohol cosumptio over the past 12 moths declied durig the period, overall 8.9 i 2004 to 5.7 i 2012 (Table 58). The proportio of me cosumig alcohol i the past 12 moths decreased substatially, from 13.6 i 2004 to 8.7 i This declie was also reflected across both youger ad older age groups over the 8-year period (Table 56). The proportios of wome cosumig alcohol also saw a reductio, from 4.6 i 2004 to 2.8 i 2012, attributable maily to the declie i cosumptio amog the youger age group (Table 57). Table 56 Past 12-moths alcohol cosumptio compariso for me Cosumed Alcohol i Past 12 Moths ± ± ± ± ± ±2.3 Table 57 Past 12-moths alcohol cosumptio compariso for wome Cosumed Alcohol i Past 12 Moths ± ± ± ± ± ±1.3 50

52 Table 58 Past 12-moths alcohol cosumptio compariso for both sexes Cosumed Alcohol i Past 12 Moths ± ± ± ± ± ± Fruit ad vegetable itake Similar to alcohol drikig, the proportios of cosumig less tha the recommeded combied five servigs of fruit ad/or vegetables per day i a typical week decreased durig the period, overall from 92.2 i 2004 to 73.1 i 2012 (Figure 2, Table 59). Both me ad wome showed similar magitude of declie (me: from 91.4 i 2004 to 72.4 i 2012; wome: from 92.9 i 2004 to 73.7 i 2012), overall ad i youger ad older age groups (Tables 59-61). Figure 2 Percetages of the populatio cosumed less tha five combied servigs of fruit ad vegetables per day betwee 2004 ad 2012 surveys 51

53 Table 59 Less tha five combied servigs of fruit ad/or vegetables per day of the week compariso for me Less tha five servigs of fruit ad/or vegetables o average per day ± ± ± ± ± ±4.5 Table 60 Less tha five combied servigs of fruit ad/or vegetables per day of the week compariso for wome Less tha five servigs of fruit ad/or vegetables o average per day ± ± ± ± ± ±3.1 Table 61 Less tha five combied servigs of fruit ad/or vegetables per day of the week compariso for both sexes Less tha five servigs of fruit ad/or vegetables o average per day ± ± ± ± ± ± Physical activity From 2004 to 2012, the proportios of Toga reportig that they egaged i low level physical activity (<600 METmiutes per week) reduced substatially by 20.2, overall 23.7 i 2012 compared to 43.9 i 2004 (Figure 3, Table 62). For both me ad wome, this magitude of declie was observed i both youger ad older age groups (Tables 62-64). I other words, the 8-year period saw a positive tred with the reductio i the overall umbers of low active Togas. 52

54 The proportio of me who reported low level of physical activity declied by half betwee the two surveys, from 33.3 i 2004 to 15.1 i The proportio of wome who reported low level of physical activity also declied durig the survey period, from half of the surveyed populatio or 53.7 i 2004 to oe third or 31.7 i For me ad wome, both youger ad older age groups experieced this positive declie. Figure 3 Low physical activity levels betwee 2004 ad 2012 surveys Table 62 Low physical activity compariso for me Low Level of Physical Activity ± ± ± ± ± ±2.8 53

55 Table 63 Low physical activity compariso for wome Low Level of Physical Activity ± ± ± ± ± ±3.8 Table 64 Low physical activity compariso for both sexes Low Level of Physical Activity ± ± ± ± ± ± Overweight ad obesity Table 65 Overweight compariso for me Overweight ± ± ± ± ± ±3.0 Table 66 Overweight compariso for wome Overweight ± ± ± ± ± ±1.7 54

56 Table 67 Overweight compariso for both sexes Overweight ± ± ± ± ± ±1.8 The 2012 survey saw a slight but o-sigificat declie i the proportio of people who were overweight, overall from 92.1 i 2004 to 90.7 i 2012 (Table 67). For wome, the overall proportios of overweight remaied uchaged from 2004 to 2012 (94.9 ad 94.0, respectively), while prevalece of overweight i me experieced a 1.9 poit decrease (89.2 i 2004 to 87.3 i 2012). Table 68 Obesity compariso for me Obese ± ± ± ± ± ±4.4 Table 69 Obesity compariso for wome Obese ± ± ± ± ± ±2.9 Table 70 Obesity compariso for both sexes Obese ± ± ± ± ± ±2.9 55

57 The 2012 survey saw a slight but o-sigificat declie i the proportio of people who were obese, overall from 68.7 i 2004 to 67.6 i 2012 (Table 70). For wome, the overall proportios of obesity icreased slightly from 2004 to 2012 (76.3 ad 77.6, respectively), while prevalece of obesity i me experieced a 3.5 poit decrease (60.7 i 2004 to 57.2 i 2012). 5.6 Combied risk factors The 2012 survey saw a slight but o-sigificat declie i the proportio of people with 3-5 risk factors (High Risk for NCDs), overall from 60.7 i 2004 to 57.1 i 2012 (Table 73). For wome, the overall proportios of High Risk remaied uchaged from 2004 to 2012 (60.8 ad 60.2, respectively), while those aged years experieced a 9.6 poit icrease i the proportios of High Risk durig the same period (65.4 i 2004 to 75.0 i 2012) (Table 72). I cotrast, the overall proportios of High Risk amog me declied over time, from 60.5 i 2004 to 56.0 i 2012 (Table 71). Table 71 Percetage of NCD risk categories amog me by age group with 3-5 risk factors ± ± ± ± ± ±5.6 Table 72 Percetage of NCD risk categories amog wome by age group with 3-5 risk factors ± ± ± ± ± ±6.9 56

58 Table 73 Percetage of NCD risk categories amog both sexes by age group with 3-5 risk factors ± ± ± ± ± ± DISCUSSION AND CONCLUSIONS The WHO STEPS survey is a valuable atioal data resource for Toga. At the populatio level, it documets the magitude of major modifiable behavioural risk factors of NCDs, idetifies who are at risk, ad allows for prioritisatio of public health itervetios. Itervetios to address "uhealthy eviromets" -- through policies, regulatios ad legislatio are of critical importace. If repeated at regular itervals, the STEPS surveys provide surveillace ad treds data for Toga to bechmark ad evaluate progress towards achievig agreed health ad developmet goals. This fial sectio of the report reflects o key fidigs from the 2012 STEPS survey, discusses the differetial chages from 2004 to 2012 i four health-related behavioural risk factors, ad presets a rage of recommedatios to prevet ad cotrol NCDs i the Kigdom of Toga. STEPS 2012 fidigs Smokig remais a public health cocer i Toga, particularly amog Toga me. Just uder oe half of me (42.1) were daily smokers at the time of the survey, compared to STEPS survey data from Cook Islads (37.5) ad America Samoa (38.1) Daily smokig is also well established amog Toga me i age years (40.9). These fidigs highlight the eed for programs to specifically target youg Toga me i a effort to prevet experimetig ad subsequetly early uptake of tobacco products at a early age. Whilst oly 9.3 of Togas are curret drikers (drak i the past 30 days), it is heavy alcohol drikig that presets a public health challege i Toga. Agai, Toga me are particular at risk with 51 cosumig 6 or more stadard alcoholic driks o a drikig day, compared to 24.2 of wome. These estimates are either similar or eve substatially lower tha those reported for Cook Islads (me: 89.3, wome: 70.7) ad America Samoa (me: 49.6, wome: 33.9; based o 5+ driks) Noetheless, the magitude of bige drikig i Toga is likely to place Togas at icreased risks of NCDs ad ijuries, ad health promotio efforts to icrease awareess of the harmful effects of heavy drikig ca cotribute to reduce these rates. The survey foud that the majority of the survey populatio cosumed less tha the recommeded itake of fruit ad vegetable (five or more serves of fruit ad vegetables per day). The low level of fruit ad/or vegetable cosumptio did ot differ sigificatly betwee me ad wome or across age groups. Substatial structural ad policy chages will be critical to effect the Toga food eviromets, ad before ay shift away from the tastes for high-fat, high-sugar ad high-salt products ca be expected. 57

59 Approximately 1 i 4 Togas do ot egage i sufficiet levels of physical activity to cofer health beefits. For those who are sufficietly active, time spet o physical activity as part of work cotributed the most to the overall activity level. Not surprisigly, egagig i physical activity through work, trasport or as part of leisure decrease with icreasig age for both me ad wome. Creatig a eablig physical eviromet supportive of physical activity, ad complemeted by health promotio activities to promote regular moderateitesity physical activity doe as part of everyday life are ecessary to produce measureable health beefits at both idividual ad populatio level. The curret STEPS survey foud high rates of overweight ad obesity amog Toga adults, with the rate beig slightly higher amog wome (94 ) tha me (87.3). The rates are similar to those reported for America Samoa (wome: 94.4; me: 92.7), ad Cook Islads (wome: 87.1; me: 89.8) Of cocer is that these high overweight/obesity rates already evidet i the youger age group (25-44 years). Targeted programs tailored to those most likely to beefit but also most vulerable to experiece rapid weight gai (e.g., youg adults) ca cofer substatial public health gais. Just over oe quarter of the survey populatio was foud to have elevated blood pressure. Hypertesio rates icreased substatially with age across both geders, placig the older age groups at a elevated risk of developig stroke or cardiovascular disease. Nearly half of the survey populatio had raised blood cholesterol, with o sigificat differece i proportios betwee me ad wome. About 1 i 4 surveyed (23.8) were at heighteed risk of developig diabetes based o their impaired fastig glycaemia level (capillary whole blood value 5.6mmol/L (100mg/dl) ad <6.1mmol/L (110mg/dl). Early detectio ad appropriate cliical maagemet of these physiological ad biochemical risk markers is highly critical to prevet the progressio to cardiovascular disease or diabetes. This survey foud a high prevalece of diabetes amog those aged years (overall 34.4; me: 29.7, wome: 38.6). Earlier STEPS surveys coducted i the Pacific betwee 2002 ad 2006 reported variable but also relatively high levels of diabetes rates amog people i the same age rage: 47 i America Samoa, 32 i Federated States of Microesia (Pohpei), 23 i Cook Islads, ad 28 i Kiribati Further ivestigatio of these data may provide isights ito potetial reasos for the variatios observed across these Pacific islad coutries ad over time. Ecouragig chages i behavioural risk factors over time The comparative aalysis show promisig chages i the four key modifiable risk factors of NCDs such as smokig, alcohol use, fruit ad vegetable itake ad physical activity. These risk factors drive NCD rates ad are cosidered as bottleecks i NCD prevetio ad cotrol (Govermet of Toga, 2010). Effectig chages i these behavioural factors through structural ad lifestyle chages will be essetial i order to impact the causal pathway of NCDs. The magitude of chage was particularly ecouragig for fruit ad vegetable itake ad physical activity. I 2012, sigificatly more Togas reported eatig more fruit ad vegetables combied compared to Sigificatly fewer Togas also were egagig i low levels of physical activity i 2012 compared to There is scope for improvemet, particularly i the areas of alcohol ad smokig, for prevetive ad health promotio efforts to cotiue to target i a attempt to reduce these rates. Methodological cosideratios 58

60 Over- or uder-estimatio of tobacco use, alcohol cosumptio, fruit ad vegetable itake, ad physical activity caot be dismissed due to the self-report of data. Differet data collectio methods used i 2004 (paper-based survey) ad i 2012 (PDA-based survey) may also impact the estimates observed. However, the STEPS questioaire uses validated measures, ad had bee tested for acceptability i the Toga cotext. This icluded coductig a pilot study to idetify ay potetial measuremet ad logistic difficulties that eeded to be addressed before the mai survey. Accordigly, STEPS field staff received comprehesive data collectio traiig ad the STEPS questios were asked of respodets usig locally developed showcards to facilitatig comprehesio. A limitatio of usig a cross-sectioal desig i STEPS surveys is that the data oly provides a sapshot of the risk factors compared to a logitudial desig where the same idividuals are moitored over time which would provide more accurate iformatio o determiats of behaviour chages. However, havig follow-up surveys such as the repeat 2012 STEPS survey which covered the same health behaviours usig the same survey istrumets ad data collectio procedures, compariso of these risk factors was possible. The high respose rate achieved idicated the acceptability of STEPS survey i Toga ad is a stregth of this study. Sustaied ad co-ordiated efforts critical to reverse the icidece of NCDs The people of Toga are at heighteed risks of o-commuicable diseases. About 1 i 2 of the surveyed populatio was classified as beig i a high-risk group (with 3-5 risk factors) for developig cardiovascular disease. Premature morbidity ad mortality associated with these NCD risk factors will ot oly icrease the burde o a already stretched health system but impact egatively o social ad ecoomic developmet of Toga. Sustaied, diverse ad co-ordiated atioal actios ivolvig health ad o-health parterships are critical to reversig some of the highest rates of NCD risk factors i the regio. Ecouragigly, the umber of Togas who reported egagig i NCD health risk behaviours decreased betwee 2004 ad For these promisig treds to cotiue existig public health efforts i Toga eed to be sustaied ad expaded ad ew parterships forged where ecessary, before Toga ca expect to see ay slowig dow i the icidece of NCDs. 7. RECOMMENDATIONS These recommedatios uderscore the importace for the Toga health systems ad parters to promote ad stregthe primary ad secodary prevetio of NCD risk factors ad NCD-related diseases through whole of-govermet ad whole-of-society approaches: Cotiue comprehesive tobacco cotrol ad ati-smokig programmes, like Tobaccofree workplaces ad Tobacco-free Hospital, to reduce smokig rates, i particular esure comprehesive bas o smokig i all public places ad provide cessatio support i all health facilities. Cotiue to icrease tobacco taxes which have bee showig to reduce tobacco prevalece. Tobacco cotrol i childre, like Tobacco-free Schools, eed to be further stregtheed sice the majority of adult tobacco users begi their tobacco use as teeagers, ad the 59

61 icreased price ad tax of tobacco products should decrease the prevalece of tobacco use amog childre effectively. Cotiue comprehesive public health programmes ad regulatios to reduce harmful alcohol cosumptio with a emphasis o prevetig youth cosumptio, regulatio of retail ad marketig ad developig public awareess programmes o the likages betwee alcohol use ad health outcomes. Alcohol cosumptio is also resposible for violece ad road traffic ijuries. Cotiue comprehesive healthy eatig programmes to icrease fruit ad vegetable itake, ad udertake policies ad regulatios to reduce excessive cosumptio of highfat, high-salt ad high-sugar foods icludig the ba of sale of sugar sweeteed beverages ad uhealthy foods iside schools. Cotiue comprehesive ad culturally-appropriate programmes to modify eviromets i order to promote daily physical activity such as walkig ad cyclig. WHO Package of Essetial NCD (PEN) Itervetio Project icludes CVD risk estimatio as a compoet. By idetifyig people at high risk of CVD i the ext 10 years, itervetios ca be directed at those who eed it most. The proportio of people with total CVD risk is relatively low ad the limited resources ca be used for them. Itegrated risk reductio usig pharmaceutical agets ad cousellig ca be more beeficial that idividual risk factor treatmet. Develop a system of commuity-based, outreached lifestyle support for the maagemet of idividuals at risk of NCDs or with diagosed NCDs focused o families ad chagig eatig ad dietary patters i homes. Promote the use of total cardiovascular risk estimatio ad provide maagemet as per atioal agreed protocols. Equip health workers ad health facilities with appropriate techology ad drugs ad medicies to maage ad treat hypertesio ad diabetes ad provide rehabilitatio services that are liked to commuity resources for survivors of heart attacks or strokes ad for amputatios. Develop facility-based targets for reductio of umbers of patiets who smoke, cosume too much salt, are hypertesive or diabetic. Itroduce iovative medical records systems that track idividuals with multiple risks for NCDs, through patiet-cards or family booklets that are moitored over by the health facility, like hospitals ad health cetres, over time. Coduct itesive aalyses ad extesive applicatio of the comparable Toga STEPS data to better uderstad the associatios betwee behavioural, physical ad biochemical risk factors ad chroic disease status over time. Cosider repeat STEPS surveys to further moitor treds at 6-8 year itervals, addig expaded quatitative questios (e.g., salt, sugar, fat itake). These surveillace data would provide evidece of et gais i NCD prevetio ad cotrol efforts across Toga ad over time. 60

62 APPENDICES 61

63 Appedix 1. Kigdom of Toga STEPS Survey Questioaire Toga Natioal NCD STEPS Survey Istrumet (Core ad Expaded) The WHO STEPwise approach to chroic disease risk factor surveillace (STEPS) 62

64 Participat Idetificatio Number WHO STEPS Istrumet for Chroic Disease Risk Factor Surveillace Toga 2012 Survey Iformatio Locatio ad Date Respose Code 1 Cluster/Cetre/Village ID I1 2 Cluster/Cetre/Village ame I2 3 Iterviewer ID I3 4 Date of completio of the istrumet dd mm year I4 Participat Id Number Coset, Iterview Laguage ad Name Respose Code Yes 1 5 Coset has bee read ad obtaied No 2 If NO, END I5 6 Time of iterview (24 hour clock) 7 Family Surame : hrs mis 8 First Name I9 Record ad file idetificatio iformatio (I5 to I10) separately from the completed questioaire. I7 I8 63

65 Participat Idetificatio Number Step 1 Demographic Iformatio CORE: Demographic Iformatio Questio Respose Code 9 Sex (Record Male / Female as observed) Male 1 Female 2 C1 10 What is your date of birth? Do't Kow If kow, Go to C4 dd mm year C2 11 How old are you? Years C3 12 I total, how may years have you spet at school or i full-time study (excludig pre-school)? Years C4 EXPANDED: Demographic Iformatio 13 What is the highest level of educatio you have completed? No formal schoolig 1 Less tha primary school 2 Primary school completed 3 Secodary school completed 4 College/Uiversity completed 5 Post graduate degree 6 Refused 88 C5 14 What is your ethic backgroud? Toga 1 No-Toga 2 Refused 88 C6 15 What is your marital status? Never married 1 Curretly married 2 Separated 3 Divorced 4 Widowed 5 Cohabitatig 6 Refused 88 C7 Govermet employee 1 Which of the followig best describes your mai work status over the past 12 moths? No-govermet employee 2 Self-employed 3 No-paid 4 16 Studet 5 Homemaker 6 C8 Retired 7 Uemployed (able to work) 8 (USE SHOWCARD) Uemployed (uable to work) 9 Refused How may people older tha 18 years, icludig yourself, live i your household? Number of people C9 64

66 Participat Idetificatio Number EXPANDED: Demographic Iformatio, Cotiued Questio Respose Code 18 Takig the past year, ca you tell me what the average earigs of the household have bee? (RECORD ONLY ONE, NOT ALL 3) Per week Go to T1 C10a OR per moth Go to T1 C10b OR per year Go to T1 C10c Refused 88 C10d Step 1 Behavioural Measuremets CORE: Tobacco Use Now I am goig to ask you some questios about various health behaviours. This icludes thigs like smokig, drikig alcohol, eatig fruits ad vegetables ad physical activity. Let's start with tobacco. Questio Respose Code 19 Have you ever smoked ay tobacco products? Yes 1 No 2 If No, go to T9a T1a 20 Do you curretly smoke ay tobacco products, such as cigarettes, cigars or pipes? (USE SHOWCARD) Yes 1 No 2 If No, go to T6 T1 21 Do you curretly smoke tobacco products daily? Yes 1 No 2 If No, go to T6 T2 22 How old were you whe you first started smokig daily? Age Do t kow 77 If Kow, go to T5a T3 Do you remember how log ago it was? I Years If Kow, go to T5a T4a 23 (RECORD ONLY 1, NOT ALL 3) OR i Moths If Kow, go to T5a T4b Do t kow 77 OR i Weeks T4c Maufactured cigarettes T5a 24 O average, how may of the followig do you smoke each day? (RECORD FOR EACH TYPE, USE SHOWCARD) Do t Kow 77 Had-rolled cigarettes Pipes full of tobacco Cigars, cheroots, cigarillos Other If Other, go to T5other, else go to T9a T5b T5c T5d T5e Durig the past 12 moths, have you tried to stop smokig? Durig ay visit to a doctor or health care provider i the past 12 moths, were you advised to quit smokig tobacco? Other (please specify): Yes 1 No 2 Yes 1 No 2 Go to T9a T5other X1 X2 NA/ did ot visit a doctor 77 65

67 Participat Idetificatio Number EXPANDED: Tobacco Use Questio Respose Code 27 I the past, did you ever smoke daily? Yes 1 No 2 If No, go to T9a T6 28 How old were you whe you stopped smokig daily? Age Do t Kow 77 If Kow, go to T9a T7 How log ago did you stop smokig daily? Years ago If Kow, go to T9a T8a (RECORD ONLY 1, NOT ALL 3) Do t Kow 77 Durig the past 7 days, o how may days did someoe i your home smoke whe you were preset? Durig the past 7 days, o how may days did someoe smoke i closed areas i your workplace (i the buildig, i a work area or a specific office) whe you were preset? OR OR Moths ago Weeks ago Number of days Do't kow 77 Number of days Do't kow or do't work i a closed area 77 If Kow, go to T9a T8b T8c T13 T14 CORE: Alcohol Cosumptio The ext questios ask about the cosumptio of alcohol. Questio Respose Code 32 Have you ever cosumed a alcoholic drik such as beer, wie, spirits, fermeted cider, etc? (USE SHOWCARD OR SHOW EXAMPLES) Yes 1 No 2 If No, go to D1 A1a Have you cosumed a alcoholic drik withi the past 12 moths? Durig the past 12 moths, how frequetly have you had at least oe alcoholic drik? (READ RESPONSES, USE SHOWCARD) Have you cosumed a alcoholic drik withi the past 30 days? Yes 1 No 2 If No, go to D1 Daily days per week days per week days per moth 4 Less tha oce a moth 5 Yes 1 No 2 If No, go to D1 A1b A2 A Durig the past 30 days, o how may occasios did you have at least oe alcoholic drik? Durig the past 30 days, whe you drak alcohol, o average, how may stadard alcoholic driks did you have durig oe drikig occasio? (USE SHOWCARD) Durig the past 30 days, what was the largest umber of stadard alcoholic driks you had o a sigle occasio, coutig all types of alcoholic driks together? Durig the past 30 days, how may times did you have for me: five or more for wome: four or more stadard alcoholic driks i a sigle drikig occasio? 66 Number Do't kow 77 Number Do't kow 77 Largest umber Do't Kow 77 Number of times Do't Kow 77 A4 A5 A6 A7

68 Participat Idetificatio Number EXPANDED: Alcohol Cosumptio Durig the past 30 days, whe you cosumed a alcoholic drik, how ofte was it with meals? Please do ot cout sacks. Durig each of the past 7 days, how may stadard alcoholic driks did you have each day? (USE SHOWCARD) Do't Kow 77 Durig or followig a drikig occasio, have you ever blacked out or woke up somewhere you do t kow or caot remember how you got there? After a drikig occasio, have you ever foud it hard to remember evets that occurred while you were drikig? Usually with meals 1 Sometimes with meals 2 Rarely with meals 3 Never with meals 4 Moday Tuesday Wedesday Thursday Friday Saturday Suday Yes 1 No Do ot remember 2 77 Yes 1 No 2 A8 A9a A9b A9c A9d A9e A9f A9g X3 X4 CORE: Diet The ext questios ask about the fruits ad vegetables that you usually eat. I have a utritio card here that shows you some examples of local fruits ad vegetables. Each picture represets the size of a servig. As you aswer these questios please thik of a typical week i the last year. Questio Respose Code I a typical week, o how may days do you eat fruit? (USE SHOWCARD) How may servigs of fruit do you eat o oe of those days? (USE SHOWCARD) I a typical week, o how may days do you eat vegetables? (USE SHOWCARD) How may servigs of vegetables do you eat o oe of those days? (USE SHOWCARD) EXPANDED: Diet What type of oil or fat is most ofte used for meal preparatio i your household? (USE SHOWCARD) (SELECT ONLY ONE) O average, how may meals per week do you eat that were ot prepared at a home? By meal, I mea breakfast, luch ad dier. 67 Number of days Do't Kow 77 If Zero days, go to D3 Number of servigs Do't Kow 77 Number of days Do't Kow 77 If Zero days, go to D5 Number of servigs Do t kow 77 Vegetable oil 1 Lard or suet 2 Butter or ghee 3 Margarie 4 Other 5 If Other, go to D5 other Noe i particular 6 Noe used 7 Do t kow 77 Other Number Do t kow 77 D1 D2 D3 D4 D5 D5other D6

69 Participat Idetificatio Number CORE: Physical Activity Next I am goig to ask you about the time you sped doig differet types of physical activity i a typical week. Please aswer these questios eve if you do ot cosider yourself to be a physically active perso. Thik first about the time you sped doig work. Thik of work as the thigs that you have to do such as paid or upaid work, study/traiig, household chores, harvestig food/crops, fishig or hutig for food, seekig employmet. I aswerig the followig questios 'vigorousitesity activities' are activities that require hard physical effort ad cause large icreases i breathig or heart rate, 'moderate-itesity activities' are activities that require moderate physical effort ad cause small icreases i breathig or heart rate. Questio Respose Code Work 50 Does your work ivolve vigorous-itesity activity that causes large icreases i breathig or heart rate like [carryig or liftig heavy loads, diggig or costructio work] for at least 10 miutes cotiuously? (USE SHOWCARD) Yes 1 No 2 If No, go to P 4 P1 51 I a typical week, o how may days do you do vigorous-itesity activities as part of your work? Number of days P How much time do you sped doig vigorous-itesity activities at work o a typical day? Hours : miutes : hrs mis Does your work ivolve moderate-itesity activity, that causes small icreases i breathig or heart rate such as brisk walkig [or carryig light loads] for at least 10 miutes cotiuously? (USE SHOWCARD) Yes 1 No 2 If No, go to P 7 P3 (a-b) P4 54 I a typical week, o how may days do you do moderate-itesity activities as part of your work? Number of days P5 How much time do you sped doig moderate-itesity P6 55 activities at work o a typical day? Hours : miutes : (a-b) hrs mis Travel to ad from places The ext questios exclude the physical activities at work that you have already metioed. Now I would like to ask you about the usual way you travel to ad from places. For example to work, for shoppig, to market, to place of worship. 56 Do you walk or use a bicycle (pedal cycle) for at least 10 miutes cotiuously to get to ad from places? Yes 1 No 2 If No, go to P 10 P7 57 I a typical week, o how may days do you walk or bicycle for at least 10 miutes cotiuously to get to ad from places? Number of days P8 58 How much time do you sped walkig or bicyclig for travel o a typical day? Hours : miutes : hrs mis P9 (a-b) 68

70 Participat Idetificatio Number CORE: Physical Activity, Cotiued Questio Respose Code Recreatioal activities The ext questios exclude the work ad trasport activities that you have already metioed. Now I would like to ask you about sports, fitess ad recreatioal activities (leisure) 59 Do you do ay vigorous-itesity sports, fitess or recreatioal (leisure) activities that cause large icreases i breathig or heart rate like [ruig or football] for at least 10 miutes cotiuously? (USE SHOWCARD) Yes 1 No 2 If No, go to P 13 P I a typical week, o how may days do you do vigorous-itesity sports, fitess or recreatioal (leisure) activities? Number of days How much time do you sped doig vigorous-itesity sports, fitess or recreatioal activities o a typical day? Hours : miutes : hrs mis Do you do ay moderate-itesity sports, fitess or recreatioal (leisure) activities that cause a small Yes 1 icrease i breathig or heart rate such as brisk walkig, [cyclig, swimmig, volleyball] for at least 10 miutes cotiuously? No 2 If No, go to P16 (USE SHOWCARD) P11 P12 (a-b) P13 63 I a typical week, o how may days do you do moderate-itesity sports, fitess or recreatioal (leisure) activities? Number of days P14 64 How much time do you sped doig moderate-itesity sports, fitess or recreatioal (leisure) activities o a typical day? Hours : miutes : hrs mis P15 (a-b) EXPANDED: Physical Activity Sedetary behaviour The followig questio is about sittig or recliig at work, at home, gettig to ad from places, or with frieds icludig time spet sittig at a desk, sittig with frieds, travelig i car, bus, trai, readig, playig cards or watchig televisio, but do ot iclude time spet sleepig. (USE SHOWCARD) 65 How much time do you usually sped sittig or recliig o a typical day? Hours : miutes : hrs mis P16 (a-b) 69

71 Participat Idetificatio Number CORE: History of Raised Blood Pressure Questio Respose Code Have you ever had your blood pressure measured by a doctor or other health worker? Have you ever bee told by a doctor or other health worker that you have raised blood pressure or hypertesio? 68 Have you bee told i the past 12 moths? Yes 1 No 2 If No, go to H6 Yes 1 No 2 If No, go to H6 Yes 1 No 2 H1 H2a H2b EXPANDED: History of Raised Blood Pressure Are you curretly receivig ay of the followig treatmets/advice for high blood pressure prescribed by a doctor or other health worker? Drugs (medicatio) that you have take i the past two weeks Yes 1 No 2 H3a Advice to reduce salt itake Yes 1 No 2 H3b 69 Advice or treatmet to lose weight Yes 1 No 2 H3c Advice or treatmet to stop smokig Yes 1 No 2 H3d Advice to start or do more exercise Yes 1 No 2 H3e 70 Have you ever see a traditioal healer for raised blood pressure or hypertesio? Yes 1 No 2 H4 71 Are you curretly takig ay herbal or traditioal remedy for your raised blood pressure? Yes 1 No 2 H5 70

72 Participat Idetificatio Number CORE: History of Diabetes Questio Respose Code 72 Have you ever had your blood sugar measured by a doctor or other health worker? Yes 1 No 2 If No, go to M1 H6 73 Have you ever bee told by a doctor or other health worker that you have raised blood sugar or diabetes? Yes 1 No 2 If No, go to M1 H7a 74 Have you bee told i the past 12 moths? Yes 1 No 2 H7b EXPANDED: History of Diabetes Are you curretly receivig ay of the followig treatmets/advice for diabetes prescribed by a doctor or other health worker? Yes 1 Isuli No 2 H8a Drugs (medicatio) that you have take i the past two weeks Yes 1 No 2 H8b 75 Special prescribed diet Yes 1 No 2 H8c Advice or treatmet to lose weight Yes 1 No 2 H8d Advice or treatmet to stop smokig Yes 1 No 2 H8e Advice to start or do more exercise Yes 1 No 2 H8f 76 Have you ever see a traditioal healer for diabetes or raised blood sugar? Yes 1 No 2 H9 77 Are you curretly takig ay herbal or traditioal remedy for your diabetes? Yes 1 No 2 H10 71

73 Participat Idetificatio Number Step 2 Physical Measuremets CORE: Height ad Weight Questio Respose Code 78 Iterviewer ID 79 Device IDs for height ad weight M1 Height M2a Weight M2b 80 Height i Cetimetres (cm). M3 81 Weight If too large for scale For wome: Are you pregat? CORE: Waist 83 Device ID for waist i Kilograms (kg). Yes 1 If Yes, go to M 8 No 2 M4 M5 M6 84 Waist circumferece i Cetimetres (cm) CORE: Blood Pressure 85 Iterviewer ID. M7 M8 86 Device ID for blood pressure 87 Cuff size used Small 1 Medium 2 Large 3 M9 M10 88 Readig 1 Systolic ( mmhg) Diastolic (mmhg) M11a M11b 89 Readig 2 Systolic ( mmhg) Diastolic (mmhg) M12a M12b 90 Readig 3 91 Durig the past two weeks, have you bee treated for raised blood pressure with drugs (medicatio) prescribed by a doctor or other health worker? Systolic ( mmhg) Diastolic (mmhg) Yes 1 No 2 M13a M13b M14 EXPANDED: Hip Circumferece ad Heart Rate 92 Hip circumferece i Cetimeters (cm). M15 72

74 Participat Idetificatio Number Step 3 Biochemical Measuremets CORE: Blood Glucose Questio Respose Code 93 Durig the past 12 hours have you had aythig to eat or drik, other tha water? Yes 1 No 2 B1 94 Techicia ID B2 95 Device ID B3 96 Time of day blood specime take (24 hour clock) Hours : miutes : hrs mis B4 97 Fastig blood glucose mmol/l mmol/l. B5 98 Today, have you take isuli or other drugs (medicatio) that have bee prescribed by a doctor or other health worker for raised blood glucose? CORE: Blood Lipids 99 Device ID Yes 1 No 2 B6 B7 100 Total cholesterol mmol/l mmol/l. B8 101 Durig the past two weeks, have you bee treated for raised cholesterol with drugs (medicatio) prescribed by a doctor or other health worker? Yes 1 No 2 B9 73

75 Appedix 2. The Data Book of the Kigdom of Toga STEPS Survey WHO STEPS Chroic Disease Risk Factor Surveillace DATA BOOK FOR THE KINGDOM OF TONGA

76 Demographic Iformatio Results Age group by sex Descriptio: Summary iformatio by age group ad sex of the respodets. Istrumet questio: Sex What is your date of birth? Age group ad sex of respodets Me Wome Both Sexes Educatio Descriptio: Mea umber of years of educatio amog respodets. Istrumet questio: I total, how may years have you spet at school or i full-time study (excludig pre-school)? Mea umber of years of educatio Me Wome Both Sexes Mea Mea Mea

77 Highest level of educatio Descriptio: Highest level of educatio achieved by the survey respodets. Istrumet questio: What is the highest level of educatio you have completed? Age Group No formal schoolig Highest level of educatio Me Less Primary tha Secodary school primary school completed school completed College/ Uiversity completed Post graduate degree completed Age Group No formal schoolig Highest level of educatio Wome Less Primary tha school primary completed school Secodary school completed College/ Uiversity completed Post graduate degree completed Age Group No formal schoolig Highest level of educatio Both Sexes Less Primary tha Secodary school primary school completed school completed College/ Uiversity completed Post graduate degree completed

78 Ethicity Descriptio: Summary results for the ethicity of the respodets. Istrumet Questio: What is your [isert relevat ethic group/racial group/cultural subgroup/others] backgroud? Ethic group of respodets Both Sexes Toga No-Toga Marital status Descriptio: Marital status of survey respodets. Istrumet questio: What is your marital status? Age Group Never married Curretly married Marital status Me Separated Divorced Widowed Cohabitig Age Group Never married Curretly married Marital status Wome Separated Divorced Widowed Cohabitig Age Group Never married Curretly married Marital status Both Sexes Separated Divorced Widowed Cohabitig

79 Employmet status Descriptio: Proportio of respodets i paid employmet ad those who are upaid. Upaid icludes persos who are o-paid, studets, homemakers, retired, ad uemployed. Istrumet questio: Which of the followig best describes your mai work status over the past 12 moths? Employmet status Me Nogovermet Govermet employee employee Selfemployed Upaid Employmet status Wome Nogovermet Govermet employee employee Selfemployed Upaid Employmet status Both Sexes Nogovermet Govermet employee employee Selfemployed Upaid

80 Upaid work ad uemployed Descriptio: Proportio of respodets i upaid work. Istrumet questio: Which of the followig best describes your mai work status over the past 12 moths? Age Group Upaid work ad uemployed Me Uemployed Nopaid maker Home- Studet Retired Able to Not able work to work Age Group Upaid work ad uemployed Wome Uemployed Nopaid maker Home- Studet Retired Able to Not able work to work Age Group Upaid work ad uemployed Both Sexes Uemployed Nopaid maker Home- Studet Retired Able to Not able work to work Per capita aual icome Descriptio: Mea reported per capita aual icome of respodets i local currecy. Istrumet questio: How may people older tha 18 years, icludig yourself, live i your household? Takig the past year, ca you tell me what the average earig of the household has bee? Mea aual per capita icome Mea

81 Tobacco Use Curret smokig Descriptio: Curret smokers amog all respodets. Istrumet questios: Have you ever smoked ay tobacco products? Do you curretly smoke ay tobacco products, such as cigarettes, cigars, or pipes? Do you curretly smoke tobacco products daily? Percetage of curret smokers Me Wome Both Sexes Curret Curret Curret smoker smoker smoker

82 Smokig Status Descriptio: Smokig status of all respodets. Istrumet questios: Have you ever smoked ay tobacco products? Do you curretly smoke ay tobacco products, such as cigarettes, cigars, or pipes? Do you curretly smoke tobacco products daily? Daily Smokig status Me Curret smoker Nodaily Former smoker No-smokers Never smoker Daily Smokig status Wome Curret smoker Nodaily Former smoker No-smokers Never smoker Daily Smokig status Both Sexes Curret smoker Nodaily Former smoker No-smokers Never smoker

83 Frequecy of smokig Descriptio: Percetage of curret daily smokers amog smokers. Istrumet questio: Have you ever smoked ay tobacco products? Do you curretly smoke ay tobacco products, such as cigarettes, cigars, or pipes? Do you curretly smoke tobacco products daily? Curret daily smokers amog smokers Me Wome Both Sexes Daily Daily Daily smokers smokers smokers Iitiatio of smokig Descriptio: Mea age of iitiatio ad mea duratio of smokig, i years, amog daily smokers (o total age group for mea duratio of smokig as age iflueces these values). Istrumet questios: How old were you whe you first started smokig daily? Do you remember how log ago it was? Mea age started smokig Me Wome Both Sexes Mea Mea Mea age age age Mea duratio of smokig Me Wome Both Sexes Mea Mea Mea age age age

84 Maufactured cigarette smokers Descriptio: Percetage of smokers who use maufactured cigarettes amog daily smokers. Istrumet questio: O average, how may of the followig do you smoke each day? Maufactured cigarette smokers amog daily smokers Me Wome Both Sexes Maufactured Mau- Mau- factured factured cigarette cigarette cigarette smoker smoker smoker

85 Amout of tobacco used amog smokers by type Descriptio: Mea amout of tobacco used by daily smokers per day, by type. Istrumet questio: O average, how may of the followig do you smoke each day? Age Group Mea amout of tobacco used by daily smokers by type Me Mea # of maufactured cig. Mea #of hadrolled cig. 95 CI Mea # of pipes of tobacco Mea amout of tobacco used by daily smokers by type Me Age Mea # Mea # Group of cigars, of other cheerots, type of cigarillos tobacco Age Group Mea amout of tobacco used by daily smokers by type Wome Mea # of maufactured cig. Mea #of hadrolled cig. 95 CI Mea # of pipes of tobacco Age Group Mea amout of tobacco used by daily smokers by type Wome Mea # Mea # of cigars, of other cheerots, type of cigarillos tobacco

86 Age Group Mea amout of tobacco used by daily smokers by type Both Sexes Mea # of maufactured cig. Mea #of hadrolled cig. 95 CI Mea # of pipes of tobacco Age Group Mea amout of tobacco used by daily smokers by type Both Sexes Mea # Mea # of cigars, of other cheerots, type of cigarillos tobacco

87 Frequecy of daily cigarette smokig Descriptio: Percetage of daily cigarette smokers smokig give quatities of maufactured or had-rolled cigarettes per day. Istrumet questios: O average, how may of the followig products do you smoke each day? Percetage of daily smokers smokig give quatities of maufactured or had-rolled cigarettes per day Me Age Group 25 < Cigs Cigs. Cigs. Cigs. Cigs Percetage of daily smokers smokig give quatities of maufactured or had-rolled cigarettes per day Wome Age Group 25 < Cigs Cigs. Cigs. Cigs. Cigs Percetage of daily smokers smokig give quatities of maufactured or had-rolled cigarettes per day Both Sexes Age Group 25 < Cigs Cigs. Cigs. Cigs. Cigs

88 Percetage of ex daily smokers i the populatio Descriptio: Percetage of ex-daily smokers amog all respodets ad the mea duratio, i years, sice ex-daily smokers quit smokig daily. Istrumet questio: I the past did you ever smoke daily? How old were you whe you stopped smokig daily? Ex-daily smokers amog all respodets Me Wome Both Sexes ex ex ex daily daily daily smokers smokers smokers Mea years sice cessatio Me Wome Both Sexes Mea Mea Mea years years years Cessatio Descriptio: Percetage of curret smokers who have tried to stop smokig durig the past 12 moths. Istrumet questios: Do you curretly smoke ay tobacco products, such as cigarettes, cigars, or pipes? Durig the past 12 moths, have you tried to stop smokig? Curret smokers who have tried to stop smokig Me Wome Both Sexes Tried Tried Tried to stop to stop to stop smokig smokig smokig

89 Advice to stop smokig Descriptio: Percetage of curret smokers who have bee advised by a doctor or other health worker to stop smokig, amog those smokers who have had a visit to a doctor or other health worker i the past 12 moths. Istrumet questios: Do you curretly smoke ay tobacco products, such as cigarettes, cigars, or pipes? Durig ay visit to a doctor or other health worker i the past 12 moths, were you advised to quit smokig tobacco? Curret smokers who have bee advised by doctor to stop smokig Me Wome Both Sexes Advised Advised Advised to stop to stop to stop smokig smokig smokig Exposure to ETS i home i past 7 days Descriptio: Percetage of respodets exposed to evirometal tobacco smoke i the home o oe or more days i the past 7 days. Istrumet questio: I the past 7 days, how may days did someoe i the house smoke whe you were preset? Exposed to ETS i home o 1 or more of the past 7 days Me Wome Both Sexes Exposed Exposed Exposed

90 Exposure to ETS i the workplace i past 7 days Descriptio: Percetage of respodets exposed to evirometal tobacco smoke i the workplace o oe or more days i the past 7 days. Istrumet questio: I the past 7 days, how may days did someoe smoke i closed areas i your workplace (i the buildig, i a work area or a specific office) whe you were preset? Exposed to ETS i the workplace o 1 or more of the past 7 days Me Wome Both Sexes Exposed Exposed Exposed

91 Alcohol Cosumptio Alcohol cosumptio status Descriptio: Alcohol cosumptio status of all respodets. Istrumet questios: Have you ever cosumed a alcoholic drik such as? Have you cosumed a alcoholic drik i the past 12 moths? Have you cosumed a alcoholic drik i the past 30 days? Curret driker (past 30 days) Alcohol cosumptio status Me Drak i Past past moths, moths ot curret abstaier Lifetime abstaier Curret driker (past 30 days) Alcohol cosumptio status Wome Drak i Past past moths, moths ot curret abstaier Lifetime abstaier Curret driker (past 30 days) Alcohol cosumptio status Both Sexes Drak i Past past moths, moths ot curret abstaier Lifetime abstaier

92 Frequecy of alcohol cosumptio Descriptio: Frequecy of alcohol cosumptio i the past 12 moths amog those respodets who have drak i the last 12 moths. Istrumet questio: Durig the past 12 moths, how frequetly have you had at least oe alcoholic drik? Age Group Daily Frequecy of alcohol cosumptio i the past 12 moths Me days p. days p. days p. week week moth < oce a moth Age Group Frequecy of alcohol cosumptio i the past 12 moths Wome Daily days p. days p. days p. week week moth < oce a moth Age Group Daily Frequecy of alcohol cosumptio i the past 12 moths Both Sexes days p. days p. days p. week week moth < oce a moth

93 Drikig occasios i the past 30 days Descriptio: Mea umber of occasios with at least oe drik i the past 30 days amog curret (past 30 days) drikers. Istrumet questio: Durig the past 30 days, o how may occasios did you have at least oe alcoholic drik? Mea umber of drikig occasios i the past 30 days amog curret (past 30 days) drikers Me Wome Both Sexes Mea Mea Mea Stadard driks per drikig day Descriptio: Mea umber of stadard driks cosumed o a drikig occasio amog curret (past 30 days) driker. Istrumet questio: Durig the past 30 days, whe you drak alcohol, o average, how may stadard alcoholic driks did you have durig oe occasio? Mea umber of stadard driks per drikig occasio amog curret (past 30 days) drikers Me Wome Both Sexes Mea Mea Mea

94 Average volume drikig categories amog all respodets Descriptio: Percetage of respodets egagig i category II ad category III drikig. Category III is defied as drikig 60g of pure alcohol o average per day for me ad 40 g for wome. Category II is defied as drikig g of pure alcohol o average per day for me ad g for wome. A stadard drik cotais approximately 10g of pure alcohol. Istrumet questios: Durig the past 30 days, o how may occasios did you have at least oe alcoholic drik? Durig the past 30 days, whe you drak alcohol, o average, how may stadard alcoholic driks did you have durig oe occasio? Category III drikig amog all respodets Me Wome Both Sexes Category Category Category III III III Category II drikig amog all respodets Me Wome Both Sexes Category Category Category II II II

95 Average volume drikig categories amog curret (past 30 days) drikers Descriptio: Percetage of curret (last 30 days) driker egagig i category I, category II ad category III drikig. Category III is defied as drikig 60g of pure alcohol o average per day for me ad 40 g for wome. Category II is defied as drikig g of pure alcohol o average per day for me ad g for wome. Category I is defied as drikig <40g of pure alcohol o average per day for me ad <20 for wome. A stadard drik cotais approximately 10g of pure alcohol. Istrumet questios: Durig the past 30 days, o how may occasios did you have at least oe alcoholic drik? Durig the past 30 days, whe you drak alcohol, o average, how may stadard alcoholic driks did you have durig oe occasio? Category I, II ad III drikig amog curret (past 30 days) drikers Me Category Category Category III II I Category I, II ad III drikig amog curret (past 30 days) drikers Wome Category Category Category III II I Category I, II ad III drikig amog curret (past 30 days) drikers Both Sexes Category Category Category III II I

96 Largest umber of driks i the past 30 days Descriptio: Largest umber of driks cosumed durig a sigle occasio i the past 30 days amog curret (past 30 days) driker). Istrumet questio: Durig the past 30 days what was the largest umber of stadard alcoholic driks you had o a sigle occasio, coutig all types of alcoholic driks together? Mea maximum umber of driks cosumed o oe occasio i the past 30 days Me Wome Both Sexes Mea Mea Mea maximum maximum maximum umber umber umber

97 Five/four or more driks o a sigle occasio Descriptio: Percetage of me who had five or more/wome who had four or more driks o ay day i the past 30 days durig a sigle occasio amog the total populatio. Istrumet questio: Durig the past 30 days, how may times did you have for me: five or more for wome: four or more stadard alcoholic driks i a sigle drikig occasio? Five/four or more driks o a sigle occasio at least oce durig the past 30 days amog total populatio Me Wome 5 driks 4driks Five/four or more driks o a sigle occasio Descriptio: Mea umber of times i the past 30 days o which curret (past 30 days) driker cosumed five (for me)/four (for wome) or more driks durig a sigle occasio amog curret (past 30 days) drikers. Istrumet questio: Durig the past 30 days, how may times did you have for me: five or more for wome: four or more stadard alcoholic driks i a sigle drikig occasio? Mea umber of times with five/four or more driks durig a sigle occasio i the past 30 days amog curret drikers Me Wome Mea umber Mea umber of times of times

98 Drikig with meals Descriptio: Percetage of curret (past 30 days) drikers who usually, sometimes, rarely or ever drik with meals. Istrumet questios: Durig the past 30 days, whe you cosumed a alcoholic drik, how ofte was it with meals? Please do ot cout sacks. Usually with meals Drikig with meals amog curret driker Me Rarely Sometimes with with meals meals Never with meals Usually with meals Drikig with meals amog curret driker Wome Rarely Sometimes with with meals meals Never with meals Usually with meals Drikig with meals amog curret driker Both Sexes Rarely Sometimes with with meals meals Never with meals

99 Past 7 days drikig Descriptio: Frequecy ad quatity of driks cosumed i the past 7 days by curret (past 30 days) drikers, grouped ito three categories. Istrumet questio: Durig each of the past 7 days, how may stadard driks of ay alcoholic drik did you have each day? Frequecy ad quatity of driks cosumed i the past 7 days Me Drak o 4+ driks o driks i 7 days ay day days Frequecy ad quatity of driks cosumed i the past 7 days Wome Drak o 4+ driks o driks i 7 days ay day days Frequecy ad quatity of driks cosumed i the past 7 days Both Sexes Drak o 4+ days

100 Fruit ad Vegetable Cosumptio Mea umber of days of fruit ad vegetable cosumptio Descriptio: mea umber of days fruit ad vegetables cosumed. Istrumet questios: I a typical week, o how may days do you eat fruit? I a typical week, o how may days do you eat vegetables? Mea umber of days fruit cosumed i a typical week Me Wome Both Sexes Mea Mea Mea umber umber umber of days of days of days Mea umber of days vegetables cosumed i a typical week Me Wome Both Sexes Mea Mea Mea umber umber umber of days of days of days

101 Mea umber of servigs of fruit ad vegetable cosumptio Descriptio: mea umber of fruit, vegetable, ad combied fruit ad vegetable servigs o average per day. Istrumet questios: I a typical week, o how may days do you eat fruit? How may servigs of fruit do you eat o oe of those days? I a typical week, o how may days do you eat vegetables? How may servigs of vegetables do you eat o oe of those days? Mea umber of servigs of fruit o average per day Me Wome Both Sexes Mea Mea Mea umber umber umber of of of servigs servigs servigs Mea umber of servigs of vegetables o average per day Me Wome Both Sexes Mea Mea Mea umber umber umber of of of servigs servigs servigs Mea umber of servigs of fruit ad/or vegetables o average per day Me Wome Both Sexes Mea Mea Mea umber umber umber of of of servigs servigs servigs

102 Fruit ad vegetable cosumptio per day Descriptio: Frequecy of fruit ad/or vegetable cosumptio. Istrumet questios: I a typical week, o how may days do you eat fruit? How may servigs of fruit do you eat o oe of those days? I a typical week, o how may days do you eat vegetables? How may servigs of vegetables do you eat o oe of those days? Age Group o fruit ad/or vegetables Number of servigs of fruit ad/or vegetables o average per day Me 1-2 servigs 3-4 servigs 5 servigs Age Group o fruit ad/or vegetables Number of servigs of fruit ad/or vegetables o average per day Wome 1-2 servigs 3-4 servigs 5 servigs Age Group o fruit ad/or vegetables Number of servigs of fruit ad/or vegetables o average per day Both Sexes 1-2 servigs 3-4 servigs 5 servigs

103 Fruit ad vegetable cosumptio per day Descriptio: Percetage of those eatig less tha five servigs of fruit ad/or vegetables o average per day. Istrumet questios: I a typical week, o how may days do you eat fruit? How may servigs of fruit do you eat o oe of those days? I a typical week, o how may days do you eat vegetables? How may servigs of vegetables do you eat o oe of those days? Less tha five servigs of fruit ad/or vegetables o average per day Me Wome Both Sexes < five servigs per day < five servigs per day < five servigs per day Type of oil used most frequetly Descriptio: Type of oil or fat most ofte used for meal preparatio i households (preseted oly for both sexes because results are for the household ot idividuals). Istrumet questio: What type of oil or fat is most ofte used for meal preparatio i your household? (households) Vegetable oil Type of oil or fat most ofte used for meal preparatio i household Lard Butter Margarie (house -holds) Type of oil or fat most ofte used for meal preparatio i household oe i particular Noe used Other Eatig outside home Descriptio: Mea umber of meals per week eate outside a home. Istrumet questio: O average, how may meals per week do you eat that were ot prepared at a home? By meal, I mea breakfast, luch ad dier. Mea umber of meals eate outside a home 102

104 Me Wome Both Sexes mea mea mea

105 Physical Activity Itroductio A populatio's physical activity (or iactivity) ca be described i differet ways. The two most commo ways are (1) to estimate a populatio's mea or media physical activity usig a cotiuous idicator such as MET-miutes per week or time spet i physical activity, ad (2) to classify a certai percetage of a populatio as 'iactive' by settig up a cutpoit for a specific amout of physical activity. Whe aalyzig GPAQ data, both cotiuous as well as categorical idicators are used. Metabolic Equivalet (MET) METs (Metabolic Equivalets) are commoly used to express the itesity of physical activities, ad are also used for the aalysis of GPAQ data. Applyig MET values to activity levels allows us to calculate total physical activity. MET is the ratio of a perso's workig metabolic rate relative to the restig metabolic rate. Oe MET is defied as the eergy cost of sittig quietly, ad is equivalet to a caloric cosumptio of 1 kcal/kg/hour. For the aalysis of GPAQ data, existig guidelies have bee adopted: It is estimated that, compared to sittig quietly, a perso's caloric cosumptio is four times as high whe beig moderately active, ad eight times as high whe beig vigorously active. Therefore, for the calculatio of a perso's total physical activity usig GPAQ data, the followig MET values are used: Domai MET value Work Moderate MET value = 4.0 Vigorous MET value = 8.0 Trasport Cyclig ad walkig MET value = 4.0 Recreatio Moderate MET value = 4.0 Vigorous MET value = 8.0 WHO global recommedatios o physical activity for health For the calculatio of the categorical idicator o the recommeded amout of physical activity for health, the total time spet i physical activity durig a typical week ad the itesity of the physical activity are take ito accout. Throughout a week, icludig activity for work, durig trasport ad leisure time, adults should do at least 150 miutes of moderate-itesity physical activity OR 75 miutes of vigorous-itesity physical activity OR A equivalet combiatio of moderate- ad vigorous-itesity physical activity achievig at least 600 MET-miutes. Former recommedatios for compariso For compariso purposes, tables presetig cut-offs from former recommedatios are also icluded i GPAQ data aalysis. 104

106 purposes The three levels of physical activity suggested for classifyig populatios were low, moderate, ad high. The criteria for these levels are show below. High A perso reachig ay of the followig criteria is classified i this category: - Vigorous-itesity activity o at least 3 days achievig a miimum of at least 1,500 MET-miutes/week OR - 7 or more days of ay combiatio of walkig, moderate- or vigorousitesity activities achievig a miimum of at least 3,000 MET-miutes per week. Moderate A perso ot meetig the criteria for the "high" category, but meetig ay of the followig criteria is classified i this category: - 3 or more days of vigorous-itesity activity of at least 20 miutes per day OR - 5 or more days of moderate-itesity activity or walkig of at least 30 miutes per day OR - 5 or more days of ay combiatio of walkig, moderate- or vigorousitesity activities achievig a miimum of at least 600 MET-miutes per week. Low A perso ot meetig ay of the above metioed criteria falls i this category. 105

107 Not meetig WHO recommedatios o physical activity for health Descriptio: Percetage of respodets ot meetig WHO recommedatios o physical activity for health (respodets doig less tha 150 miutes of moderateitesity physical activity per week, or equivalet). Istrumet questios activity at work travel to ad from places recreatioal activities Not meetig WHO recommedatios o physical activity for health Me Wome Both Sexes ot ot ot meetig meetig meetig recs recs recs Levels of total physical activity Descriptio: Percetage of respodets classified ito three categories of total physical activity. Istrumet questios: activity at work travel to ad from places recreatioal activities Level of total physical activity Me Low High Moderate Level of total physical activity Wome Low High Moderate Level of total physical activity 106

108 Both Sexes Low High Moderate Total physical activitymea Descriptio: Mea miutes of total physical activity o average per day. Istrumet questios activity at work travel to ad from places recreatioal activities Mea miutes of total physical activity o average per day Me Wome Both Sexes Mea Mea Mea miutes miutes miutes Total physical activitymedia Descriptio: Media miutes of total physical activity o average per day. Istrumet questios activity at work travel to ad from places recreatioal activities Media miutes of total physical activity o average per day Me Wome Both Sexes Iterquartile Media quartile Media Iter- rage miutes rage miutes (P25-P75) (P25-P75) Media miutes Iterquartile rage (P25-P75)

109 Domaispecific physical activitymea Descriptio: Mea miutes spet i work-, trasport- ad recreatio-related physical activity o average per day. Istrumet questios: activity at work travel to ad from places recreatioal activities Mea miutes of work-related physical activity o average per day Me Wome Both Sexes Mea Mea Mea miutes miutes miutes Mea miutes of trasport-related physical activity o average per day Me Wome Both Sexes Mea Mea Mea miutes miutes miutes Mea miutes of recreatio-related physical activity o average per day Me Wome Both Sexes Mea Mea Mea miutes miutes miutes

110 Domaispecific physical activity - media Descriptio: Media miutes spet o average per day i work-, trasport- ad recreatio-related physical activity. Istrumet questios: activity at work travel to ad from places recreatioal activities Media miutes of work-related physical activity o average per day Me Wome Both Sexes Iterquartile Media quartile Media quartile Iter- Iter- Media miutes rage miutes rage miutes rage (P25-P75) (P25-P75) (P25-P75) Media miutes of trasport-related physical activity o average per day Me Wome Both Sexes Iterquartile Media quartile Media quartile Iter- Iter- Media miutes rage miutes rage miutes rage (P25-P75) (P25-P75) (P25-P75) Media miutes of recreatio-related physical activity o average per day Me Wome Both Sexes Iterquartile Media quartile Media quartile Iter- Iter- Media miutes rage miutes rage miutes rage (P25-P75) (P25-P75) (P25-P75)

111 No physical activity by domai Descriptio: Percetage of respodets classified as doig o work-, trasport- or recreatioal-related physical activity. Istrumet questios: activity at work travel to ad from places recreatioal activities No work-related physical activity Me Wome Both Sexes o o o activity activity activity at work at work at work No trasport-related physical activity Me Wome Both Sexes o o o activity activity activity for for for trasport trasport trasport No recreatio-related physical activity Me Wome Both Sexes o o o activity at activity at activity at recreatio recreatio recreatio

112 Compositio of total physical activity Descriptio: Percetage of work, trasport ad recreatioal activity cotributig to total activity. Istrumet questios: activity at work travel to ad from places recreatioal activities Activity from work Compositio of total physical activity Me Activity for trasport Activity durig leisure time Activity from work Compositio of total physical activity Wome Activity for trasport Activity durig leisure time Activity from work Compositio of total physical activity Both Sexes Activity for trasport Activity durig leisure time

113 No vigorous physical activity Descriptio: Percetage of respodets ot egagig i vigorous physical activity. Istrumet questios: activity at work recreatioal activities No vigorous physical activity Me Wome Both Sexes o o o vigorous vigorous vigorous activity activity activity

114 Sedetary Descriptio: Miutes spet i sedetary activities o a typical day. Istrumet questio: sedetary behaviour Miutes spet i sedetary activities o average per day Me Mea miutes Media miutes Iter-quartile rage (P25-P75) Miutes spet i sedetary activities o average per day Wome Mea miutes Media miutes Iter-quartile rage (P25-P75) Miutes spet i sedetary activities o average per day Both Sexes Mea miutes Media miutes Iter-quartile rage (P25-P75)

115 Blood Pressure ad Diabetes History Blood pressure measuremet ad diagosis Descriptio: Blood pressure measuremet ad diagosis amog all respodets. Istrumet questios: Have you ever had your blood pressure measured by a doctor or other health worker? Have you ever bee told by a doctor or other health worker that you have raised blood pressure or hypertesio? Have you bee told i the past 12 moths? Age Group Never measured Blood pressure measuremet ad diagosis Me diagosed, measured, but ot ot withi past diagosed 12 moths diagosed withi past 12 moths Blood pressure measuremet ad diagosis Wome Age Group diagosed, Never measured, diagosed but ot measured ot withi past withi past diagosed 12 moths 12 moths Age Group Never measured Blood pressure measuremet ad diagosis Both sexes diagosed, measured, but ot ot withi past diagosed 12 moths diagosed withi past 12 moths

116 Blood pressure treatmet amog those diagosed Descriptio: raised blood pressure treatmet results amog those previously diagosed with raised blood pressure. Istrumet questios: Have you ever bee told by a doctor or other health worker that you have raised blood pressure or hypertesio? Are you curretly receivig ay of the followig treatmets/advice for high blood pressure prescribed by a doctor or other health worker? Drugs (medicatio) that you have take i the last 2 weeks? Curretly takig blood pressure drugs prescribed by doctor or health worker amog those diagosed Me Wome Both Sexes takig takig takig meds meds meds

117 Blood pressure lifestyle advice Descriptio: Percetage of respodets who received lifestyle advice from a doctor or health worker to treat raised blood pressure amog those previously diagosed with raised blood pressure. Istrumet questios: Whe was your blood pressure last measured by a health professioal? Have you ever bee told by a doctor or other health worker that you have raised blood pressure or hypertesio? Are you curretly receivig ay of the followig treatmets/advice for high blood pressure prescribed by a doctor or other health worker? Advised by doctor or health worker to reduce salt itake amog those previously diagosed Me Wome Both Sexes Advised by doctor or health worker to lose weight amog those previously diagosed Me Wome Both Sexes Advised by doctor or health worker to stop smokig amog those previously diagosed Me Wome Both Sexes Advised by doctor or health worker to start or do more exercise amog those previously diagosed Me Wome Both Sexes

118 Blood pressure advice by a traditioal healer Descriptio: Percetage of respodets who have sought advice or received treatmet from traditioal healers for raised blood pressure amog those previously diagosed with raised blood pressure. Istrumet questios: Whe was your blood pressure last measured by a health professioal? Have you ever bee told by a doctor or other health worker that you have raised blood pressure or hypertesio? Have you ever see a traditioal healer for raised blood pressure? Are you curretly takig ay herbal or traditioal remedy for your high blood pressure? See a traditioal healer amog those previously diagosed Me Wome Both Sexes Curretly takig herbal or traditioal remedy for high blood pressure amog those previously diagosed Me Wome Both Sexes

119 Diabetes measuremet ad diagosis Descriptio: Diabetes measuremet ad diagosis amog all respodets. Istrumet questios: Have you ever had your blood sugar measured by a doctor or other health worker? Have you ever bee told by a doctor or other health worker that you have raised blood sugar or diabetes? Have you bee told i the past 12 moths? Age Group Never measured Blood sugar measuremet ad diagosis Me diagosed, measured, but ot ot withi past diagosed 12 moths diagosed withi past 12 moths Age Group Never measured Blood sugar measuremet ad diagosis Wome diagosed, measured, but ot ot withi past diagosed 12 moths diagosed withi past 12 moths Age Group Never measured Blood sugar measuremet ad diagosis Both sexes diagosed, measured, but ot ot withi past diagosed 12 moths diagosed withi past 12 moths

120 Diabetes treatmet amog those diagosed Descriptio: Diabetes treatmet results amog those previously diagosed with raised blood sugar or diabetes. Istrumet questios: Have you ever had your blood sugar measured by a doctor or other health worker? Have you ever bee told by a doctor or other health worker that you have raised blood sugar or diabetes? Are you curretly receivig ay of the followig treatmets/advice for diabetes prescribed by a doctor or other health worker? Curretly takig isuli prescribed for diabetes amog those previously diagosed Me Wome Both Sexes takig takig takig isuli isuli isuli Curretly takig oral drugs prescribed for diabetes amog those previously diagosed Me Wome Both Sexes takig takig takig meds meds meds

121 Diabetes lifestyle advice Descriptio: Percetage of respodets who received diabetes lifestyle advice from a doctor or health worker amog those previously diagosed with diabetes. Istrumet questios: Have you ever had your blood sugar measured by a doctor or other health worker? Have you ever bee told by a doctor or other health worker that you have raised blood sugar or diabetes? Are you curretly receivig ay of the followig treatmets/advice for diabetes prescribed by a doctor or other health worker? Advised by doctor or health worker to have special prescribed diet amog those previously diagosed Me Wome Both Sexes Advised by doctor or health worker to lose weight amog those previously diagosed Me Wome Both Sexes Advised by doctor or health worker to stop smokig amog those previously diagosed Me Wome Both Sexes Advised by doctor or health worker to start or do more exercise amog those previously diagosed Me Wome Both Sexes

122 Diabetes advice by traditioal healer Descriptio: Percetage of respodets who are have sought advice or treatmet from traditioal healers for diabetes amog those previously diagosed. Istrumet questios: Have you ever had your blood sugar measured by a doctor or other health worker? Have you ever bee told by a doctor or other health worker that you have raised blood sugar or diabetes? Have you ever see a traditioal healer for diabetes or raised blood sugar? Are you curretly takig ay herbal or traditioal remedy for your diabetes? See a traditioal healer for diabetes amog those previously diagosed Me Wome Both Sexes Curretly takig herbal or traditioal treatmet for diabetes amog those previously diagosed Me Wome Both Sexes

123 Physical Measuremets Height, weight ad BMI Descriptio: Mea height, weight, ad body mass idex amog all respodets (excludig pregat wome for weight ad BMI). Istrumet questios: Height Weight Mea height (cm) Me Wome Mea Mea Mea weight (kg) Me Wome Mea Mea Mea BMI (kg/m 2 ) Me Wome Both Sexes Mea Mea Mea

124 BMI categories Descriptio: Percetage of respodets (excludig pregat wome) i each BMI category. Istrumet questios: Height Weight BMI classificatios Me Age Group Uderweight weight Normal BMI Obese < BMI classificatios Wome Age Group Uderweight weight Normal BMI Obese < Age Group Uderweight <18.5 BMI classificatios Both Sexes Normal weight BMI Obese BMI 25 Descriptio: Percetage of respodets beig classified as overweight (BMI 25) Istrumet questios: Height Weight BMI 25 Me Wome Both Sexes BMI 25 BMI 25 BMI

125 Waist circumferece Descriptio: Mea waist circumferece amog all respodets (excludig pregat wome). Istrumet questio: Waist circumferece measuremet Waist circumferece (cm) Me Wome Mea Mea Hip circumferece Descriptio: Mea hip circumferece amog all respodets (excludig pregat wome). Istrumet questio: Hip circumferece measuremet Hip circumferece (cm) Me Wome Mea Mea Waist / hip ratio Descriptio: Mea waist-to-hip ratio amog all respodets (excludig pregat wome). Istrumet questio: Waist ad hip circumferece measuremet Mea waist / hip ratio Me Wome Mea Mea

126 Blood pressure Descriptio: Mea blood pressure amog all respodets, icludig those curretly o medicatio for raised blood pressure. Istrumet questio: Readig 1-3 systolic ad diastolic blood pressure Mea systolic blood pressure (mmhg) Me Wome Both Sexes Mea Mea Mea Mea diastolic blood pressure (mmhg) Me Wome Both Sexes Mea Mea Mea

127 Raised blood pressure Descriptio: Percetage of respodets with raised blood pressure. Istrumet questio: Durig the past two weeks, have you bee treated for raised blood pressure with drugs (medicatio) prescribed by a doctor or other health worker? Readig 1-3 systolic ad diastolic blood pressure SBP 140 ad/or DBP 90 mmhg, excludig those o medicatio for raised blood pressure Me Wome Both Sexes SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised blood pressure Me Wome Both Sexes SBP 160 ad/or DBP 100 mmhg, excludig those o medicatio for raised blood pressure Me Wome Both Sexes SBP 160 ad/or DBP 100 mmhg or curretly o medicatio for raised blood pressure Me Wome Both Sexes

128 Treatmet ad cotrol of raised blood pressure Descriptio: Percetage of respodets with treated ad/or cotrolled of raised blood pressure amog those with raised blood pressure (SBP 140 ad/or DBP 90 mmhg) or curretly o medicatio for raised blood pressure. Istrumet questios: Durig the past two weeks, have you bee treated for raised blood pressure with drugs (medicatio) prescribed by a doctor or other health worker? Readig 1-3 systolic ad diastolic blood pressure Respodets with treated ad/or cotrolled raised blood pressure Me O medicatio O Not o ad medicatio medicatio SBP<140 ad SBP 140 ad SBP 140 ad ad/ordbp 90 ad/ordbp 90 DBP< Respodets with treated ad/or cotrolled raised blood pressure Wome O medicatio O Not o ad medicatio medicatio SBP<140 ad SBP 140 ad SBP 140 ad ad/ordbp 90 ad/ordbp 90 DBP< Respodets with treated ad/or cotrolled raised blood pressure Both Sexes O medicatio O Not o ad medicatio medicatio SBP<140 ad SBP 140 ad SBP 140 ad ad/ordbp 90 ad/ordbp 90 DBP<

129 Biochemical Measuremets Mea fastig blood glucose Descriptio: mea fastig blood glucose results icludig those curretly o medicatio for diabetes (o-fastig recipiets excluded). Istrumet questios: Durig the last 12 hours have you had aythig to eat or drik, other tha water? Blood glucose measuremet Mea fastig blood glucose (mmol/l) Me Wome Both Sexes Mea Mea Mea Mea fastig blood glucose (mg/dl) Me Wome Both Sexes Mea Mea Mea

130 Raised blood glucose Descriptio: Categorizatio of respodets ito blood glucose level categories ad percetage of respodets curretly o medicatio for raised blood glucose (o-fastig recipiets excluded). Istrumet questios: Are you curretly receivig ay of the followig treatmets for diabetes prescribed by a doctor or other health worker? Isuli? Oral drugs (medicatio) that you have take i the last 2 weeks? Durig the last 12 hours have you had aythig to eat or drik, other tha water? Blood glucose measuremet Today, have you take isuli or other drugs (medicatio) that have bee prescribed by a doctor or other health worker? Impaired Fastig Glycaemia* Me Wome Both Sexes Raised blood glucose or curretly o medicatio for diabetes ** Me Wome Both Sexes Curretly o medicatio for diabetes Me Wome Both Sexes * Impaired fastig glycaemia is defied as either plasma veous value: 6.1mmol/L (110mg/dl) ad <7.0mmol/L (126mg/dl) capillary whole blood value: 5.6mmol/L (100mg/dl) ad <6.1mmol/L (110mg/dl) ** Raised blood glucose is defied as either plasma veous value: 7.0 mmol/l (126 mg/dl) capillary whole blood value: 6.1 mmol/l (110 mg/dl) 129

131 Total cholesterol Descriptio: Mea total cholesterol amog all respodets icludig those curretly o medicatio for raised cholesterol. Istrumet questios: Total cholesterol measuremet Mea total cholesterol (mmol/l) Me Wome Both Sexes Mea Mea Mea Mea total cholesterol (mg/dl) Me Wome Both Sexes Mea Mea Mea

132 Raised total cholesterol Descriptio: Percetage of respodets with raised total cholesterol ad percetage of respodets curretly o medicatio for raised cholesterol. Istrumet questios: Total cholesterol measuremet Durig the past two weeks, have you bee treated for raised cholesterol with drugs (medicatio) prescribed by a doctor or other health worker? Total cholesterol 5.0 mmol/l or 190 mg/dl or curretly o medicatio for raised cholesterol Me Wome Both Sexes Total cholesterol 6.2 mmol/l or 240 mg/dl or curretly o medicatio for raised cholesterol Me Wome Both Sexes

133 Summary of Combied Risk Factors Summary of Combied Risk Factors Descriptio: Percetage of respodets with 0, 1-2, or 3-5 of the followig risk factors: curret daily smoker less tha 5 servigs of fruits & vegetables per day low level of activity (<600 MET -miutes) overweight or obese (BMI 25 kg/m 2 ) raised BP (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio for raised BP). Istrumet questios: combied from Step 1 ad Step 2 Summary of Combied Risk Factors Me with 0 with 1-2 with 3-5 risk risk risk factors factors factors Summary of Combied Risk Factors Wome with 0 with 1-2 with 3-5 risk risk risk factors factors factors Summary of Combied Risk Factors Both Sexes with 0 with 1-2 with 3-5 risk risk risk factors factors factors

134 Appedix 3. List of STEPS Field Survey Staff from the Kigdom of Toga Natioal Field Survey Team Catherie Latu Kalesita Fotu Paula Vivili Fusi Kaho Latu Fusimalohi Elisiva Naati Seilii Soakai Mele Vuki Ada Moadsiri Meleae Eke Elisapesi Niulala Luseae Liogitau Lesieli Vaisi Mele Fifita Moe Veikoso Ema Mafi Molimoli Pole Siu Kaihea Rural Togatapu Field Survey Team Aa Pouhila Seii Pasa Stella Mioeti Mele Fagaloka Powai Schaaf Lieti Koloi Losalie Kaufusi Ofa Talaoa Ogoalupe Oliveti Kafoatu Tupou Paea Higao Liliai Latukefu Simioe Tei Limisesi Kaivelata 133

135 Urba Togatapu Field Survey Team Saitia Makaafi Makelesi Pese Vasitai Toli Malaata Mata uvave Maumi Kegike Kuluveti Wolfgramm Ofa Tukuafu Kalolaie Malolo Oita Sila Tupou Taufa Eviligi Mahe Sela Tuitupou Outer Islads Field Survey Teams VAVAU Emelie Takai Teisa 'Oe'oe - Sivihiva Kivalu Tapaita Lea - Malaata Mata'uvave Emelie Takai Aa Tautua'a HA APAI Saae Fahamokioa Paea Fifita Halaevalu Toga oevai Kalo Hoeft Mele Latavao EUA Sailopa Vea Sela Latu Kalo Latu Kaufo ou Taufa Pei NIUATOPUTAPU Aa Hakaumotu 134

136 Appedix 4: Group Photos of the High-level Multi-sectoral Natioal NCD Workshops Held i the Kigdom of Toga sice 1 Jue,

137 136

138 137

139 138

140 139

141 Appedix 5. Refereces 1. World Health Orgaizatio. Prevetig chroic diseases: A vital ivestmet. WHO global report. Geeva: World Health Orgaizatio, World Health Orgaizatio. Global status report o ocommuicable diseases Geeva: World Health Orgaizatio, Murray CJ, Lopez AD. Mortality by cause for eight regios of the world: Global Burde of Disease Study. Lacet, 349(9061): , Uited Natios. Political Declaratio of the High-level Meetig of the Geeral Assembly o the Prevetio ad Cotrol of No-commuicable Diseases,. A/66/L.1, Miistry of Health, Toga. Health Service Delivery Profile, Kigdom of Toga, Miistry of Health ad World Health Orgaizatio, Govermet of Toga. 2d Natioal Milleium Developmet Goals Report. Status ad Progress betwee Miistry of Fiace ad Natioal Plaig, Smith BJ, Phogsava P, Havea D, Halavatau V, Chey T, Members of the Health Behaviour ad Lifestyle of Pacific Youth Survey Collaboratig Group, Toga Core Survey Team. Body mass idex, physical activity ad dietary behaviours amog adolescets i the Kigdom of Toga. Public Health Nutritio, 10: , Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishig a stadard defiitio for child overweight ad obesity worldwide: iteratioal survey. British Medical Joural, 320: , Boita R, de Courte M, Dwyer T, Jamrozik K, Wikelma R. Surveillace of risk factors for ocommuicable diseases: The WHO STEPwise approach. Summary. Geeva: World Health Orgaizatio, UNDP. Uited Natios Developmet Program. Iteratioal Huma Developmet Idicators. Toga Armstrog T, Bull F. Developmet of the World Health Orgaizatio Global Physical Activity Questioaire (GPAQ). Joural of Public Health, 14(2):66-70, WHO. World Health Orgaizatio. Global physical activity Questioaire (GPAQ). Aalysis Guide. World Health Orgaizatio. Access 5 Jue istrumet/e/idex.html, Keke K, Phogsava P, Li D, Bacigalupo M, et al, eds. Nauru NCD Risk Factors STEPS Report. Suva, Fiji: Miistry of Health, Nauru ad World Health Orgaizatio,

142 14. Maga A, Courte M, Li D, Uele F, et al, eds. America Samoa NCD Risk Factors STEPS Report. Suva, Fiji: Departmet of Health, America Samoa ad World Health Orgaizatio, Nelesoe T, Pryor J, Li D, Tavite S, et al, eds. Tokelau NCD Risk Factors STEPS Report. Suva, Fiji: Departmet of Health, Tokelau ad World Health Orgaizatio, Samo M, Phogsava P, Li D, Riley L, et al, eds. Federated States of Microesia (Pohpei) NCD Risk Factors STEPS Report. Suva, Fiji: Departmet of Health ad Social Affairs, FSM ad World Health Orgaizatio, Luta T, Phogsava P, Li D, Riley L, et al, eds. Kiribati NCD Risk Factors STEPS Report. Suva, Fiji: Miistry of Health ad Medical Services, Kiribati ad World Health Orgaizatio, Laesago N, Roberts G, Li D, Paulse J, et al, eds. Solomo Islads NCD Risk Factors STEPS Report. Suva, Fiji: Miistry of Health ad Medical Services, Solomo Islads ad World Health Orgaizatio, Tairea K, Phogsava P, Li D, Fariu R, et al, eds. Cook Islads NCD Risk Factors STEPS Report. Suva, Fiji: Miistry of Health, Cook Islads ad World Health Orgaizatio, Samo M, Roberts G, Li D, Marar J, et al, eds. Federated States of Microesia (Chuuk) NCD Risk Factors STEPS Report. Suva, Fiji: Departmet of Health ad Social Affairs, FSM ad World Health Orgaizatio, Palu T, Phogsava P, Li D, Riley L, et al, eds. Kigdom of Toga NCD Risk Factors STEPS Report. Suva, Fiji: Miistry of Health, Toga ad World Health Orgaizatio,

143 KEY CONTACTS Toga Miistry of Health Cotact: Dr Siale Akau ola Chief Executive Officer Miistry of Health P. O. Box 59 Nuku alofa, Kigdom of Toga Tel: (676) Fax: (676) WHO Cotacts: Dr Li Da World Health Orgaizatio Coutry Liaiso Officer; Uited Natios Coutry Security Focal Poit P.O. Box 70 Nuku alofa, Kigdom of Toga Tel: (676) 25522, Fax: (676) Dr Cheria Varghese Team Leader Pacific NCD & Health through the Life-Course Divisio of Pacific Techical Support/Office for the South Pacific World Health Orgaizatio Plaza 1, Dowtow Boulevard, P. O. Box 113 Suva, Fiji Tel: (679) Fax: (679) Uiversity of Sydey Cotact: Dr Philayrath Phogsava Prevetio Research Collaboratio School of Public Health Sydey Medical School Charles Perkis Cetre Uiversity of Sydey NSW 2006 Sydey, Australia Tel: (61 2) Fax: (61 2)

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