Kingdom of Tonga NCD Risk Factors STEPS REPORT

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2 Kigdom of Toga NCD Risk Factors STEPS REPORT Prited i Suva, Fiji September, 2012

3 Ackowledgemets The Kigdom of Toga NCD Risk Factors STEPS REPORT (referred as the Report ) is a record of a combied effort of several orgaizatios ad may idividuals. We would like to ackowledge each orgaizatio ad everyoe s cotributios, dedicatio ad determiatio i completig the survey ad fializig the Report. The Report is a collaborative effort betwee Miistry of Health, Kigdom of Toga ad World Health Orgaizatio (WHO). The Report was compiled by: Dr Taiela Palu (MOH, Toga), Dr Philayrath Phogsava (Uiv. of Sydey), Dr Li Da (WHO, Nuku alofa), Ms Leae Riley (WHO, Geeva), Dr Malakai Ake (MOH), Dr Paula Vivili (MOH), Dr Adrew Coli Bell (WHO, Suva), Ms Elisiva Na ati, Dr Cathy Latu Tekiteki (MOH), Mr Shalvidra Raj (WHO, Suva) ad Latu Fusimalohi (MOH). Appreciatio is exteded to the Ho. Miister for Health, Lord/Mr Tu i afitu, the Director of Health, Dr Siale Akau ola for their leadership ad support of the NCD STEPS work i the Kigdom of Toga. A special thak is made to the STEPS field survey staff (see Appedix 3 of the Report). Grateful ackowledgemet is made to Dr Dogil Ah (Director, Pacific Techical Support ad Represetative, South Pacific, WHO, Suva) ad Dr Ha Tieru (Director, Divisio of Buildig Healthy Commuities ad Populatios, WHO, Maila) for their great support. We ackowledge the statistical support ad result geeratio provided by Ms Leae Riley, Ms Melaie Cowa ad Ms Regia Guthold (WHO, Geeva) ad Mr Shalvidra Raj who made substatial cotributio to the data aalysis. Ms Katalia Palu ad Ms Mele Taufa Fifita (WHO, Nuku alofa) provided admiistrative support to the fializatio of the Report. The Toga STEPS survey ad the Report were fuded by the Australia Agecy for Iteratioal Developmet (AusAID), New Zealad Aid Programme (NZAID) ad WHO. The Miistry of Health, Kigdom of Toga provided i-kid cotributio. Dr Philayrath Phogsava drafted the first versio of the Report. Dr Li Da, Ms Leae Riley, Dr Graham Roberts (Uiv. of New South Wales), Dr Adrew Coli Bell, Dr Cheria Varghese (WHO, Maila), Ms Regia Guthold ad Mr Shalvidra Raj have coducted techical reviews for the Report. The coutry cosultatio held i Nuku alofa, Toga was atteded by Dr Siale Akau ola, Dr Malakai Ake, Dr Paula Vivili, Ms Elisiva Na ati, Latu Fusimalohi, Dr Taiela Palu, Dr Cathy Latu Tekiteki (MOH, Toga), Ms Greta Crasto, Ms Louise Scott (AusAID, Toga), Ms Siutaisa L. Toumoua ad Dr Li Da (WHO, Nuku alofa). Durig the coutry cosultatio, the Fata-'o-Tu'i Toga, oe of the most chiefly tapa desigs i Toga, was selected to be put at the bottom of the Report cover. "Fata" refers to the cetral beam of the royal traditioal house where the Tu'i Toga (the first out of the three royal dyasties i the old days) sits. Dr Li Da, Dr Graham Roberts, Dr Philayrath Phogsava ad Dr Adrew Coli Bell are the fial techical ad editorial reviewers of the Report. WHO Suva Office arraged the pritig, o behalf of the Miistry of Health, Kigdom of Toga. 2

4 CONTENTS FOREWORD 8 EXECUTIVE SUMMARY INTRODUCTION Backgroud ad Ratioale The Natioal Cotext Geography ad Populatio Govermet, Educatio ad the Ecoomy Health Status OBJECTIVES METHODOLOGY STEPS Survey Structure Samplig Frame ad Sample Size Data Collectio Procedures Step 1 - Behavioral Risk Factors Iterviews Step 2 - Physical Measuremets Step 3 - Biochemical Measuremets Data Maagemet ad Statistical Aalysis RESULTS Characteristics of Survey Populatio Tobacco Use Alcohol Cosumptio Fruit ad Vegetable Itake Physical Activity Measuremets Aalysis Levels of Physical Activity Overweight ad Obesity 39 3

5 4.6.1 Height ad Weight Body Mass Idex Categories Waist Circumferece Blood Pressure ad Hypertesio Fastig Blood Glucose ad Raised Blood Glucose Total Cholesterol Combied Risk Factors DISCUSSION AND CONCLUSIONS RECOMMENDATIONS 51 APPENDICES 54 Appedix 1 Kigdom of Toga STEPS Survey Questioaire 55 Appedix 2 The Data Book of the Kigdom of Toga STEPS Survey 67 Appedix 3 List of STEPS Field Survey Staff from the Kigdom of Toga 112 Appedix 4 Refereces 114 KEY CONTACTS 4

6 LIST OF FIGURES Figure 1 The WHO STEPwise approach to surveillace of NCD risk 20 factors Figure 2 Sequece of data collectio ad statios at the survey site 21 LIST OF TABLES Table 1 Demographic characteristics of study populatio 23 Table 2 Mea umber of years of educatio by geder ad age group 23 Table 3 Percetage of curret smokers i the study populatio 24 Table 4 Curret smokig status amog me i the study populatio by age group 25 Table 5 Curret smokig status amog wome i the study populatio by age group 25 Table 6 Curret smokig status amog both sexes i the study populatio by age group 26 Table 7 Mea age started smokig amog curret daily smokers 26 Table 8 Mea umber of years of smokig amog curret daily smokers 27 Table 9 Percetage of curret daily smokers who smoke maufactured cigarettes 27 Table 10 Percetage of alcohol cosumptio amog me durig the past 12 moths by age 28 Table 11 Percetage of alcohol cosumptio amog wome durig the past 12 moths by age 29 Table 12 Percetage of alcohol cosumptio amog both sexes durig the past 12 moths by age group 29 Table 13 Number of driks per day amog both sexes who are curret drikers by age group 30 Table 14 Mea umber of days i a week that fruits are cosumed by geder ad age group 30 Table 15 Mea umber of days i a week that vegetables are cosumed by geder ad age group 31 Table 16 Mea umber of servigs of fruits cosumed o a day whe fruits were eate 31 Table 17 Mea umber of servigs of vegetables cosumed o a day whe vegetables were eate 32 Table 18 Mea umber of combied servigs of fruit ad vegetables cosumed per day of the week 32 Table 19 Percetage who cosumed less tha five combied servigs of fruit ad vegetables per day of the week 33 Table 20 Categories of overall physical activity amog me by age group 35 Table 21 Categories of overall physical activity amog wome by age group 35 Table 22 Categories of overall physical activity amog both sexes by age group 36 5

7 Table 23 Level of Total physical activity (mea miutes per day) by geder ad age group 37 Table 24 Level of Work-related physical activity (mea miutes per day) by geder ad age group 38 Table 25 Level of Trasport-related physical activity (mea miutes per day) by geder ad age group 38 Table 26 Level of Recreatio-related physical activity (mea miutes per day) by geder ad age group 39 Table 27 Mea height by geder ad age group 40 Table 28 Mea weight by geder ad age group 40 Table 29 Mea body mass idex (kg/m 2 ) by geder ad age group 41 Table 30 BMI classificatios amog me by age group 41 Table 31 BMI classificatios amog wome by age group 42 Table 32 BMI classificatios amog both sexes by age group 42 Table 33 Percetage of obesity (BMI 30) by geder ad age group 43 Table 34 Mea waist circumferece (cm) by geder ad age group 43 Table 35 Mea restig systolic blood pressure (mmhg) by geder ad age group 44 Table 36 Mea restig diastolic blood pressure (mmhg) by geder ad age group 45 Table 37 Percetage with hypertesio (SBP 140 ad/or DBP 90 or curretly o medicatio for raised blood pressure) 45 Table 38 Mea fastig blood glucose i mmol/l by geder ad age group 46 Table 39 Prevalece of raised blood glucose by geder ad age group 46 Table 40 Mea levels of total blood cholesterol (mmol/l) by geder ad age group 47 Table 41 Percetage with raised blood cholesterol ( 5.0 mmol/l or 190 mg/dl) 47 Table 42 Percetage of NCD risk categories amog me by age group 48 Table 43 Percetage of NCD risk categories amog wome by age group 48 Table 44 Percetage of NCD risk categories amog both sexes by age group 49 6

8 LIST OF ABBREVIATIONS BMI BP CHD CI CVD DBP 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 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 Nocommuicable diseases (NCDs), icludig cardiovascular diseases, diabetes, ad cacer have become a high disease burde i most of the coutries i the world. NCDs are the major diseases i the Kigdom of Toga. I order to address these growig problems 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 iclude smokig, alcohol use, physical iactivity, obesity, high blood pressure, a raised level of blood glucose or cholesterol, ad a ubalaced diet. To icrease our capacity to udertake populatio risk surveillace, the Miistry of Health, Kigdom of Toga joied forces with WHO ad other parters to udertake the 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 results from the survey provide 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 STEPS survey carried out i Toga i Sept. to Nov., It shows 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 improve health service delivery. This is the first populatio-based atiowide STEPS survey o the prevalece of the NCD risk affectig our populatio. It represets a milestoe i our efforts to address the icreasig NCD epidemic affectig our people ad marks a icreased commitmet of us 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, log days, persistece ad dedicatio from the Toga survey team. We owe each of them our sicere appreciatio. We also wish to thak all the supportig staff i the Miistry of Health ad our parters, WHO for its excellet coordiatio ad strog techical support, ad AusAID for its fiacial support. 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 our coutry. The fidigs ad recommedatios i this report will guide our actios for prevetig ad cotrollig NCDs ad improvig health for all i the Kigdom of Toga. Lord/Mr Tu i afitu Miister for Health Miistry of Health Kigdom of Toga Dr Siale Akau ola Director of Health Miistry of Health Kigdom of Toga 9

11 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, more tha 148 coutries ad areas throughout the world utilize WHO STEPS to coduct atioal surveys o risk factors ad prevalece of NCDs. The publicatio of the "Kigdom of Toga NCD Risk Factors STEPS REPORT" marks a milestoe as it provides the scietific, atioal ad comparable data that will assist the govermet ad other key stakeholders i addressig the escalatig issue of NCDs. 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. Some of the key results of the STEPS survey ad report i the Kigdom of Toga iclude the followig: 27.6% of the populatio smoked tobacco daily. 13.4% of the populatio was curret alcohol drikers. 92.8% of the populatio cosumed less tha five combied servigs of fruit ad vegetables per day. 43.9% of the populatio was with low level of physical activity. The prevalece of overweight i the populatio was 92.1%, the prevalece of obesity was 68.7%. The prevalece of hypertesio was 23.1%. The prevalece of raised blood glucose i the populatio was 16.4%. The prevalece of raised blood cholesterol i the populatio was 49.7%. 99.9% of the populatio was at high risk or moderate risk of NCDs. These results clearly documet that NCDs are a major problem i Toga. The applicatio of this Kigdom of Toga NCD Risk Factors STEPS REPORT iclude updatig the atioal NCD strategy, idetifyig evidece-based prioritized itervetio for NCD prevetio ad 10

12 cotrol, providig atioal baselie 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, uhealthy diet, physical iactivity ad harmful use of alcohol. WHO is hooured to be a critical part of the collaborative efforts betwee the Toga Miistry of Health, Australia Agecy for Iteratioal Developmet ad New Zealad Aid Programme to complete the Toga STEPS survey ad report. WHO is proud to collaborate with the Miistry of Health i publishig this first Kigdom of Toga NCD Risk Factors STEPS REPORT, ad will cotiue to work with health authorities, health workers, other key stakeholders ad the public to address the issues raised i this report. Dr Dogil Ah 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 Kigdom of Toga coducted a populatio-wide atioal survey to documet the prevalece of ocommuicable diseases (NCDs) ad their associated risk factors amog Togas aged 15 to 64 year old i The Toga STEPS survey was part of the global effort to reverse the treds of NCDs. The key objectives of the Toga NCD STEPS survey were to: documet the prevalece ad magitude of major modifiable risk factors for NCDs icludig tobacco use, alcohol cosumptio, eatig patters, physical activity, overweight ad obesity, blood pressure, blood glucose ad cholesterol levels documet the prevalece of key NCDs amog adults i Toga compare NCDs ad their risk factors across differet age groups ad betwee me ad wome. A total of 1250 households were approached ad oe adult aged years from each household was radomly selected to participate i the survey, the respose rate was 80%. About oe third of the sample (30.8%) was i the age group years, with over half of participats beig females (57.8%). Educatioal levels were similar across sex ad age groups, with the exceptio of females aged who had received margially less years of educatio. Followig the stadard age group reportig for WHO STEPS surveys ad reports, year data was preseted i the three Steps. For Step 1 results, year data was also preseted, compared ad highlighted. Step 1: Behavioural risk factors Tobacco use The overall prevalece of curret smokig amog those aged years was 31.0%. The proportio was sigificatly higher for me (46.2%) tha wome (16.3%). Amog curret smokers, 27.6% smoked daily, with a geder differece of 41.9% of me ad 13.8% of wome who smoked daily. The mea age of smokig uptake amog daily smokers was 18.2 years, with me reported a slightly youger age of smokig uptake (17.5 years) tha wome (20.3 years). People i the years age group also reported startig at a relatively youger age of 15.9 years. The mea duratio of smokig was 14.5 years, ad 84.0% of daily smokers smoked maufactured cigarettes. Amog those aged years, the overall prevalece of curret smokig was 29.8%, with a sigificatly higher proportio of me (46.2%) tha wome (14.3%) who smoked. Amog curret smokers, 26.4% smoked daily; 41.5% of me ad 12.2% of wome. The mea age of smokig uptake amog daily smokers was 19.7 years, with me reported a lower mea age of smokig uptake (18.7 years) tha wome (22.7 years). The mea duratio of smokig was 20.4 years, ad 82.5% of daily smokers smoked maufactured cigarettes. Alcohol cosumptio The overall prevalece of curret drikers (defied as havig cosumed alcohol i the past 12 moths) amog those aged years was 13.4%, with a sigificat differece foud i 12

14 alcohol cosumptio betwee me (22.2%) ad wome (4.8%). The highest proportio of curret drikers was i the age group (21.7%); 37.9% of me ad 5.2% of wome. Amog those aged years, the prevalece of curret drikers was 8.9%; 13.6% of me ad 4.6% of wome. Fruit ad vegetable itake Amog those aged years, the majority (92.8%) reported cosumig less tha five combied servigs of fruit ad vegetable per day. The mea umber of days per week of combied fruit ad vegetables cosumed was 4.2 days. O days whe fruit ad vegetables were both cosumed, the mea umber of combied servigs was 2.4 serves. Me ad wome were similar i their reported cosumptio of combied servigs of fruit ad vegetables. The patter of cosumptio amog those aged years was similar, with the majority (92.2%) reported cosumig less tha five combied servigs of fruit ad vegetable per day. The mea umber of days per week of combied fruit ad vegetables cosumed was 4.3 days. O days whe fruit ad vegetables were both cosumed, the mea umber of combied servigs was 2.5 serves. Physical activity Amog those aged years, 43.9% of those surveyed reported a low level of total physical activity, defied as less tha 600 METmiutes per week. A higher proportio of wome (54.8%) tha me (32.4%) reported low level of physical activity. There was little variatio i prevalece across the age groups. I Toga, work-related physical activities cotributed the largest portio of all total physical activity (81.3 miutes per day), followed by trasport (33.8 miutes per day) ad recreatio/leisure (15.6 miutes per day). Mea total daily miutes (across all domais) were for me ad 85.3 for wome. Amog those aged years, a similar patter of physical activity was foud with 43.9% reportig a low level of total physical activity. A higher proportio of wome (53.7%) tha me (33.3%) reported a low level of physical activity. Work-related physical activities accouted for the largest portio of all total physical activity (92.4 miutes per day), followed by trasport (33.9 miutes per day) ad recreatio/leisure (12.3 miutes per day). Mea total daily miutes (across all domais) were for me ad 91.5 for wome. Step 2: Physical risk factors Amog those aged years, the overall prevalece of overweight (BMI 25kg/m 2 ) was 92.1% (89.2% of me ad 94.9% of wome). By age years, 89.6% of the sample i this age was classified as overweight, 96.6% i the age group years. The prevalece of obesity (BMI 30kg/m 2 ) was 68.7% (60.7% of me ad 76.3% of wome). Oly 7.7% of the sample (10.5% of me ad 5.1% of wome) had a ormal body weight (18.5 BMI 24.9). Wome had a margially higher mea waist circumferece (105.2cm) tha me (103.4cm). With the exceptio of the yougest age group (98.2cm), mea waist circumferece for me i all age groups exceeded 102cm, a cut-off value for me where the risk of cardiovascular disease icreases. Amog wome i all age groups, the mea waist circumferece values exceeded 88cm, a cut-off value for wome for icreased cardiovascular disease risk. 13

15 I Toga, oe fifth of the surveyed populatio (23.1%) was hypertesive (defied as havig SBP 140 mmhg ad/or DBP 90 mmhg or o medicatio for raised blood pressure). A slightly higher proportio of me (26.5%) tha wome (19.9%) was hypertesive. Step 3: Biochemical risk factors Amog those aged years, the overall prevalece of raised blood glucose was 16.4% based o measures of fastig capillary whole blood (fastig glucose level 6.1 mmol/l or o medicatio for raised blood glucose). There was o statistical geder differece i raised blood glucose levels (me: 16.3%; wome: 16.6%). The highest rate of raised blood glucose amog wome was i age years ad i age years (32.8%% ad 35.3% respectively). Overall, 49.7% of the surveyed populatio aged years had raised total blood cholesterol levels exceedig 5.0 mmol/l ( 190 mg/dl). A sigificatly higher proportio of me (66.1%) tha wome (34.2%) had elevated blood cholesterol. The prevalece of raised blood cholesterol icreased with age i both geders. Amog wome, about half (50.6%) had raised cholesterol by age years. Amog me, elevated cholesterol was already evidet i 60.2% of those aged years. Combied risk factors The risk of developig a NCD icreases with icreasig umber of NCD risk factors. As such, STEPS survey participats were categorized ito three NCD risk groups: High Risk (with 3-5 risk factors), Moderate Risk (with 1-2 risk factors) or Low Risk (with o risk factor). The combied NCD risk factors icluded beig curret daily smokers, beig overweight (BMI 25 kg/m 2 ), havig raised blood pressure (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio), havig cosumed less tha five combied servigs of fruit ad vegetables per day, ad havig egaged i a low level of physical activity (<600 METmiutes per week). Overall 60.7% of the surveyed populatio was at High Risk of NCDs, with a further 39.2% at Moderate Risk. Both me (60.5%) ad wome (60.8%) were equally at High Risk of NCDs. By age years, over half of the surveyed populatio was already at High Risk (58.1%), 57.9% i me ad 58.3% i wome. Coclusio The Toga STEPS survey has provided scietific ad strog evidece that NCDs ad associated modifiable risk factors are of the major public health cocer i Toga. With very high rates of overweight ad obesity ad a relatively high rate of blood cholesterol, the Toga STEPS survey provides a importat data resource that ca iform settig priorities, developig prevetive strategies for those vulerable ad at risk, as well as for those livig with NCDs. Recommedatios Addressig surveillace ad iformatio eeds 14

16 This icludes: Securig political ad fiacial commitmets to develop a systematic ad plaed STEPS NCDs risk factors data collectio system, supported by a workforce skilled i implemetig the survey, i order to have established a ogoig moitorig ad surveillace system that is scietifically rigorous ad robust i Toga. Supplemetig the core Toga STEPS questioaire with additioal questios to esure that Toga STEPS provide timely ad relevat epidemiological data for plaig ad policy developmet. Such questios for future cosideratio could iclude salt cosumptio ad metal health. For the 1 st time, amog the published STEPS reports i the PICs, the prevalece of age ad age were both preseted i the core tables of the Step 1 i this STEPS report. These compared data show that whe usig age, the prevalece of most idicators (especially i the tobacco ad alcohol sectios) were higher, compared to years. Therefore, tobacco use ad harmful alcohol cosumptio amog Toga youth ad adolescets eed to be paid more public health attetio. Cosiderig settig up atioal targets ad idicators for NCD prevetio ad cotrol. Participatig i the compariso of STEPS fidigs across other Pacific islad coutries ad areas that have completed the STEPS survey ad published STEPS reports. Coductig data compariso over time after the 2 d -roud STEPS survey i Toga i is completed. Addressig policy, orgaizatioal ad evirometal factors This icludes: Implemetig the WHO Framework Covetio o Tobacco Cotrol, such as addressig smoke-free eviromets ad icreasig tobacco taxatio. Limitig the marketig ad advertisig of uhealthy foods ad driks. Developig policies supportig the importatio of healthy foods. Improvig the availability ad affordability of fruit ad vegetables. Developig policies to establish ad support physical activity-friedly eviromets, such as walkig paths, ope public gree spaces for recreatioal activities, sports facilities ad workplace physical activity programs. Implemetig settig-based policies to support healthy lifestyle ad practices, e.g. healthy food services ad physical activity promotio policies i workplaces, churches ad schools. Policies to support health system stregtheig icludig skilled workforce, fiacial coverage, essetial drugs, affordable techology for maagig NCDs. Addressig kowledge ad awareess of NCD behavioural risk factors This icludes implemetig: Comprehesive ati-smokig programs to reduce smokig rates, particularly targetig adolescets ad youths to prevet smokig uptake, ad smokig cessatio programs to reduce smokig rates across all age groups. Comprehesive public health programs to reduce harmful alcohol cosumptio, icludig social marketig ad mass commuicatio campaigs to icrease awareess of the adverse effects of harmful alcohol cosumptio. 15

17 Comprehesive public health programs promotig the cosumptio of the recommeded levels of fruit ad vegetables. Comprehesive social marketig ad mass commuicatio campaigs to icrease public awareess of the adverse effects of excessive cosumptio of high-fat, high-salt, ad high-sugar foods. Culturally-appropriate ad diverse programs to promote daily physical activity. Public awareess campaigs o the importace of regular moitorig ad screeig of blood pressure, blood sugar ad blood cholesterol levels. A system of commuity-based, outreached care for the maagemet of idividuals with diagosed NCDs. 16

18 1. INTRODUCTION 1.1 Backgroud ad Ratioale Globally, o-commuicable diseases (NCDs) such as diabetes, cardiovascular disease, cacer, chroic respiratory coditios accout for 63% of all deaths 1. Oce cosidered as diseases of affluece, NCDs have ow ivaded may low- ad middle-icome coutries. I 2008, approximately 80% of NCD deaths (or four out of five deaths) occurred i developig coutries 1, compared to just less tha 40% of NCD deaths i Importatly, a large proportio of NCD deaths occurred durig the most productive period of huma life, before the age of Worldwide, the social, ecoomic ad health cosequeces associated with NCDs are sigificat cotributig to 48% of the healthy life years lost (Disability Adjusted Life Years, DALYs), compared to 40% of commuicable diseases, materal ad child health, utritioal deficiecies 3. Addig to the disease burde is the cotiuig presece of commuicable diseases i may developig coutries. Sice the icidece ad prevalece of NCDs are expected to accelerate i the future, due to the icreasig prevalece of NCD risk factors as a cosequece of globalizatio ad urbaizatio, urget prevetive actios are required to mitigate the social, ecoomic ad health burde o coutries. There are four major modifiable risk factors for NCDs: uhealthy diet, physical iactivity, tobacco use, ad harmful alcohol use. Some of these risk factors might cluster i idividuals (i.e. alcohol ofte clusterig with smokig, physical iactivity clusterig with poor diet, overweight ad high blood pressure ad high cholesterol). Chagig these risk factors ca substatially improve idividual health ad wellbeig 1. The WHO STEPwise Approach to Surveillace of NCD Risk Factors outlies a stadardized process ad system for coutries to collect ad documet the magitude ad patters of the four major NCD risk factors 4. The uderlyig priciple of the WHO STEPS surveys is that coutries collect the same core iformatio o diet, physical activity, tobacco use, ad alcohol use (Step 1), with optios to collect additioal iformatio such as blood pressure, height, weight ad waist circumferece (Step 2), ad fastig blood glucose ad cholesterol (Step 3), depedig o eed ad available resources. Coutries ca also collect other iformatio (such as ijuries, metal health) of local relevace. The stadardized survey data collectio ad aalysis would the allow for the coutry-specific data to be comparable withi- ad betwee-coutries. Previous NCD risk factor surveys have bee coducted i the mai islad of Togatapu i 1998, i Ha apai ad Vava u i This Toga STEPS survey was the first atioal NCD risk factors survey to be coducted across three islad groups of Ha apai ad Vava u. The STEPS data will iform policy ad program developmet i the immediate term, but will also form the basis for log-term ogoig moitorig ad surveillace of NCD risk factors i Toga. 17

19 1.2 The Natioal Cotext Geography ad Populatio The Kigdom of Toga is a islad sovereig atio located i the South Pacific Ocea. Its 170 islads are scattered over approximately 800,000km (500miles), with oly 36 of the islads ihabited. The islads are divided ito five mai islad groups: Togatapu, Ha apai, Vava u, Eua ad Niuas. Based o the 2011 Cesus, two thirds of the 103,000 ihabitats live o the mai islad, Togatapu ad especially aroud the capital city of Nuku alofa 5. Toga is the oly sovereig moarchy amog the Pacific islad coutries ad areas, ad the oly pacific islad atio that has avoided coloizatio 6. Togas are Polyesia by ethicity ad represet 98% of the ihabitats, with the balace comprised of Melaesias, other Pacific isladers, Europeas ad Chiese. Toga is the official laguage of the islad, but Eglish is also widely used Govermet, Educatio ad the Ecoomy Toga is a costitutioal moarchy. Goverace executive power is vested i the Cabiet of Miisters, headed by the Prime Miister. Members of Legislative Assembly are elected by popular vote. Local villages or group of villages are govered by tow or district officials, respectively. Educatio i Toga is broadly divided ito primary, secodary ad post-secodary. The govermet of Toga fuds the majority of primary schools ad approximately oe third of secodary schools; the rest are auspiced by various deomiatios. Togas ejoy a very high educatio level, with a 99% literacy rate 5. As a small islad atio, Toga has limited huma ad fiacial resources. Similar to may of its eighbours, Toga s ecosystem is fragile ad highly vulerable to atural disasters ad risig sea levels. Toga relies to a large degree o imported goods, ad remittaces from Togas livig overseas. Fishig comprises the mai agricultural idustry, although its growth ad ability to attract foreig ivestmet is tempered by high trasportatio costs ad variable weather. Overall, Toga's Huma Developmet Idex (HDI; the Uited Natios composite measure of health, educatio ad icome) is 0.704, givig it a rakig of 90 out of 187 coutries with comparable data 7. The HDI of East Asia ad the Pacific as a regio is 0.671, placig Toga above the regioal average Health Status Life expectacy for Toga for 2005 to 2008 was estimated to be betwee 60.4 to 64.2 years for males ad 65.4 to 69.0 for females, well below previously published estimates. The low life expectacy, at a relatively low ifat mortality rate ad high premature adult mortality, suggested that NCDs are havig a profoud limitig effect o health status i Toga 8. It was previously reported that more tha 60.0% of adults i Toga are obese accordig to the WHO BMI categories for obesity for adults (i.e. body mass idex BMI 30kgm 2 ) ad that 18

20 37.0% have hypertesio ad 15.1% have diabetes 9 ). However, limited populatio-wide data exists o the prevalece of behavioural (poor diet, physical iactivity, alcohol ad tobacco use) ad metabolic risk factors (total cholesterol ad glucose levels) for NCDs amog adults i Toga. Documetig the magitude ad extet of these modifiable risk factors will provide a valuable atioal resource for settig public health priorities ad actios to reverse the tide o obesity ad other NCDs i Toga. 2. OBJECTIVES The key objectives of the Toga STEPS survey were to: documet the prevalece ad magitude of major modifiable risk factors for NCDs icludig tobacco use, alcohol cosumptio, eatig patters, physical activity, overweight ad obesity, blood pressure, blood glucose ad cholesterol levels documet the prevalece of key NCDs amog adults i Toga compare NCDs ad their risk factors across differet age groups ad betwee me ad wome. I the immediate term, the Toga STEPS data will provide iformatio for atioal policy ad program developmet. 3. METHODOLOGY 3.1 STEPS Survey Structure The Toga STEPS survey was a cross-sectioal study, ad followed the stadardized sequetial three-step process (Figure 1) recommeded for all STEPS surveys 10. This is to facilitate withi ad betwee coutry comparisos of the Toga STEPS survey data. Step 1: A questioaire-based (iterview) survey o tobacco use, alcohol drikig, fruit ad vegetable cosumptio, physical activity, history of hypertesio ad history of diabetes. Step 2: Physiological measures of blood pressure, height, weight, ad waist circumferece. Step 3: Biochemical measures of fastig blood glucose ad total cholesterol. The Toga STEPS survey also followed other STEPS surveys coducted i the Pacific regio by collectig core data across all three steps, with scope to add more self-reported questios, physical ad biochemical measuremets to the core questios, depedig o local eeds ad situatios. 19

21 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 3.2 Samplig Frame ad Sample Size The survey populatio icluded idividuals aged years livig i Toga at the time of the survey. The samplig frame was household lists of the 1996 Populatio Cesus, supplemeted by the additioal households iformatio from the 2001 Agricultural Cesus. Iformatio from these two databases was compared to yield more complete ad updated sampled cesus blocks (CBs) from which the fial selectio of sampled households was draw. A sample of 1,250 households was selected; 750 households from Togatapu ad 250 households each from Ha apai ad Vava u. I each selected household, oe perso aged years was selected radomly to take part i the survey. Oly participats aged years were selected to participate i physical ad biochemical measuremets (STEPS 2 ad 3). 3.3 Data Collectio Procedures The STEPS survey was coducted i September All data collectio took place i dedicated STEPS survey cetres. Survey staff received itesive traiig i the STEPS survey methodology ad data collectio protocol. The survey questioaire was i Eglish, with iterviews coducted i Eglish ad/or Toga. At the STEPS registratio desk, survey iterviewers obtaied iformed coset from all survey participats, briefed participats of the survey procedure, cofirmed date of birth, ad where relevat cofirmed fastig status of the participat. Figure 2 briefly outlies the sequece of data collectio ad measuremets for the survey, which followed the recommeded STEPwise protocols. 20

22 Registratio Statio If fastig If ot fastig Re-scheduled Height Measuremets Weight Measuremets Hip/Waist Measuremets Iterview Statio Blood Test Statio Blood Pressure Statio Check out Refreshmet Statio Figure 2. Sequece of data collectio ad statios at the survey site Step 1 - Behavioural Risk Factors Iterviews All participats completed the face-to-face iterview i which questios were asked about years of formal educatio, tobacco use, alcohol drikig, fruit ad vegetable cosumptio, physical activity ad history of hypertesio ad diabetes Step 2 - Physical Measuremets This Step icludes measurig participats restig blood pressure, height, weight ad waist circumferece. 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. The average of the secod ad third readigs was computed ad used i the aalysis. The Seca Leicester Height Measure was used to measure height to the earest whole cetimetre ad the Siltec PS500L to measure weight to the earest 0.1 kg. Participats were measured wearig oly light clothig ad without shoes. The Figure Fider costat tesio tape was used to measure waist circumferece ad recorded to the earest 0.1 cm. Height, weight ad waist circumferece were measured oce. Waist circumferece of female pregat participats was ot measured Step 3 - Biochemical Measuremets This Step icludes assessig participats fastig blood glucose ad fastig total cholesterol level by figer prick test. As required by the STEPS protocol, participats who took part i 21

23 Step 3 of the survey fasted from 10:00pm the previous ight util 7:00am the followig morig, whe their capillary blood samples were draw usig the figer prick test method. 3.4 Data Maagemet ad Statistical Aalysis The data of this STEPS survey were cleaed ad etered by the coutry staff i Toga usig EpiIfo. WHO Office i Geeva coducted data weightig, cleaig ad geeratig the mai outputs. WHO Office i Suva produced the data book. Data aalysis were coducted usig EpiIfo. Meas were computed for cotiuous variables ad frequecy distributios calculated for categorical variables. For both frequecy estimates ad meas, 95% cofidece itervals were reported by 10-year age groups ad geder. I this report, mai data tables preset fidigs for those aged years, reported by 10- year age groups ad by geder. I the same tables are also summary results related to behavioural risk factors for those aged years followig the stadard age group reportig for WHO STEPS surveys. 4. RESULTS 4.1 Characteristics of Survey Populatio This sectio presets results of the Toga STEPS survey. Data for those aged years are reported i the mai tables, followig the stadard age group reportig for WHO STEPS surveys, ad data for the age group are preseted i a separate lie uder the mai table. Text descriptio accompayig each table relates to the age groups 15-64, ad commetary o the years is also provided at the ed of each sectio. A total of 1250 households were approached ad oe adult aged years from each household was radomly selected to participate i the survey, the respose rate was 80%. Table 1 presets the age ad geder distributio of the etire survey respodets aged years. Higher proportios of female tha male respodets participated i the survey (57.8% ad 42.2%, respectively). This patter was cosistet across all age groups, except for those aged years (me: 52.3%; wome: 47.7%). Amog the respodets aged years, 58.2% were females ad 41.8% were males. This uequal distributio has bee take ito accout durig data weightig, so that the true male/female distributio of the populatio has bee reflected i the results. 22

24 Table 1 Demographic characteristics of study populatio Age group ad sex of respodets Me Wome Both Sexes % % % Table 2 presets the mea years of educatio of the survey respodets, by geder. Both geders ad all age groups had similar mea years of educatio (me: 10.7 years; wome: 10.4 years), with me havig oly margially more years of educatio tha wome i age group years. The oldest age group (55-64 years) of wome reported the lowest mea years of educatio (8.2 years). Amog the respodets aged years, both geders had similar mea years of educatio (me: 10.6 years; wome: 10.3 years). 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 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 had smoked ay tobacco product (such as cigarettes, cigars or rolled tobacco) i the past 12 moths. 23

25 Daily smokers those who smoke ay tobacco product every day. No-daily smokers those curret smokers who do ot smoke o a daily basis. Table 3 shows the proportio of curret smokers i the survey populatio, with 31.0% aged years beig curret smokers. Sigificatly more me (46.2% ±6.7) were curret smokers, compared to 16.3% ±5.2 of female respodets. Except for the yougest age group (15-24 years), this statistically sigificat geder differece was observed i all age groups. Amog wome, the highest proportio of curret smokers was i the yougest age group years (20.4% ±8.2), while amog me curret smokig was highest proportio i the oldest age group years (61.3% ±11.2). Table 3 also shows that amog respodets aged years, sigificatly more me (46.2% ±5.2) were curret smokers, compared to 14.3% ±4.6 of wome. Table 3 Percetage of curret smokers i the study populatio Percetage of curret smokers Me Wome Both Sexes % % % Curret Curret Curret smoker smoker smoker ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.7 Table 4 shows that 53.9% (±6.7) of male respodets were o-smokers. Of the 46.2% of curret smokers, 41.9% (±8.3) smoked o a daily basis. More tha half (57.2% ±11.1) of me aged years were daily smokers. The secod highest proportio of daily smokers was i the yougest age group years (42.7% ±16.4), ad decreased thereafter to 35.2% (±10.6) of daily smokers i the age group years. Amog those aged years, 53.8% (±5.6) of me were o-smokers ad of the balace 41.5% (±7.6) smoked o a daily basis. 24

26 Table 4 Curret smokig status amog me i the study populatio by age group Smokig status Me Curret smoker % Does % Daily % No-daily ot smoke ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±5.6 Table 5 shows that 83.7% (±5.2) of the female respodets were o-smokers. Of the 16.3% who were curret smokers 13.8% (±3.4) smoked o a daily basis. The highest proportio of daily smokers was i the yougest age group years (17.1% ±6.1), ad decreased i age gradually to 6.0% (±7.0) i the oldest age group years. Amog those aged years, 85.7% (±4.6) of wome were o-smokers ad of the balace 12.2% (±3.4) smoked o a daily basis. Table 5 Curret smokig status amog wome i the study populatio by age group Smokig status Wome Curret smoker % Does % No- % Daily ot smoke daily ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±4.6 Table 6 presets the prevalece of o-smokers, o-daily smokers ad daily smokers for me ad wome combied. A total of 69.0% (±4.1) of respodets were o-smokers, 3.3% (±1.9) were o-daily smokers, ad 27.6% (±4.6) were daily smokers. The highest proportio of daily smokers (30.5% ±9.9) was amog i age group years, with a margially lower proportio (29.9% ±10.3) i age group years; this high level was sustaied through age group years (25.3% ±6.6) ad declied slightly i age group years (22.9% ±6.4). Amog those aged years, 70.2% (±3.7) were o-smokers, 3.4% (±1.6) were o-daily smokers, ad 26.4% (±4.1) were daily smokers. 25

27 Table 6 Curret smokig status amog both sexes i the study populatio by age group Smokig status Both Sexes Curret smoker % Does 95% % No- % Daily ot smoke CI daily ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.7 Table 7 shows that amog curret daily smokers across both geders, the yougest age group of years reported uptake at a youger age (15.9 years ±0.6) tha the older age groups. For me, the mea age of startig smokig was 17.5 (±0.8) years, compared to 20.3 years (±1.3) for wome. A similar patter was observed amog those aged years, with me reportig a lower mea age of smokig uptake (18.7 ±0.7) tha wome (22.7 ±1.7). Table 7 Mea age started smokig amog curret daily smokers Mea age started smokig Age Me Wome Both Sexes Group Mea Mea Mea age age age ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.8 Table 8 shows that amog curret daily smokers aged years, the mea umber of years of smokig was 14.5 ±2.2 years. Me reported smokig for a mea of 15.6 ±3.2 years ad wome for a mea duratio of 11.4 ±1.7 years. Male respodets i age group reported a mea duratio of smokig as 39.9 ±2.1 years, compared to 21.8 ±18.2 years for wome. Due to the small umbers these results eed to be iterpreted with cautio. For those aged years, me reported a higher mea years of smokig tha wome (me: 21.5 ±2.3; wome: 16.8 ±3.3). 26

28 Table 8 Mea umber of years of smokig amog curret daily smokers Mea duratio of smokig Age Me Wome Both Sexes Group Mea 95% Mea 95% Mea 95% duratio CI duratio CI duratio CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±1.6 Table 9 shows that maufactured cigarettes were smoked by the majority of curret daily smokers: 84% ±6.0. The proportios were similar for me (83.7% ±6.6) ad wome (84.7% ±10.5). The proportios reportig smokig maufactured cigarettes were high i all age groups of both geders, with the lowest reported i the oldest age group of years across both geders: 61.6% ±14.9 amog me ad 54.9% ±62.0. Amog those aged years, 82.5% ±5.4 of curret daily smokers reported smokig maufactured cigarettes. Table 9 Percetage of curret daily smokers who smoke maufactured cigarettes Age Group Maufactured cigarette smokers amog daily smokers Me Wome Both Sexes % Mau- % Maufactured % Maufactured 95% factured 95% cigarette CI Cigarette CI cigarette smoker smoker smoker ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Alcohol Cosumptio To assess patters ad prevalece of alcohol cosumptio, respodets were asked if they ever cosumed alcohol, ad the frequecy ad quatity of alcohol cosumed. Curret drikers were defied as havig cosumed a alcoholic drik i the last 12 moths. 27

29 Tables summarise the prevalece of alcohol cosumptio durig the past 12 moths amog me, wome ad both geders respectively. Overall, 13.4% (±5.7) reported havig cosumed alcohol i the last 12 moths (Table 12). There was a sigificat geder differece i cosumptio, with 22.2% (±11.4) of me reported havig cosumed alcohol i the past 12 moths compared with just 4.8% (±2.3) of wome (Tables 10 ad 11). Table 10 shows that the highest proportio of drikig occurred i the yougest age group years for me (37.9% ±21.1) ad i the years age group for wome (8.6% ±5.8) (Table 11). The prevalece of 12-moth drikig decreased with icreasig age for me, but for wome the proportios fluctuated across age groups; from 5.2% ±8.4 (15-24 years) to 8.6% ±5.8 (25-34 years), ad decreased to 4.8% ±4.4 (35-44 years) ad to 0.7% ± 1.7 (45-54years). No alcohol cosumptio i the past 12 moths was reported by wome aged years. Amog years, the prevalece of alcohol cosumptio i the past 12 moths was 8.9% ±5.2; with me twice more likely tha wome to cosume alcohol over this period (me 13.6% ±7.9; wome 4.6% ±3.0). Age Group Table 10 Percetage of alcohol cosumptio amog me durig the past 12 moths (mos.) by age group % Curret driker (drak i last 12 mos.) Alcohol cosumptio status Me % past 12 mos. abstaier % Lifetime abstaier ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±9.8 28

30 Age Group Table 11 Percetage of alcohol cosumptio amog wome durig the past 12 moths by age group % Curret driker (drak i last 12 mos.) Alcohol cosumptio status Wome % past 12 mos. abstaier % Lifetime abstaier ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.0 Age Group Table 12 Percetage of alcohol cosumptio amog both sexes durig the past 12 moths by age group % Curret driker (drak i last 12 mos.) Alcohol cosumptio status Both Sexes % past 12 mos. abstaier % Lifetime abstaier ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±5.7 Table 13 presets iformatio o the umber of stadard driks cosumed per drikig day across both geders. Overall, the survey respodets drak a average of 8.6 stadard driks o a drikig day. The majority of respodets (61.8% ±19.1) reported drikig 6 or more stadard driks o a drikig day, compared to 15.4% ±17.0 drikig 4-5 stadard driks, 16.3% ±14.2 drikig 2-3 driks ad 6.5% ±7.2 drikig just 1 drik o a drikig day. A similar cosumptio patter was also observed for those aged years, with 77.8% ±22.1 reported drikig 6 or more stadard driks o a drikig. 29

31 Age Group % 1 drik Table 13 Number of driks per day amog both sexes who are curret drikers by age group Number of stadard driks cosumed o a drikig day Both Sexes 95% CI % 2-3 driks 95% CI % 4-5 driks 95% CI % 6+ drik s 95% CI Mea # of stadard driks ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± % CI 4.4 Fruit ad Vegetable Itake Fruit ad vegetable itake was assessed by askig how may days respodets cosumed fruit ad vegetables i a typical week, ad how may servigs of each they cosumed o oe of those days. Table 14 shows that me ad wome reported similar mea days of fruit cosumed i a typical week across all age groups, with a overall mea days of 2.6 ±0.2. Age Group Table 14 Mea umber of days i a week that fruits are cosumed by geder ad age group Mea umber of days fruit cosumed i a typical week Me Wome Both Sexes Mea Mea 95% umber umber CI of days of days Mea umber of days ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.2 Table 15 shows that both geders reported a mea 4.2 ±0.8 days of vegetables cosumed i a typical week. Wome reported margially higher mea days of vegetable cosumptio tha me (wome 4.6 ±0.7 ad me 3.8 ±0.9). Wome across all age groups reported similar mea days of vegetable cosumptio i a typical week, with a similar patter of cosumptio oted for me also across all age groups. 30

32 For those aged years, a mea 4.3 ±0.5 days of vegetables was cosumed i a typical week, with wome reportig a margially higher mea days of vegetable cosumptio tha me (wome 4.6 ±0.5 ad me 4.0 ±0.5). Age Group Table 15 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 95% umber umber umber CI of days of days of days ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.5 Table 16 shows the mea umber of servigs of fruit o a day whe fruit was eate as beig similar across all age groups ad both geders. For those aged years, the mea umber of fruit servigs was 1.3 ±0.2 serves, ad 1.4 ±0.2 serves amog those aged years. Age Group Table 16 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 95% umber 95% umber of CI of CI of servigs servigs servigs ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.2 95% CI 31

33 Table 17 shows the mea servigs of vegetables o a day whe vegetables were eate as beig similar across all age groups ad geders. For those aged years, the mea umber of vegetable servigs was 1.1 ±0.3 serves, ad 1.2 ±0.2 serves amog those aged years. Age Group Table 17 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 95% umber of of CI of servigs servigs servigs ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.2 Table 18 shows the average cosumptio of combied servigs of fruit ad vegetables o a average day. Overall, respodets reported a average of 2.4 ±0.4 combied servigs of fruit ad vegetables, with o differece betwee me ad wome. The mea umber of servigs reported was similar across all age groups across both geders. Age Group Table 18 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 95% umber of of CI of servigs servigs servigs ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.3 32

34 Table 19 shows that for both geders 92.8% ±2.3 cosumed less tha five combied servigs of fruit ad vegetables o a average day with o sigificat differece betwee me (92.3% ±3.4) ad wome (93.2% ±2.3). All age groups across both geders reported high proportios eatig less tha 5 combied servigs per average day. For those aged years, 92.2% ±2.1 of respodets cosumed less tha 5 combied servigs of fruit ad vegetables o a average day with o differece betwee me (91.4% ±3.4) ad wome (92.9% ±2.0). Age Group Table 19 Percetage who cosumed less tha five combied servigs of fruit ad vegetables per day of the week 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 Respodets were asked how ofte (days) ad how log (hours ad miutes) they participated i three domais of physical activity i a typical week defied as: work-related, trasport-related ad leisure-related. For work ad leisure-related physical activity, respodets were asked how may days per week ad how may hours/miutes per day they participated i moderate ad vigorous itesity activities. For trasport-related physical activity, respodets were asked how ofte ad how log they either walk ad/or cycle to ad from places Aalysis The three activity levels were defied, combiig all domais: low, moderate, ad high (see below defiitio). To derive these overall activity levels, the total time participats spet i a activity per week was computed by multiplyig the umber of days by the duratio of the activity. This was doe for each activity type, ad the values were the added. To accout for the differet levels of eergy expediture required for moderate ad vigorous activities, differet MET values were assiged to these two itesities ad multiplied with the 33

35 activity duratio. 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 : 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 defied as: Low activity: <600 METmiutes per week Moderate activity: METmiutes per week High activity: >1500 METmiutes per week Furthermore, data was aalyzed for each domai separately. Mea miutes spet i work, trasport ad leisure time activity are preseted below Levels of Physical Activity Table 20 presets patter of total physical activity categorized ito low, moderate ad high levels amog male respodets. Physical activity doe as part of work, trasport ad recreatio were combied 32.4% ±9.8 of me reported a low level of total physical activity. Moderate physical activity was reported by 18.5% ±7.6 of me ad a high level of physical was reported by 49% ±7.4. At least half (50.3% ±15.5) of the survey respodets i age group years reported high total physical activity; total physical activity level peaked to 56% ±10.5 i age group years ad decreased gradually to 42.1% ±11.7 i age group years, but icreased to 49.6% ±9.4 i the oldest cohort years. For low total physical activity, the highest proportio was recorded i age group years (41.3% ±12.0) ad the lowest i age group years (23.9% ±11.2). For the age group, 48.3% ±8.6 reported high total physical activity, 18.4% ±4.4 reported moderate ad 33.3% ±7.7 low total physical activity. 34

36 Table 20 Categories of overall physical activity amog me by age group Level of total physical activity Age Me Group % % Low Moderate % High ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±8.6 A differet physical activity patter was oted amog wome. Table 21 shows that whe physical activity doe as part of work, trasport ad recreatio time are combied 54.8% ±10.3 of wome reported a low level of total physical activity, with little variatio across the age groups. Moderate physical activity was reported by 23.6% ±4.5 of wome, ad a high level of physical was reported by 21.7%±7.8. The proportios of high level of total physical activity decreased with icreasig age, the oldest age group reported the highest proportio of high level of total physical activity relative to the youger age groups. For the age group, 23.6% ±6.9 reported high total physical activity, 22.6% ±4.3 reported moderate ad 53.7% ±6.6 low total physical activity. Table 21 Categories of overall physical activity amog wome by age group Level of total physical activity Age Wome Group % % Low Moderate % High ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±6.9 For the total survey sample, 43.9% ±7.4 idicated a low level of total physical activity, with miimal variatio across the age groups (Table 22). Moderate physical activity was reported by 21.1% ±4.0 ad a high level of physical activity was reported by 34.9% ±6.6. Youger age groups recorded high proportios of low total physical activity which chaged little with icreasig age. The proportios of total moderate physical activity fluctuated slightly across the age groups, but overall about oe i five Togas had a moderate level of physical activity at the time of the survey. 35

37 For the age group, 35.5% ±7.0 reported high total physical activity, 20.6% ±3.3 reported moderate ad 43.9% ±5.9 low total physical activity. Table 22 Categories of overall physical activity amog both sexes by age group Level of total physical activity Age Both Sexes Group % % Low Moderate % High ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±7.0 Table 23 presets the mea miutes of egagig i total physical activity per day across all three domais by geder ad age. Overall, respodets reported a average of ±15.9 miutes per day spet i total physical activity. There was a statistically sigificat geder differece with me egagig i physical activity for a average of ±22.9 miutes per day compared to wome for a average of 85.3 ±15.7 miutes per day. This differece was largely due to more work-related activity amog me. The average time spet i total physical activity amog me peaked i the age group ad declied thereafter, although the average miutes reported by the oldest age group (178.6 ±31.3) was higher tha the average miutes reported by the yougest age group (159.9 ±59.6). The same patter was oted for wome, with mea miutes peaked i the years age group (96.6 ±13.9) ad declied to 84.5 ±39.1 i the oldest age group, but still higher tha the yougest age group (73.3 ±38.9). For the age group, respodets reported a average of ±20.2 miutes per day spet i physical activity, with a average of ±36.6 miutes reported by me ad 91.5 ±11.3 miutes reported by wome. 36

38 Table 23 Level of Total physical activity (mea 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 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±20.2 Tables summarize results o mea miutes per day egaged i work, trasport ad recreatio-related physical activity. Across both geders, work (81.3 ±11.0) accouted for the largest portio of all physical activity followed by trasport (33.8 ±3.8) ad recreatio (15.6 ±4.8). For the age group, work (92.4±13.0) also accouted for the largest portio of all physical activity followed by trasport (33.9 ±5.8) ad recreatio (12.3 ±5.1). Table 24 shows that work-related physical activities comprised ±17.1 miutes/day for me ad 53.8 ±11.1 miutes/day for wome, a statistically sigificat geder differece. Across all age groups me reported egagig i more miutes of work-related physical activity tha wome. For the age group, work-related physical activities comprised ±26.7 miutes/day for me ad 58.8 ±11.9 miutes/day for wome. 37

39 Table 24 Level of Work-related physical activity (mea miutes per day) by geder ad age group Mea miutes of work-related physical activity o average per day Age Me Wome Both Sexes Group Mea Mea Mea miutes miutes miutes ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±13.0 Table 25 shows that trasport-related physical activities comprised 43.0 ±5.6 miutes/day for me ad 25.2 ±5.7 miutes/day for wome, a statistically sigificat geder differece. For the age group, trasported-related physical activities comprised 42.1±7.4 miutes/day for me ad 26.2 ±6.3 miutes/day for wome. Table 25 Level of Trasport-related physical activity (mea miutes per day) by geder ad age group Mea miutes of trasport-related physical activity o average per day Age Me Wome Both Sexes Group Mea Mea Mea miutes miutes miutes ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±5.8 Table 26 shows that recreatio-related physical activities comprised a average of 25.5 ±7.6 miutes/day for me ad a average of 6.3 ±2.3 miutes/day for wome. While me geerally reported egagig i more miutes/day of recreatio related physical activity tha wome i all age groups, wome i age group reported egagig i more recreatioal physical activities tha me (wome 11.0 ±7.6; me 6.2 ±6.7). For the age group, recreatio-related physical activities comprised 18.5 ±9.0 miutes/day for me ad 6.5 ±2.5 miutes/day for wome. 38

40 Table 26 Level of Recreatio-related physical activity (mea miutes per day) by geder ad age group Mea miutes of recreatio-related physical activity o average per day Age Me Wome Both Sexes Group Mea 95% Mea 95% Mea 95% miutes CI miutes CI miutes CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Overweight ad Obesity Height ad Weight The height ad weight of each participat aged years was measured followig the stadardized STEPS protocol. The body mass idex (BMI) of each participat was 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 27 ad 28 show that me were sigificatly taller (175.9cm ±1.0) tha wome (165.2cm ±0.8) ad me were also margially heavier (98.6kg ±3.5) tha wome (95.5kg±1.7). 39

41 Table 27 Mea height by geder ad age group Mea height (cm) Me Wome Mea Mea ± ± ± ± ± ± ± ± ± ±0.8 Table 28 Mea weight by geder ad age group Mea weight (kg) Me Wome Mea Mea ± ± ± ± ± ± ± ± ± ±1.7 For both me ad wome, average body weight peaked i age group (wome 98.7kg ±2.9; me 106.6kg ±5.8) Body Mass Idex Categories Table 29 summarizes the mea BMI for both geders ad combied. The overall mea BMI was 33.3kg/m 2 ±0.6. Wome had a statistically higher mea BMI (34.9kg/m 2 ±0.6) tha me (31.7kg/m 2 ±1.1) ad i all age groups, although sigificat geder differece was oly oted i age groups ad The mea BMI for both me ad wome fluctuated slightly across age groups. 40

42 Table 29 Mea body mass idex (kg/m 2 ) by geder ad age group Age Group Mea BMI (kg/m 2 ) Me Wome Both Sexes Mea Mea Mea ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.6 Tables 30 to 32 preset the distributio of the sample populatio across three BMI classificatios: uderweight, ormal ad overweight/obese for me, wome ad both geders combied. Table 32 shows that 89.2% ±4.7 of me are classified as overweight/ obese, 10.5% ±4.7 as havig ormal weight ad 0.3% ±0.4 as beig uderweight. Table 30 BMI classificatios amog me by age group BMI classificatios Me Age Group % Uderweight weight weight % Normal % Over- < ± ± ± ± ± ± ± ± ± ± ± ±4.7 Table 31 shows that 94.9% ±2.3 of wome are classified as overweight/obese ad 5.1% ±2.3 as havig a ormal BMI. 41

43 Table 31 BMI classificatios amog wome by age group BMI classificatios Wome Age Group % Uderweight weight weight % Normal % Over- < ± ± ± ± ± ± ± ± ± ±2.3 Table 32 shows that overall 92.1% ±2.1 of the survey populatio are classified as beig overweight/obese, 7.7% ±2.1 as havig a ormal BMI ad 0.1% ±0.2 as beig uderweight. For both me ad wome, the high prevalece of overweight/obese was evidet at the yougest age group. Table 32 BMI classificatios amog both sexes by age group BMI classificatios Both Sexes Age Group % Uderweight weight weight % Normal % Over- < ± ± ± ± ± ± ± ± ± ± ± ±2.1 Table 33 presets rates of obesity (BMI 30 kg/m 2 ) for both geders ad combied. The overall prevalece of obesity was 68.7% ±4.2. The obesity rate was sigificatly higher amog wome (76.3% ±3.8) tha amog me (60.7% ±8.9). For me, the highest prevalece of obesity was i the age group (73.1% ± 13.7), ad for wome i the age group (82.3% ±7.0). 42

44 Age Group Table 33 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 % % % ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Waist Circumferece As a risk factor for cardiovascular diseases, cetral obesity was assessed by measurig waist circumferece of participats. Table 34 shows the mea waist circumferece for both me ad wome. Wome had a margially higher mea waist circumferece (105.2m ±2.1) tha me (103.4cm ±3.3). The mea waist circumferece did ot vary markedly by age amog wome. For me, the mea waist circumferece icreased from 98.2cm ±2.6 i the yougest age group to ± 4.3 i the ext age group years ad decreased margially thereafter. Table 34 Mea waist circumferece (cm) by geder ad age group Waist circumferece (cm) Me Wome Mea Mea ± ± ± ± ± ± ± ± ± ± Blood Pressure ad Hypertesio All survey respodets aged years had their blood pressure measured, were asked if they had had their blood pressure measured i the last 12 moths or withi the last 1-5 years or loger, 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, participats were cosidered as havig hypertesio followig the STEPS classificatio protocol: 43

45 a mea systolic pressure of 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 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 35 ad 36 preset mea restig systolic blood pressure ad mea restig diastolic blood pressure, respectively, for me ad wome separately ad combied. Table 37 shows a statistically higher mea systolic blood pressure amog me tha wome (129.4mmHg ±2.7 ad 122.7mmHg ±1.8 respectively). Systolic blood pressure icreased with age amog wome. For me, mea systolic blood pressure fluctuated across age groups. Table 35 Mea restig systolic blood pressure (mmhg) by geder ad age group Mea systolic blood pressure (mmhg) Age Me Wome Both Sexes Group Mea Mea Mea ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±1.9 Table 36 shows a slightly higher mea diastolic blood pressure i me ad wome (76.4mmHg ±2.3 ad 74.3mmHg ±1.8 respectively), icreasig with age i both geders from age group

46 Table 36 Mea restig diastolic blood pressure (mmhg) by geder ad age group Age Group Mea diastolic blood pressure (mmhg) Me Wome Both Sexes Mea Mea Mea ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±1.7 Table 37 presets the prevalece of hypertesio for both geders ad combied. Hypertesio was recorded for 23.1% ±5.0 of the total survey populatio. There was o statistical differece i hypertesio prevalece betwee me ad wome (26.5% ±7.3 ad 19.9% ±3.8 respectively). The prevalece of hypertesio more tha doubled for wome by age years (19.3% ±11.2) ad icreased thereafter. Also i age group years the male hypertesio rate icreased substatially to 33.4% ±12.9 (from 19.8% ±11.2 i age group 25-34). Table 37 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 Age Me Wome Both Sexes Group % % % ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Fastig Blood Glucose ad Raised Blood Glucose Survey participats were asked if they had bee told by a health worker that they had diabetes i the previous 12 moths, withi 1-5 years or loger, ad whether they were curretly receivig medical treatmet for diabetes. Participats fastig blood sugar levels were measured by drawig capillary whole blood usig the figer prick test method. Estimates of diabetes prevalece were computed based o the capillary whole blood glucose tests ad based o the WHO guidelies for defiig ad classifyig diabetes mellitus: fastig capillary whole blood value of glucose 6.1 mmol/l ( 110 mg/dl) whether or ot they had previously bee told by a health worker that they had diabetes, OR 45

47 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. Table 38 summarizes results o mea fastig blood glucose for both geders ad combied. The overall mea fastig blood glucose was 5.7mmol/L ±0.2. Me reported a slightly higher mea fastig blood glucose level (5.8mmol/L ±0.4) tha wome (5.6mmo/L ±0.3). For wome, mea fastig blood glucose levels icreased with icreasig age, ad peaked i those aged (6.3mmol/L ±0.6). For me, mea fastig glucose levels fluctuated across age groups, ad peaked i the oldest age group (7.0mmol/L ±1.2). Age Group Table 38 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 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.2 Age Group Table 39 Prevalece of raised blood glucose by geder ad age group Raised blood glucose* Me Wome Both Sexes % % % ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±5.5 * capillary whole blood value: 6.1 mmol/l (110 mg/dl) Table 39 shows the prevalece of raised blood glucose for both geders ad combied. The overall prevalece of raised blood glucose for Toga was 16.4% ±5.5 amog those aged years. Prevalece of raised blood glucose was similar amog wome ad me (16.6% ±5.1 ad 16.3% ±7.7 respectively). By age years, about oe quarter of me was diabetic (25.6% ±16.8). By age years, about oe third of wome had raised blood glucose (32.8% ±12.6). 46

48 4.9 Total Cholesterol Table 40 shows the overall mea cholesterol level for both geders ad combied. The overall mea was 5.1mmol/L ±0.1, with me recordig a sigificatly higher mea level tha wome (5.4mmol/L ±0.1 ad 4.8mmol/L ±0.1 respectively), with the differece ot statistically differet. Mea levels for me ad wome showed slight variatio across age groups. Table 40 Mea levels of total blood cholesterol (mmol/l) by geder ad age group Age Group Mea total cholesterol (mmol/l) Me Wome Both Sexes Mea Mea Mea ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.1 Age Group Table 41 Percetage with raised blood cholesterol ( 5.0 mmol/l or 190 mg/dl) Total cholesterol 5.0 mmol/l or 190 mg/dl Me Wome Both Sexes % % % ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±5.2 Elevated total blood cholesterol was defied by a cut-off poit 5.0 mmol/l (or 190 mg/dl) ad used to classify participats as beig i a high-risk group for coroary artery disease. Table 41 shows that early half of the survey populatio (49.7% ±5.2) had raised blood cholesterol, a statistically sigificatly greater proportio i me tha i wome (66.1% ±5.1 ad 34.2% ±5.9 respectively). This statistical sigificat geder differece exists from age years. The prevalece of raised blood cholesterol icreased as people aged for both me ad wome. 47

49 4.10 Combied Risk Factors To summarize the fidigs, the followig five risk factors for NCDs were summed to idicate the overall risk for NCDs: 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 physical activity (<600 METmiutes per week). Based o these combied risk factors, three levels of the overall risk for NCDs were created as follows: Low Risk: 0 of 5 risk factors Moderate Risk: 1 or 2 of 5 risk factors High Risk: 3 or more of 5 risk factors Table 42 shows that 60.5% ±6.9 of male respodets were classified as beig at High Risk ad 39.5% ±6.9 as at Moderate Risk. Table 42 Percetage of NCD risk categories amog me by age group Summary of Combied Risk Factors Me Age Group % with 0 % with 1- % with 3- risk 2 risk 5 risk factors factors factors ± ± ± ± ± ±6.9 Age Group Table 43 Percetage of NCD risk categories amog wome by age group Summary of Combied Risk Factors Wome % with 0 % with 1- risk 2 risk factors factors % with 3-5 risk factors ± ± ± ± ± ±4.1 48

50 Table 43 shows wome at the same level of risk as me with 60.8% ±4.1 cosidered to be at High Risk ad 39.0% ±4.0 at Moderate Risk. Table 44 Percetage of NCD risk categories amog both sexes by age group Age Group Summary of Combied Risk Factors Both Sexes % with 0 % with 1- risk 2 risk factors factors % with 3-5 risk factors ± ± ± ± ± ± ± ±4.4 Overall, 60.7% ±4.4 of the Toga survey populatio was at High Risk of NCDs (Table 44). By age years, more tha half of the sample was at High Risk (58.1% ±5.8) ad this patter treded upwards to 65.4% ±6.6 i the oldest age group. 5. DISCUSSION AND CONCLUSIONS The WHO STEPwise Approach to Surveillace of NCD Risk Factors provides a system for gatherig populatio-based data o behavioural, athropometric ad metabolic risk factors for chroic diseases. The STEPwise framework was developed i respose to the growig eed for data o NCD risk factors i coutries i the world. For Toga, the STEPS survey has provided up-to-date epidemiological evidece that NCDs- related behavioural, metabolic ad athropometric risk factors are sigificat public health issues i Toga. This sectio discusses key fidigs from the Toga STEPS survey ad presets a rage of recommedatios to prevet ad cotrol NCDs i the Kigdom of Toga. Tobacco use is a leadig modifiable behavioural risk factor of NCDs. The STEPS survey highlighted that tobacco smokig is well established i Toga, with close to oe third of Togas aged 15 years ad over beig curret (daily ad o-daily) smokers, with a sigificatly higher proportio of males (46.2%) beig curret smokers, compared with females (16.3%). Smokig uptake occurred i mid adolescece for the yougest age group for both me ad wome, while older age groups reported a later uptake age of early 20s. These fidigs highlight the eed for programs to prevet youg Togas from experimetig with tobacco products at a early age; sice the youger adolescets start smokig, the more likely they are to become regular smokers i adulthood 13. The prevalece of daily tobacco use amog age groups was: Toga (27.6%), Nauru (49.5%), America Samoa (29.9%), Tokelau (46.9%), Federated States of Microesia (Pohpei) (25.5%), Kiribati (59.0%), Solomo Islads (30.6%), Cook Islads (33.3%), Federated States of Microesia (Chuuk) (28.7%) About oe i five (22.2%) male Togas were classified as curret drikers (drikig alcohol i the past 12 moths), compared to 4.8% of females. This geder differece may be explaied by social ad cultural factors; however, due to the small umbers cautio is 49

51 warrated whe iterpretig these fidigs. Similarly, the magitude ad extet of harmful or bige drikig i Toga could ot be determied with certaity due agai to the small umbers respodig to these alcohol measures. As foud i other completed STEPS surveys ad published STEPS reports i the Pacific, the majority of Togas reported ot cosumig the recommeded five combied servigs of fruit ad vegetables per day. The low level of fruit ad vegetable cosumptio did ot differ betwee me ad wome or across age groups. A better uderstadig of the idividual, cultural, social ad ecoomical factors that might facilitate dietary chages is a importat precursor for effective policy ad program developmet. Regardless, some of the strategies that could be cosidered iclude makig affordable ad accessible locally-cultivated produce, ad creatig societal orms for healthy eatig. The latter strategy could be cosidered as part of a settig-based approach (church, schools, workplaces). Measures of physical activity clearly showed that early half of the Toga populatio egaged i low levels of physical activity, defied as achievig less tha 600 METmiutes per week. There was a marked geder differece whereby more tha half of the females surveyed (54.8%) reported the lowest amout of physical activity i cotrast to half of the males surveyed (49.0%) reported the highest amout of physical activity. Recreatioalrelated physical activity cotributed least (15.6 miutes per day) to the total physical activity udertake by Togas, while physical activity doe as part of work cotributed the most (81.3 miutes per day). Overall, the data o physical activity idicated that the majority of Togas, especially wome, are ot egagig i a level of physical activity that is beeficial to their health. The prevalece of overweight amog those aged 25 to 64 years was 92.1%, with the rate beig slightly higher amog wome (94.9%) tha me (89.2%), with 76.3% of wome beig obese ad 60.7% of me obese. These extremely high prevalece rates are observed i all age groups, ad across both geders. While represetig oe of the highest overweight ad obesity rates i the regio, the rates i Toga are similar to those reported. The prevalece of overweight ad obesity amog age groups was: Nauru (Overweight: 93.3%; Obesity: 74.9%), America Samoa (Overweight: 93.5%; Obesity: 74.6%), Tokelau (Overweight: 93.5%; Obesity: 74.7%), Federated States of Microesia (Pohpei) (Overweight: 73.1%; Obesity: 42.6%), Kiribati (Overweight: 81.5%; Obesity: 50.6%), Solomo Islads (Overweight: 67.4%; Obesity: 32.8%), Cook Islads (Overweight: 88.5%; Obesity: 61.4%), Federated States of Microesia (Chuuk) (Overweight: 76.5%; Obesity: 47.3%) I Toga, these high rates of overweight ad obesity were evidet i the yougest age group (25-34 years). Prevetig uhealthy weight gai at a relatively youger age would be importat for addressig the sigificat health cosequeces associated with overweight ad obesity. Approximately oe i five Togas aged years was foud to have hypertesio, with a margially higher proportio of me (26.5%) tha wome (19.9%) beig at risk. Rates of hypertesio icreased with age across both geders, placig the older age groups at a elevated risk of developig stroke or cardiovascular disease, ad cosequetly premature mortality ad morbidity. Effective log-term moitorig ad cliical maagemet of hypertesio is required to prevet the progressio to chroic diseases. The prevalece of hypertesio amog age groups was: Toga (23.1%), Nauru (24.3%), America Samoa (34.2%), Tokelau (18.1%), Federated States of Microesia (Pohpei) (21.2%), Kiribati (17.3%), Solomo Islads (10.7%), Cook Islads (33.2%), Federated States of Microesia (Chuuk) (15.2%)

52 The prevalece of raised blood glucose amog those aged years i the populatio was 16.4%, with o sigificat differece betwee me ad wome. By age group years, the prevalece was 20.1% (me: 25.6%; wome: 14.8%). I America Samoa, the prevalece amog those also aged years was 47.3%; ad i Cook Islads 23.6% 15, 20. Although relatively lower tha other rates i the Pacific, the levels of raised blood glucose are still at high levels, especially amog those aged 35 years ad older. Raised blood cholesterol was foud i two thirds of me (66.1%) ad oe third of wome (34.2%). The relatively high prevalece of high blood cholesterol was already evidet i the yougest age group years, with 60.2% of me ad 18.4% of wome with this problem. A few caveats should be oted whe discussig these results. First, the relatively small sample size i the older age groups ad i relatio to some key behavioural measures such as alcohol cosumptio ad physical activity could affect the precisio, evidet i wider cofidece itervals observed. Secod, the reliace upo self-report of health behaviour has the potetial for bias as survey respodets over-estimate or uder-estimate their drikig patter, dietary practices or physical activity participatio. However, the STEPS questioaire is comprised of well-validated measures that are stadardized i terms of defiitios ad cocepts, ad survey staff were thoroughly traied i the admiistratio of these measures. Additioally, traied staff followed a stadardized data collectio protocol that was relatively simple for survey staff to execute. The Toga STEPS survey has cofirmed that its populatio is experiecig some of the highest rates of NCD risk factors i the Pacific ad globally. Specifically, behavioural risk factors for NCDs are prevalet i Toga for both geders ad across all adult age groups. Nearly two thirds (60.7%) of the populatio aged years were classified as beig at High Risk of developig NCDs (with 3-5 risk factors). Sustaied, diverse but complemetary atioal actios are eeded to reverse the escalatig NCD risk factors epidemic, as reductios i smokig ad alcohol ad improvemets i physical activity ad dietary practices will take several years to maifest. Moreover, the four major NCD risk factors are strogly iflueced by the social, cultural, religious, evirometal ad political iflueces. Ackowledgig this complexity of determiats, committed advocacy ad resources are a ecessary atecedet to achievig chage at the whole populatio level. Buildig cosesus, commo agedas ad collaboratio across govermet miistries ad with idustry, atioal ad iteratioal developmet parters will be fudametal to the process. The fial sectio of this report outlies a portfolio of measures, if effectively implemeted, will cotribute to prevetig obesity, diabetes ad other NCDs i Toga. 6. RECOMMENDATIONS Addressig surveillace ad iformatio eeds This icludes: Securig political ad fiacial commitmets to develop a systematic ad plaed STEPS NCDs risk factors data collectio system, supported by a workforce skilled i implemetig the survey, i order to have established a ogoig moitorig ad surveillace system that is scietifically rigorous ad robust i Toga. 51

53 Supplemetig the core Toga STEPS questioaire with additioal questios to esure that Toga STEPS provide timely ad relevat epidemiological data for plaig ad policy developmet. Such questios for future cosideratio could iclude salt cosumptio ad metal health. For the 1 st time, amog the published STEPS reports i the PICs, the prevalece of age ad age were both preseted i the core tables of the Step 1 i this STEPS report. These compared data show that whe usig age, the prevalece of most idicators (especially i the tobacco ad alcohol sectios) were higher, compared to years. Therefore, tobacco use ad harmful alcohol cosumptio amog Toga youth ad adolescets eed to be paid more public health attetio. Cosiderig settig up atioal targets ad idicators for NCD prevetio ad cotrol. Participatig i the compariso of STEPS fidigs across other Pacific islad coutries ad areas that have completed the STEPS survey ad published STEPS reports. Coductig data compariso over time after the 2 d -roud STEPS survey i Toga i is completed. Addressig policy, orgaizatioal ad evirometal factors This icludes: Implemetig the WHO Framework Covetio o Tobacco Cotrol, such as addressig smoke-free eviromets ad icreasig tobacco taxatio. Limitig the marketig ad advertisig of uhealthy foods ad driks. Developig policies supportig the importatio of healthy foods. Improvig the availability ad affordability of fruit ad vegetables. Developig policies to establish ad support physical activity-friedly eviromets, such as walkig paths, ope public gree spaces for recreatioal activities, sports facilities ad workplace physical activity programs. Implemetig settig-based policies to support healthy lifestyle ad practices, e.g. healthy food services ad physical activity promotio policies i workplaces, churches ad schools. Policies to support health system stregtheig icludig skilled workforce, fiacial coverage, essetial drugs, affordable techology for maagig NCDs. Addressig kowledge ad awareess of NCD behavioural risk factors This icludes implemetig: Comprehesive ati-smokig programs to reduce smokig rates, particularly targetig adolescets ad youths to prevet smokig uptake, ad smokig cessatio programs to reduce smokig rates across all age groups. Comprehesive public health programs to reduce harmful alcohol cosumptio, icludig social marketig ad mass commuicatio campaigs to icrease awareess of the adverse effects of harmful alcohol cosumptio. Comprehesive public health programs promotig the cosumptio of the recommeded levels of fruit ad vegetables. Comprehesive social marketig ad mass commuicatio campaigs to icrease public awareess of the adverse effects of excessive cosumptio of high-fat, high-salt, ad high-sugar foods. Culturally-appropriate ad diverse programs to promote daily physical activity. 52

54 Public awareess campaigs o the importace of regular moitorig ad screeig of blood pressure, blood sugar ad blood cholesterol levels. A system of commuity-based, outreached care for the maagemet of idividuals with diagosed NCDs. 53

55 APPENDICES 54

56 Appedix 1. Kigdom of Toga STEPS Survey Questioaire Toga Natioal NCD Survey STEPS Istrumet The WHO STEPwise approach to Surveillace of ocommuicable diseases (STEPS) 55