Federated States of Micronesia (Chuuk) NCD Risk Factors STEPS REPORT

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2 Federated States of Microesia (Chuuk) NCD Risk Factors STEPS REPORT Prited i Suva, Fiji May, 2012

3 Ackowledgemets The Federated States of Microesia (Chuuk) NCD Risk Factors STEPS Report (referred as the Report ) is a record of a combied effort of several orgaizatios ad 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 the Federated States of Microesia (referred as FSM ) Departmet of Health ad Social Affairs, Departmet of Health Services of the State of Chuuk, FSM, ad World Health Orgaizatio (referred as WHO ). The Report compiled by: Mr Marcus Samo (FSM), Dr Graham Roberts (UNSW), Dr Li Da (WHO, Suva), Mr Julio Marar (Chuuk, FSM), Ms Leae Riley (WHO, Geeva), Ms Moria Shomour (Chuuk, FSM), Mr Shalvidra Raj (WHO, Suva), Mr Kipier Lippwe (FSM), Dr Doria Fred (Chuuk, FSM), Mr Amato Elymore, Mr Carter Apaisam (FSM), Mr Abrahm Rold ad Mr Saphy William (Chuuk, FSM). Great appreciatio is to the Departmet of Health ad Social Affairs, FSM, thaks to the Secretary for Health ad Social Affairs, Dr Vita A. Skillig ad the Director of Health Services, Chuuk, FSM, Mr Julio Marar for their support. Thaks to Dr Ja Pryor ad Ms Shakila Naidu, former staff of Fiji School of Medicie, for coductig the traiig. A special thak to the staff for the field survey. Grateful ackowledgemet is made to Dr Dogil Ah (Director, Pacific Techical Support ad Represetative, South Pacific, WHO Office i Suva) ad Dr Ha Tieru (Director, Divisio of Buildig Healthy Commuities ad Populatios, WHO Office i Maila) for their great support. We ackowledge the statistical support ad result geeratio provided by Ms Leae Riley, Ms Melaie Cowa, Ms Regia Guthold (WHO Office i Geeva), Mr Shalvidra Raj who made substatial cotributio to the completio of data aalyses. The FSM (Chuuk) STEPS survey ad the Report were fuded by the Australia cy for Iteratioal Developmet (AusAID), New Zealad cy for Iteratioal Developmet (NZAID), ad WHO. Chuuk Departmet of Health Services ad FSM Departmet of Health ad Social Affairs provided fudig-i-kid. Dr Graham Roberts (Uiversity of New South Wales) drafted the first versio of the Report, workig closely with WHO Office i Suva. Dr Li Da, Ms Leae Riley, Dr Philayrath Phogsava (Uiversity of Sydey), Dr Adrew Coli Bell (WHO Office i Suva), Dr Hai-Rim Shi, Dr Cheria Varghese (WHO Office i Maila), Mr Shalvidra Raj, Ms Regia Guthold ad Ms Melaie Cowa have coducted techical reviews for the Report. The coutry cosultatios held i Chuuk ad Pohpei, FSM were atteded by Mr Marcus Samo, Mr Resty Shotaro (Chuuk, FSM), Mr Kipier Lippwe, Ms Moria Shomour, Dr Kio S. Rube, Ms Maurita H. Bualuay (Chuuk, FSM) ad Dr Li Da. Durig the coutry cosultatio, the Love Stick ad Devil Mask, as the symbols of Chuuk, FSM, were selected to be put at the bottom of the cover of the Report. Traditioally, Love Stick was a carved woode stick with a uique patter which was used as a social product of expressio, idetificatio ad feedback betwee youg lovers durig datig; Devil Mask was a carved woode mask to scare the ghost away from stealig food. Dr Li Da, Dr Philayrath Phogsava ad Dr Graham Roberts are the fial techical ad editorial reviewers of the Report. WHO Suva Office arraged the pritig, o behalf of FSM Departmet of Health ad Social Affairs. 2

4 CONTENTS FOREWORD 8 EXECUTIVE SUMMARY INTRODUCTION Backgroud ad Ratioale The Natioal Cotext Geography Populatio ad Livig Eviromet Govermet, Culture ad the Ecoomy Nocommuicable Disease Health Status ad Health Ifrastructure Developig WHO STEPS Survey i FSM (Chuuk) OBJECTIVES METHODOLOGY Survey Structure Sample Size Data Collectio Procedures Registratio of Participats Step 1 - Behavioral Risk Factors Iterviews Step 2 - Physical Measuremets Step 3 - Biochemical Measuremets Check-out Statio ad Couselig Data Maagemet ad Aalyses Data Etry Data Weightig ad Aalysis RESULTS Characteristics of Survey Populatio Tobacco Use Betel Nut Use Alcohol Cosumptio Itake of Fruit ad Vegetables Physical Activity Measuremets Aalyses Levels of Physical Activity Overweight ad Obesity 44 3

5 4.7.1 Height ad Weight Body Mass Idex Categories Waist Circumferece Blood Pressure ad Hypertesio Fastig Blood Glucose ad Diabetes Total Cholesterol Combied Risk Factors DISCUSSION AND CONCLUSIONS RECOMMENDATIONS 56 APPENDICES 58 Appedix 1 FSM (Chuuk) STEPS Survey Questioaire 59 Appedix 2 The Data Book of the Federated States of Microesia (Chuuk) STEPS Survey 69 Appedix 3 List of staff for the FSM (Chuuk) STEPS Survey 118 Appedix 4 Refereces 119 KEY CONTACTS 4

6 LIST OF FIGURES Figure 1 The WHO STEPwise approach to surveillace of NCDs 20 Figure 2 Sequece of data collectio ad statios at the survey base 21 LIST OF TABLES Table 1 Demographic descriptio of study populatio 26 Table 2 Mea umber of years of educatio by geder ad age group 26 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 27 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 curret betel ut chewers amog me durig the past 12 moths by age group 30 Table 11 Percetage of curret betel ut chewers amog wome durig the past 12 moths by age group 31 Table 12 Percetage of curret betel ut chewers amog both sexes durig the past 12 moths by age group 31 Table 13 Curret chewig status amog me i the study populatio by age group 32 Table 14 Curret chewig status amog wome i the study populatio by age group 32 Table 15 Curret chewig status amog wome i the study populatio by age group 33 Table 16 Percetage of alcohol cosumptio amog me durig the past 12 moths by age group 34 Table 17 Percetage of alcohol cosumptio amog wome durig the past 12 moths by age group 34 Table 18 Percetage of alcohol cosumptio amog both sexes durig the past 12 moths by age group 35 Table 19 Frequecy ad quatity of driks cosumed i the last 7 days by curret (last 30 days) driker, grouped ito three categories 35 Table 20 Number of driks per day amog me who are curret drikers by age group 36 Table 21 Number of driks per day amog both sexes who are curret drikers by age group 36 Table 22 Mea umber of days i a week that fruits are cosumed by geder ad age group 37 Table 23 Mea umber of days i a week that vegetables are cosumed 5

7 by geder ad age group 37 Table 24 Mea umber of servigs of fruits cosumed o a day whe fruits were eate 38 Table 25 Mea umber of servigs of vegetables cosumed o a day whe vegetables were eate 38 Table 26 Mea umber of combied servigs of fruit ad vegetables cosumed per day of the week 39 Table 27 Percetage who cosumed less tha five combied servigs of fruit ad vegetables per day of the week 39 Table 28 Categories of overall physical activity amog me by age group 41 Table 29 Categories of overall physical activity amog wome by age group 41 Table 30 Categories of overall physical activity amog both sexes by age group 42 Table 31 Level of total physical activity (mea miutes per day) by geder ad age group 42 Table 32 Level of work-related physical activity (mea miutes per day) by geder ad age group 43 Table 33 Level of trasport-related physical activity (mea miutes per day) by geder ad age group 43 Table 34 Level of recreatio-related physical activity (mea miutes per day) by geder ad age group 44 Table 35 Mea height by geder ad age group 44 Table 36 Mea weight by geder ad age group 45 Table 37 Mea body mass idex (kg/m 2 ) by geder ad age group 45 Table 38 BMI classificatios amog me by age group 46 Table 39 BMI classificatios amog wome by age group 46 Table 40 BMI classificatios amog both sexes by age group 46 Table 41 Percetage of obesity (BMI 30 kg/m 2 ) by geder ad age group 47 Table 42 Mea waist circumferece (cm) by geder ad age group 47 Table 43 Mea restig systolic blood pressure (mmhg) by geder ad age group 48 Table 44 Mea restig diastolic blood pressure (mmhg) by geder ad Table 45 age group 48 Percetage with hypertesio (SBP 140 ad/or DBP 90 OR curretly o medicatio for raised blood pressure) 49 Table 46 Mea fastig blood glucose i mmol/l by geder ad age group 50 Table 47 Mea fastig blood glucose i mg/dl by geder ad age group 50 Table 48 Prevalece of diabetes by geder ad age group 51 Table 49 Mea levels of total blood cholesterol (mmol/l) by geder ad 51 age group Table 50 Mea levels of total blood cholesterol (mg/dl) by geder ad age group 52 Table 51 Percetage with raised blood cholesterol ( 5.0 mmol/l or 190 mg/dl) 52 Table 52 Percetage of NCD risk categories amog me by age group 53 Table 53 Percetage of NCD risk categories amog wome by age group 53 Table 54 Percetage of NCD risk categories amog both sexes by age group 53 6

8 LIST OF ABBREVIATIONS BMI BP CHD CI CVD DBP DM FBS FSM 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 Federated States of Microesia 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 the world today, a dramatic icrease i chroic ocommuicable diseases (NCDs) that leads to death has bee experieced i almost every coutry. I order to address this growig problem effectively ad efficietly, we must have accurate iformatio regardig the risk factors that cotribute to the developmet of NCDs. We also must have scietific NCD data to idetify the itervetio o NCDs ad their risk factors. A Risk factor of NCDs refers to ay characteristic or exposure that icreases a perso s likelihood of developig a NCD. These risk factors iclude tobacco use, harmful alcohol use, physical iactivity, obesity, high blood pressure, a raised level of cholesterol, a raised level of blood glucose, ad a ubalaced diet. Each coutry eeds to establish its capacity i order to coduct populatio risk surveillace over time for the plaig of program activities ad services. We are pleased that the World Health Orgaizatio (WHO) has bee workig with us to stregthe our atioal ad state capacity i populatio risk factors survey ad aalysis. The Federated States of Microesia (Chuuk) NCD STEPS survey was specifically desiged to assess the prevalece of the commo NCDs ad their risk factors i our populatio. The iformatio from this survey provides a importat platform for the developmet ad implemetatio of strategic plas ad programs to address the growig epidemic of NCDs i Chuuk, FSM. This report showed a high prevalece of NCDs ad their risk factors amog our populatio ad suggests actios to: cotrol ad prevet NCDs; provide a supportive physical eviromet ad ifrastructure, ad improved health service delivery. 8

10 This is the first state-wide populatio-based survey o the prevalece of NCDs ad their risk factors i the history of the State of Chuuk, FSM. It is a milestoe to address the icreasig NCD epidemic affectig our people ad marks a icreased commitmet by the FSM Departmet of Health ad Social Affairs ad the Chuuk Departmet of Health Services 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, so as to deal with the emergecy declared o NCD i Chuuk. We would like to thak all the staff of the Miistry of Health, parters for completig the first ever NCD populatio survey i Chuuk, FSM, thak WHO for its strog ad excellet techical support, ad thak AusAID ad NZAID for the fiacial support. This report is dedicated to the hard work ad commitmet evideced from the iceptio to the completio of the NCD Risk Factors STEPS survey i Chuuk. We hope that the fidigs ad recommedatios i this report will guide our actios for prevetig ad cotrollig NCDs ad improvig health for all i Chuuk, FSM. Dr Vita A. Skillig Secretary Departmet of Health ad Social Affairs Federated States of Microesia 9

11 The WHO STEPwise Approach to Surveillace of Risk Factors for NCDs (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 147 coutries ad areas throughout the world utilize WHO STEPS to coduct atioal surveys o risk factors of chroic disease ad morbidity of NCDs. The publicatio of the Federated States of Microesia (Chuuk) NCD Risk Factors STEPS REPORT marks a milestoe as it provides the scietific, updated ad comparable data that will assist the govermet i addressig the escalatig issue of NCDs. The 10 published NCD STEPS reports across the Pacific have idetified the extremely high prevalece of NCDs over the past decade occurred i the Pacific islad coutries ad areas (PICs), causig up to 75% of all deaths ad a similar percetage of log term illess ad disability. Declared at the 9th Health Miisters Meetig held i Jue, 2011 that the Pacific islad coutries ad areas is i a NCD crisis requirig urget attetio ad actio. The Federated States of Microesia (Chuuk) STEPS Survey was coducted i Some of the key results of the survey ad the report, for the age group of years old, iclude the followig: 28.7% of the populatio smoked tobacco daily. 12.8% of populatio chewed betel uts daily, amog them me (17.7%) were sigificatly higher tha wome (8.1%). 10

12 49.6% of me drak a average of 5 or more stadard driks of alcohol, 43.5% of wome drak a average of 4 or more stadard driks of alcohol per day i the past week. 90.4% of the populatio cosumed less tha five combied servigs of fruit ad vegetables per day. 63.1% of the populatio was with low level of physical activity. The prevalece of overweight i the populatio was 76.5%, the prevalece of obesity was 47.3%. The prevalece of diabetes i the populatio was 35.4%. The prevalece of hypertesio was 15.2%. These results clearly documet that NCDs are a major problem i Federated States of Microesia (Chuuk). The STEPS results ca be used for formulatig or updatig the atioal ad state-level NCD strategy, evaluatig the impact of itegrated NCD itervetio activities, moitorig treds ad comparig the NCD data with Pohpei, FSM, other PICs ad may coutries i the world. Future priorities eed to be give to both primary ad secodary prevetio activities to prevet ad cotrol key NCDs, icludig diabetes, cardiovascular diseases, cacer, ad their risk factors icludig smokig use, uhealthy diet, physical iactivity ad harmful use of alcohol. WHO is hooured to be a critical part of the collaborative efforts betwee the Federated States of Microesia Departmet of Health ad Social Affairs, Chuuk State Departmet of Health Services, Australia cy for Iteratioal Developmet ad New Zealad cy for Iteratioal Developmet to complete the Federated States of Microesia (Chuuk) STEPS survey ad the report. WHO is proud to collaborate with the Federated States of Microesia i publishig this first Federated States of Microesia (Chuuk) NCD Risk Factors STEPS Report, ad will cotiue to work with health authorities, health workers ad the public to address the issues raised i this report. Dr Dogil Ah Director, Pacific Techical Support Represetative, South Pacific World Health Orgaizatio 11

13 EXECUTIVE SUMMARY The Federated States of Microesia (Chuuk) NCD STEPS survey provides the baselie assessmet of the risk factors of ocommuicable diseases (NCDs) ad their associated risk factors amog Chuuk Isladers. The key objectives of the NCD STEPS survey were: To documet the prevalece ad magitude of key NCDs amog adults To documet the prevalece ad magitude of major modifiable risk factors for NCDs icludig tobacco use, betel ut use, harmful use of alcohol, poor eatig patters, physical iactivity, obesity, high blood pressure, raised blood glucose ad cholesterol levels To compare NCDs ad their risk factors across differet age groups ad betwee me ad wome. A total of 2,831 idividuals aged participated i the survey. The sample was equally distributed across age groups. Educatioal levels were cosistet across sex ad age groups, apart from females aged 55-64, who had received margially less years of educatio. This report s mai tables preset data ad commetary o the sample aged years (=2,034), followig the stadard age group reportig for WHO STEPS surveys. Additioal results for 797 respodets aged years are also provided at the ed of each sectio of Step 1. Step 1. Behavioural risk factors Overall, the prevalece of curret smokers amog those aged years was 32.4%. More tha half of me (51%) were curret smokers compared to oly 14% of wome. Amog the total populatio, 28.7% smoked daily, with a geder differece of 47% of me ad 10.6% of wome. The mea age of smokig uptake was 18 years, although people i the years age group reported startig at 15.5 years, suggestive of a recet reductio i the age of smokig uptake. The mea duratio of smokig i both sexes combied was 22.9 years, ad 84% of curret smokers smoked maufactured cigarettes. Betel uts were chewed by 31.8% of me ad 13.3% of wome, mostly i the age group after which chewig betel use declied. Of males ad females combied 22.5% chewed betel i the last 12 moths ad 12.8% o a daily basis. Importatly, the proportio chewig betel ut (54.8%) amog those aged was more tha double the older groups. A sigificat geder differece was foud i alcohol cosumptio betwee males ad females, with 34.3% of males ad oly 1.3% of females cosumig alcohol i the past 12 moths. Combied, 17.7% of the populatio had cosumed alcohol i the past 12 moths while 11% of the populatio (=222) was classified as curret drikers (drak i the last 12 moths) of whom 73% were males ad 27% females. Drikig was highest i the age group of (23.7%) mostly due to me (43.3%). Half (49.6%) of male curret drikers reported drikig more tha 5 stadard driks o a drikig day ad 16.7% reported drikig 20+ driks i the past 7 days. The highest proportio of bige drikig amog me was i the oldest age group although drikig levels were ot 12

14 statistically differet amog me of all age groups. Of those aged alcohol cosumptio status did ot differ sigificatly from older age groups. Just over iety percet (90.4%) of Chuuk Isladers cosumed fruit ad vegetables at a rate below the recommeded levels of 5 combied servigs of fruit ad vegetables per day. The mea umber of days per week fruit ad vegetables were cosumed was 2.6 ad 3.1 days, respectively. Whe fruit ad vegetables were both cosumed o those days, the self-reported mea umber of combied fruit ad vegetables servigs was 2 serves per average day with o differece betwee sexes. The survey foud that 63% of the populatio reported a low level of total physical activity, that is, less tha 600 METmiutes per week. 600 METmiutes per week are equivalet to 30 miutes of moderate-itesity physical activity for 5 days per week, or 20 miutes of vigorous activity for 3 days per week. A greater proportio of wome (68%) udertook low level of physical activity tha me (59%). Coversely, a higher proportio of me reported a high level of total physical activity tha wome (31% ad 20% respectively) largely due to work-related activities. The greatest part of physical activity i Chuuk was udertake as part of work, followed by trasport ad the recreatio-related activities. Youg people aged partook i less work related physical activity tha older cohorts, while youg males did sigificatly more recreatio related physical activity tha youg females. Step 2: Physical risk factors Males were sigificatly taller (169.2cm) tha females (158.9cm). Mea weights for females were higher tha for males i age groups ad ad lower i the older age groups but the overall differece was ot statistically sigificat. More tha three quarters of the populatio was classified as overweight. The overall prevalece of overweight (BMI 25kg/m 2 ) was 76.5% (65% of males ad 88% of females). Those cosidered obese (BMI 30kg/m 2 ) was 47% overall (31% of males ad 63% of females). Less tha a quarter (23%) of the populatio (34.4% of males ad 11.8% of females) had a ormal body mass idex (18.5 BMI< 25kg/m 2 ). Mea waist circumferece was statistically differet betwee the sexes overall (94.3cm i males ad 101.4cm i females) due to large differeces i age groups ad but were ot sigificatly differet i older groups. Wome i all age groups had mea waist circumferece values exceedig 88cm, a cut-off value for wome cosidered to icrease cardiovascular disease risk. Mea waist circumferece for males i all age groups remaied below 102cm where the risk of cardiovascular disease icreases. The results showed that 15.2% of the populatio was hypertesive (defied as havig SBP 140 mmhg ad/or DBP 90 mmhg or o medicatio for raised blood pressure). Hypertesio icreased with age i both geders, icreased sigificatly i the years age group ad was highest (43%) i me i the years age group. 13

15 Step 3. Biochemical risk factors Based o measures of fastig capillary whole blood, the overall prevalece of diabetes (fastig glucose level 6.1 mmol/l or o medicatio for raised blood glucose) i the populatio aged years was 35.4% with o statistical differeces betwee sexes but with statistically sigificat icreases from age to i both sexes. The highest rate is amog both me ad wome aged (69.4% ad 63% respectively). Overall, 19.2% of the sample was foud to have raised total blood cholesterol levels exceedig 5.0 mmol/l ( 190 mg/dl) icreasig by age i both sexes. The icrease i wome i age group 55-64, where almost half (47.1%) of the populatio had raised cholesterol, is statistically sigificatly differet from the rate i males of the same age ad from the precedig female age group. Combied risk factors As the umber of NCD risk factors for a idividual icreases, so does the risk of developig a NCD. STEPS reports classify the surveyed populatio ito three NCD risk categories: 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 i the computatio of NCD risk categories were curret daily smokers, overweight (BMI 25 kg/m 2 ), raised blood pressure (SBP 140 ad/or DBP 90 mmhg or curretly o medicatio), cosumig less tha five combied servigs of fruit ad vegetables per day, ad a low level of physical activity (<600 METmiutes per week). This survey foud that overall 62.4% of the populatio was at High Risk of NCDs, shared equally amog males ad females, but sigificatly icreased i the age group Coclusio The survey has provided strog evidece that NCDs ad related modifiable risk factors are prevalet i Chuuk to the degree where overall 62% of the sample populatio was classed as beig at High Risk of NCDs. The Chuuk STEPS survey represets a sigificat step forward i gatherig iformatio for the atioal ad state strategy for the prevetio, cotrol ad maagemet of NCDs. While rates of overweight for males is a cocer ad prevalece of diabetes are similar, differeces betwee the sexes idicate that males are more likely to smoke, drik alcohol to excess, chew betel ut while youg ad, amog older me, eat less fruit ad vegetables tha others. Females are more at risk from lower levels of physical activity, beig overweight or obese ad havig a high waist circumferece, ad, particularly, higher levels of blood cholesterol at older age. These factors idetify potetial to target health promotio ad disease prevetio programs to alter behavioural ad lifestyle factors that cotribute to NCD risks. Accordigly, the followig recommedatios are outlied as priority actios for the State of Chuuk: Addressig Iformatio eeds 14

16 That the Departmet of Health: Use the opportuity of the publicatio of this Chuuk NCD Risk Factors STEPS Report to iitiate a ew NCD risk factor awareess ad reductio campaig i the State of Chuuk Establish strog leadership ad secure political ad fiacial commitmet to maitai a systematic ad rigorous approach to STEPS data collectio supported by a workforce traied i implemetig the survey, i order to create a ogoig ad robust STEPS surveillace system i Chuuk. Repeat the NCD STEPwise surveys periodically to determie the effectiveess, or otherwise, of NCD prevetio ad cotrol measures implemeted i Chuuk. Participate i the compariso of NCD STEPS data across other Pacific Islad coutries ad areas that have completed the NCD STEPS surveys, i order to idetify the risk factors that are particular to ad most ameable to modificatio, as well as to idetify the evidece-based prioritized itervetio i Chuuk, FSM. Addressig policy, orgaizatioal ad evirometal factors That govermet of FSM: Earmark fuds for ogoig NCD strategy implemetatio ad moitorig Implemet the WHO Framework Covetio o Tobacco Cotrol Cosider the potetial for maufacturers ad importers of cigarettes ad alcohol to be taxed to the degree that they subsidize health promotio iitiatives. Geerate resources for ogoig atioal health educatio programs aimed at atioal ad persoal productivity Develop policies supportig the growth ad importatio of healthy foods Improve the availability of fruit ad vegetables Icrease tax o certai imported uhealthy food items, like turkey tails, cored beef ad spam Develop policies to establish physical activity-friedly eviromets, such as walkig tracks, sports facilities ad workplace fitess programs Addressig NCD behavioural risk factors That govermet, Departmet of Health ad NGOs create ad provide: Comprehesive o-smokig ad o-betel ut use campaigs to reduce tobacco use rates, particularly targetig teeagers ad the youger adult age groups to prevet smokig uptake, ad smokig cessatio programs to reduce smokig rates across all age groups Comprehesive health promotio campaigs to reduce alcohol cosumptio, particularly targeted at youg people ad bige drikig Itegrated health promotio campaigs promotig the cosumptio of the recommeded levels of fruit ad vegetables, iclusive of a expressed strategy to esure proper utritio i older age Public awareess of the adverse effects of excessive cosumptio of high-fat, highsalt, ad high-sugar foods Culturally-appropriate ad diverse programs to promote daily physical activity 15

17 Iclude walk ways to improve physical activity i plaig ew road desig i Chuuk Public awareess campaigs o the importace of regular moitorig ad screeig of blood pressure, blood cholesterol ad blood sugar levels Public awareess programs targeted to icrease awareess of the multipliers of NCD risk associated with combiig the 5 major NCD risk factors (curret daily smokig, beig overweight, havig raised blood pressure, eatig less tha five combied servigs of fruit ad vegetables per day, ad havig a low level of physical activity) A system of commuity-based care for the maagemet of idividuals with diagosed NCDs 16

18 1. INTRODUCTION 1.1 Backgroud ad Ratioale I all coutries, ocommuicable diseases (NCDs) are resposible for a high proportio of death ad disability. I developig coutries, the burde of disease caused by NCDs is icreasig rapidly ad there are sigificat social, ecoomic, ad health cosequeces for these coutries. NCDs caused a estimated 60% of deaths i the world ad 43% of the global burde of diseases i Based o curret treds, by the year 2020 these diseases are predicted to accout for 73% of deaths ad 60% of the disease burde. Most of these icreases will reflect the epidemiological trasitio i developig coutries; from commuicable to ocommuicable diseases. Uless icreasig prevalece ca be reversed the disability ad depedecy that accompaies NCDs will preset a icreasig burde o health facilities ad o families. Despite such observatios that NCDs are a icreasig health burde to the coutry, to date there is o i-depth kowledge of the prevalece of the commo risk factors cotributig to NCDs i the Chuuk State. I FSM, 75% of death was due to NCD 1 There is a eed for a clearer uderstadig of the productio, trade, cultural ad behavioural factors that cotribute to NCDs i order to improve prevetio ad cotrol programs. This STEPS survey, beig the first i Chuuk, provides a baselie for future STEPS surveys to assist i determiig the effectiveess, or otherwise, of prevetio ad cotrol measures. It also provides the basis for compariso with other coutries. I the immediate term, this STEPS report provides iformatio for atioal policy developmet, health educatio programs ad health protectio ad promotio iitiatives, as ultimately, the improvemets i diet ad physical activity ad the cotrol of risk lade cosumptios are vested with the atio, the commuity ad the idividual. 1.2 The Natioal Cotext Geography The Federated States of Microesia (FSM) are located i Oceaia, ad comprise a islad group i the North Pacific Ocea, about three-quarters of the way from Hawaii to Idoesia. Chuuk has a lad area of 49 square miles ad ecompasses fiftee large islads, 192 outer islads ad 80 islets. Chuuk State comprises 5 regios: North Namoeas, South Namoeas, Faichuk, Mortlock ad Northwest. The weather is tropical with heavy year-roud raifall, especially i the easter islads. Chuuk is located o souther edge of the typhoo belt ad occasioally sustais severe damage, icludig ladslides. The islads of Chuuk vary from moutaious islads with volcaic outcroppigs to low coral atolls 2. 17

19 1.2.2 Populatio ad Livig Eviromet The populatios of the 5 regios of Chuuk were estimated i 2010 to be 14,611 (30%) i North Namoeas, 10,233 (21%) i South Namoeas, 9,807 (20.2%) i Faichuk, 7,181 (14.8%) i Mortlock ad 6,819 (14%) i Northwest. The 47,871 persos i Chuuk State i 1989 lived i 5,982 households, a average of 8.00 persos per household. The size of households i Chuuk is large eve by Pacific Islad stadards, ad is gettig larger. Almost 3 out of every 10 households i Chuuk had 10 or more persos Govermet, Culture ad the Ecoomy Chuuk is oe of four islad states that comprise the Federated States of Microesia, the other three beig Pohpei, Kosrae ad Yap. FSM is a semi-idepedet atio uder a Compact of Free Associatio with the Uited States allowig its citizes to work ad live i the US. The compact ad its subsidiary agreemets commit the US to cotiue to provide, at o cost to the FSM, may services icludig defece, air safety, weather predictio, health services ad assistace i the evet of atural disasters util the ed of the compact 3. Chuuk s GDP i 2007 was $53.6 millio with GDP per capita estimated to be $1,006 aually 4. Most (91.5%) of households i Chuuk have a cash icome, but average USD 6,195 per aum, less tha other FSM Sates ad rely to a large degree o subsistece farmig ad fishig. The Chuukese laguage is withi the Austroesia liguistic group. All 3 dialects i the Chuuk group are mutually uderstood. The exteded family is the most commo form of household, where fathers are the head ad where first-bor male childre iherit the resposibilities of the father. The atio's ecoomic performace is still heavily depedet o govermet spedig, fuded by the Compact with the U.S. The idustries of fisheries, tourism ad commercial agriculture combied accout for oly a small percet of the total FSM ecoomy. There is o maufacturig idustry, although cold storage facilities ad fish processig plats are i developmet. The mai reveue eared from fishig has bee from the aual licese fees that FSM egotiates with outside atios watig to fish i its waters, ad fishig geerates 85% of export reveue. Tourism, the secod targeted area of developmet, is costraied by high airfares ad limited tourist facilities, but the potetial exists for growth i this area 5. Commercial agriculture accouts for oly 1% of the ecoomy Nocommuicable Disease, Health Status ad Health Ifrastructure The Chuuk State Departmet of Health ad Hospital compiles iformatio o hospital presetatios ad o morbidity ad mortality. I 2009 the leadig causes of morbidity icluded Diseases of the Respiratory System, Certai Ifectious ad Parasitic Diseases, 18

20 Diseases of the Ski ad Subcutaeous Tissues, Diseases of the Musculoskeletal System ad Coective Tissues ad Diseases of the Circulatory System. Leadig causes of Mortality were Diseases of the Circulatory System, Diseases of Edocrie, Nutritio ad Metabolism, Diseases of the Respiratory System, Neoplasms ad Certai Ifectious ad Parasitic Diseases. Premature adult mortality is high, with a average life expectacy of 66 years. The 2000 cesus estimated the followig rates of birth, fertility, mortality ad life expectacy idicate that Chuuk does ot differ sigificatly from the other states of FSM. Idicator All FSM Chuuk State Crude Birth Rate, per Total Fertility Rate (TFR) Crude Death Rate, per Child Mortality Rate, per Ifat Mortality Rate Life expectacy at birth Source: 2000 FSM Cesus There are 65 public sector ad 6 private sector health facilities i FSM, which iclude the oly hospital at Weo (with 125 beds) ad 64 Dispesaries. Each of the FSM States has a Departmet of Health that provides cliical services ad coordiates public health programs comprisig dispesaries ad various vertical programs through muicipal govermets. The private sector services iclude 3 health cliics ad 3 pharmacies. Medical referrals abroad are to the Philippies, Hawaii ad Guam 7. The reliace o primary health care approaches challeges the atio to provide adequate services for the prevetio ad maagemet of NCDs at the local level. 1.3 Developig WHO STEPS Survey i Chuuk State Before this STEPS survey, o state-wide epidemiological data o NCD risk factors was collected i the State of Chuuk, Federated States of Microesia. Recogizig the gap i kowledge o the magitude of major NCDs ad their risk factors for plaig ad policy developmet, STEPS survey was coducted i OBJECTIVES The overall aim of the NCD STEPS risk factor survey is to ivestigate the prevalece of key NCDs ad their associated risk factors. The STEPS survey: 19

21 Documets the prevalece ad magitude of key NCDs amog adults Documets the prevalece ad magitude of major modifiable risk factors for NCDs icludig smokig, alcohol cosumptio, poor eatig patters, physical iactivity, obesity, high blood pressure, raised blood glucose ad cholesterol Compare NCDs ad their risk factors by age ad geder groups. 3. METHODOLOGY 3.1 Survey Structure With the techical assistace of the FSM Cesus Office, the FSM (Chuuk) STEPS survey followed a sequetial three-step process as follows (Figure 1): Step 1: A questioaire-based (iterview) survey o tobacco use, betel ut use, alcohol drikig, fruit ad vegetable cosumptio, ad physical activity. Step 2: Physiological measures of blood pressure, height, weight, hip ad waist circumferece. Step 3: Biochemical measures of fastig blood glucose, total cholesterol ad triglycerides. Similar to other STEPS surveys coducted i the Pacific regio, the Chuuk survey collected core iformatio across all three steps. STEPS stadardized survey methodology was followed. This approach esures that Chuuk has available populatiowide ad represetative data for betwee-coutry comparisos as well as withi-coutry comparisos. I future surveys, Chuuk could add more questios or measuremets to the core questios, depedig o local eeds. Step 3 Step 2 Biochemical measuremets Step 1 Physical measuremets Self report iformatio Figure 1. The WHO STEPwise approach to surveillace of NCD Risk Factors 3.2 Sample Size Miimum Expaded Optioal The STEPS guidelies require a miimum sample size of 2000 participats, with at least 300 participats i each of 10 age-geder categories. Accordigly, 2,831 participats were selected from the age group years to udergo STEP 1 ad STEP 2. This 20

22 sample comprised 2,034 people i the age group ad 797 people i the age group Thirty precet of the sample aged was selected to participate i STEP Data Collectio Procedures Survey persoel obtaied iformed coset from survey participats ad gave fastig istructios to those radomly selected for STEP 3 (excludig the age group) ad made appoitmet times for those who coseted to participate i the survey. All study i Chuuk followed the same procedure for selectig eligible participats. Registratio Statio Blood test Statio If fastig If ot fastig Refreshmet Statio Iterview Statio Height Measuremets Weight Measuremets Blood pressure Statio Hip/Waist Measuremets Check out & couselig Figure 2: Sequece of data collectio ad statios at the survey base Registratio of Participats At the registratio statio, survey persoel: Cofirmed coset of the participat to be ivolved i the survey Esured that participats uderstood Step1, 2 ad 3 ivolved i the survey Obtaied participat date of birth ad cofirmed that they were withi the target age group Cofirmed fastig status of the participat Directed the participat to the appropriate statio depedig o the fastig status of the participat Step 1 - Behavioural Risk Factors Iterviews All participats participated i a face-to-face iterview i which questios were asked o smokig, alcohol ad betel ut cosumptio, fruit ad vegetable cosumptio, physical activity ad history of chroic coditios ad medicatios. Participats were also asked about the umber of years they had participated i formal educatio. 21

23 3.3.3 Step 2 - Physical Measuremets Survey staff coducted the physical measuremets followig the recommeded STEPwise protocols. The OMRON M4 Digital Automatic Blood Pressure Moitor was used to measure restig blood pressure. Blood pressure was measured three times; the first readig followed by two more measuremets take with 2-3 miute itervals. The three readigs of the blood pressure were recorded, ad the average of the secod ad third readigs was used i the aalysis. 22

24 Height ad weight were measured oce usig the Seca Leicester Height Measure to the earest whole cetimeter ad the Siltec PS500L to the earest 0.1 kg, respectively. Participats were measured without shoes ad wearig oly light clothig. Waist ad hip circumferece was measured oce usig the Figure Fider costat tesio tape ad recorded to the earest 0.1 cm. Waist circumferece of female pregat participats was ot measured Step 3 - Biochemical Measuremets The survey icluded assessmets of fastig blood glucose, fastig total cholesterol ad triglycerides. Participats fasted from 10:00pm the previous ight util 7:00am the followig morig, whe their capillary blood samples were draw usig the method of figer prick. 23

25 3.3.5 Check-out Statio ad Couselig All participats received health advice ad couselig ad were provided with literature about smokig, alcohol drikig, obesity ad utritio, physical activity, hypertesio, diabetes, ad heart diseases. Participats who were idetified as beig at high risk of developig, or with, advaced chroic coditios were referred for a follow-up cliical examiatio. 24

26 3.4 Data Maagemet ad Aalyses Data Etry Submitted questioaires were checked radomly by staff to assess overall quality of data collectio ad completeess. Data etry was coducted by the survey staff at the Miistry of Health office usig the EpiData software cofigured for double data etry fuctio Data Weightig ad Aalysis Post-stratificatio weights were calculated usig the 2005 populatio projectios based o Chuuk 2004 cesus of the populatio aged years. Weighted sample meas were computed for cotiuous variables. Frequecy distributios were calculated usig weighted frequecies for categorical variables. For both weighted frequecy estimates ad weighted meas, 95% cofidece itervals were reported by 10-year age groups ad geder. With support from the Divisio of Pacific Techical Support, WPRO/WHO Office i Suva, WHO Office i Geeva performed fial data cleaig, data weightig, ad aalysis. Data aalyses were coducted usig the EpiIfo 2002 Versio The Divisio of Pacific Techical Support, WPRO/WHO Office i Suva compiled the whole Data Book. I this report, mai data tables preset fidigs for those aged years, followig the stadard age group reportig for WHO STEPS surveys. However, as data for the age group of years was also collected, additioal commetary is preseted at the ed of each sectio of behavioural risk factors. 4. RESULTS 4.1 Characteristics of Survey Populatio The study radomly selected ad ivited 3,000 Chuuk Isladers aged years to participate i the survey. A total of 2,831 idividuals participated (respose rate of 94.4%). Data for those aged years are reported here 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 paragraph at the ed of each sectio for Step 1. Table 1 presets the age ad geder distributio of the survey sample aged More wome respodets participated i the survey tha me (64.6% ad 35.4%) respectively. The age rage of the sample is close to beig equally distributed across age groups. Percetages give i the text relate to the age groups 25-64, ad commetary o the age group is provided at the ed of each sectio. Comparative referece is made to the fidigs of STEPwise surveys i Pohpei 8 withi the Federated States of 25

27 Microesia, ad other Pacific islad coutries ad areas i particular, Kiribati 9, Cook Islads 10 ad the Solomo Islads 11. Table 1 Demographic descriptio of study populatio group ad sex of respodets Me Wome Both Sexes % % % Table 2 presets the mea years of educatio of the survey respodets. Both geders ad all age groups have similar mea years of educatio, with me havig oly margially more years of educatio tha wome i age group The oldest age group (55-64) of wome reported the shortest mea years of educatio. Table 2 Mea umber of years educatio by geder ad age group Mea umber of years of educatio Me Wome Both Sexes Mea Mea Mea Tobacco Use Tobacco use was measured by askig participats if they curretly smoke tobacco products. Respodets were categorized 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. Daily smokers those who smoke ay tobacco product every day. 26

28 No-daily smokers those curret smokers who do ot smoke o a daily basis. Table 3 shows that 32.4% of all respodets were curret smokers. More tha half of me (51% ±4.2) were curret smokers, compared to just 14% ±3.3 of wome respodets. This statistically sigificat geder differece was observed i all age groups. The highest proportio of curret smokers amog both geders was i the years age group (35.9% ±4.4) although this was due to the highest proportio of all male curret smokers beig i that age group. Amog wome, curret smokig was highest i the group. Table 3 Percetage of curret smokers i the study populatio Percetage of curret smokers Me Wome Both Sexes % % % Curret Curret Curret smoker smoker smoker ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.2 95% CI Table 4 shows that 49% of male respodets were o-smokers. Of the balace (51%) who smoked, 47% ±4 smoked o a daily basis. More tha half (52.7% ±6.7) of me aged years were daily smokers. The proportio of daily smokers decreased thereafter to 35.6% ±8.4 of daily smokers i the age group years, as did the proportio of o-daily smokers. Table 4 Curret smokig status amog me i the study populatio by age group Smokig status Me Curret smoker % Does % Nodaily smoke ot % Daily ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±4.2 27

29 Table 5 shows that 86% of the female respodets were o-smokers. Of the 14% who smoked 10.6% ±3.2 smoked o a daily basis. The proportios of daily smokers icreased with icreasig age, from 5.2% ±2.7 i the yougest age group (25-34 years) to 15.1% ±5.5 i the age group (45-54 years), while the proportio of o-daily smokers was uchaged i age groups ad ad decreased i age years. Table 5 Curret smokig status amog wome i the study populatio by age group Smokig status Wome Curret smoker % Does % Nodaily smoke ot % Daily ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.3 Table 6 presets the prevalece of daily smokers, o-daily smokers ad o-smokers for me ad wome combied. Overall, 28.7% ±3 of survey respodets were daily smokers, 3.7% ±1.1 were o-daily smokers ad 67.6% ±3.2 were o-smokers. The highest proportio of daily smokers (32.2% ±4.4) was amog me i age group 35-44, ad this was essetially sustaied through age group (31.3% ±4.9). Table 6 Curret smokig status amog both sexes i the study populatio by age group Smokig status Both Sexes Curret smoker % Does % Nodaily smoke ot % Daily ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.2 Table 7 shows that amog curret daily smokers, the mea age of startig smokig for me was 17.2 ±0.7 years ad for wome was 21.6 ±1.9 years. This geder differece of wome reportig uptake at a older age occurs i all age groups. Across both sexes, the yougest cohort of years reported uptake earlier tha the older cohorts. The highest mea age of smokig uptake (28.2 ±7.5) was reported amog wome i age groups

30 Table 7 Mea age started smokig amog curret daily smokers Mea age started smokig Me Wome Both Sexes Mea Mea Mea 95% age age age CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.8 Table 8 shows that amog curret daily smokers overall, the mea umber of years of smokig was 22.9 ±1 years. Me reported smokig for a mea of 23 ±1.1 years ad wome for a mea of 22.3 ±2.4 years. Respodets i age group reported a mea duratio of smokig as 40.6 ±2.3 years for me ad 29.8 ±7.7 years for wome. Table 8 Mea umber of years of smokig amog curret daily smokers Mea duratio of smokig Me Wome Both Sexes Mea Mea Mea 95% duratio duratio duratio CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±1.0 Table 9 shows that maufactured cigarettes were commoly smoked by curret daily smokers: 84.5% ±4.6 of me ad 82% ±6.2 of wome. The smokig of maufactured cigarettes was high i all age groups of both geders, the lowest occurrig amog me age

31 Table 9 Percetage of curret daily smokers who smoke maufactured cigarettes Maufactured cigarette smokers amog daily smokers Me Wome Both Sexes % Maufactured cigarette smoker % Maufactured cigarette smoker % Maufactured cigarette smoker ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.9 95% CI Amog those aged years, 27.6% ±4.6 were curret smokers (45.8% ±7.1 male ad 7.7% ±2.7 female). Amog the total populatio aged 15-24, 35.1% ±6.8 of males ad 2.6% ±1.4 of females reported smokig o a daily basis, averagig to 19.6% ±3.9 for the overall populatio. Males aged reported started smokig at age 15.4 ±0.6 years ad havig smoked for a mea of 5 ±0.6 years. Wome reported startig at age 16.9 ±0.9 years ad havig smoked for a mea of 3.6 ±1.9 years. Notably, the age of smokig uptake i both geders of this age group was youger tha i older cohorts. The majority (83.4% ±6.7) of the populatio i age group smoked maufactured cigarettes, similar to all other age groups. 4.3 Betel Nut Use Table 10 shows that 68.2% ±7.0 of male respodets were abstaiers from chewig betel ut. Of the 31.8% ±7.0 of me who chewed betel ut i the past 12 moths the largest proportio (59.5% ±10.8) was i the age group Rates of betel ut use amog me declied sigificatly i subsequet age groups. Table 10 Percetage of curret betel ut chewers amog me durig the past 12 moths by age group Betel ut chewig status Me % Chewed i last 12 moths % Abstaier ± ± ± ± ± ± ± ± ± ±7.0 30

32 Table 11 shows that 86.7% ±2.5 of female respodets were abstaiers from chewig betel ut. Of the 13.3% ±2.5 of wome who chewed betel ut i the past 12 moths the largest proportio (29.4% ±5) was i the age group Rates of betel ut use amog females declied sigificatly thereafter. Table 11 Percetage of curret betel ut chewers amog wome durig the past 12 moths by age group Betel ut chewig status Wome % Chewed i last 12 moths % Abstaier ± ± ± ± ± ± ± ± ± ±2.5 Table 12 shows that 77.5% ±3.9 of all respodets were abstaiers from chewig betel ut. Of the 22.5%±3.9 who chewed betel ut i the past 12 moths the largest proportio (44.6% ±6.4) was i the age group Rates of betel use declied sigificatly for both sexes i subsequet age groups. Table 12 Percetage of curret betel ut chewers amog both sexes durig the past 12 moths by age group Betel ut chewig status Both Sexes % Chewed i last 12 moths % Abstaier ± ± ± ± ± ± ± ± ± ±3.9 Table 13 presets the curret prevalece of daily betel ut users, o-daily users ad o-users amog me. Overall, 17.7 % ±4.7 of male respodets were daily chewers, 14.1% ±3.2 were o-daily chewers ad 68.2% ±7 were o-betel ut chewers. The highest proportio of daily betel ut chewers (36.6% ±8.1) was reported i the age group

33 Table 13 Curret chewig status amog me i the study populatio by age group Chewig status Me Curret chewer % Does % Nodaily % Daily ot chew ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±7.0 Table 14 presets the curret prevalece of daily betel ut users, o-daily users ad o-users amog wome. Overall, 8.1% ±2.8 of female respodets were daily chewers, 5.2% ±1.6 were o-daily chewers ad 86.7% ±2.5 were o-betel ut chewers. The highest proportio of daily betel ut chewers (19.5% ±5.3) was reported i the age group Table 14 Curret chewig status amog wome i the study populatio by age group Chewig status Wome Curret chewer % Does % Nodaily % Daily ot chew ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±2.5 Table 15 presets the curret prevalece of daily betel users, o-daily users ad ousers amog both me ad wome combied. Overall, 77.5% ±3.9 were o-betel ut users, 12.8% ±2.5 were daily chewers, 9.7% ±2.1 were o-daily chewers. The highest proportio of daily betel ut chewers (28.1% ±4.6) was reported i the age group

34 Table 15 Curret chewig status amog both sexes i the study populatio by age group Chewig status Both Sexes Curret chewer % Does % Nodaily % Daily ot chew ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.9 Amog those aged 15-24, 65.8% ±8.2 of males ad 42.7% ±6.2 of females were curret betel ut chewers, givig ad average of 54.8% ±4.8 overall. Almost half (49.7% ±8.6) of males ad 31.8% ±5.2 of females chewed betel uts o a daily basis, averagig to 41.2% ±4.7 overall. 4.4 Alcohol Cosumptio This sectio describes patters of alcohol cosumptio i Chuuk. To assess patters ad prevalece of alcohol cosumptio, respodets were asked if they ever cosumed alcohol, ad the frequecy ad quatity of alcohol cosumed. Those who had cosumed a alcoholic drik i the past 12 moths were classified as curret drikers. Tables summarise the prevalece of alcohol cosumptio durig the past 12 moths amog me, wome ad both sexes respectively. There was a statistically sigificat geder differece i alcohol cosumptio behavior, with more tha a third of males (34.3% ±5.9) (Table 16) ad just over 1% of females (1.3% ±0.6) (Table 17) classified as curret drikers. Amog male curret drikers the largest proportio (43.3% ±8.6) occurs i the age group ad declies thereafter. 33

35 Table 16 Percetage of alcohol cosumptio amog me durig the past 12 moths by age group % Lifetime Abstaier Alcohol cosumptio status Me % Past 12 mos. abstaier % curret driker (drak i past 12 mos.) ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±5.9 95% CI Amog female curret drikers the largest proportio (3.4% ±1.5) occurs i the age group 25-34, declies sigificatly thereafter ad ceases i age groups ad over. Table 17 Percetage of alcohol cosumptio amog wome durig the past 12 moths by age group % Lifetime Abstaier Alcohol cosumptio status Wome % Past 12 mos. abstaier % curret driker (drak i past 12 mos.) ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.6 Table 18 shows that cosistet i all age groups more tha two thirds (68.9% ±3.9) of the populatio reported beig lifetime abstaiers from alcohol. The highest proportio of curret drikers amog both geders was i the years age group (23.7% ±3.3). Thereafter, the proportio of curret drikers decreased with icreasig age. 34

36 Table 18 Percetage of alcohol cosumptio amog both sexes durig the past 12 moths by age group % Lifetime Abstaier Alcohol cosumptio status Both Sexes % Past 12 mos. abstaier % curret driker (drak i past 12 mos.) ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.3 95% CI Table 19 presets iformatio o curret drikers by the frequecy (umber of drikig days) of alcohol cosumptio, quatity of driks cosumed (umber of driks o ay drikig day) ad the proportio of the sample that drak more tha 20 alcoholic driks i the past 7 days. It shows that amog male curret drikers (9.4% ±4.5) cosumed alcohol o 4 of the past 7 days, almost half (49.6% ±5.4) cosumed 5 or more driks o ay drikig day ad 16.7% ±5 drak 20 or more driks over a 7 day period. The highest proportios of males who drak 5 or more stadard driks o ay day were i the age groups (65% ±19.4) ad (55.6% ±14.2). Table 19 Frequecy ad quatity of driks cosumed i the last 7 days by curret (last 30 days) driker, grouped ito three categories Frequecy ad quatity of driks cosumed i the last 7 days Me % Drak % 5+ % 20+ o 4+ driks o driks i 7 days ay day days ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±5.0 95% CI Table 20 presets iformatio o the umber of stadard driks cosumed per drikig day by male curret drikers (average of 10.3 ±1.1 stadard driks) o a drikig day ad shows that heavy drikig is commo amog all age groups from but is most commo amog older me i age group

37 Table 20 Number of driks per day amog me who are curret drikers by age group % 1 drik Number of stadard driks cosumed o a drikig day 95% CI % 2-3 driks Me % 4-5 driks 95% CI % 6+ driks Mea # of stadard driks ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±1.1 95% CI Table 21 shows that curret drikers of both geders combied drik a average of 10.1 ±1 stadard driks o a drikig day, but with the low umber of females i the sample of curret drikers the overall populatio averages just below the male rate. % 1 drik Table 21 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 % 2-3 driks % 4-5 driks % 6+ driks Mea # of stadar d driks ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±1.0 Amog those aged 15-24, 31.5% ±7.2 of males ad 2.7% ±1.4 of females were curret drikers. Amog males, 12.3% ±8.7 cosumed alcohol o 4 of the past 7 days, 60.4% ±14.6 cosumed 6+ driks o ay drikig day ad 15.1% ±7.2 drak 20+ stadard driks i the past 7 days. Both sexes combied cosumed a average of 8.5 ±1.3 stadard driks o a drikig day, although ot statistically less tha the average for all older age groups. 4.5 Itake of Fruit ad Vegetables Respodets fruit ad vegetable itake was assessed by askig how may days they cosumed fruit ad vegetables i a typical week, ad how may servigs of each they cosumed o oe of those days. Table 22 shows that me ad wome reported similar mea days of fruit cosumed i a typical week (2.6 ±0.2) overall ad across all age groups. 36

38 Table 22 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 Mea umber umber umber of days of days of days ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.2 95% CI Table 23 shows that both sexes reported similar mea days of vegetable cosumptio i a typical week (3.3 ±0.3 for wome ad 2.9 ±0.3 for me) overall ad across all age groups. Table 23 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 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.3 Table 24 shows the reported cosumptio of servigs of fruit o a day whe fruit was eate as beig similar across all categories of age ad sex. 37

39 Table 24 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 umbe umbe umb 95% 95% r of r of er of CI CI servig servi servi s gs gs ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.1 95% CI Table 25 shows the reported cosumptio of servigs of vegetables o a day whe vegetables were eate as beig similar across all categories of age ad sex. Table 25 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 servig servig servig s s s ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.1 95% CI Table 26 shows the reported average cosumptio of combied servigs of fruit ad vegetables o a average day ad shows that overall respodets reported a average of 2 ±0.2 combied servigs of fruit ad vegetables cosistetly across all age groups, although males i age group reported cosumig the least (1.6 ±0.3). 38

40 Table 26 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 umbe umbe umbe 95% r of r of r of CI servig servi servi s gs gs ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.2 95% CI Table 27 shows that 90.4% ±1.8 of respodets of both geders cosumed less tha five combied servigs of fruit ad vegetables o a average day with o differece betwee me (91.4% ±2.3) ad wome (89.4% ±2.5), although males i age group preseted the highest proportio of those eatig less tha 5 combied servigs per average day. Table 27 Percetage who cosumed less tha five combied servigs of fruit ad vegetables per day of the week Less tha five servigs of fruit ad vegetables o average per day Me Wome Both Sexes % < five % < five % < five servigs servigs servigs per day per day per day ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±1.8 Those aged cosumed fruit ad vegetables at similar rates to the other age groups ad showed similar proportios of those receivig less tha 5 combied servigs of fruit ad vegetables o a average day. 95% CI 4.6 Physical Activity Measuremets I Step 1 respodets were asked how ofte (frequecy) ad how log (duratio) they egaged i three domais of physical activity i a typical week: work-related, trasportrelated ad leisure-related. I the work ad leisure domais, respodets were asked how may days per week ad how may hours/miutes per day they participate i 39

41 moderate ad vigorous itesity activities. I the trasport domai, 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 separately to determie the proportio of activity udertake i each domai as a compoet of total physical activity. For each domai, three levels of activity were recorded: low, moderate, ad high. I each domai, the total time participats spet i a activity per 7 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 week. 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, the followig MET values were allocated to the three physical activity domais: Moderate physical activity (work ad leisure domai) High physical activity (work ad leisure domai) Travel related walkig/cyclig = 4.0 METS = 8.0 METS = 4.0 METS The followig levels of activity i terms of METmiutes were defied as: Low activity: Moderate activity: High activity: <600 METmiutes per week METmiutes per week >1500 METmiutes per week Levels of Physical Activity Table 28 shows that whe physical activity doe as part of work, trasport ad leisure time is combied 58.6% ±6.2 of me reported a low level of total physical activity. Moderate physical activity was reported by 9.8% ±2.4 of me ad a high level of physical was reported by 31.6% ±5.8. The proportios of low total physical activity icreased i age group 45-54, while the proportios reportig moderate ad high levels of physical activity varied little, although a high level of total physical activity decreased i age group ad further decreased i age group

42 Table 28 Categories of overall physical activity amog me by age group Level of total physical activity Me % % Low Moderate % High ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±5.8 Table 29 shows that whe physical activity doe as part of work, trasport ad leisure time is combied 67.5% ±4.9 of wome reported a low level of total physical activity. Moderate physical activity was reported by 12.5% ±2.2 of wome ad a high level of physical was reported by 20.1% ±3.9. The proportios of low total physical activity varied little amog the age groups of wome. A high level of total physical activity decreased i the age group Table 29 Categories of overall physical activity amog wome by age group Level of total physical activity Wome % % Low Moderate % High ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.9 Table 30 shows that whe physical activity doe as part of work, trasport ad leisure time is combied almost two thirds (63.1% ±4.9) of both geders reported a low level of total physical activity. Moderate physical activity was reported by 11.2% ±1.7 ad a high level of physical was reported by 25.8% ±4.4. The proportios of low total physical activity icreased ad high activity decreased i age group ad agai i age group 55-64, while the proportios reportig a moderate level of physical activity chaged little. 41

43 Table 30 Categories of overall physical activity amog both sexes by age group Level of total physical activity Both Sexes % % Low Moderate % High ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±4.4 Table 31 presets the mea miutes of total physical activity across all three domais per day by geder ad age. Overall, respodets reported a average of 85.6 ±13.7 mea miutes per day spet i total physical activity, although there was a statistically sigificat geder differece with me egaged i physical activity for a mea of ±18.2 miutes per day ad wome for a mea of 67.4 ±11 miutes per day. I both sexes physical activity peaked i the groups ad declied thereafter. Table 31 Level of total physical activity (mea miutes per day) by geder ad age group Mea miutes of total physical activity o average per day Me Wome Both Sexes Mea Mea Mea 95% miutes miutes miutes CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±13.7 Tables preset results o mea miutes per day egaged i work-related (Table 32) trasport-related (Table 33) ad recreatio-related (Table 34) physical activity. Overall, ad i both sexes, work accouted for the greatest part of all physical activity followed by trasport ad recreatio. Table 32 shows that work-related physical activities comprised 70.1 ±13 mea miutes/day for me ad 48.7 ±9 mea miutes/day for wome. Across all age groups me reported egagig i more mea miutes of work-related physical activity tha wome. 42

44 Table 32 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 Me Wome Both Sexes Mea Mea Mea 95% miutes miutes miutes CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±10.1 Table 33 shows that trasport-related physical activities comprised 25.5 ±6.8 mea miutes/day for me ad 16.9 ±2.5 mea miutes/day for wome. Across all age groups me reported egagig i more mea miutes/day of trasport related physical activity tha wome. Table 33 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 Me Wome Both Sexes Mea Mea Mea 95% miutes miutes miutes CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±4.2 Table 34 shows that recreatio-related physical activities comprised 8.7 ±3.7 mea miutes/day for me ad 1.7 ±1 mea miutes/day for wome. I all age groups me reported egagig i more mea miutes/day of recreatio related physical activity tha wome. 43

45 Table 34 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 Me Wome Both Sexes Mea Mea Mea 95% miutes Miutes miutes CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±2.1 Amog those aged years, 63.3% ±6.3 of males reported a low level of physical activity as did 71.2% ±5.7 of females. Males reported more mea miutes of total physical activity tha females (70.3 ±16.2 mea miutes ad 52.6 ±15.8 respectively) largely due to more recreatio-related activity. 4.7 Overweight ad Obesity Height ad Weight The height ad weight of each participat 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 ). BMI risk categories are defied as follows: Uderweight BMI < 18.5 Normal weight 18.5 BMI 24.9 Overweight BMI 25.0 Obese BMI 30.0 Tables 35 ad 36 show that me were sigificatly taller (169.2cm ±0.9) tha wome (158.9cm ±0.4) ad wome were margially heavier (82.8kg ±1.6) tha me (80.9kg ±2.6) although the differece is ot statistically sigificat. Table 35 Mea height by geder ad age group Mea height (cm) Me Wome Mea Mea ± ± ± ± ± ± ± ± ± ±0.4 44

46 Amog both sexes weight icreased after age but decreased i the oldest age group. Weight peaked i wome i age group ad i me age group Table 36 Mea weight by geder ad age group Mea weight (kg) Me Wome Mea Mea ± ± ± ± ± ± ± ± ± ±1.6 Amog those aged both males ad females had achieved the all age group average height, yet both sexes were yet to achieve the all age group average weight Body Mass Idex Categories Table 37 presets the mea BMI scores for both geders, idividually ad combied. The overall mea BMI was 30.5kg/m 2 ±0.7. Wome had a higher mea BMI (32.7kg/m 2 ±0.6) tha me (28.2 kg/m 2 ±0.8) ad i all age groups. The mea BMI for both me ad wome varied little across age groups. Amog those aged of both geders the BMI was lower tha the average BMI i age group Table 37 Mea body mass idex (kg/m 2 ) by geder ad age group Mea BMI (kg/m 2 ) Me Wome Both Sexes 95% 95% 95% Mea Mea Mea CI CI CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.7 Tables 38, 39 ad 40 preset the proportio of the sample populatio i three BMI classificatios - uderweight, ormal ad overweight (icludes obese) for me, wome ad both geders combied. Table 38 shows that 65.2% ±6.2 of me are classified as overweight, 34.4% ±6.2 as ormal ad 0.4% ±0.5 as uderweight. 45

47 Table 38 BMI classificatios amog me by age group BMI classificatios Me % Uderweight weight weight % Normal % Over- < ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±6.2 Table 39 shows that 87.6% ±2.5 of wome are classified as overweight, 11.8% ±2.4 as ormal ad 0.6% ±0.5 as uderweight. Table 39 BMI classificatios amog wome by age group BMI classificatios Wome % Uderweight weight weight % Normal % Over- < ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±2.5 Table 40 shows that the proportio of males ad females combied classified as beig overweight was 76.5% ±3.6, as ormal 23% ±3.6 ad 0.5% ±0.3 as uderweight. Table 40 BMI classificatios amog both sexes by age group BMI classificatios Both Sexes % Uderweight weight weight % Normal % Over- < ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.6 Table 41 presets rates of obesity (BMI 30kg/m 2 ) for both geders, idividually ad combied. The overall prevalece of obesity was 47.3% ±4.9. The obesity rate was sigificatly higher amog wome (63% ±4.5) tha amog me (31.3% ±6.3). The 46

48 highest prevalece of obesity was i the age group (wome 68.8% ±5.1 ad me 40% ±7.5). Table 41 Percetage of obesity (BMI 30 kg/m 2 ) by geder ad age group Me Wome Both Sexes % 95% % 95% % 95% BMI 30 CI BMI 30 CI BMI 30 CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Waist Circumferece Waist circumferece was assessed as a measure of cetral obesity, a measure of risk of cardiovascular diseases. Table 42 shows the mea waist circumferece for both me ad wome. Wome had a sigificatly higher mea waist circumferece (101.4cm ±1.7) tha me (94.3cm ±2.7). The mea waist circumferece varied by age to a greater degree amog me tha wome. Table 42 Mea waist circumferece (cm) by geder ad age group Waist circumferece (cm) Me Wome Mea Mea ± ± ± ± ± ± ± ± ± ± Blood Pressure ad Hypertesio As part of the Step 2 protocol, all survey participats aged years had their blood pressure measured ad were asked if they had had their blood pressure measured i the last 12 moths, 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. The STEPS protocol reports the presece of hypertesio to iclude people with: 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 47

49 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. Table 43 presets mea restig systolic blood pressure ad Table 44 mea restig diastolic blood pressure for both sexes, ad for me ad wome separately. Table 43 shows a statistically higher mea systolic blood pressure i males tha i females (121.5 ±2.0 ad ±1.4 respectively). Systolic blood pressure icreases with age i both sexes, particularly i the age group Table 43 Mea restig systolic blood pressure (mmhg) by geder ad age group Mea systolic blood pressure (mmhg) Me Wome Both Sexes Mea Mea Mea ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±1.3 Table 44 shows a similar mea diastolic blood pressure i males ad females (73.6 ±1.8 ad 73.3 ±1.1 respectively), icreasig with age i both geders from age group % CI Table 44 Mea restig diastolic blood pressure (mmhg) by geder ad age group Mea diastolic blood pressure (mmhg) Me Wome Both Sexes 95% Mea Mea Mea CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±1.2 48

50 Table 45 presets the prevalece of hypertesio i the populatio, cosistet with the above defiitio. Hypertesio was foud i 15.8% ±3.6 of me ad 14.6% ±1.8 of wome ad 15.2% ±2 overall. The prevalece of hypertesio icreased with icreasig age i both me ad wome. From the base of age group of 35-44, the male ad female rates more tha double i age group (9.6% to 22.3% for males ad 11% to 23.6% for females). I age group the male rate doubles agai ad the female rate icreases by half. Table 45 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 % % % 95% CI ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Fastig Blood Glucose ad Diabetes Survey participats were asked if they had bee told by a health worker i the previous 12 moths that they had diabetes, withi 1-5 years or loger, ad whether they were curretly receivig medical treatmet for diabetes. To measure fastig blood sugar levels, capillary whole blood was draw usig the figer prick method. Estimates of diabetes prevalece were computed based o the capillary whole blood glucose test results ad by followig the WHO guidelies for defiig ad classifyig diabetes mellitus. fastig capillary whole blood value of glucose greater tha or equal to 6.1 mmol/l ( 110 mg/dl) whether or ot they had previously bee told by a health worker that they had diabetes, OR ormal capillary whole blood value of glucose less tha 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 46 summarizes results o mea fastig blood glucose for both geders idividually ad combied. The overall mea fastig blood glucose was 6 mmol/l ±0.2. Me reported a margially lower mea fastig glucose level (5.9 mmol/l ±0.2) tha 49

51 wome (6.2 mmo/l ±0.3). For both me ad wome, mea fastig blood glucose levels icreased with icreasig age, peaked i males i the oldest age group ad i females aged Table 46 Mea fastig blood glucose i mmol/l by geder ad age group Mea fastig blood glucose (mmol/l) Me Wome Both Sexes 95% 95% Mea Mea CI CI Mea ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.2 Table 47 Mea fastig blood glucose i mg/dl by geder ad age group Mea fastig blood glucose (mg/dl) Me Wome Both Sexes 95% 95% Mea Mea CI CI Mea ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.9 Table 48 shows the prevalece of diabetes for both geders idividually ad combied. The overall prevalece diabetes was 35.4% ±5.6. Diabetes prevalece was oly margially greater i wome tha i me (36.4% ±5.7 ad 34.4% ±7 respectively). More tha half of the sample i the age group was diabetic (53.4% ±7.5). The oset of adult diabetes is evidet i the icrease i age group thereafter both geder rates icrease with icreasig age. 50

52 Table 48 Prevalece of diabetes by geder ad age group Raised blood glucose or curretly o medicatio for diabetes ** Me Wome Both Sexes 95% 95% % % CI CI % ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±5.6 ** capillary whole blood value: 6.1 mmol/l 4.10 Total Cholesterol For elevated total blood cholesterol, a cut-off poit 5.0 mmol/l (or 190 mg/dl) was used to classify participats as beig i a high-risk group for coroary artery disease. Table 49 shows the overall mea cholesterol level for both geders idividually ad combied. The overall mea was 4.6 mmol/l ±0.1 ad similar mea levels for me (4.5 mmol/l ±0.1) ad wome (4.7 mmol/l ±0.1) showed little variace across age groups. Table 49 Mea levels of total blood cholesterol (mmol/l) by geder ad age group Mea total cholesterol (mmol/l) Me Wome Both Sexes 95% 95% Mea Mea CI CI Mea ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±0.1 Table 50 shows the mea levels of blood cholesterol by age for both geders idividually ad combied. Mea total blood cholesterol i wome was greater tha i me (182.8mg/dl ±3.4 ad 174.7mg/dl ±4.3 respectively) ad i all age groups, although the differeces were ot statistically sigificat. 51

53 Table 50 Mea levels of total blood cholesterol (mg/dl) by geder ad age group Mea total cholesterol (mg/dl) Me Wome Both Sexes 95% 95% Mea Mea CI CI Mea ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±3.0 Table 51 shows that close to a fifth of the populatio (19.2% ±4.9) had raised blood cholesterol, a greater proportio i wome tha i me (24.2% ±5.2 ad 12.4% ±8.6 respectively) ad i all age groups, particularly i age group where a statistical differece exists as almost half (47.1% ±11.5) of wome but oly 19.4% ±15.5 of me had raised blood cholesterol. Table 51 Percetage with raised total blood cholesterol ( 5.0 mmol/l or 190 mg/dl) Total cholesterol 5.0 mmol/l or 190 mg/dl Me Wome Both Sexes 95% 95% % % CI CI % ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± Combied Risk Factors To summarize the fidigs for the five importat risk factors for NCDs, the followig factors were combied ad are preseted i Tables 52, 53, ad 54 i two age groups, ad 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). These five risk factors were summed to idicate the overall risk for NCDs 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 52

54 Table 52 shows that almost two thirds of male respodets (62.4% ±6) were classified as at High Risk ad more tha a third (36.3% ±5.7) as at Moderate Risk. Table 52 Percetage of NCD risk categories amog me by age group Raised Risk Me % with 0 % with 1-2 % with 3-5 risk risk risk factors factors factors ± ± ± ± ± ± ± ± ±6.0 Table 53 shows wome at the same level of risk as me with 62.4% ±5.3 at High Risk ad 36.9% ±5.1 at Moderate Risk. Table 53 Percetage of NCD risk categories amog wome by age group Raised Risk Wome % with 0 % with 1-2 % with 3-5 risk risk risk factors factors factors ± ± ± ± ± ± ± ± ±5.3 Table 54 shows that the highest level of risk (71.5% ±5.6) was i the older age group, although 56.6% ±5 i the youger group were also at high risk. Overall, 62.4% ±4.7 of the Chuuk populatio was at High Risk of NCDs. Table 54 Percetage of NCD risk categories amog both sexes by age group Raised Risk Both Sexes % with 0 % with 1-2 % with 3-5 risk risk risk factors factors factors ± ± ± ± ± ± ± ± ±4.7 53

55 5. DISCUSSION AND CONCLUSIONS This sectio summarizes key fidigs from the STEPS survey ad presets a rage of recommedatios to cotrol ad prevet NCDs i the State of Chuuk. Behavioural risk factors for NCDs are commo i the State of Chuuk ad preset a public health problem for both sexes at all ages of adulthood, with almost two thirds (62.4%) of the populatio aged classified as beig at High Risk of developig a NCD (with 3-5 cocurret risk factors). The highest level of combied risk factors is i the age groups i both sexes. A additioal third (36.6%) of the populatio was at Moderate Risk with 1-2 cocurret risk factors. As the combiatio of risk factors icrease the risk of developig ad dyig from a NCD also icreases. The prevalece of combied risk factors i Chuuk was margially higher tha i Pohpei, sigificatly higher tha i the Solomo Islads but lower tha i the Cook Islads ad i Kiribati Sigificatly more females abstai from smokig tha males (86% ad 49% respectively). This geder differece appears to have a socio-cultural sigificace which is worth ivestigatig for its potetial wider applicatio. Those females that do smoke have similar duratio of usage to me. For curret smokers, smokig uptake occurred i the late tees for males ad early 20s for females. Betel ut appears to be used oly by youger people as the usage drops off to egligible levels i the older age groups reducig the risk of oral cacers. Just over oe third of males were classified as curret drikers ad a egligible proportio of females. This geder differece has socio-cultural sigificace as most wome declared themselves lifetime abstaiers. Iterestigly, 41% of me also declared themselves lifetime abstaiers. The highest proportio of curret drikers ad the highest frequecy of drikig amog me occur i the yougest age group, although me i the oldest age groups drak the highest umber of stadard driks o ay drikig day. The majority (90.4%) of the populatio did ot cosume the recommeded five combied servigs of fruit ad vegetables per day. The cosumptio of fruit ad vegetables did ot differ much across geder ad age groups but suggest that males of the age group were less well fed tha the rest of the populatio. The low level of fruit ad vegetable cosumptio is cosistet with the low level of agriculture, which i tur suggests high levels of food importatio. That more tha a half of males ad over two thirds of females reported low levels of physical activity may also be cosequet to the low level of agricultural productivity. As measured by METmiutes, males egaged i more physical activity tha females across all age groups ad activity related groups (work, trasport ad recreatio), but both geders scored low levels of physical activity per week. Although low physical activity, i compariso with others, METmiutes i Chuuk overall (428) were margially higher tha i Pohpei (387) ad i Kiribati (344.5) ad sigificatly higher tha Cook Islads (238.5), but less tha i the Solomos (505). Youg people i the age group egaged i less METmiutes per week tha the years age groups (351.5 METmiutes for males ad 263 for females). Work related physical activity accouted for sigificatly more physical activity amog me. 54

56 BMI for females was sigificatly higher tha for males i all age groups. Almost two thirds of wome (63%) ad oe third of me (31.3%) were classified as obese. Obesity i males is sigificatly less prevalet tha i Pohpei, Kiribati ad Cook Islads but more so tha i the Solomo Islads The highest proportios of overweight ad obese females were i the ad year age groups, while the highest proportio of overweight ad obese males were i the age group. This decade differece may be explaied by a combiatio of biological ad social roles, where females are still i the reproductive years ad males have decreased their level of physical activity ad icreased their waist circumferece. The mea waist circumferece i wome icreased i the age group to 102.5cm, exceedig 88cm, a cut-off value for wome cosidered to icrease cardiovascular disease risk. Mea waist circumferece i me icreased a decade later i the age group to 100.3cm but remaied below 102cm where the risk of cardiovascular disease icreases. Hypertesio was estimated to be 15.2% of the populatio. Males i the year group appear to have the highest rate. A substatial proportio (38%) of the older populatio either has hypertesio ad a elevated risk of developig cardiovascular disease or stroke, raisig a sigificat risk of premature adult mortality. Cocurretly, over oe third of the populatio (35.4%) ad two thirds (66.3%) of those aged has diabetes. Both sexes show the marked icrease associated with adult oset i the age group. I compariso to Pohpei ad other Kiribati, Cook Islads, ad i particular the Solomo Islads 8-11, Chuuk shows the highest rate of diabetes, ad, although it is ot statistically differet to Pohpei, it is idetified as a major threat to populatio health. Almost oe fifth (19.2%) of the populatio was foud to have elevated fastig blood cholesterol, icreasig i wome i the age group ad i me a decade later i the group. Rates i females cotiue to rise to a sigificatly degree to 47% i the age group. These behavioural, physiological ad biochemical measures idicate the sigificat presece of NCDs ad NCD risk factors i the Chuuk State, all of which icreased markedly i the older age groups. While the behavioural risk factor data were collected from self-reports ad, as such, the prevalece of some risk factors may be overestimated or uder-estimated, the key stregth of the survey is its size ad its populatio-wide characteristics. Most importatly, after weightig of the data, this STEPS survey ca represet the whole populatio aged years of the State of Chuuk. The Chuuk STEPS survey has cofirmed that NCDs pose a sigificat threat to public health ad logevity, ad a challege to atioal productivity. A atioal strategy is required to address cross-sector cotributig factors, such as the availability of fruit ad vegetables for daily cosumptio, the licesig ad regulatio of products that impact adversely o health status, health educatio campaigs o the outcomes of risk lade behaviors, particularly amog youg people who may yet have the potetial to avoid NCDs. 55

57 Importatly, all of the risk factors metioed herei are modifiable. However, for such a strategy to be effective, the populatio has to recogize the risks ad value the outcome of improved health. This chage will eed to be drive by iformatio, such as that provided i this STEPS report ad provided i a maer that is sesitive to the prevailig social, ecoomic ad cultural eviromets of Chuuk State ad its people. 6. RECOMMENDATIONS Addressig Iformatio eeds That the Departmet of Health Use the opportuity of the publicatio of this FSM (Chuuk) NCD Risk Factors STEPS Report to iitiate a ew NCD risk factor prevetio ad reductio campaig i the State of Chuuk Establish strog leadership ad secure political ad fiacial commitmet to maitai a systematic ad rigorous approach to STEPS data collectio supported by a workforce traied i implemetig the survey, i order to create a ogoig ad robust STEPS surveillace system i Chuuk Coordiate ad coduct the 2 d -roud NCD STEPS survey as a whole coutry (rather tha idividual state) to determie the effectiveess Participate i the compariso of NCD STEPS data across other Pacific Islad coutries that have completed the NCD STEPS surveys ad published STEPS reports 8-11, i order to idetify the risk factors that are particular to ad most ameable to modificatio, as well as to idetify the evidece-based prioritized itervetio i Chuuk, FSM Addressig policy, orgaizatioal ad evirometal factors That govermet of FSM: Earmark fuds for ogoig NCD strategy implemetatio ad moitorig i Chuuk Implemet the WHO Framework Covetio o Tobacco Cotrol Cosider the potetial for maufacturers ad importers of cigarettes ad alcohol to be taxed to the degree that they subsidize health promotio iitiatives Geerate resources for ogoig atioal health educatio programs aimed at atioal ad persoal productivity Develop policies supportig the growth ad importatio of healthy foods Improve the availability of fruit ad vegetables Develop policies to establish physical activity-friedly eviromets, such as walkig tracks, sports facilities ad workplace fitess programs Addressig NCD behavioural risk factors That govermet, Departmet of Health ad NGOs create ad provide: Comprehesive o-smokig ad o-betel ut use campaigs to reduce tobacco use rates, particularly targetig teeagers ad the youger adult age groups to prevet 56

58 smokig uptake, ad smokig cessatio programs to reduce smokig rates across all age groups Itegrated health promotio campaigs to reduce alcohol cosumptio, particularly targeted at youg people ad bige drikig Comprehesive health promotio campaigs promotig the cosumptio of the recommeded levels of fruit ad vegetables, iclusive of a expressed strategy to esure proper utritio i older age Public awareess of the adverse effects of excessive cosumptio of high-fat, highsalt, 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 cholesterol ad blood sugar levels Public awareess programs targeted to icrease awareess of the multipliers of NCD risk associated with combiig the 5 major NCD risk factors (curret daily smokig, beig overweight, havig raised blood pressure, eatig less tha five combied servigs of fruit ad vegetables per day, ad havig a low level of physical activity) A system of commuity-based care for the maagemet of idividuals with diagosed NCDs 57

59 APPENDICES 58

60 PAGE 59 - DOC 3-APPENDIX 1-QUESTIONNAIRE Respodet Idetificatio Number The FSM Departmet of HESA ad the Chuuk State Departmet of Health Services i collaboratio with the World Health Orgaizatio & the World Health Orgaizatio The WHO STEPwise approach to Surveillace of No-Commuicable Diseases (STEPS) Check if the followig are completed (to be checked by:) Yes No Sigature Fastig status (Registratio Statio) Step 1, 2 & 3 data collectio (Checkout Statio) First EpiData data etry (Data etry persoel) Secod EpiData data etry (Data etry persoel) Data etry irregularities (Data etry persoel) Idetificatio Iformatio: I 1 Islad code I 2 Islad Name: I 3 Village code: (SEE NOTE BELOW) I 4 Village Name I 5 Iterviewer code I 6 Date of completio of the questioaire //200 Day Moth Year Respodet ID Number - Coset I 7 Coset has bee read out to respodet Yes 1 No 2 If NO, read coset I 8 Coset has bee obtaied (verbal or writte) Yes 1 No 2 If NO, END I 9 I 10 I 11 I 12 I 13 I 14 Iterview Laguage Time of iterview (24 hour clock) Family Name First Name Hospital Number Cotact phoe umber where possible Chuukese 1 Eglish 2 59 : -- - I 15 Specify whose phoe Work 1 Home 2 Neighbour 3 Other (specify) 4 Note: Idetificatio iformatio I7 to I15 should be stored separately from the questioaire because it cotais cofidetial iformatio. Please ote: Village code is required as part of mai istrumet for data aalyses. Date of iterview is required to calculate age.

61 PAGE 60 - DOC 3-APPENDIX 1-QUESTIONNAIRE Respodet Idetificatio Number Step 1 C1 Sex (Record Male / Female as observed ) C2 What is your date of birth? If Do t Kow, See Note* below ad Go to C3 Demographic Iformatio Male 1 Female 2 Day Moth Year19 C3 How old are you? Years C4 What is your ethic backgroud? Chuukese 1 Mortlockese 2 Hallese 3 Westlockese 4 Pohpeia 5 C5 C6 C7 C8 C9 C10 C11 I total, how may years have you spet at school or i full-time study (excludig pre-school)? What is the highest level of educatio you have completed? Which of the followig best describes your mai work status over the last 12 moths? USE SHOWCARD How may people older tha 18 years, icludig yourself, live i your household? Takig the past year, ca you tell me what the average earigs of the household have bee? If you do t kow the amout, ca you give a estimate of the aual household icome if I read some optios to you? Is it For each of the followig, idicate whether ay immediate member of your family (sibligs, parets, or childre) has bee affected by this health problem TICK all that apply Pohpei O.I Yapese Yap - O.I Kosraea Filipio Others Years Never atteded school 1 Elemetary school (1-8 Grades) 2 High school (9-12Grades) 3 2 Year college 4 4 Year college 5 Postgraduate 6 Govermet employee 1 No-govermet employee 2 Self-employed 3 No-paid 4 Studet 5 Homemaker 6 Retired 7 Uemployed (able to work) 8 Uemployed (uable to work) 9 Per week OR per moth OR per year Number of people Go to Next Sectio (S1a) if give estimated earigs Refused 8 Less tha $5,000 1 betwee$5,000 ad $10,000 2 betwee $10,000 ad $15,000 3 betwee $15,000 ad $20,000 4 More tha$20,000 5 Refused 8 Heart disease Metal health disease Diabetes Stroke Asthma Kidey disease Liver disease Hypertesio Cacer (specify site if possible) Hearig related Visual related If Refused Go to C10 Note*: 1) The Date of Birth (C2) or the age (C3) or both (C2 ad C3) have to be filled. If both C2 ad C3 ot available, the STOP. CODE DK FOR DON T KNOW or DON T REMEMBER 60

62 PAGE 61 - DOC 3-APPENDIX 1-QUESTIONNAIRE Respodet Idetificatio Number Step 1 Tobacco Use (Sectio S) 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 smokig. S 1a S 1b S 2a S 2b S 3 S 4 Do you curretly smoke ay tobacco products, such as cigarettes, cigars or pipes? If Yes, Do you curretly smoke tobacco products daily? How old were you whe you first started smokig daily? Do you remember how log ago it was? Yes 1 No Yes 1 No 2 Do t remember D K Years I Years OR OR i Moths i Weeks 2 Moths Weeks O average, how may of the followig do you smoke each day? Maufactured cigarettes (RECORD FOR EACH TYPE) Had-rolled cigarettes If you smoke, how useful would each of the followig be i helpig you to quit? (code for each group as below) Not useful Somewhat useful Very useful Pipes full of tobacco Cigars, cheroots, cigarillos Other (please specify): Frieds Substace abuse & metal health program staff Medical Doctor Hag out with frieds who do t smoke Pastor/Miister/Priest Youth groups Teacher/Professor Ucles, spouse or other relatives Parets Exercise/Icrease participatio i sports Stay away from bars/ight clubs S 5 I the past did you ever smoke daily? Yes 1 S 6a S 6b S 7a S 7b S 8 Behavioural Measures How old were you whe you stopped smokig daily? No 2 If you do t remember how old you were, how log ago? I Years OR i Moths OR i Weeks Do you curretly use smokeless tobacco such as chewig tobacco or suff? if Yes, do you curretly use smokeless tobacco products daily? O average, how may times do you use smokeless tobacco o the days that you use it? Yes 1 No 2 Yes 1 No 2 Number of times per day If No, go to S5 If No, go to S5 If Kow, go to S 3 If No, go to S7a If No, go to S9 61

63 PAGE 62 - DOC 3-APPENDIX 1-QUESTIONNAIRE S 9 S 10 I the past, did you ever use smokeless tobacco daily? If you use smokeless tobacco, how useful would each of the followig be i helpig you to quit? (code for each group as below) Not useful Somewhat useful Very useful Betel Nut Use (Sectio N) The ext questios ask about the use of betel ut N 1a Do you curretly chew betel ut? N 1b N 2 N 3 N 4 N 5 N 6 If Yes, Do you curretly chew betel uts daily? Whe you chew, how may uts o average do you chew at oe time? O average, how may times each day do you chew? Whe you chew betel ut how ofte do you add cigarettes or tobacco Have you ever chewed betel ut daily i the past? If you chew betel but, how useful would each of the followig be i helpig you to quit? (code for each group as below) Not useful Somewhat useful Very useful Respodet Idetificatio Number Yes 1 No 2 Frieds Substace abuse & metal health program staff Medical Doctor Hag out with frieds who do t smoke Pastor/Miister/Priest Youth groups Teacher/Professor Ucles, spouse or other relatives Parets Exercise/Icrease participatio i sports Stay away from bars/ight clubs Yes No Yes No Times per day all the time sometimes Never Yes No Frieds Substace abuse & metal health program staff Medical Doctor Hag out with frieds who do t smoke Pastor/Miister/Priest Youth groups Teacher/Professor Ucles, spouse or other relatives Parets Exercise/Icrease participatio i sports Stay away from bars/ight clubs If No, go to N1a If No, go to N5 If No, go to N5 Alcohol Cosumptio (Sectio A) The ext questios ask about the cosumptio of alcohol. A 1a Have you ever cosumed a drik that cotais alcohol such as beer, wie, spirit or fermeted cider? USE SHOWCARD or SHOW EXAMPLES A 1b Have you cosumed alcohol withi the past 12 moths? A 2 A 3 I the past 12 moths, how frequetly have you had at least oe drik? (READ RESPONSES) USE SHOWCARD Whe you drik alcohol, o average, how may driks do you have durig oe day? Respose Yes No Yes No 5 or more days a week 1-4 days per week 1-3 days a moth Less tha oce a moth Number Codig Colum Do t kow D K Note: Code DK for Do t kow or Do t remember If No, Go to D1a If No, Go to D1a 62

64 PAGE 63 - DOC 3-APPENDIX 1-QUESTIONNAIRE A 4 A 5a A 5b A 6 A 7 Durig each of the past 7 days, how may stadard driks of ay alcoholic drik did you have each day? (RECORD FOR EACH DAY USE SHOWCARD) For Me I the past 12 moths o how may days did you have 5 or more alcoholic driks o a sigle day? For Wome I the past 12 moths o how may days did you have 4 or more alcoholic driks o a sigle day? I the past 12 moths, what was the largest umber of driks you had o a sigle occasio, coutig all types of alcoholic beverages combied? If you cosume alcohol, how useful would each of the followig be i helpig you to quit? (code for each group as below) Not useful Somewhat useful Very useful Respodet Idetificatio Number Moday Tuesday Wedesday Thursday Friday Saturday Suday Number of days Number of days Number of driks Frieds Substace abuse & metal health program staff Medical Doctor Hag out with frieds who do t smoke Pastor/Miister/Priest Youth groups Teacher/Professor Ucles, spouse or other relatives Parets Exercise/Icrease participatio i sports Stay away from bars/ight clubs Diet (Sectio D) The ext questios ask about the fruits ad vegetables that you usually eat. I have a utritio card here that describes some examples of local fruits ad vegetables. As you aswer these questios please thik of a typical week i the last year. D 1a D 1b D 2a D 2b 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 Number of days Number of servigs Do t kow D K Number of days Number of servigs Do t kow D K If Zero days, go to D2a If Zero days, go to D3 63

65 PAGE 64 - DOC 3-APPENDIX 1-QUESTIONNAIRE D 3 O how may days do you eat the followig i a typical week? Do you usually prepare meals? Respodet Idetificatio Number Yes No Meat Chicke Eggs Milk Products Fish 1 2 D 4b D 5 D 6 What type of oil or fat is most ofte used for meal preparatio i your household? SELECT ONLY ONE Vegetable oil 1 Lard or suet 2 Butter 3 Margarie 4 Cocout oil 5 Other 6 Noe i particular 7 Noe used 8 Do t kow 9 I a typical week, o how may days do you eat fresh fish? Number of days I a typical week, o how may days do you eat caed fish? Number of days Note: Code DK for Do t kow or Do t remember. Physical Activity (Sectio P) Next I am goig to ask you about the time you sped doig differet types of physical activity. Please aswer these questios eve if you do ot cosider yourself to be a 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, household chores, harvestig food, fishig or hutig for food, seekig employmet. [Isert other examples if eeded] P 1 Did you work mostly i the household? Yes 1 No 2 P 2 How log is your typical work day? Number of hours hrs Does your work ivolve mostly sittig or stadig, with Yes 1 P 3 walkig for o more tha 10 miutes at a time? No 2 P 4 Does your work ivolve vigorous activity, like [heavy Yes 1 liftig, diggig or costructio work] for at least 10 No 2 miutes at a time? INSERT EXAMPLES & USE SHOWCARD P 4a I a typical week, o how may days do you do Days a week vigorous activities as part of your work? P 4b O a typical day o which you do vigorous activity, I hours ad miutes how much time do you sped doig such work? hrs : mis OR i Miutes oly or miutes P 5 P 6a P 6b Does your work ivolve moderate-itesity activity, like brisk walkig [or carryig light loads] for at least 10 miutes at a time? INSERT EXAMPLES & USE SHOWCARD I a typical week, o how may days do you do moderate-itesity activities as part of your work? O a typical day o which you did moderate-itesity activities, how much time do you sped doig such work? Yes No Days a week I hours ad miutes OR i Miutes oly 1 2 hrs : mis or miutes If Yes, go to P7 If No, go to P5 If No, go to P7 64

66 PAGE 65 - DOC 3-APPENDIX 1-QUESTIONNAIRE Respodet Idetificatio Number Other tha activities that you ve already metioed, I would like to ask you about the way you travel to ad from places. For example to work, for shoppig, to market, to church. [isert other examples if eeded] P 7 Do you walk or use a bicycle (pedal cycle) for at least 10 miutes cotiuously to get to ad from places? Yes No 1 If No, go to P9 2 I a typical week, o how may days do you walk or P 8a bicycle for at least 10 miutes to get to ad from Days a week places? O a typical day durig which you would walk or P 8b I hours ad miutes bicycle for travel for at least 10 miutes, how much hrs : mis time would you sped doig this? OR i Miutes oly or miutes The ext questios ask about activities you do i your leisure time. Thik about activities you do for recreatio, fitess or sports [isert relevat terms]. Do ot iclude the physical activities you do at work or for travel metioed already. Does your [recreatio, sport or leisure time] ivolve P 9 Yes 1 mostly sittig, recliig, or stadig, with o physical activity lastig more tha 10 miutes at a time? No 2 P 10 P 11a P 11b P 12 P 13a P 13b I your [leisure time], do you do ay vigorous activities like [ruig or streuous sports, weight liftig] for at least 10 miutes at a time? INSERT EXAMPLES & USE SHOWCARD If Yes, I a typical week, o how may days do you do vigorous activities as part of your [leisure time]? O a typical day o which you do vigorous activity as part of your [leisure time], how much time do you sped doig this? Note: Code DK for Do t kow or Do t remember. I your [leisure time], do you do ay moderate-itesity activities like brisk walkig,[cyclig or swimmig] for at least 10 miutes at a time? INSERT EXAMPLES & USE SHOWCARD If Yes I a typical week, o how may days do you do moderate-itesity activities as part of [leisure time]? O a typical day o which you do moderate-itesity activity as part of your [leisure time], how much time do you sped doig this? Yes No Days a week I hours ad miutes OR i Miutes oly Yes No Days a week I hours ad miutes OR i Miutes oly 1 2 hrs : mis or miutes If Yes, go to P 14 If No, go to P If No, go to P 14 hrs : mis or miutes The followig questio is about sittig or recliig. Thik back over the past 7 days, to time spet at work, at home, i [leisure], icludig time spet sittig at a desk, visitig frieds, readig, or watchig televisio, but do ot iclude time spet sleepig. Over the past 7 days, how much time did you sped I hours ad miutes P 14 sittig or recliig o a typical day? hrs : mis OR i Miutes oly or miutes History of High Blood Pressure H 1 H 2 Whe was your blood pressure last measured by a health professioal? Durig the past 12 moths have you bee told by a doctor or other health worker that you have elevated blood pressure or hypertesio? H 3 H 3a Drugs (medicatio) that you have take i the last 2 weeks Withi past 12 moths 1-5 years ago Not withi past 5 yrs Yes No Are you curretly receivig ay of the followig treatmets for high blood pressure prescribed by a doctor or other health worker? Yes 1 No H 3b Special prescribed diet Yes No H 3c Advice or treatmet to lose weight Yes No If No, skip to Next Sectio 65

67 PAGE 66 - DOC 3-APPENDIX 1-QUESTIONNAIRE Respodet Idetificatio Number H 3d Advice or treatmet to stop smokig Yes No H 3e Advice to start or do more exercise Yes No H 4 H 5 History of Diabetes H 6 H 7 Durig the past 12 moths have you see a traditioal healer for elevated blood pressure or hypertesio Are you curretly takig ay herbal or traditioal remedy for your high blood pressure? Whe was your blood sugar last measured by a health professioal Have you ever bee told by a doctor or other health worker that you have diabetes? Yes No Yes No Withi past 12 moths 1-5 years ago Not withi past 5 yrs H 8 H 8a Isuli Yes No H 8b Yes No Are you curretly receivig ay of the followig treatmets for diabetes prescribed by a doctor or other health worker? 1 2 Oral drug (medicatio that you have take i the last Yes 1 2 weeks No Durig the past 12 moths have you see a Yes 1 traditioal healer for diabetes? No 2 Are you curretly takig ay herbal or traditioal Yes 1 remedy for your diabetes? No 2 H 8c Special prescribed diet Yes No H 8d Advice or treatmet to lose weight Yes No H 8e Advice or treatmet to stop smokig Yes No H 8f Advice to start or do more exercise Yes No H 9 H 10 H 11 H 12 About how may times i the past 12 moths has a health worker checked your feet for ay sores or irritatios? Whe was the last time you had a eye examiatio i which pupils were dilated Number of times Withi the past moth (aytime less tha 1 moth ago) Withi the past year (1 moth but less tha 12 moths ago) H 13 I the past 12 moths have you had a flu shot? Yes No Do t kow/not sure Withi the past 2 years (1 year but less tha 2 years ago) or more years Never Do t kow/not sure Refused If No, skip to Next Sectio 66

68 PAGE 67 - DOC 3-APPENDIX 1-QUESTIONNAIRE Respodet Idetificatio Number H 14 Commets: Step 1 V 2 I the last 12 moths, have you had a peumoia shot? This shot is usually give oly oce or twice i a perso s lifetime ad is differet from the flu shot. It is also called peumococcal vaccie. Are there ay irregularities or problems with the questios? Yes No Do t kow/not sure (to be aswered by the Iterviewer) Yes No If yes, please describe. Step 2 Physical Measuremets Height ad weight M 1 Techicia ID Code M 2a & 2b M 3 M 4 Device IDs for height ad weight M 5 (For wome) Are you pregat? Yes No Ucertai Waist ad Hip M 6 Techicia ID (2a) height Codig Colum (2b) weight. Height (i Cetimetres) Weight If too large for scale, code (i Kilograms) M 7 Device ID for waist M 8 Waist circumferece (i Cetimetres). M 9 Hip circumferece (i Cetimetres). Blood pressure M 10 M 11 Techicia ID Device ID for blood pressure M 12 Cuff size used Normal Large Maual Codig Colum M 13a Readig 1 Systolic BP Systolic mmhg M 13b Diastolic BP Diastolic mmhg M 14a Readig 2 Systolic BP Systolic mmhg M 14b Diastolic BP Diastolic mmhg M 15a Readig 3 Systolic BP Systolic mmhg M 15b Diastolic BP Diastolic mmhg If Yes, Skip Waist ad Hip 67

69 PAGE 68 - DOC 3-APPENDIX 1-QUESTIONNAIRE Respodet Idetificatio Number Step 3 Biochemical Measuremets Blood glucose B 1 B 2 B 3 B 4 B 5 Sice 10pm last ight, have you had aythig to eat or drik, other tha water? Techicia ID Code Device ID code Time of day blood specime take (24 hour clock) Blood glucose Blood Lipids B 6 B 7 B 8 Techicia ID Code (cholesterol) Device ID code (cholesterol) Total cholesterol Yes No Ucertai Low High Uable to assess Low High Uable to assess Codig Colum hrs : mis mmol/l. mmol/l. B 9 Techicia ID Code (triglycerides) B 10 Device ID code (triglycerides) B 11 Triglycerides Low High Uable to assess mmol/l. Commets: Step 2 ad 3 (to be aswered by ay Step 2 or 3 techicia) V Are there ay irregularities or problems with the Yes 1 3 measuremets? No 2 If yes, please describe. 68

70 Appedix 2. The Data Book of the FSM (Chuuk) STEPS Survey WHO STEPS Chroic Disease Risk Factor Surveillace DATA BOOK FOR FEDERATED STATES OF MICRONESIA (CHUUK) 69

71 Demographic Iformatio Results group by sex Descriptio: Summary iformatio by age group ad sex of the respodets. Istrumet questio: Sex What is your date of birth? group ad sex of respodets Me Wome Both Sexes % % %

72 Ethicity Descriptio: Summary results for the ethicity of the respodets. Istrumet Questio: What is your ethic backgroud? Ethic group of respodets Both Sexes Chuukese Mortlockese Hallese Wortlockese Filipio Other

73 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

74 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? % Never atteded school Highest level of educatio Me % Elemetary % High school (1-8 school (9- Grades) 12Grades) % 2 Year college % 4 Year college % Postgraduate % Never atteded school Highest level of educatio Wome % High school (9-12Grades) % Elemetary school (1-8 Grades) % 2 Year college % 4 Year college % Postgraduate % Never atteded school Highest level of educatio Both Sexes % Elemetary school (1-8 Grades) % High school (9-12Grades) % 2 Year college % 4 Year college % Postgraduate

75 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 last 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

76 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 last 12 moths? Upaid work ad uemployed Me Uemployed % Home- % Nopaid % Retired % Studet % Able to % Not able maker work to work Upaid work ad uemployed Wome Uemployed % Home- % Nopaid % Retired % Studet % Able to % Not able maker work to work Upaid work ad uemployed Both Sexes Uemployed % Home- % Nopaid % Retired % Studet % Able to % Not able maker work to work

77 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 1187 $ Estimated household earigs Descriptio: summary of participat household earigs by quitile. Istrumet questio: If you do't kow the amout, ca you give a estimate of the aual household icome if I read some optios to you? % Quitile 1: Uder $5,000 Estimated household earigs % Quitile 2: % Quitile 3: $5,000 ad $10,000 ad $10,000 $15,000 % Quitile 4: $15,000 ad $20,000 % Quitile 5: Over $20,

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

79 Smokig Status Descriptio: Smokig status of all respodets. Istrumet questios: Do you curretly smoke ay tobacco products, such as cigarettes, cigars, or pipes? Do you curretly smoke tobacco products daily? Smokig status Me Curret smoker % Does % Nodaily % Daily ot smoke Smokig status Wome Curret smoker % Does % Nodaily % Daily ot smoke Smokig status Both Sexes Curret smoker % Does % Nodaily % Daily ot smoke

80 Frequecy of smokig Descriptio: Percetage of curret daily smokers amog smokers. Istrumet questio: 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 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

81 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? Mea # of maufacture d cig. Mea amout of tobacco used by daily smokers by type Me Mea Mea #of # of had pipes - of rolled tobac cig. co Mea # of other type of tobacc o Mea # of mau - factur ed cig. Mea amout of tobacco used by daily smokers by type Wome Mea #of hadrolled cig. Mea # of pipes of tobac co Mea # of other type of tobacc o Mea # of mau - factur ed cig. Mea amout of tobacco used by daily smokers by type Both Sexes Mea #of hadrolled cig. Mea # of pipes of tobac co Mea # of other type of tobacc o

82 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? How log ago did you stop smokig daily? Mea age started smokig Me Wome Both Sexes Mea Mea Mea age age age started started started smokig smokig smokig Mea duratio of smokig Me Wome Both Sexes Mea Mea Mea yrs of yrs of yrs of smokig smokig smokig

83 Betel Nut Use Betel Nut Use Descriptio: Percetage of participats who chew betel ut. Betel Nut Use Me Curret User % Does ot use % Daily % Nodaily Betel Nut Use Wome Curret User % Does ot use % Daily % Nodaily Betel Nut Use Both Sexes Curret User % Does ot use % Daily % Nodaily

84 Alcohol Cosumptio Alcohol cosumptio status Descriptio: Alcohol cosumptio status of all respodets. Istrumet questios: Have you ever cosumed alcohol? Have you cosumed alcohol (such as beer, wie, spirits, fermeted cider, or (add other local examples) withi the past 12 moths? Alcohol cosumptio status Me % Past 12 % curret % Lifetime mos. driker (drak i Abstaier abstaier past 12 mos.) Alcohol cosumptio status Wome % Past 12 % curret % Lifetime mos. driker (drak i Abstaier abstaier past 12 mos.) Alcohol cosumptio status Both Sexes % Past 12 % curret % Lifetime mos. driker (drak i Abstaier abstaier past 12 mos.)

85 Frequecy of alcohol cosumptio Descriptio: Frequecy of alcohol cosumptio i the last year amog those respodets who have drak i the last 12 moths. Istrumet questio: I the past 12 moths, how frequetly have you had at least oe drik? % less tha oce a moth Frequecy of alcohol cosumptio i the last 12 moths Me % 1-3 % 1-4 days per days per moth week % >=5 days per week Frequecy of alcohol cosumptio i the last 12 moths Wome % less tha oce a moth % 1-3 days per moth % 1-4 days per week % >=5 days per week % less tha oce a moth Frequecy of alcohol cosumptio i the last 12 moths Both Sexes % 1-3 % 1-4 days per days per moth week % >=5 days per week

86 Stadard driks per drikig day Descriptio: Number of stadard driks cosumed o a drikig day amog those respodets who have drak i the last 12 moths. Istrumet questio: Whe you drik alcohol, o average, how may driks do you have durig oe day? (years ) % 1 drik Number of stadard driks cosumed o a drikig day Me % 2-3 driks % 4-5 driks % 6+ driks Mea # of stad ard driks % 1 drik Number of stadard driks cosumed o a drikig day Wome % 2-3 driks % 4-5 driks % 6+ driks Mea # of stadar d driks % CI % 1 drik Number of stadard driks cosumed o a drikig day Both Sexes % 2-3 driks % 4-5 driks % 6+ driks Mea # of stadard driks

87 Heavy drikig Descriptio: Frequecy ad quatity of driks cosumed i the last 7 days by curret (last 30 days) driker, 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 last 7 days Me % Drak % 5+ % 20+ o 4+ driks o driks i 7 days ay day days Frequecy ad quatity of driks cosumed i the last 7 days Wome % Drak % 4+ % 15+ o 4+ driks o driks i 7 days ay day days Frequecy ad quatity of driks cosumed i the last 7 days Both Sexes % Drak o 4+ days

88 Hazardous ad harmful drikig Descriptio: Percetage of curret (last 30 days) driker egagig i hazardous ad harmful drikig i the last 7 days. Harmful drikig is defied as 60g of pure alcohol o average per day for me ad 40 g for wome. Hazardous drikig is defied as g of pure alcohol o average per day for me ad g for wome. A stadard drik cotais approximately 10g of pure alcohol. Istrumet questio: Durig each of the past 7 days, how may stadard driks of ay alcoholic drik did you have each day? Hazardous ad harmful drikig i the last 7 days Me % % harmful hazardous drikig drikig Hazardous ad harmful drikig i the last 7 days Wome % % harmful hazardous drikig drikig

89 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

90 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

91 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? % 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 % 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 % 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

92 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 % < five % < five servigs servigs servigs per day per day per day

93 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 % % % % Butt Cocout Noe Lard er Oil used % Other Fish Cosumptio Descriptio: Mea o. of days per week tied or fresh fish cosumed. Fresh Fish Cosumptio Me Wome Both Sexes Mea Mea Mea o. of o. of o. of days days days Tied Fish Cosumptio Me Wome Both Sexes Mea Mea Mea o. of o. of o. of days days days

94 Physical Activity Itroductio Aalysis physical activity data ca be very complicated ad the result cofusig. The followig guidelies will help clarify the results of the physical activity data ad will also provide valuable iformatio o the classificatios. Make sure you use some of these guidelies whe you report physical activity data. MET values are applied to vigorous ad moderate itesity variables i the work, trasport ad recreatio domais. These have bee calculated usig a average of the typical types of activity udertake. Differet types of activities have bee grouped together ad give a MET value based o the itesity of the activity. Applyig MET values to types of activities allows us to calculate total physical activity. For more iformatio regardig MET values go the STEPS website at The calculatios below use multiple questios i the physical activity sectio. To simplify this a bit the questios have bee clustered ito four groups (as they appear i the Istrumet). I the Istrumet questios sectio of the table, oly the group label appears. The specific questios for each group are preseted below. Activity at work: Does your work ivolve vigorous-itesity activity that causes large icreases i breathig or heart rate like [examples] for at least 10 miutes cotiuously? I a typical week, o how may days do you do vigorous-itesity activities as part of your work? How much time do you sped doig vigorous-itesity activities at work o a typical day? Does your work ivolve moderate-itesity activity, that causes small icreases i breathig or heart rate such as brisk walkig for at least 10 miutes cotiuously? I a typical week, o how may days do you do moderate-itesity activities as part of your work? How much time do you sped doig moderate-itesity activities at work o a typical day? Travel to ad from places: Do you walk or use a bicycle for at least 10 miutes cotiuously to get to ad from places? 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? Cotiued o ext page 93

95 Physical Activity, Cotiued Itroductio (cot.) How much time do you sped walkig or bicyclig for travel o a typical day? Recreatioal activities: Do you do ay ivolve vigorous-itesity sports, fitess or recreatioal activities that cause large icreases i breathig or heart rate like [examples] for at least 10 miutes cotiuously? I a typical week, o how may days do you do vigorous-itesity sports, fitess or recreatioal activities? How much time do you sped doig vigorous-itesity sports, fitess or recreatioal activities o a typical day? Do you do ay ivolve moderate-itesity sports, fitess or recreatioal activities that cause large icreases i breathig or heart rate like [examples] for at least 10 miutes cotiuously? I a typical week, o how may days do you do moderate--itesity sports, fitess or recreatioal activities? How much time do you sped doig moderate--itesity sports, fitess or recreatioal activities o a typical day? Sedetary behaviour : How much time do you usually sped sittig or recliig o a typical day? 94

96 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 Both Sexes % % Low % High Moderate

97 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 Media miutes of total physical activity o average per day Me Wome Both Sexes Iter-quartile Iter-quartile Media Media rage (P25- rage (P25- miutes miutes P75) P75) Iter-quartile rage (P25- P75)

98 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

99 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 (P25- miutes rage miutes rage (P25- P75) (P25-P75) 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)

100 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

101 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

102 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

103 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)

104 Blood Pressure ad Diabetes History Blood pressure diagosis ad treatmet Descriptio: Raised blood pressure diagosis ad treatmet results amog all respodets. Istrumet questios: Durig the past 12 moths have you bee told by a doctor or other health worker that you have elevated 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? Raised blood pressure diagosed by doctor or health worker i last 12 moths Me Wome Both Sexes % % % diagosed diagosed diagosed Curretly takig blood pressure drugs prescribed by doctor or health worker Me Wome Both Sexes % takig % takig % takig meds meds meds

105 Blood pressure lifestyle advice Descriptio: Percetage of respodets who received lifestyle advice from a doctor or health worker to treat raised blood pressure. Istrumet questio: 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 have special prescribed diet Me Wome Both Sexes % % % Advised by doctor or health worker to lose weight Me Wome Both Sexes % % % Advised by doctor or health worker to stop smokig Me Wome Both Sexes % % % Advised by doctor or health worker to start or do more exercise Me Wome Both Sexes % % %

106 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. Istrumet questios: Durig the past 12 moths have you 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 i the last 12 moths Me Wome Both Sexes % % % Curretly takig herbal or traditioal remedy for high blood pressure Me Wome Both Sexes % % %

107 Diabetes diagosis ad treatmet Descriptio: Diabetes diagosis ad treatmet results amog all respodets. Istrumet questios: Durig the past 12 moths, have you ever bee told by a doctor or other health worker that you have diabetes? Are you curretly takig ay of the followig treatmets/advice for diabetes prescribed by a doctor or other health worker? Diabetes diagosed by doctor or health worker i last 12 moths Me Wome Both Sexes % % % diagosed diagosed diagosed Curretly takig isuli prescribed for diabetes by doctor or health worker Me Wome Both Sexes % takig % takig % takig isuli isuli isuli Curretly takig oral drugs prescribed for diabetes by doctor or health worker Me Wome Both Sexes % takig % takig % takig meds meds meds

108 Diabetes lifestyle advice Descriptio: Percetage of respodets who received lifestyle advice from a doctor or health worker to diabetes. Istrumet questio: Are you curretly takig 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 Me Wome Both Sexes % % % Advised by doctor or health worker to lose weight Me Wome Both Sexes % % % Advised by doctor or health worker to stop smokig Me Wome Both Sexes % % % Advised doctor or health worker to start or do more exercise Me Wome Both Sexes % % %

109 Diabetes advice by traditioal healer Descriptio: Percetage of respodets who are have sought advice or treatmet from traditioal healers for diabetes. Istrumet questios: Durig the past 12 moths have you see a traditioal healer for diabetes? Are you curretly takig ay herbal or traditioal remedy for your diabetes? See a traditioal healer for diabetes i the last 12 moths Me Wome Both Sexes % % % Curretly takig herbal or traditioal treatmet for diabetes Me Wome Both Sexes % % %

110 Physical Measuremets Height, weight ad BMI Descriptio: Mea height, weight, ad body mass idex amog all respodet (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

111 BMI categories Descriptio: Percetage of respodets (excludig pregat wome) i each BMI category. Istrumet questios: Height Weight BMI classificatios Me % Uderweight weight weight Obese % Normal % Over- % < BMI classificatios Wome % Uderweight weight weight Obese % Normal % Over- % < % Uderweight <18.5 % Normal weight BMI classificatios Both Sexes % Overweight % Obese

112 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

113 Blood pressure Descriptio: Mea blood pressure amog all respodets. 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 Raised blood pressure Descriptio: Percetage of respodets with raised blood pressure. Istrumet questio: Readig 1-3 systolic ad diastolic blood pressure SBP 140 ad/or DBP 90 mmhg Me Wome Both Sexes % % % SBP 160 ad/or DBP 100 mmhg Me Wome Both Sexes % % %

114 Biochemical Measuremets Mea fastig blood glucose Descriptio: mea fastig blood glucose results excludig those curretly o medicatio for diabetes (No-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 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

115 Raised blood glucose Descriptio: Categorizatio of respodets ito blood glucose level categories ad percetage 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 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) 114

116 Total cholesterol Descriptio: Mea total cholesterol amog all respodets ad percetage of respodets with raised total cholesterol. Istrumet questio: 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 Total cholesterol 5.0 mmol/l or 190 mg/dl Me Wome Both Sexes % % % Total cholesterol 6.2 mmol/l or 240 mg/dl Me Wome Both Sexes % % %

117 Fastig Triglycerides Descriptio: Mea fastig triglycerides amog all respodets ad percetage of respodets with raised fastig triglycerides. Istrumet questio: Triglyceride measuremet Triglycerides (mmol/l) Me Wome Both Sexes Mea Mea Mea Triglycerides (mg/dl) Me Wome Both Sexes Mea Mea Mea Percetage of those with Triglycerides 1.7 mmol/l or 150 mg/dl Me Wome Both Sexes % % % Percetage of those with Triglycerides 2.0 mmol/l or 180 mg/dl Me Wome Both Sexes % % %

118 Raised Risk Raised risk 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 Raised Risk Me % with 0 % with 1-2 % with 3-5 risk risk risk factors factors factors Raised Risk Wome % with 0 % with 1-2 % with 3-5 risk risk risk factors factors factors Raised Risk Both Sexes % with 0 % with 1-2 % with 3-5 risk risk risk factors factors factors

119 Appedix 3. List of Staff for the FSM (Chuuk) STEPS Survey Mr Amato Elymore Mr Carter Apaisam Dr. Doria Fred Abrahm Rold Jacitha Lippwe Helde Heldart Moria Shomour Kethrud Maas Ophil Remit Suaita Takiri Asely Tarech Garry Narruh Kaylee Raymod Herche Nowell Iva Akapito Ira Akapito, Jr. Mechor Agkel Alcher Ramey Joyful Sam Pete Stais 118

120 Appedix 4. Refereces 1. Samo M, Elymore A, Apaisam C. Mortality Aalysis i the Federated States of Microesia. I: Pacific Health Dialog Govermet of the Federated States of Microesia, Geography, 2011, 3. Govermet of Australia, Departmet of Foreig Affairs ad Trade, Federated States of Microesia Coutry Brief, March Federated States of Microesia, Divisio of Statistics, Type of Icome by State 2006, 5. Fracis X. Hezel, SJ, A Overview of FSM Ecoomy, upublished, 7 November 2002, 6. Federated States of Microesia, Departmet of Ecoomic Affairs, 2002a: 7 cited i Hezel op. cit. 7. Jesse, B. 2009, Coutry Presetatio, Federated States of Microesia, Pacific Health Iformatio Network, 8. 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, 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, 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,

121 KEY CONTACTS FSM Departmet of Health ad Social Affairs Cotact: Marcus H. Samo, MPH Assistat Secretary for Health Departmet of Health ad Social Affairs Federated States of Microesia Capitol Street, P.O. Box PS 70 Palikir, FSM Tel: (691) Fax: (691) WHO Cotact: Dr Li Da Medical Officer Nocommuicable Diseases Divisio of Pacific Techical Support/Office for the South Pacific World Health Orgaizatio Plaza Oe, Dowtow Boulevard P. O. Box 113 Suva, Fiji Tel: (679) Fax: (679) Uiversity of New South Wales Cotact: Dr Graham Roberts Deputy Director Huma Resources for Health Kowledge Hub School of Public Health ad Commuity Medicie Room 208, Level 2, Samuels Buildig Faculty of Medicie Uiversity of New South Wales Kesigto, 2052, Australia Tel: (612)

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