presented by Trevor Ferguson on behalf of JHLS-III Investigators Jamaica Health and Lifestyle Survey 2016 - 2017: Prevalence of NCD Risk Factors and Cardiovascular Disease presented by Trevor Ferguson on behalf of JHLS-III Investigators

Introduction – NCDs and Public Health Noncommunicable diseases (NCDs), including heart disease, stroke, cancer, diabetes, and chronic lung disease remain a global public health problem NCDs are responsible for 71% of deaths globally In Jamaica, NCDs accounted for approximately 62% of deaths among men and 74% of deaths among women in 2016

Introduction – NCDs and Public Health Data from JHLS-II, completed in 2007-2008, showed high prevalence of behavioural and metabolic risk factors for NCDs JHLS-III, conducted between 2016-2017, provides updated estimates on the burden of NCDs and their risk factors

Content Covered Obesity Diabetes mellitus Hypertension High Cholesterol Heart Attack Stroke

Study Design A community based interviewer-administered health examination survey of non-institutionalised Jamaicans, resident in Jamaica, aged 15 years and older Designed to be nationally representative Multi-stage sampling design Randomly selected rural and urban enumeration districts stratified by parish Systematic sampling of households within each ED One participant selected per household – using Kish method

Weighted Analyses Sampling weights – based on Probability of selection of dwellings and enumeration districts Adjusted for unit non-response Calibrated using population distribution at parish-level sex-specific by 5-year age bands

Weighted Estimates More conservative estimates of the variability associated with the statistics Description that can be generalised to Jamaican population of 15 years and older

Recruitment

The Recruited Sample 1089 (38.8%) males, 1718 (61.2%) females Males Total Kingston 74 189 263 St. Andrew 125 246 371 St Thomas 66 98 164 Portland 82 122 204 St. Mary 70 152 St Ann 57 59 116 Trelawny 76 135 211 Males Females Total St James 73 126 199 Hanover 60 75 135 Westmoreland 52 98 150 St Elizabeth 109 132 241 Manchester 94 118 212 Clarendon 70 110 180 St Catherine 81 128 209 1089 (38.8%) males, 1718 (61.2%) females

RESULTS

Distribution of Nutritional Status by Sex (BMI categories) 54% of persons ≥15 yrs were overweight (25% pre-obese; 29% obese) Pre-obese = BMI 25.0-29.9; Obese = BMI≥30 kg/m2 p<0.001 for male: female difference

Pre-Obesity and Obesity by Age High prevalence of overweight (pre- obesity and obesity) in all age groups Lowest in 15-24 age group Highest among those 35-44 & 45-54 years Small decrease in the older age groups P<0.001 for difference in proportion for obesity by age (pp. 156-157) Pre-obese = BMI 25.0-29.9; Obese = BMI≥30 kg/m2

Prevalence of obesity by sex (BMI ≥30 kg/m2) Marked sex difference in prevalence of obesity – female >> male

Prevalence of Obesity (BMI ≥30) by Parish (Females) Highest prevalence: Trelawny (58.0%) , St James (47.0%) , Kingston (46.1%) Lowest prevalence: Manchester (32.2%), St Mary (34.5%), St Ann (36.6%)

Prevalence of Obesity (BMI ≥30) by Parish (Males) Highest prevalence: Hanover (22.9%) , St Catherine (22.0%), St Ann (19.5%) Lowest prevalence: Westmoreland (2.0%), Portland (4.2%), St Thomas (7.6%)

Prevalence Diabetes Mellitus (defined as FBS ≥ 7 Prevalence Diabetes Mellitus (defined as FBS ≥ 7.0 mmol/l or on medication for diabetes) Overall diabetes prevalence 11.9% (95%CI 10.5 - 13.4%) Significantly higher prevalence among women 15% vs. 9% (p<0.001) Prevalence among persons 15-74 years 10.2% (95% CI 8.9 - 11.7%) Absolute increase of 2.3% compared to JHLS-II in 2008

Prevalence of Diabetes Mellitus by Age pp. 165-166 P<0.001 for both males and females

Prevalence of Diabetes by Parish (Females) Female (p=0.167) Highest prevalence: Manchester (22%) , Westmoreland (21%), Trelawny (19%) Lowest prevalence: St Mary (8%), St Ann (9%), Portland (12%)

Prevalence of Diabetes by Parish (Males) Male (p=0.038) Highest prevalence: Hanover (19%) , Clarendon (19%), Kingston (17%) Lowest prevalence: St Thomas (2%), St Mary (4%), Trelawny (4%)

Prevalence of Diabetes Mellitus by Rural / Urban Residence No significant differences between rural and urban residents 11.4% among rural vs. 12.3% among urban residents

Overall 24% of persons 15 years or older have diabetes or prediabetes Pre-diabetes by Sex Prediabetes defined as fasting glucose of 5.6-6.9 mmol/l Sex Category Pre-diabetes (%) Male 10.7 Female 13.1 Both Sexes 12.0 p<0.001 Overall 24% of persons 15 years or older have diabetes or prediabetes

Definition & Classification of High BP JNC 7 (2003) Normal SBP <120 mmHg & DBP <80 mmHg Prehypertension SBP 120-139 mmHg or DBP 80-89 mmHg Hypertension SBP ≥140 mmHg or DBP ≥90 mmHg ACC/AHA 2017 Normal SBP <120 mmHg & DBP <80 mmHg Elevated BP SBP 120-129 mmHg or Hypertension SBP ≥130 mmHg or DBP ≥80 mmHg JNC7 = The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 

Prevalence of Hypertension by Sex using JNC-7 (2003) and ACC/AHA (2017) criteria ACC/AHA 2017 (SBP ≥130 or DBP ≥80) JNC-7 (SBP ≥140 or DBP ≥90) p=0.039 p=0.506

Proportion of Population in Blood Pressure Categories (JNC-7 & ACC/AHA) % Normal 32.2 Prehypertension 34.0 Hypertension 33.8 ACC/AHA 2017 % Normal 32.2 Elevated BP 10.2 Hypertension 57.6 Only 32% of Jamaican adults have normal blood pressure 2/3 of the population have elevated blood pressure

Hypertension by Age and Sex (JNC7) P<0.001 for both males and females

Hypertension – Rural vs Urban (JNC7) No significant rural urban differences in the prevalence of HTN 34.5% rural vs 33.1% urban

Hypertension by Parish (JNC7)

Prevalence of High Cholesterol (total cholesterol ≥5.2 mmol/l) Estimated prevalence of high cholesterol = 18% Higher in women compared to men 20% vs. 16%, p=0.024 Urban vs. Rural Rural prevalence 20%; urban prevalence 16%; p=0.083 Rural urban difference significant among females: 23% (rural) vs. 17% (urban); p=0.036 Rural urban difference

Prevalence of High Cholesterol by Age P<0.001 for both males and females

Hypertension and Diabetes by BMI Category BMI categories: <18.5 = underweight; 18-5-24.9 = normal weight; 25.0-29.9 = pre-obese; ≥30 = obese (units = kg/m2)

Level of Awareness (%) for HTN & DM

Treatment and Control (%) among Persons Aware of HTN, DM Male % Female Both Sexes Hypertension On Treatment 63.3 73.2 70.2 Controlled1 26.0 33.1 31.0 Diabetes 91.3 93.0 92.5 29.0 27.0 27.5 1 Controlled calculated as proportion of those on treatment

Prevalence of Heart Attack by Sex and Age Overall prevalence of heart attack 0.4% (4.2 per 1000) Prevalence is lower than 0.6% seen in 2008 As expected no cases among persons <35; absence of cases in 45-54 probably due to chance given the small numbers

Prevalence of Stroke by Sex and Age Overall prevalence of stroke was 1.2% (10 per 1000) Prevalence is slightly lower than 1.4% seen in 2008 No cases among persons <25; high prevalence among persons ≥75 years

Secular Trends among persons 15-74 years for 2001, 2008, 2017 Condition 2001 % 2008 2017 % Change Pre-obese/Obese 45.7 51.8 53.9 17.9 Obesity 19.7 25.3 28.9 46.7 Hypertension 20.9 25.2 31.5 50.7 Diabetes mellitus 7.2 7.9 10.2 41.7 High Cholesterol 14.6 11.7 17.1

Summary / Key Findings Prevalence of NCD risk factors remain high and appear to be increasing More than half of the population is pre-obese/obese 2/3 have elevated blood pressure 1/8 have diabetes; ¼ had pre-diabetes or diabetes combined Just under 1/5 have high cholesterol 4/10 persons with HTN or DM unaware of their condition Only 30% of treated persons with HTN or DM are controlled

Implications Jamaica will to continue to face challenges with complications of diabetes & hypertension, particularly heart disease, stroke & chronic kidney disease Health care expenditure is likely to increase May negatively impact economy due to reduced productivity among persons who are ill Likely to see increase in dependency ratio due to more persons being unable to work

Recommendations Population wide intervention to reduce obesity, diabetes and hypertension Jamaica Moves  programme - physical activity, healthy eating; promotion of age-appropriate health checks for NCDs and NCD awareness. Improved socioeconomic circumstances and improved access to care Population wide screening for hypertension, diabetes and high cholesterol to increase awareness and ensure persons are treated Engagement of health care providers in both public and private sector to improve quality of care

JHLS-III Research Team Rainford Wilks Karen Webster Marshall Tulloch-Reid Shelly McFarlane Andriene Grant Novie Younger-Coleman Nadia Bennett Trevor Ferguson Tamu Davidson Colette Cunningham-Myrie Damian Francis Ishtar Govia Suzanne Soares-Wynter William Aiken Shari Williams Jovan Wiggan Nicolas Elias Georgiana Gordon-Strachan Tiffany Palmer Natalie Guthrie Georgia Williamson Ardene Harris Sharmaine Edwards