Effects of inappropriate cause-of-death certification on mortality from cardiovascular disease and diabetes mellitus in Tonga.

BACKGROUND: Cardiovascular disease (CVD) and diabetes mellitus are major health issues in Tonga and other Pacific countries, although mortality levels and trends are unclear. We assess the impacts of cause-of-death certification on coding of CVD and diabetes as underlying causes of death (UCoD). METHODS: Tongan records containing cause-of-death data (2001-2018), including medical certificates of cause-of-death (MCCD), had UCoD assigned according to International Classification of Diseases 10th revision (ICD-10) coding rules. Deaths without recorded cause were included to ascertain total mortality. Diabetes and hypertension causes were reallocated from Part 1 of the MCCD (direct cause) to Part 2 (contributory cause) if potentially fatal complications were not recorded, and an alternative UCoD was assigned. Proportional mortality by cause based on the alternative UCoD were applied to total deaths then mortality rates calculated by age and sex using census/intercensal population estimates. CVD and diabetes mortality rates for unaltered and alternative UCoD were compared using Poisson regression. RESULTS: Over 2001-18, in ages 35-59 years, alternative CVD mortality was higher than unaltered CVD mortality in men (p = 0.043) and women (p = 0.15); for 2010-18, alternative versus unaltered measures in men were 3.3/103 (95%CI: 3.0-3.7/103) versus 2.9/103 (95%CI: 2.6-3.2/103), and in women were 1.1/103 (95%CI: 0.9-1.3/103) versus 0.9/103 (95%CI: 0.8-1.1/103). Conversely, alternative diabetes mortality rates were significantly lower than the unaltered rates over 2001-18 in men (p < 0.0001) and women (p = 0.013); for 2010-18, these measures in men were 1.3/103 (95%CI: 1.1-1.5/103) versus 1.9/103 (95%CI: 1.6-2.2/103), and in women were 1.4/103 (95%CI: 1.2-1.7/103) versus 1.7/103 (95%CI: 1.5-2.0/103). Diabetes mortality rates increased significantly over 2001-18 in men (unaltered: p < 0.0001; alternative: p = 0.0007) and increased overall in women (unaltered: p = 0.0015; alternative: p = 0.014). CONCLUSIONS: Diabetes reporting in Part 1 of the MCCD, without potentially fatal diabetes complications, has led to over-estimation of diabetes, and under-estimation of CVD, as UCoD in Tonga. This indicates the importance of controlling various modifiable risks for atherosclerotic CVD (including stroke) including hypertension, tobacco use, and saturated fat intake, besides obesity and diabetes. Accurate certification of diabetes as a direct cause of death (Part 1) or contributory factor (Part 2) is needed to ensure that valid UCoD are assigned. Examination of multiple cause-of-death data can improve understanding of the underlying causes of premature mortality to better inform health planning.

Two decades of chronic kidney disease of unknown aetiology (CKDu) research: Existing evidence and persistent gaps from epidemiological studies in Sri Lanka.

BACKGROUND: Chronic Kidney Disease of unknown origin (CKDu) excludes known primary renal conditions or systemic disease (such as diabetes mellitus or hypertension). Prominence of CKDu has been noted for some decades in Sri Lanka, especially among men in particular rural areas, prompting many studies directed towards environmental causation. This article critically reviews relevant primary studies. METHODS: Articles for this literature review (n = 86) were found by searching Medline, Embase, Global Health and ProQuest databases over 2000-2020 utilizing a standard algorithm. Articles were critiqued according to criteria for diagnosis of CKDu, aetiological agents investigated, analytic methods employed and findings. RESULTS: Criteria for diagnosis of CKDu varied significantly, including pre-selection by proteinuria, eGFR and biopsy proven interstitial nephritis. Prevalence studies have been largely conducted in the North Central Province, with recent studies demonstrating the presence of CKDu in other regions. Aetiological factors investigated in primary studies included water source, use of agrochemicals, agricultural work, heavy metals, snake bites, ayurvedic medication, heat stress, infectious diseases and usage of tobacco and betel leaf. There is no conclusive evidence for any one aetiological agent despite consistent evidence of distal factors such as male sex, rural residence and farming. CONCLUSIONS: The current body of evidence for any aetiological agent as the cause of CKDu in Sri Lanka is limited. Further research with stronger study designs is necessary to increase knowledge of aetiology of CKDu in Sri Lanka to identify and eliminate exposure to possible causative agent(s) prior to concluding that the disease is multifactorial.

Trends in mortality and life expectancy in Fiji over 20 years.

BACKGROUND: Fiji, a Pacific Island nation of 884,887 (2017 census), has experienced a prolonged epidemiological transition. This study examines trends in mortality and life expectancy (LE) in Fiji by sex and ethnicity over 1996-2017, with comparisons to published estimates. METHODS: Trends in infant mortality rates (IMR), under-5 mortality (U5M), adult mortality (probability of dying), LE (at birth) and directly age-standardised death rates (DASRs) by sex and ethnicity, are calculated (with 95% confidence limits) using unit death records from the Fiji Ministry of Health and Medical Services. The LE gap between populations, or within populations over time, is examined using decomposition by age. Period trends are assessed for statistical significance using linear regression. RESULTS: Over 1996-98 to 2014-17: IMR and U5M for i-Taukei and Fijians of Indian descent declined; U5M decline for i-Taukei (24.6 to 20.1/1000 live births) was significant (p = 0.016). Mortality (15-59 years) for i-Taukei males was unchanged at 27% but declined for Indians 33 to 30% (p = 0.101). Mortality for i-Taukei females increased 22 to 24% (p = 0.011) but declined for Indians 20 to 18% (p = 0.240). DASRs 1996-2017 were lower for i-Taukei (9.3 to 8.2/1000 population) than Indian males (10.6 to 9.8/1000). DASRs declined for i-Taukei (both sexes, p < 0.05), and for Indians (both sexes, p > 0.05). Over 22 years, LE at birth increased by 1 year or less (p = 0.030 in male i-Taukei). In 2014-17, LE (years) for males was: i-Taukei 64.9, Indians 63.5; and females: i-Taukei 67.0 and Indians 68.2. Mortality changes in most 5-year age groups increased or decreased the LE gap less than 10 weeks over 22 years. Compared to international agency reports, 2014-17 empirical LE estimates (males 64.7, females 67.8) were lower, as was IMR. CONCLUSIONS: Based on empirical data, LE in Fiji has minimally improved over 1996-2017, and is lower than some international agencies report. Adult mortality was higher in Indian than i-Taukei men, and higher in i-Taukei than Indian women. Exclusion of stillbirths resulted in IMRs lower than previously reported. Differing mortality trends in subgroups highlight the need to collect census and health data by ethnicity and sex, to monitor health outcomes and inform resource allocation.

Mortality in Tonga over three triennia, 2010-2018.

BACKGROUND: Tonga is a South Pacific Island country with a population of 100,651 (2016 Census). This study examines Tongan infant mortality rates (IMR), under-five mortality rates (U5MR), adult mortality and life expectancy (LE) at birth from 2010 to 2018 using a recent collation of empirical mortality data over the past decade for comparison with other previously published mortality estimates. METHODS: Routinely collected mortality data for 2010-2018 from the Ministry of Health, national (Vaiola) hospital, community nursing reports, and the Civil Registry, were consolidated by deterministic and probabilistic linkage of individual death records. Completeness of empirical mortality reporting was assessed by capture-recapture analysis. The reconciled data were aggregated into triennia to reduce stochastic variation, and used to estimate IMR and U5MR (per 1000 live births), adult mortality (15-59, 15-34, 35-59, and 15-64 years), and LE at birth, employing the hypothetical cohort method (with statistical testing). Mortality trends and differences were assessed by Poisson regression. Mortality findings were compared with published national and international agency estimates. RESULTS: Over the three triennia in 2010-2018, levels varied minimally for IMR (12-14) and U5MR (15-19) per 1000 births (both ns, p > 0.05), and also for male LE at birth of 64-65 years, and female LE at birth 69-70 years. Cumulated risks of adult mortality were significantly higher in men than women; period mortality increases in 15-59-year women from 18 to 21% were significant (p < 0.05). Estimated completeness of the reconciled data was > 95%. International agencies reported generally comparable estimates of IMR and U5MR, with varying uncertainty intervals; but they reported significantly lower adult mortality and higher LE than the empirical estimates from this study. CONCLUSIONS: Life expectancy in Tonga over 2010-2018 has remained relatively low and static, with low IMR and U5MR, indicating the substantial impact from premature adult mortality. This analysis of empirical data (> 95% complete) indicates lower LE and higher premature adult mortality than previously reported by international agencies using indirect and modelled methods. Continued integration of mortality recording and data systems in Tonga is important for improving the completeness and accuracy of mortality estimation for local health monitoring and planning.

General practitioners' perceptions on the feasibility and acceptability of implementing a risk prediction checklist to support their end-of-life discussions in routine care: a qualitative study.

BACKGROUND: General practitioners' (GPs) play a central role in facilitating end-of-life discussions with older patients nearing the end-of-life. However, prognostic uncertainty of time to death is one important barrier to initiation of these discussions. OBJECTIVE: To explore GPs' perceptions of the feasibility and acceptability of a risk prediction checklist to identify older patients in their last 12 months of life and describe perceived barriers and facilitators for implementing end-of-life planning. METHODS: Qualitative, semi-structured interviews were conducted with 15 GPs practising in metropolitan locations in New South Wales and Queensland between May and June 2019. Data were analysed thematically. RESULTS: Eight themes emerged: accessibility and implementation of the checklist, uncertainty around checklist's accuracy and usefulness, time of the checklist, checklist as a potential prompt for end-of-life conversations, end-of-life conversations not an easy topic, end-of-life conversation requires time and effort, uncertainty in identifying end-of-life patients and limited community literacy on end-of-life. Most participants welcomed a risk prediction checklist in routine practice if assured of its accuracy in identifying which patients were nearing end-of-life. CONCLUSIONS: Most participating GPs saw the value in risk assessment and end-of-life planning. Many emphasized the need for appropriate support, tools and funding for prognostic screening and end-of-life planning for this to become routine in general practice. Well validated risk prediction tools are needed to increase clinician confidence in identifying risk of death to support end-of-life care planning.

Continued increases in blood pressure over two decades in Samoa (1991-2013); around one-third of the increase explained by rising obesity levels.

BACKGROUND: To analyse trends over the period 1991-2013 in systolic blood pressure (SBP), diastolic blood pressure (DBP) and the prevalence of hypertension in adults aged 25-64 years in Samoa; and to assess the contribution of rising obesity levels to period trends. METHODS: Unit record data from seven population-based surveys (n = 10,881) conducted between 1991 and 2013 were included for analysis. Surveys were adjusted to the nearest previous census to improve national representativeness. Hypertension was defined as SBP ≥140 mmHg and/or DBP ≥90 mmHg and/or on medication for hypertension. Obesity was measured by body mass index (BMI). Poisson, linear and meta-regression were used to assess period trends. RESULTS: Over 1991-2013 mean SBP and DBP (mmHg), and the prevalence of hypertension (%) increased in both sexes. Increases in hypertension were: from 18.3 to 33.9% (p < 0.001) in men (mean BP from 122/74 to 132/78); and from 14.3 to 26.4% (p < 0.001) in women (mean BP from 118/73 to 126/78). The estimate of the age-adjusted mean SBP and DBP over 1991-2013, and the relative risk for hypertension in 2013 compared to 1991, were attenuated after adjusting for BMI: by 22% (men) and 32% (women) for mean SBP; 37% (men) and 32% (women) for mean DBP; and 19% in both sexes for hypertension. CONCLUSIONS: Significant increases have occurred in SBP/DBP and hypertension prevalence in both sexes in Samoa during 1991-2013, which would contribute significantly to premature mortality from cardiovascular disease. Obesity accounts for around one-third of the rising trend in blood pressure in the Samoan population. Strengthening of population control of hypertension through reduction in obesity and salt intake, and case detection and treatment through primary care, is required to reduce premature mortality from cardiovascular disease in Samoa.

Declines and Plateaux in Smoking Prevalence Over Three Decades in Fiji.

OBJECTIVES: To examine trends from 1980 to 2011 in daily tobacco smoking by sex, ethnicity, age, and urban/rural in Fiji Melanesian (i-Taukei) and Indian adults aged 25-64 years. METHODS: Unit record data from five population-based surveys (n = 14 528) allowed classification of participants as: (1) never-smoker, ex-smoker, or non-daily smoker; or (2) daily smoker, reporting smoking <20 or ≥20 tobacco products (cigarettes/cigars/pipes) a day. Trends were examined using spline analyses. RESULTS: Over 1980-2011 the prevalence of reported daily tobacco smoking decreased significantly in both sexes and ethnicities, with the greatest decline during 1980-2000. Declines were from 81.7% to 27.0% in i-Taukei men; 55.3% to 26.3% in Indian men; 48.1% to 9.5% in i-Taukei women; and 13.8% to 1.3% in Indian women (p < .0001). Declines were consistent across all age groups in men, while there were greater declines among older age groups in women; and greater declines from higher prevalences in rural compared to urban areas in both sexes and ethnicities. Smoking ≥20 tobacco products per day declined significantly in i-Taukei men from 8.0% to 1.9% (p < .0001); there were also declines in Indian men (4.6% to 2.0%) and i-Taukei women (2.6% to 0.6%), but these were not statistically significant; and Indian women remained <0.2% throughout the period. CONCLUSIONS: Significant declines in daily tobacco smoking have occurred in Fiji in both sexes and ethnicities during the past 30 years, which is consistent with declines in tobacco apparent consumption and household expenditure. However, prevalence remains high in men at around 27% in 2011, with plateau at this level in i-Taukei. IMPLICATIONS: This is the first study to show nationally representative population trends in tobacco smoking in a developing country over such a long period (>30 years) based on empirical unit record data (n = 14 528). Cardiovascular disease is a leading cause of mortality throughout the Pacific Island region. This is the first study to show evidence of substantial declines over several decades in a cardiovascular disease risk factor in a Pacific Island country, and provides important evidence for further research into the interventions and events which may have facilitated this decline.

Tobacco smoking trends in Samoa over four decades: can continued globalization rectify that which it has wrought?

BACKGROUND: The island country of Samoa (population 188,000 in 2011) forms part of Polynesia in the South Pacific. Over the past several decades Samoa has experienced exceptional modernization and globalization of many sectors of society, with noncommunicable diseases (NCD) now the leading cause of morbidity and mortality. The evolution of risk factor prevalence underpinning the increase in NCDs, however, has not been well described, including tobacco smoking which is related to cardiovascular disease, lung cancer, and chronic obstructive pulmonary disease. METHODS: The present study examines tobacco smoking in relation to different forms and effects of globalization in Samoa using 7 population-based surveys (n = 9223) over 1978-2013. RESULTS: The prevalence of daily tobacco smoking steadily decreased over 1978-2013 from 76% to 36% in men, and from 27% to 15% in women (p < 0.0001 both sexes). During 1991-2013, current tobacco smoking also steadily decreased from 64% to 40% in men (p < 0.0001), and from 21% to 17% in women (p < 0.05). Declines were similar in younger (25-44 years) and older (45-64 years) men and women. Colonial globalization facilitated the introduction and prolific spread of tobacco trade and consumption in the Pacific Islands from the sixteenth century, with many populations inexorably pulled into trade relations and links to the global economy. It has also been a different globalization which may have led to the decline in smoking prevalence in Samoa in recent decades, through global dissemination since the 1950s of information on the harmful effects of tobacco smoking derived from research studies in the USA and Europe. CONCLUSIONS: Over the past 35 years tobacco smoking has steadily declined among Samoan adults; the only NCD risk factor to demonstrate marked declines during this period. By 2013 tobacco smoking in women had decreased to levels similar to Australia and New Zealand (ANZ), however in men smoking prevalence remained more than three times higher than ANZ. The impact on smoking prevalence of the variety of tobacco control interventions that have been implemented so far in Samoa need to be evaluated in order to determine the most effective initiatives that should be prioritized and strengthened.

Diabetes incidence and projections from prevalence surveys in Fiji.

BACKGROUND: Type 2 diabetes mellitus (T2DM) incidence is traditionally derived from cohort studies that are not always feasible, representative, or available. The present study estimates T2DM incidence in Fijian adults from T2DM prevalence estimates assembled from surveys of 25-64 year old adults conducted over 30 years (n = 14,288). METHODS: T2DM prevalence by five-year age group from five population-based risk factor surveys conducted over 1980-2011 were variously adjusted for urban-rural residency, ethnicity, and sex to previous censuses (1976, 1986, 1996, 2009) to improve representativeness. Prevalence estimates were then used to calculate T2DM incidence based on birth cohorts from the age-period (Lexis) matrix following the Styblo technique, first used to estimate annual risk of tuberculosis infection (incidence) from sequential Mantoux population surveys. Poisson regression of year, age, sex, and ethnicity strata (n = 160) was used to develop projections of T2DM prevalence and incidence to 2020 based on various scenarios of population weight measured by body mass index (BMI) change. RESULTS: T2DM prevalence and annual incidence increased in Fiji over 1980-2011. Prevalence was higher in Indians and men than i-Taukei and women. Incidence was higher in Indians and women. From regression analyses, absolute reductions of 2.6 to 5.1% in T2DM prevalence (13-26% lower), and 0.5-0.9 per 1000 person-years in incidence (8-14% lower), could be expected in 2020 in adults if mean population weight could be reduced by 1-4 kg, compared to the current period trend in weight gain. CONCLUSIONS: This is the first application of the Styblo technique to calculate T2DM incidence from population-based prevalence surveys over time. Reductions in population BMI are predicted to reduce T2DM incidence and prevalence in Fiji among adults aged 25-64 years.

Absolute cardiovascular risk in a Fiji medical zone.

BACKGROUND: The population of Fiji has experienced emergence of non-communicable disease (NCD) and a plateau in life expectancy over the past 20 years. METHODS: A mini-STEPS survey (n = 2765) was conducted in Viseisei in Western Fiji to assess NCD risk factors (RFs) in i-Taukei (Melanesians) and those of Indian descent aged 25-64 years (response 73 %). Hypertension (HT) was defined as systolic blood pressure (BP) ≥140 mmHg or diastolic BP ≥90 mmHg or on medication for HT; type 2 diabetes mellitus (T2DM) as fasting plasma glucose ≥7.0 mmol/L or on medication for T2DM; and obesity as a body mass index (kilograms/height(metres)(2)) ≥30. Data were age-adjusted to 2007 Fiji Census. Associations between RFs and ethnicity/education were investigated. Comparisons with Fiji STEPS surveys were undertaken, and the absolute risk of a cardiovascular disease (CVD) event/death in 10 years was estimated from multiple RF charts. RESULTS: NCD/RFs increased with age except excessive alcohol intake and daily smoking (women) which declined. Daily smoking was higher in men 33 % (95 % confidence interval: 31-36) than women 14 % (12-116); women were more obese 40 % (37-43) than men 23 % (20-26); HT was similar in men 37 % (34-40) and women 34 % (31-36), as was T2DM in men 15 % (13-17) and women 17 % (15-19). i-Taukei men had an odds ratio (OR) of 0.41 (0.28-0.58) for T2DM compared to Indians (1.00); and i-Taukei (both sexes) had a higher OR for obesity and low fruit/vegetable intake, daily smoking, excessive alcohol intake and HT in females. Increasing education correlated with lesser smoking, but with higher obesity and lower fruit/vegetable intake. Compared to the 2011 Fiji STEPS survey, no significant differences were evident in obesity, HT or T2DM prevalences. The proportion (40-64 years) classified at high or very high risk (≥20 %) of a CVD event/death (over 10 years) based on multiple RFs was 8.3 % for men (8.1 % i-Taukei, 8.5 % Indian), and 6.7 % for women (7.9 % i-Taukei, 6.0 % Indian). CONCLUSIONS: The results of the survey highlight the need for individual and community interventions to address the high levels of NCD/RFs. Evaluation of interventions is needed in order to inform NCD control policies in Fiji and other Pacific Island nations.

Trends in Sri Lankan cause-specific adult mortality 1950-2006.

BACKGROUND: Although all-cause mortality in Sri Lanka decreased significantly from 1950 to 1970, subsequent declines have been more modest with divergent trends by age and sex. This study investigates these trends through cause of death analysis for 1950-2006 in adults aged 15-64 years. METHODS: Deaths were obtained from the World Health Organisation (WHO) mortality database for 1950 to 2003, and the Department of Census and Statistics Sri Lanka for 1992-95 and 2004-06 where WHO data was unavailable. Adult deaths were categorised by age (15-34 and 35-64 years) and sex into: infectious diseases; external-causes; circulatory diseases; cancers; digestive diseases; respiratory diseases; pregnancy-related; ill-defined; and other-causes. Cause-specific mortality rates were directly age-standardised to the 2001 Sri Lankan Census population. RESULTS: Mortality declined in females aged 15-34 years by 85% over 1950-2006, predominantly due to sharp declines in infectious disease and pregnancy-related mortality over 1950-70. Among males aged 15-34 years the mortality decline was less at 47%, due to a rise in external-cause mortality during 1970-2000. In females aged 35-64 years mortality declined by 67% over 1950-2006, predominantly due to a sharp decline in infectious disease, ill-defined and other cause mortality over 1950-70. Among males aged 35-64 years, decline in mortality is evident to 1960 (19%) from decline in infectious disease mortality, followed by increased mortality from circulatory diseases and external cause mortality, despite continued decline in infectious disease mortality. All-cause mortality in males 35-64 years has stagnated since 1970, with fluctuating increases. Circulatory diseases were the leading cause of death among adults 35-64 years in 2002-06, with the male rate almost three times higher than females. CONCLUSIONS: Significant disparities are demonstrated in Sri Lankan cause-specific adult mortality by sex and age group for 1950-2006. Female mortality progressively declined while male mortality demonstrated periods of increase and stagnation. Among males aged 15-34 years this coincides with periods of civil conflict over 1970-2000. Among males aged 35-64 years the increased mortality from non-communicable disease and external causes are the main reasons for stagnation in all-cause mortality since the 1970's.

Sexual Intercourse and Its Correlates Among School-aged Adolescents in Indonesia: Analysis of the 2015 Global School-based Health Survey.

OBJECTIVES: This study aimed to determine the prevalence and correlates of sexual intercourse among junior secondary and high school students in Indonesia from the 2015 Global School-based Health Survey (GSHS). METHODS: The survey was conducted among 11 110 students from 75 schools in Indonesia using a self-administered questionnaire. Univariate and multivariate analyses were conducted to explore associations between sexual intercourse and socio-demographic variables, substance use, mental distress, and protective factors. RESULTS: Overall, 5.3% of students reported having ever had sex (6.9% of boys and 3.8% of girls). Of students who engaged in sexual intercourse, 72.7% of boys and 90.3% of girls had an early sexual debut (before reaching the age of 15) and around 60% had multiple sex partners. Sexual intercourse was associated with gender, school grade, smoking, alcohol consumption, drug use, suicidal ideation, truancy, peer support, and parental supervision. CONCLUSIONS: These findings indicate a pressing need to develop more comprehensive sexual health education in the national curriculum. An effective strategy should also address other risky behaviours.

Diabetes incidence and projections from prevalence surveys in Samoa over 1978-2013.

OBJECTIVES: This study estimates type 2 diabetes (T2DM) incidence in Samoans aged 25-64 years from sequential, irregularly spaced, cross-sectional population prevalence surveys. METHODS: T2DM prevalence from eight population surveys conducted over 1978-2013 (n = 12,516) was adjusted for census region, sex, and 5-year age group to the nearest previous census. Annual T2DM incidence was calculated from adjusted prevalences (by sex), using birth cohorts constructed from age-period matrices. Projections of T2DM incidence to 2020 were estimated, based on various scenarios of population weight change using Poisson regression. RESULTS: Over 1978-2013, T2DM incidence was estimated to increase from 1.12 to 8.44 per 1000 person-years in men and from 2.55 to 8.04 per 1000 in women. Based on regression modeling, if mean population weight was stabilized from 2013, absolute incidence reductions of 0.9 per 1000 person-years (7% lower) are predicted in 2020, compared to the current period trend in weight gain. CONCLUSIONS: T2DM incidence can be calculated from irregularly conducted population risk factor surveys which may be useful in developing countries with limited resources.

Differentials in Cardiovascular Risk Factors and Diabetes by Socioeconomic Status and Sex in Kalutara, Sri Lanka.

Since 1950, cardiovascular disease (CVD) has emerged as a leading cause of mortality in Sri Lanka, especially in men. In 2014, a survey in Kalutara to assess CVD and type 2 diabetes mellitus (T2DM) risk factors in adults aged 25 to 64 years (n = 1011), and associations with sex and socioeconomic status (SES), found similar CVD risk factors in both sexes, except for daily tobacco smoking at 19% in men and nil in women, and higher body mass index (BMI) in women than men. With increasing SES in men, there were significant linear increases in mean BMI, waist circumference, mean systolic and diastolic blood pressure, mean fasting plasma glucose, and T2DM prevalence, but decreases in tobacco smoking. Whereas in women higher SES was associated with a significant increase in mean BMI, but a significant decrease in hypertension prevalence. Tobacco smoking is the main risk factor explaining higher CVD mortality in men compared with women.

Diabetes and obesity trends in Fiji over 30 years.

BACKGROUND: No systematic comparison has been conducted in Fiji using all suitable surveys of type 2 diabetes mellitus (T2DM) and obesity prevalence after standardizing methodology and definitions. METHODS: Unit records from six surveys of Fiji adults were variously adjusted for age, ethnicity (Fiji Melanesians, i-Taukei, and Fijians of Asian Indian descent [Indians]) and urban-rural by sex to previous censuses. Trends were assessed using meta-regression (random effect models) and estimates projected to 2020. Poisson regression of strata was used to assess the effect of body mass index (BMI) increases on T2DM period trends. RESULTS: Over 1980-2011, T2DM prevalence increased in i-Taukei men (3.2% to 11.1%; 1.32%/5 years) and women (5.3% to 13.6%; 1.40%/5 years) and Indian men (11.1% to 17.9%; 1.24%/5 years) and women (11.2% to 19.9%; 1.71%/5 years). Projected T2DM prevalence in 2020 is 13.3% and 16.7% in i-Taukei men and women, and 23.4% and 24.1% in Indian men and women, respectively. Obesity prevalence increased in i-Taukei men (12.6% to 28.9%; 2.99%/5 years) and women (30.1% to 52.9%; 3.84%/5 years) and in Indian men (2.8% to 9.4%; 1.21%/5 years) and women (13.2% to 26.6%; 2.61%/5 years). Projected obesity prevalence in 2020 is 34.0% and 60.0% in i-Taukei and women, and 11.4% and 31.0% in Indian men and women, respectively. After age-adjustment, an estimated 27%, 25%, 16% and 18% of the T2DM period trend is attributable to BMI in i-Taukei men and women and Indian men and women, respectively. CONCLUSIONS: Prevalence of T2DM in Fiji is projected to continue increasing, driven by rising obesity, with consequences for premature mortality and life expectancy.

Changes in cardiovascular disease risk factors over 30 years in Polynesians in the French Pacific Territory of Wallis Island.

BACKGROUND: Wallis Island is part of a French Territory in the South Pacific. In 1980 the prevalence of hypertension and type 2 diabetes mellitus (T2DM) was low, consistent with a subsistence economy. Considerable social and economic changes have occurred over the last 30 years. METHODS: Survey data from 1980 and 2009 were analysed by sex in 10-year age groups, and 25-64 years age-standardised to the 2008 Census. Means and prevalences were calculated for blood pressure, fasting plasma glucose, body mass index (BMI), blood cholesterol and triglycerides as risk factors contributing to cardiovascular disease. RESULTS: During 1980-2009 there were significant increases (p < 0.05) in age-standardised means and prevalences of blood pressure and hypertension, fasting plasma glucose and T2DM, BMI and obesity, blood cholesterol (men) and triglycerides; and non-significant increases in mean diastolic blood pressure and fasting plasma glucose in women. Mean cholesterol and the prevalence of elevated cholesterol declined in women. Hypertension prevalence increased from 12% to 43% in men and from 15% to 30% in women, with 42% of the increase in men and 33% of the increase in women statistically explained by increases in BMI. T2DM increased from 2.3% to 12.2% in men and from 4.0% to 15.8% in women, with 35% of the increase in men and 26% of the increase in women statistically explained by increases in BMI. CONCLUSIONS: Risk factors for cardiovascular disease have increased considerably in Wallis Island over the past 30 years, consistent with modernisation in way of life.

Diabetes and Obesity Trends in Tonga Over 40 Years.

Disparate population surveys of type 2 diabetes mellitus (T2DM) have been conducted in Tonga for 4 decades. This study standardizes these surveys to enable assessment of T2DM and obesity trends in Tongans aged 25 to 64 years over 1973-2012, and projects T2DM prevalence to 2020 based on demographic and population weight changes. Eight surveys were standardized to the nearest census to produce nationally representative estimates. Linear period trends and prevalence projections to 2020 were produced using random-effects meta-regression. Over 1973-2012, T2DM prevalence increased from 5.2% to 19.0% (1.9%/5 years) and obesity prevalence from 56.0% to 70.2% (2.7%/5 years). T2DM prevalence period projection to 2020 is 22.3%. Based on modeling using body mass index, T2DM prevalence in 2020 could have been 12.7% and 16.8% in 2020 had mean population weight been 1 to 4 kg lower than 2012 levels.

Continued increases in hypertension over three decades in Fiji, and the influence of obesity.

OBJECTIVES: To analyse trends during 1980-2011 in hypertension prevalence and SBP/DBP by sex in Fiji Melanesian (i-Taukei) and Indian adults aged 25-64 years; and to assess effects of BMI. METHODS: Unit record data from five population-based surveys were included (n = 14, 191). Surveys were adjusted to the nearest previous census to improve national representativeness. Hypertension was defined as SBP at least 140  mmHg and/or DBP at least 90  mmHg and/or on medication for hypertension. Regression (Poisson and linear) was used to assess period trends. RESULTS: Over 1980-2011 hypertension prevalence (%) and mean blood pressure (BP) (SBP/DBP mmHg) increased significantly (P < 0.001) in both sexes and ethnicities. Increases in hypertension were: from 16.2 to 41.3% in i-Taukei men (mean BP from 122/73 to 135/81); from 20.5 to 37.8% in Indian men (mean BP from 122/74 to 133/81); from 25.9 to 36.9% in i-Taukei women (mean BP from 126/76 to 132/81); and from 17.6 to 33.1% in Indian women (mean BP 117/71 to 130/81). The age-adjusted trend in hypertension and mean BP (over 32 years) declined after adjusting for BMI, with effects of obesity greater in women than men, and in Indians than i-Taukei. BMI explained 45% of the age-adjusted increase in DBP over the period in Indians (both sexes), and 16% (men) and 38% (women) in i-Taukei. CONCLUSION: Significant increases have occurred in hypertension prevalence and SBP/DBP in both sexes and ethnicities of Fiji during 1980-2011 with no indication of decline, contributing to significant premature mortality from cardiovascular disease.

Erroneous inflation of diabetes prevalence: Are there global implications?

Comparison of the prevalence of type 2 diabetes mellitus (T2DM) in adults aged 25-64 years in selected Pacific Island countries using whole blood and plasma glucose cut-off points. Unit records of STEPwise approach to Surveillance (STEPS) surveys obtained from Fiji, Samoa, and Tonga Ministries of Health; T2DM prevalence recalculated using whole blood and plasma cut-off points. Shaded bars indicate T2DM prevalence based on correct glucose cut-off points for the glucose meter used (fasting blood glucose [FBG] ≥6.1 mmol/L for early surveys1,3,5 ; fasting plasma glucose [FPG] ≥7.0 mmol/L for later surveys),2,4,6 whereas open bars show T2DM prevalence based on incorrect glucose cut-off points (FPG ≥6.1 mmol/L for later surveys).2,4,6 Highlights Incorrect glucose cut-off points were applied to the Fiji 2011, Samoa 2013, and Tonga 2012 STEPS surveys. This doubled the actual T2DM prevalences compared to using the correct glucose cut-off points. The errors occurred due to modern glucose meters producing measurements in plasma-equivalent concentrations from whole blood samples. The incorrect whole blood glucose cut-off (≥6.1mmol/L) was applied instead of the correct plasma glucose cut-off (≥7.0mmol/L). This error likely affects other Pacific states, and may have global ramifications.

Measuring progress towards achieving Millennium Development Goals in small populations: is under-five mortality in Tuvalu declining?

OBJECTIVES: Infant mortality rates (IMR) and under-five mortality rates (U5MR) in Tuvalu (2010 population 11,149) for 1990-2011 were evaluated to determine best estimates of levels and trends. METHODS: Estimates were graphed over time to identify trends/inconsistencies, and censored for reliability/plausibility. Where possible, 95% confidence intervals (CIs) and tests for linear trend were calculated. RESULTS: Ministry of Health (MoH) data indicates IMR and U5MR (per 1,000 live births) declined over 1990-2008: IMR 62 (95%CI 46-81) for 1991-93 (51 deaths) to 19 (95%CI 10-33) for 2006-08 (12 deaths); U5MR 67 (95%CI 50-87) for 1991-93 (55 deaths) to 19 (95%CI 10-33) for 2006-08 (12 deaths). The 2007 Demographic and Health Survey (DHS) suggests recent trends are increasing: IMR 24 for 1998-2002 to 31 (95%CI 20-42) for 2003-07; U5MR 29 for 1998-2002 to 36 (95%CI 30-43) for 2003-07 (deaths not provided). Tests for linear trend and 95%CIs indicate MoH declines are statistically significant, but recent increased estimates from DHS are not, and could be affected by recall bias. CONCLUSIONS: Small populations provide challenges in interpretation of IMR/U5MR trends. To ensure the correct interpretation of rates, CIs (95%) and tests for trend should be calculated. Tuvalu has experienced steady decline in IMR/U5MR over the past 20 years.