Establishing national noncommunicable disease surveillance in a developing country: a model for small island nations.

Objective To describe the surveillance model used to develop the first national, population-based, multiple noncommunicable disease (NCD) registry in the Caribbean (one of the first of its kind worldwide); registry implementation; lessons learned; and incidence and mortality rates from the first years of operation. Methods Driven by limited national resources, this initiative of the Barbados Ministry of Health (MoH), in collaboration with The University of the West Indies, was designed to collect prospective data on incident stroke and acute myocardial infarction (MI) (heart attack) cases from all health care facilities in this small island developing state (SIDS) in the Eastern Caribbean. Emphasis is on tertiary and emergency health care data sources. Incident cancer cases are obtained retrospectively, primarily from laboratories. Deaths are collected from the national death register. Results Phased introduction of the Barbados National Registry for Chronic NCDs ("the BNR") began with the stroke component ("BNR-Stroke," 2008), followed by the acute MI component ("BNR-Heart," 2009) and the cancer component ("BNR-Cancer," 2010). Expected case numbers projected from prior studies estimated an average of 378 first-ever stroke, 900 stroke, and 372 acute MI patients annually, and registry data showed an annual average of about 238, 593, and 349 patients respectively. There were 1 204 tumors registered in 2008, versus the expected 1 395. Registry data were used to identify public health training themes. Success required building support from local health care professionals and creating island-wide registry awareness. With spending of approximately US$ 148 per event for 2 200 events per year, the program costs the MoH about US$ 1 per capita annually. Conclusions Given the limited absolute health resources available to SIDS, combined surveillance should be considered for building a national NCD evidence base. With prevalence expected to increase further worldwide, Barbados' experiences are offered as a "road map" for other limited-resource countries considering national NCD surveillance.

Systematic review of studies evaluating urinary iodine concentration as a predictor of 24-hour urinary iodine excretion for estimating population iodine intake.

OBJECTIVE: To examine the usefulness of "spot" urine iodine concentrations (UICs) in predicting 24-hour urine iodine excretion (UIE) for estimating average population iodine intake. METHODS: An electronic literature search was conducted for articles published through 19 May 2013 in MEDLINE (from 1950), EMBASE (from 1980), and the Cochrane Library (from 1993) using the terms "urinary excretion (timed or spot or random) and (24 h or 24 hour), iodine (iodine deficiency), iodine (intake)," and "urine (timed, spot, random, 24-hour)." Full-text articles about studies that examined > 40 healthy human subjects and measured UIE using the 24-hour urine collection method and UIC and/or UIE using one alternative method (spot (random), timed, and "overnight" (first morning urine), fasting or not fasting) were selected and reviewed. RESULTS: The review included data from 1 434 participants across the six studies that met the inclusion criteria. The main statistical methods for comparing data from the 24-hour urine collections with the values obtained from the alternative method(s) were either regression (ß) or correlation (r) coefficients and concordance analysis through Bland-Altman plots. The urine samples collected using the alternative methods were subject to greater intra-individual and inter-individual variability than the 24-hour urine collections. There was a wide range in coefficient values for the comparisons between 24-hour URE measured in 24-hour urine collection and 24-hour UIE estimated using the alternative sampling methods. No alternative sampling method (spot, timed, or "overnight") was appropriate for estimating 24-hour UIE. CONCLUSIONS: The results of this systematic review suggest current data on UICs as a means of predicting 24-hour UIE for estimating population sodium intake are inadequate and highlight the need for further methodological investigations.

Policy initiatives, culture and the prevention and control of chronic non-communicable diseases (NCDs) in the Caribbean.

OBJECTIVE: To explore interactions between disease burden, culture and the policy response to non-communicable diseases (NCDs) within the Caribbean, a region with some of the highest prevalence rates, morbidity and mortality from NCDs in the Americas. METHODS: We undertook a wide ranging narrative review, drawing on a variety of peer reviewed, government and intergovernmental literature. RESULTS: Although the Caribbean is highly diverse, linguistically and ethnically, it is possible to show how 'culture' at the macro-level has been shaped by shared historic, economic and political experiences and ties. We suggest four broad groupings of countries: the English-speaking Caribbean Community (CARICOM); the small island states that are still colonies or departments of colonial powers; three large-Spanish speaking countries; and Haiti, which although part of CARICOM is culturally distinct. We explore how NCD health policies in the region stem from and are influenced by the broad characteristics of these groupings, albeit played out in varied ways in individual countries. For example, the Port of Spain declaration (2007) on NCDs can be understood as the product of the co-operative and collaborative relationships with CARICOM, which are based on a shared broad culture. We note, however, that studies investigating the relationships between the formation of NCD policy and culture (at any level) are scarce. CONCLUSION: Within the Caribbean region it is possible to discern relationships between culture at the macro-level and the formation of NCD policy. However, there is little work that directly assesses the interactions between culture and NCD policy formation. The Caribbean with its cultural diversity and high burden of NCDs provides an ideal environment within which to undertake further studies to better understand the interactions between culture and health policy formation.

Consumer attitudes, knowledge, and behavior related to salt consumption in sentinel countries of the Americas.

OBJECTIVE: To describe individual attitudes, knowledge, and behavior regarding salt intake, its dietary sources, and current food-labeling practices related to salt and sodium in five sentinel countries of the Americas. METHODS: A convenience sample of 1 992 adults (≥ 18 years old) from Argentina, Canada, Chile, Costa Rica, and Ecuador (approximately 400 from each country) was obtained between September 2010 and February 2011. Data collection was conducted in shopping malls or major commercial areas using a questionnaire containing 33 questions. Descriptive estimates are presented for the total sample and stratified by country and sociodemographic characteristics of the studied population. RESULTS: Almost 90% of participants associated excess intake of salt with the occurrence of adverse health conditions, more than 60% indicated they were trying to reduce their current intake of salt, and more than 30% believed reducing dietary salt to be of high importance. Only 26% of participants claimed to know the existence of a recommended maximum value of salt or sodium intake and 47% of them stated they knew the content of salt in food items. More than 80% of participants said that they would like food labeling to indicate high, medium, and low levels of salt or sodium and would like to see a clear warning label on packages of foods high in salt. CONCLUSIONS: Additional effort is required to increase consumers' knowledge about the existence of a maximum limit for intake and to improve their capacity to accurately monitor and reduce their personal salt consumption.

Systematic review of studies comparing 24-hour and spot urine collections for estimating population salt intake.

OBJECTIVE: To examine the usefulness of urine sodium (Na) excretion in spot or timed urine samples to estimate population dietary Na intake relative to the gold standard of 24-hour (h) urinary Na. METHODS: An electronic literature search was conducted of MEDLINE (from 1950) and EMBASE (from 1980) as well as the Cochrane Library using the terms "sodium," "salt," and "urine." Full publications of studies that examined 30 or more healthy human subjects with both urinary Na excretion in 24-h urine and one alternative method (spot, overnight, timed) were examined. RESULTS: The review included 1 380 130 participants in 20 studies. The main statistical method for comparing 24-h urine collections with alternative methods was the use of a correlation coefficient. Spot, timed, and overnight urine samples were subject to greater intra-individual and interindividual variability than 24-h urine collections. There was a wide range of correlation coefficients between 24-h urine Na and other methods. Some values were high, suggesting usefulness (up to r = 0.94), while some were low (down to r = 0.17), suggesting a lack of usefulness. The best alternative to collecting 24-h urine (overnight, timed, or spot) was not clear, nor was the biological basis for the variability between 24-h and alternative methods. CONCLUSIONS: There is great interest in replacing 24-h urine Na with easier methods to assess dietary Na. However, whether alternative methods are reliable remains uncertain. More research, including the use of an appropriate study design and statistical testing, is required to determine the usefulness of alternative methods.

Reducing salt intake in the Americas: Pan American Health Organization actions.

This article outlines the rationale for reducing dietary salt and some of the Pan American Health Organization actions to facilitate reductions in dietary salt in the Americas. Excessive dietary salt (sodium chloride and other sodium salts) is a major cause of increased blood pressure, which increases risk for stroke, heart disease, and kidney disease. Reduction in salt intake is beneficial for people with hypertension and those with normal blood pressure. The World Health Organization recommends a population salt intake of less than 5 grams/person/day with a Pan American Health Organization expert group recommendation that this be achieved by 2020 in the Americas. In general, the consumption of salt is more than 6 grams/day by age 5 years, with consumption of salt averaging between 9 and 12 grams per day in many countries. Recent salt intake estimates from Brazil (11 grams of salt/day), Argentina (12 grams of salt/day), Chile (9 grams of salt/day) and the United States (8.7 grams of salt/day) confirm that high salt intakes are prevalent in Americas. Sources of dietary salt vary, from 75% of it coming from processed food in developed countries, to 70% coming from discretionary salt added in cooking or at the table in parts of Brazil. The Pan American Health Organization has launched a regionwide initiative called the ?Cardiovascular Disease Prevention Through Dietary Salt Reduction,? led by an expert working group. Working closely with countries, the expert group developed resources to aid policy development through five subgroups: (a) addressing industry engagement and product reformulation; (b) advocacy and communication; (c) surveillance of salt intake, sources of salt in the diet, and knowledge and opinions on salt and health; (d) salt fortification with iodine; and (e) national-level health economic studies on salt reduction.

Sodium Levels in Packaged Foods Sold in 14 Latin American and Caribbean Countries: A Food Label Analysis.

Population-wide sodium reduction is a cost-effective approach to address the adverse health effects associated with excess sodium consumption. Latin American and Caribbean (LAC) countries consume excess dietary sodium. Packaged foods are a major contributor to sodium intake and a target for sodium reduction interventions. This study examined sodium levels in 12 categories of packaged foods sold in 14 LAC (n = 16,357). Mean sodium levels and percentiles were examined. Sodium levels were compared to regional sodium reduction targets. In this baseline analysis, 82% of foods met the regional target and 47% met the lower target. The greatest proportion of products meeting the regional target were uncooked pasta and noodles (98%), flavored cookies/crackers (97%), seasonings for sides/main dishes (96%), mayonnaise (94%), and cured/preserved meats (91%). A large proportion of foods met the lower target among uncooked pasta and noodles (88%), cooked pasta and noodles (88%), and meat/fish seasonings (88%). The highest the highest median sodium levels were among condiments (7778 mg/100 g), processed meats (870 mg/100 g), mayonnaise (755 mg/100 g), bread products (458 mg/100 g), cheese (643 mg/100 g), and snack foods (625 mg/100 g). These baseline data suggest that sodium reduction targets may need to be more stringent to enable effective lowering of sodium intake.

Physical activity interventions in Latin America: a systematic review.

BACKGROUND: Recommendations for physical activity in the Guide to Community Preventive Services (the Community Guide) have not been systematically examined or applied in developing countries such as those in Latin America. The aim of this systematic review was to assess the current evidence base concerning interventions to increase physical activity in Latin America using a modified Community Guide process and to develop evidence-based recommendations for physical activity interventions. METHODS: In 2006, a literature review of both peer-reviewed and non-peer-reviewed literature in Portuguese, Spanish, and English was carried out to identify physical activity interventions conducted in community settings in Latin America. Intervention studies were identified by searching ten databases using 16 search terms related to physical activity, fitness, health promotion, and community interventions. All intervention studies related to physical activity were summarized into tables. Six reviewers independently classified the intervention studies by the categories used in the Community Guide and screened the studies for inclusion in a systematic abstraction process to assess the strength of the evidence. Five trained researchers conducted the abstractions. RESULTS: The literature search identified 903 peer-reviewed articles and 142 Brazilian theses related to physical activity, of which 19 were selected for full abstraction. Only for school-based physical education classes was the strength of the evidence from Latin America sufficient to support a practice recommendation. CONCLUSIONS: This systematic review highlights the need for rigorous evaluation of promising interventions to increase physical activity in Latin America. Implementation and maintenance of school physical education programs and policies should be strongly encouraged to promote the health of Latin American children.

Training practitioners in evidence-based chronic disease prevention for global health.

Too often, public health decisions are based on short-term demands rather than long-term research and objectives. Policies and programmes are sometimes developed around anecdotal evidence. The Evidence-Based Public Health (EBPH) programme trains public health practitioners to use a comprehensive, scientific approach when developing and evaluating chronic disease programmes. Begun in 2002, the EBPH programme is an international collaboration. The course is organized in seven parts to teach skills in: 1) assessing a community's needs; 2) quantifying the issue; 3) developing a concise statement of the issue; 4) determining what is known about the issue by reviewing the scientific literature; 5) developing and prioritizing programme and policy options; 6) developing an action plan and implementing interventions; and 7) evaluating the programme or policy. The course takes an applied approach and emphasizes information that is readily available to busy practitioners, relying on experiential learning and includes lectures, practice exercises, and case studies. It focuses n using evidence-based tools and encourages participants to add to the evidence base in areas where intervention knowledge is sparse. Through this training programme, we educated practitioners from 38 countries in 4 continents. This article describes the evolution of the parent course and describes experiences implementing the course in the Russian Federation, Lithuania, and Chile. Lessons learned from replication of the course include the need to build a "critical mass" of public health officials trained in EBPH within each country and the importance of international, collaborative networks. Scientific and technologic advances provide unprecedented opportunities for public health professionals to enhance the practice of EBPH. To take full advantage of new technology and tools and to combat new health challenges, public health practitioners must continually improve their skills.

Baseline and Estimated Trends of Sodium Availability and Food Sources in the Costa Rican Population during 2004-2005 and 2012-2013.

In 2012, Costa Rica launched a program to reduce salt and sodium consumption to prevent cardiovascular disease and associated risk factors, but little was known about the level of sodium consumption or its sources. Our aim was to estimate the magnitude and time trends of sodium consumption (based on food and beverage acquisitions) in Costa Rica. Data from the National Household Income and Expenditure Surveys carried out in 2004-2005 (n = 4231) and 2012-2013 (n = 5705) were used. Records of food purchases for household consumption were converted into sodium and energy using food composition tables. Mean sodium availability (per person/per day and adjusted for a 2000-kcal energy intake) and the contribution of food groups to this availability were estimated for each year. Sodium availability increased in the period from 3.9 to 4.6 g/person/day (p < 0.001). The income level was inversely related to sodium availability. The main sources of sodium in the diet were domestic salt (60%) in addition to processed foods and condiments (with added sodium) (27.4%). Dietary sources of sodium varied within surveys (p < 0.05). Sodium available for consumption in Costa Rican households largely exceeds the World Health Organization-recommended intake levels (<2 g sodium/person/day). These results are essential for the design and implementation of effective policies and interventions.

Accuracy and Usefulness of Select Methods for Assessing Complete Collection of 24-Hour Urine: A Systematic Review.

Twenty-four-hour urine collection is the recommended method for estimating sodium intake. To investigate the strengths and limitations of methods used to assess completion of 24-hour urine collection, the authors systematically reviewed the literature on the accuracy and usefulness of methods vs para-aminobenzoic acid (PABA) recovery (referent). The percentage of incomplete collections, based on PABA, was 6% to 47% (n=8 studies). The sensitivity and specificity for identifying incomplete collection using creatinine criteria (n=4 studies) was 6% to 63% and 57% to 99.7%, respectively. The most sensitive method for removing incomplete collections was a creatinine index <0.7. In pooled analysis (≥2 studies), mean urine creatinine excretion and volume were higher among participants with complete collection (P<.05); whereas, self-reported collection time did not differ by completion status. Compared with participants with incomplete collection, mean 24-hour sodium excretion was 19.6 mmol higher (n=1781 specimens, 5 studies) in patients with complete collection. Sodium excretion may be underestimated by inclusion of incomplete 24-hour urine collections. None of the current approaches reliably assess completion of 24-hour urine collection.

Inaugural Maximum Values for Sodium in Processed Food Products in the Americas.

Reducing dietary salt/sodium is one of the most cost-effective interventions to improve population health. There are five initiatives in the Americas that independently developed targets for reformulating foods to reduce salt/sodium content. Applying selection criteria, recommended by the Pan American Health Organization (PAHO)/World Health Organization (WHO) Technical Advisory Group on Dietary Salt/Sodium Reduction, a consortium of governments, civil society, and food companies (the Salt Smart Consortium) agreed to an inaugural set of regional maximum targets (upper limits) for salt/sodium levels for 11 food categories, to be achieved by December 2016. Ultimately, to substantively reduce dietary salt across whole populations, targets will be needed for the majority of processed and pre-prepared foods. Cardiovascular and hypertension organizations are encouraged to utilize the regional targets in advocacy and in monitoring and evaluation of progress by the food industry.

Salt Reduction Initiatives around the World - A Systematic Review of Progress towards the Global Target.

OBJECTIVE: To quantify progress with the initiation of salt reduction strategies around the world in the context of the global target to reduce population salt intake by 30% by 2025. METHODS: A systematic review of the published and grey literature was supplemented by questionnaires sent to country program leaders. Core characteristics of strategies were extracted and categorised according to a pre-defined framework. RESULTS: A total of 75 countries now have a national salt reduction strategy, more than double the number reported in a similar review done in 2010. The majority of programs are multifaceted and include industry engagement to reformulate products (n = 61), establishment of sodium content targets for foods (39), consumer education (71), front-of-pack labelling schemes (31), taxation on high-salt foods (3) and interventions in public institutions (54). Legislative action related to salt reduction such as mandatory targets, front of pack labelling, food procurement policies and taxation have been implemented in 33 countries. 12 countries have reported reductions in population salt intake, 19 reduced salt content in foods and 6 improvements in consumer knowledge, attitudes or behaviours relating to salt. CONCLUSION: The large and increasing number of countries with salt reduction strategies in place is encouraging although activity remains limited in low- and middle-income regions. The absence of a consistent approach to implementation highlights uncertainty about the elements most important to success. Rigorous evaluation of ongoing programs and initiation of salt reduction programs, particularly in low- and middle- income countries, will be vital to achieving the targeted 30% reduction in salt intake.

Targets and timelines for reducing salt in processed food in the Americas.

Reducing dietary salt is one of the most effective interventions to lessen the burden of premature death and disability. In high-income countries and those in nutrition transition, processed foods are a significant if not the main source of dietary salt. Reformulating these products to reduce their salt content is recommended as a best buy to prevent chronic diseases across populations. In the Americas, there are targets and timelines for reduced salt content of processed foods in 8 countries--Argentina, Brazil, Canada, Chile, Ecuador, Mexico, and the National Salt Reduction Initiative in the United States and Paraguay. While there are common elements across the countries, there are notable differences in their approaches: 4 countries have exclusively voluntary targets, 2 countries have combined voluntary and regulated components, and 1 country has only regulations. The countries have set different types of targets and in some cases combined them: averages, sales-weighted averages, upper limits, and percentage reductions. The foods to which the targets apply vary from single categories to comprehensive categories accounting for all processed products. The most accessible and transparent targets are upper limits per food category. Most likely to have a substantive and sustained impact on salt intake across whole populations is the combination of sales-weighted averages and upper limits. To assist all countries with policies to improve the overall nutritional value of processed foods, the authors call for food companies to supply food composition data and product sales volume data to transparent and open-access platforms and for global companies to supply the products that meet the strictest targets to all markets. Countries participating in common markets at the subregional level can consider harmonizing targets, nutrition labels, and warning labels.

NCD Prevention and Control in Latin America and the Caribbean: A Regional Approach to Policy and Program Development.

This article describes efforts from the Pan American Health Organization (PAHO) that have supported progress in country-driven planning and implementing of actions to address noncommunicable diseases (NCD), as well as mechanisms that PAHO has supported for countries in the Americas to share and build on each other's experiences. The Regional Strategy and Plan of Action for NCD, approved by all member states in 2006, is the major frame for this work. The strategy has 4 lines of action: policy and advocacy; surveillance; health promotion and disease prevention; and integrated management of NCD and risk factors. Cross-cutting strategies include resource mobilization, communication, training, and networks and partnerships. The strategy is operationalized through biannual work plans for which countries link and commit to achieving specific objectives. PAHO then provides technical support toward achieving these plans, and countries report progress annually. The CARMEN (Collaborative Action for Risk Factor Prevention and Effective Management of NCD [Conjunto de Acciones para la Reducción y el Manejo de las Enfermedades No transmisibles]) Network provides a major platform for sharing, and the multisector Pan American Forum for Action on NCD has been launched to extend the network to include business and civil society. PAHO also supported civil society capacity building. Almost all member states have made substantial progress in implementing their national chronic disease programs, in most instances reporting exceeding the indicators of the strategic plan related to chronic diseases. From the Caribbean countries, leadership has been provided to achieve the historic UN High-Level Meeting on NCD in September 2011. The region is on track to meet the mortality reduction target set for 2013, though much remains to be done to further increase awareness of and resources for scaling up NCD prevention and control programs, given the huge health and economic burden, increasing costs, and worrying increases of some conditions such as obesity. Major challenges include getting NCD into social protection packages, building the human resource capacity, strengthening surveillance, achieving true intersectoral and multipartner action, given that most determinants of the epidemic lie outside the health sector, and increasing investment in prevention.

How three countries in the Americas are fortifying dietary salt reduction: a north and south perspective.

A chronic disease/risk factor prevention framework with three policy environments--communications, physical and economic--was used to organize population level interventions that address the "over consumption of dietary salt", a key risk factor for cardiovascular diseases. The framework was then used to map the population based strategies to reduce dietary salt consumption being applied in three countries in the Americas--Argentina, Canada and Chile--each with a history of multi-sector approaches to deal with the risk factors for chronic disease, offering a north versus south perspective. Results show that in all three countries policy instruments are concentrated in the communications environment, e.g., media and education campaigns and/or regulations for standardized information on the salt or sodium content of packaged food products. Notable gaps are the requirement for nutrient information on meals and food items prepared by food establishments and restrictions on advertising and marketing of foods to children. In the physical environment, referring to the sodium levels in commercially prepared foods and meals available on the market, voluntary reformulation of food products is underway at this time in the three countries. Argentina and Chile began with bread and have gradually added other food categories; Canada at the outset is addressing all food categories where products have added salt. Argentina alone is at this point actively approaching regulations to limit the salt content of food, preferring this over ongoing monitoring of voluntary targets. No government in the three counties has yet considered action in the economic environment, a complex area where the research on and initiatives to limit or disadvantage energy-dense food products to address obesity may also capture foods that are highly salted. In the meantime, with recent research estimating substantially higher gains in population health from government legislation to limit salt in foods compared to voluntary approaches, decision makers in countries, whether in the north or south, committed to reducing dietary salt can take Argentina's example to strengthen their interventions in the physical environment with regulatory instruments. This will sustain reformulations made to date, "level the playing field" industry-wide and broadly and equitably distribute the health benefits of low salt foods.

Establishing national noncommunicable disease surveillance in a developing country: a model for small island nations / Introducción de la vigilancia nacional de las enfermedades no transmisibles en un país en desarrollo: un modelo para las pequeñas naciones insulares

ABSTRACT Objective To describe the surveillance model used to develop the first national, population-based, multiple noncommunicable disease (NCD) registry in the Caribbean (one of the first of its kind worldwide); registry implementation; lessons learned; and incidence and mortality rates from the first years of operation. Methods Driven by limited national resources, this initiative of the Barbados Ministry of Health (MoH), in collaboration with The University of the West Indies, was designed to collect prospective data on incident stroke and acute myocardial infarction (MI) (heart attack) cases from all health care facilities in this small island developing state (SIDS) in the Eastern Caribbean. Emphasis is on tertiary and emergency health care data sources. Incident cancer cases are obtained retrospectively, primarily from laboratories. Deaths are collected from the national death register. Results Phased introduction of the Barbados National Registry for Chronic NCDs (“the BNR”) began with the stroke component (“BNR–Stroke,” 2008), followed by the acute MI component (“BNR–Heart,” 2009) and the cancer component (“BNR–Cancer,” 2010). Expected case numbers projected from prior studies estimated an average of 378 first-ever stroke, 900 stroke, and 372 acute MI patients annually, and registry data showed an annual average of about 238, 593, and 349 patients respectively. There were 1 204 tumors registered in 2008, versus the expected 1 395. Registry data were used to identify public health training themes. Success required building support from local health care professionals and creating island-wide registry awareness. With spending of approximately US$ 148 per event for 2 200 events per year, the program costs the MoH about US$ 1 per capita annually. Conclusions Given the limited absolute health resources available to SIDS, combined surveillance should be considered for building a national NCD evidence base. With prevalence expected to increase further worldwide, Barbados’ experiences are offered as a “road map” for other limited-resource countries considering national NCD surveillance.

RESUMEN Objetivo Describir el modelo de vigilancia que se utilizó para crear el primer registro poblacional nacional de múltiples enfermedades no transmisibles en el Caribe (uno de los primeros registros de esta clase en el mundo), la ejecución del registro, las lecciones aprendidas y las tasas de incidencia y mortalidad desde sus primeros años de funcionamiento. Métodos Esta iniciativa del Ministerio de Salud de Barbados, realizada en colaboración con la Universidad de las Indias Occidentales e impulsada por la limitación de los recursos nacionales, tuvo por finalidad recoger datos prospectivos sobre los casos nuevos de accidente cerebrovascular e infarto agudo de miocardio en todos los establecimientos de atención de salud de este pequeño estado insular en desarrollo del Caribe oriental. El análisis se centró en las fuentes de datos sobre la atención de salud terciaria y de urgencia. La información sobre los casos nuevos de cáncer se obtuvo de manera retrospectiva, principalmente de los laboratorios. Los datos sobre las defunciones se tomaron del registro nacional de mortalidad. Resultados La introducción progresiva del Registro Nacional de Enfermedades Crónicas no Transmisibles de Barbados se inició con el componente de los accidentes cerebrovasculares en 2008, seguido del componente de infarto agudo de miocardio en 2009 y el componente de cáncer en 2010. Las estimaciones previstas con base en los estudios anteriores fueron en promedio de 378 casos de un primer accidente cerebrovascular, 900 casos de accidente cerebrovascular y 372 pacientes con infarto agudo de miocardio cada año; los datos del registro mostraron un promedio anual cercano a 238, 593 y 349 casos respectivamente. En el 2008, se registraron 1204 casos de cáncer, frente a los 1395 previstos. En función de los datos del registro se definieron los temas de capacitación en salud pública. El éxito de la iniciativa exigió fomentar el apoyo de los profesionales de salud a nivel local y dar a conocer la existencia del registro en toda la isla. Con un gasto cercano a 148 dólares por episodio y 2200 episodios por año, el programa cuesta al Ministerio de Salud alrededor de un dólar por habitante cada año. Conclusiones Dada la limitación de los recursos absolutos destinados a la salud en los pequeños estados insulares en desarrollo, es preciso analizar la posibilidad de realizar una vigilancia combinada, con el objeto de crear una base nacional de datos fidedignos sobre las enfermedades no transmisibles. Ante la perspectiva de un aumento continuo de la prevalencia mundial, la experiencia en Barbados se ofrece como una “hoja de ruta” destinada a otros países con recursos limitados que planean introducir la vigilancia nacional de las enfermedades no transmisibles.