Small Island Developing States: addressing the intersecting challenges of non-communicable diseases, food insecurity, and climate change.

Small Island Developing States (SIDS) include 37 UN member countries sharing economic, environmental, and social vulnerabilities and intractable health challenges. In over 80% of SIDS, more than one in six adults die prematurely from a non-communicable disease (NCD), with poor diet being a major factor. Complex upstream food system determinants include marginalised local food production and reliance on low nutritional quality food imports. These drivers need to be seen against colonial and post-colonial political-economic legacies as well as the environmental and climate crises that challenge local production systems. A range of policy commitments (eg, the 2023 Bridgetown Declaration on NCDs and Mental Health) highlight these complex interdependencies and call for cross-sectoral food system policies to improve food security, food sovereignty, and nutrition, including integrating measures for climate change adaptation and mitigation. Although addressing these intersecting challenges will also depend on global efforts, the unique approach of SIDS can inform other settings.

Influence of lipid bilayer on the structure of the muscle-type nicotinic acetylcholine receptor.

The muscle-type nicotinic acetylcholine receptor is a transmitter-gated ion channel residing in the plasma membrane of electrocytes and striated muscle cells. It is present predominantly at synaptic junctions, where it effects rapid depolarization of the postsynaptic membrane in response to acetylcholine released into the synaptic cleft. Previously, cryo-EM of intact membrane from Torpedo revealed that the lipid bilayer surrounding the junctional receptor has a uniquely asymmetric and ordered structure, due to a high concentration of cholesterol. It is now shown that this special lipid environment influences the transmembrane (TM) folding of the protein. All five submembrane MX helices of the membrane-intact junctional receptor align parallel to the surface of the cholesterol-ordered lipids in the inner leaflet of the bilayer; also, the TM helices in the outer leaflet are splayed apart. However in the structure obtained from the same protein after extraction and incorporation in nanodiscs, the MX helices do not align to a planar surface, and the TM helices arrange compactly in the outer leaflet. Realignment of the MX helices of the nanodisc-solved structure to a planar surface converts their adjoining TM helices into an obligatory splayed configuration, characteristic of the junctional receptor. Thus, the form of the receptor sustained by the special lipid environment of the synaptic junction is the one that mediates fast synaptic transmission; whereas, the nanodisc-embedded protein may be like the extrajunctional form, existing in a disordered lipid environment.

Situating commercial determinants of health in their historical context: a qualitative study of sugar-sweetened beverages in Jamaica.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of mortality across the Caribbean and similar regions. Structural determinants include a marked increase in the dependency on food imports, and the proliferation of processed foods, including sugar-sweetened beverages (SSBs). We focused on Jamaica as a case study and the health challenge of SSBs, and situated contemporary actions, experiences and policies within their historical context to investigate underlying drivers of commercial determinants of health and attempts to counter them. We asked: how can a historical perspective of the drivers of high level SSB consumption in Jamaica contribute to an enhanced understanding of the context of public health policies aimed at reducing their intake? METHODS: An ethnographic approach with remote data collection included online semi-structured interviews and workshops with 22 local experts and practitioners of health, agriculture and nutrition in Jamaica and attending relevant regional public webinars on SSBs and NCD action in the Caribbean. Our analysis was situated within a review of historical studies of Caribbean food economies with focus on the twentieth century. Jamaican and UK-based researchers collected and ethnographically analysed the data, and discussed findings with the wider transdisciplinary team. RESULTS: We emphasise three key areas in which historical events have shaped contextual factors of SSB consumption. Trade privileged sugar as a cash crop over food production during Jamaica's long colonial history, and trade deregulation since the 1980s through structural adjustment opened markets to transnational companies. These changes increased Jamaican receptiveness to the mass advertisement and marketing of these companies, whilst long-standing power imbalances hampered taxation and regulation in contemporary public health actions. Civil society efforts were important for promoting structural changes to curb overconsumption of SSBs and decentring such entrenched power relations. CONCLUSION: The contemporary challenge of SSBs in Jamaica is a poignant case study of commercial determinants of health and the important context of global market-driven economies and the involvement of private sector interests in public health policies and governance. Historically contextualising these determinants is paramount to making sense of the sugar ecology in Jamaica today and can help elucidate entrenched power dynamics and their key actors.

Understanding the links between human health, ecosystem health, and food systems in Small Island Developing States using stakeholder-informed causal loop diagrams.

Globalized food systems are a major driver of climate change, biodiversity loss, environmental degradation, and the increasing prevalence of overweight and obesity in society. Small Island Developing States (SIDS) are particularly sensitive to the negative effects of rapid environmental change, with many also exhibiting a heavy reliance on food imports and high burdens of nutrition-related disease, resulting in calls to (re)localize their food systems. Such a transition represents a complex challenge, with adaptation interventions in one part of the food system contingent on the success of interventions in other parts. To help address this challenge, we used group model-building techniques from the science of system dynamics to engage food system stakeholders in Caribbean and Pacific SIDS. Our aim was to understand the drivers of unhealthy and unsustainable food systems in SIDS, and the potential role that increased local food production could play in transformative adaptation. We present two causal loop diagrams (CLDs) considered helpful in designing resilience-enhancing interventions in local food systems. These CLDs represent 'dynamic hypotheses' and provide starting points that can be adapted to local contexts for identifying food system factors, understanding the interactions between them, and co-creating and implementing adaptation interventions, particularly in SIDS. The results can help guide understanding of complexity, assist in the co-creation of interventions, and reduce the risk of maladaptive consequences.

Gestational diabetes mellitus in Cameroon: prevalence, risk factors and screening strategies.

Background: The burden of gestational diabetes (GDM) and the optimal screening strategies in African populations are yet to be determined. We assessed the prevalence of GDM and the performance of various screening tests in a Cameroonian population. Methods: We carried out a cross-sectional study involving the screening of 983 women at 24-28 weeks of pregnancy for GDM using serial tests, including fasting plasma (FPG), random blood glucose (RBG), a 1-hour 50g glucose challenge test (GCT), and standard 2-hour oral glucose tolerance test (OGTT). GDM was defined using the World Health Organization (WHO 1999), International Association of Diabetes and Pregnancy Special Group (IADPSG 2010), and National Institute for Health Care Excellence (NICE 2015) criteria. GDM correlates were assessed using logistic regressions, and c-statistics were used to assess the performance of screening strategies. Findings: GDM prevalence was 5·9%, 17·7%, and 11·0% using WHO, IADPSG, and NICE criteria, respectively. Previous stillbirth [odds ratio: 3·14, 95%CI: 1·27-7·76)] was the main correlate of GDM. The optimal cut-points to diagnose WHO-defined GDM were 5·9 mmol/L for RPG (c-statistic 0·62) and 7·1 mmol/L for 1-hour 50g GCT (c-statistic 0·76). The same cut-off value for RPG was applicable for IADPSG-diagnosed GDM while the threshold was 6·5 mmol/L (c-statistic 0·61) for NICE-diagnosed GDM. The optimal cut-off of 1-hour 50g GCT was similar for IADPSG and NICE-diagnosed GDM. WHO-defined GDM was always confirmed by another diagnosis strategy while IADPSG and GCT independently identified at least 66·9 and 41·0% of the cases. Interpretation: GDM is common among Cameroonian women. Effective detection of GDM in under-resourced settings may require simpler algorithms including the initial use of FPG, which could substantially increase screening yield.

The Impact of Nutrition-Based Interventions on Nutritional Status and Metabolic Health in Small Island Developing States: A Systematic Review and Narrative Synthesis.

Small island developing states (SIDS) have a high burden of nutrition-related disease associated with nutrient-poor, energy-dense diets. In response to these issues, we assessed the effectiveness of nutrition-based interventions on nutritional status (under-nutrition) and metabolic health (over-nutrition) among persons in SIDS. We included SIDS-based nutrition studies with change in nutrition status (e.g., markers of anaemia) or metabolic status (e.g., markers of glycaemia) as outcomes. The PRISMA framework was applied and MEDLINE, Embase, CINAHL, OARE library, Web of Science, Scopus, ASSIA, EconLit, AGORA, AGRICOLA, AGRIS, WHO-EMRO, and LILACS were searched (2000−2020). Cochrane risk of bias (ROB) and Cochrane ROBINS-I tools assessed ROB for randomised and non-randomised studies, respectively. PROSPERO registration (CRD42021236396) was undertaken. We included 50 eligible interventions, involving 37,591 participants: 14 trials reported on nutritional status, 36 on metabolic health. Effective interventions, evaluated at the individual level, took a multifaceted approach for metabolic outcomes; while nutrition outcomes utilised supplements. Most intervention types were suitable for issues related to 'over' nutrition versus 'under' nutrition. Twenty-six studies (nutrition status (six); metabolic health (twenty)) were effective (p < 0.05). With the current rise of nutrition-related public health challenges, there is a need for further development and evaluation of these and related interventions at the population level.

Structure of a cholinergic cell membrane.

Cell membranes are complex assemblies of proteins and lipids making transient or long-term associations that have yet to be characterized at a molecular level. Here, cryo-electron microscopy is applied to determine how phospholipids and cholesterol arrange between neighboring proteins (nicotinic acetylcholine receptors) of Torpedo cholinergic membrane. The lipids exhibit distinct properties in the two leaflets of the bilayer, influenced by the protein surfaces and by differences in cholesterol concentration. In the outer leaflet, the lipids show no consistent motif away from the protein surfaces, in keeping with their assumed fluidity. In the inner leaflet, where the cholesterol concentration is higher, the lipids organize into extensive close-packed linear arrays. These arrays are built from the sterol groups of cholesterol and the initial saturated portions of the phospholipid hydrocarbon chains. Together, they create an ordered ∼7 Å-thick "skin" within the hydrophobic core of the bilayer. The packing of lipids in the arrays appears to bear a close relationship to the linear cholesterol arrays that form crystalline monolayers at the air-water interface.

Dietary Patterns, Food Insecurity, and Their Relationships with Food Sources and Social Determinants in Two Small Island Developing States.

Small Island Developing States (SIDS) have high burdens of nutrition-related chronic diseases. This has been associated with lack of access to adequate and affordable nutritious foods and increasing reliance on imported foods. Our aim in this study was to investigate dietary patterns and food insecurity and assess their associations with socio-demographic characteristics and food sources. We recruited individuals aged 15 years and above from rural and urban areas in Fiji (n = 186) and St. Vincent and the Grenadines (SVG) (n = 147). Data collection included a 24 h diet recall, food source questionnaire and the Food Insecurity Experience Scale. We conducted latent class analysis to identify dietary patterns, and multivariable regression to investigate independent associations with dietary patterns. Three dietary patterns were identified: (1) low pulses, and milk and milk products, (2) intermediate pulses, and milk and milk products and (3) most diverse. In both SIDS, dietary pattern 3 was associated with older age, regularly sourcing food from supermarkets and borrowing, exchanging, bartering or gifting (BEB). Prevalence of food insecurity was not statistically different across dietary patterns. In both SIDS, food insecurity was higher in those regularly sourcing food from small shops, and in SVG, lower in those regularly using BEB. These results complement previous findings and provide a basis for further investigation into the determinants of dietary patterns, dietary diversity and food insecurity in these settings.

Peripheral Arterial Disease Prevalence in a Population-Based Sample of People with Diabetes on the Caribbean Island of Barbados.

Background: Peripheral arterial disease (PAD) is a risk factor for amputation and systemic atherosclerotic disease. Barbados has a high diabetes prevalence, and 89% of diabetes-related hospital admissions are for foot problems. Foot examination is infrequent in Barbados primary care. The prevalence and potential risk factors for PAD in people with diabetes in Barbados were studied. Methods: Multistage probability sampling was used to select a representative population sample of people ≥25 years of age with known diabetes or fasting blood glucose ≥7 mmol/L or HbA1c ≥6.5%. We administered the Edinburgh claudication questionnaire and assessed the ankle brachial pressure index (ABI) and Doppler waveform in both dorsalis pedis and posterior tibial arteries. Participants were classified into categories based on ABI as follows: PAD ≤0.90 in any leg; borderline 0.91 to 0.99 in one leg and the other not ≤0.90 or >0.4; normal 1.00 to 1.40 in both legs; and non-compressible >1.40 in one leg and the other not ≤0.9. Waveforms crossing the zero-flow baseline were categorised as normal. Multivariable logistic regression assessed the associations of potential risk factors with PAD. Results: Of 236 participants (74% response rate, 33% male, median age 58.6 years), 51% had previously diagnosed diabetes. Of nine people with symptoms of definite or atypical claudication, four had PAD and one had non-compressible arteries. ABI prevalence (95% CI) was PAD 18.6% (13.8, 24.6), borderline 21.9% (16.6, 28.4), normal 55.5% (49.4, 61.5) and non-compressible 3.9% (1.6, 9.3). Increasing age and female gender were independently associated with PAD. Over 80% of normal legs (ABI 1.00 to 1.40) had normal posterior tibial and dorsalis pedis waveforms, while only 23% legs with PAD (ABI ≤0.90) had normal waveforms in both arteries (Kappa = 0.43). Conclusion: Asymptomatic PAD is common in people with diabetes and requires ABI screening to detect it. Female gender is associated with PAD.

Perspectives on strengthening local food systems in Small Island Developing States.

Small Island Developing States (SIDS) share high burdens of nutrition-related conditions, including non-communicable diseases, associated with an increasing reliance on imported, processed foods. Improving health through increasing the production and consumption of local, nutritious foods is a policy objective of many SIDS governments. This study aimed to understand contemporary challenges and opportunities to strengthening local food systems in two case study settings, Fiji and St. Vincent and the Grenadines. Fifty-two in-depth, semi-structured interviews were conducted with key stakeholders involved in local food production. Interviews were analysed by both country teams using thematic analysis. Local food production networks in both settings included formal governance bodies as well as more informal connections through civil society and communities. Their main function was the sharing of resources and knowledge, but levels of trust and cooperation between the stakeholders varied in a market open to intense competition from imports. Local food production was hindered by few and slow investments by local governments, dated technology, and lack of knowledge. Stakeholders believed this marginalisation was occurring against a background of rising preferences for imported foods in the population, and increasing disinterest in employment in the sector. Despite the challenges, strong narratives of resilience and opportunity were highlighted such as national pride in local produce for commercialisation and local diets. Efforts to support local food production in SIDS should focus on strengthening governance structures to prioritise local produce over corporate and import markets, assist collaboration and co-learning, and support alternative agro-food practices. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-022-01281-0.

Exploring ways to respond to rising obesity and diabetes in the Caribbean using a system dynamics model.

Diabetes and obesity present a high and increasing burden of disease in the Caribbean that have failed to respond to prevention policies and interventions. These conditions are the result of a complex system of drivers and determinants that can make it difficult to predict the impact of interventions. In partnership with stakeholders, we developed a system dynamics simulation model to map the system driving diabetes and obesity prevalence in the Caribbean using Jamaica as a test case. The study aims to use the model to assess the magnitude changes necessary in physical activity and dietary intake to achieve global targets set by the WHO Global Action plan and to test scenarios for interventions to reduce the burden of diabetes and obesity. Continuing current trends in diet, physical activity, and demographics, the model predicts diabetes in Jamaican adults (20+ years) to rise from 12% in 2018 to 15.4% in 2030 and 20.9% by 2050. For obesity, it predicts prevalence to rise from 28.6% in 2018 to 32.1% by 2030 and 39.2% by 2050. The magnitude change necessary to achieve the global targets set by the World Health Organization is so great as to be unachievable. However, a combination of measures both upstream (including reducing the consumption of sugar sweetened beverages and ultra processed foods, increasing fruit and vegetable intake, and increasing moderate-to-vigorous activity) at the population level, and downstream (targeting people at high risk and with diabetes) can significantly reduce the future burden of diabetes and obesity in the region. No single intervention reduces the prevalence of these conditions as much as a combination of interventions. Thus, the findings of this model strongly support adopting a sustained and coordinated approach across various sectors to synergistically maximise the benefits of interventions.

Interventions in Small Island Developing States to improve diet, with a focus on the consumption of local, nutritious foods: a systematic review.

Introduction: Food security in Small Island Developing States (SIDS) is an international policy priority. SIDS have high rates of nutrition-related non-communicable diseases, including obesity and type 2 diabetes, micronutrient deficiencies and, in many, persistent childhood stunting. This is associated with an increasing reliance on imported processed food of poor nutritional quality. Calls have been made for strengthening local food systems, resilient to climate change, to increase the consumption of nutritious locally produced food. We aimed to systematically review interventions intended to improve diet in SIDS, and specifically explore whether these interventions applied a local food approach. Methods: The search strategy was applied to 11 databases, including in health, social science and agriculture. Screening of titles, abstracts and data extraction was undertaken in duplicate. Risk of bias was assessed using Cochrane tools. Narrative synthesis of the results was undertaken. The study protocol was registered (PROSPERO registration number: 2020CRD42020201274). Results: From 26 062 records, 154 full texts were reviewed and 24 were eligible. Included studies were from the Caribbean, Pacific, Mauritius and Singapore. Five were a randomised study design, one an interrupted time series analysis, eight controlled and ten uncontrolled pre-test and post-test. Nine studies included some aspect of a local food approach. Most interventions (n=15) included nutrition education, with evidence of effectiveness largely limited to those that also included practical skills training, such as vegetable gardening or food preparation. Three studies were considered low risk of bias, with the majority (n=13) of moderate risk. Conclusion: There is a lack of robust evidence on interventions to improve diet in SIDS. The evidence suggests that multifaceted approaches are likely to be the most effective, and local food approaches may promote effectiveness, through mechanisms of cultural and contextual relevance. Further development and evaluation of interventions is urgently required to increase the comparability of these studies, to help guide policy on improving nutrition in SIDS.

Protein-lipid interplay at the neuromuscular junction.

Many new structures of membrane proteins have been determined over the last decade, yet the nature of protein-lipid interplay has received scant attention. The postsynaptic membrane of the neuromuscular junction and Torpedo electrocytes has a regular architecture, opening an opportunity to illuminate how proteins and lipids act together in a native membrane setting. Cryo electron microscopy (Cryo-EM) images show that cholesterol segregates preferentially around the constituent ion channel, the nicotinic acetylcholine receptor, interacting with specific sites in both leaflets of the bilayer. In addition to maintaining the transmembrane α-helical architecture, cholesterol forms microdomains - bridges of rigid sterol groups that link one channel to the next. This article discusses the whole protein-lipid organization of the cholinergic postsynaptic membrane, its physiological implications and how the observed details relate to our current concept of the membrane structure. I suggest that cooperative interactions, facilitated by the regular protein-lipid arrangement, help to spread channel activation into regions distant from the sites of neurotransmitter release, thereby enhancing the postsynaptic response.

Systems science for developing policy to improve physical activity, the Caribbean.

The World Health Organization (WHO) Global Action Plan on Physical Activity recommends adopting a systems approach to implementing and tailoring actions according to local contexts. We held group model-building workshops with key stakeholders in the Caribbean region to develop a causal loop diagram to describe the system driving the increasing physical inactivity in the region and envision the most effective ways of intervening in that system to encourage and promote physical activity. We used the causal loop diagram to inform how the WHO Global Action Plan on Physical Activity might be adapted to a local context. Although the WHO recommendations aligned well with our causal loop diagram, the diagram also illustrates the importance of local context in determining how interventions should be coordinated and implemented. Some interventions included creating safe physical activity spaces for both sexes, tackling negative attitudes to physical activity in certain contexts, including in schools and workplaces, and improving infrastructure for active transport. The causal loop diagram may also help understand how policies may be undermined or supported by key actors or where policies should be coordinated. We demonstrate how, in a region with a high level of physical inactivity and low resources, applying systems thinking with relevant stakeholders can help the targeted adaptation of global recommendations to local contexts.

Le Plan d'action mondial pour l'activité physique élaboré par l'Organisation mondiale de la Santé (OMS) recommande d'adopter une approche systémique pour la création et le déploiement d'actions adaptées aux contextes locaux. Nous avons organisé des ateliers de construction de modèles regroupant divers acteurs clés de la région Caraïbes. Objectif: développer un diagramme de boucles causales afin d'identifier le système à l'origine de la sédentarité croissante dans cette région, mais aussi de concevoir les moyens les plus efficaces pour s'immiscer dans ce système en vue d'encourager et de promouvoir l'exercice physique. Nous avons employé le diagramme de boucles causales pour définir comment le Plan d'action mondial pour l'activité physique de l'OMS peut être adapté au contexte local. Bien que les recommandations de l'OMS se rapprochent considérablement de notre diagramme, ce dernier illustre aussi l'importance du contexte local dans la manière dont les interventions sont censées être coordonnées et mises en œuvre. Certaines de ces interventions prévoyaient d'ouvrir des espaces sécurisés dédiés à la pratique sportive pour les deux sexes, de lutter contre les attitudes négatives vis-à-vis de l'activité physique dans des situations spécifiques, notamment à l'école et au travail, et de rendre les infrastructures compatibles avec les modes de transport actifs. Le diagramme de boucles causales permet en outre de mieux comprendre comment les acteurs clés peuvent soutenir ou au contraire discréditer les politiques en la matière, et de voir où ces politiques ont besoin de coordination. Nous démontrons comment, dans une région marquée par un taux de sédentarité élevé et de faibles ressources, l'adoption d'une approche systémique impliquant les principaux intervenants peut contribuer à ajuster avec précision des recommandations mondiales à des contextes locaux.

El Plan de acción mundial sobre actividad física de la Organización Mundial de la Salud (OMS) recomienda adoptar un enfoque sistémico para implementar y adaptar las acciones según los contextos locales. Celebramos talleres de construcción de modelos de grupo con las principales partes interesadas en la región del Caribe para desarrollar un diagrama de circuito causal para describir el sistema que impulsa la creciente inactividad física en la región y prever las formas más eficaces de intervenir en ese sistema para fomentar y promover la actividad física. Utilizamos el diagrama de circuito causal para informar sobre cómo se podría adaptar el Plan de acción mundial sobre actividad física de la OMS a un contexto local. Aunque las recomendaciones de la OMS se ajustaban bien a nuestro diagrama, este también ilustra la importancia del contexto local a la hora de determinar cómo deben coordinarse y aplicarse las intervenciones. Algunas intervenciones incluyen la creación de espacios seguros para la actividad física para ambos sexos, la lucha contra las actitudes negativas hacia la actividad física en determinados contextos, incluidos los colegios y los lugares de trabajo, y la mejora de las infraestructuras para el transporte activo. El diagrama de circuito causal también puede ayudar a entender cómo las políticas pueden ser socavadas o apoyadas por actores clave o dónde deben coordinarse las políticas. Demostramos cómo, en una región con un alto nivel de inactividad física y pocos recursos, la aplicación del pensamiento sistémico con las partes interesadas pertinentes puede ayudar a la adaptación específica de las recomendaciones globales a los contextos locales.

REPRINT OF: CLASSIFICATION OF DIABETES MELLITUS.

Executive Summary This document updates the 1999 World Health Organization (WHO) classification of diabetes. It prioritizes clinical care and guides health professionals in choosing appropriate treatments at the time of diabetes diagnosis, and provides practical guidance to clinicians in assigning a type of diabetes to individuals at the time of diagnosis. It is a compromise between clinical and aetiological classification because there remain gaps in knowledge of the aetiology and pathophysiology of diabetes. While acknowledging the progress that is being made towards a more precise categorization of diabetes subtypes, the aim of this document is to recommend a classification that is feasible to implement in different settings throughout the world. The revised classification is presented in Table 1. Unlike the previous classification, this classification does not recognize subtypes of type 1 diabetes and type 2 diabetes and includes new types of diabetes ("hybrid types of diabetes" and "unclassified diabetes").

Evidence of a health risk 'signalling effect' following the introduction of a sugar-sweetened beverage tax.

Consuming sugar-sweetened beverages (SSBs) has been associated with increased rates of obesity and type 2 diabetes, making SSBs an increasingly popular target for taxation. In addition to changing prices, the introduction of an SSB tax may convey information about the health risks of SSBs (a signalling effect). If SSB taxation operates in part by producing a health risk signal, there may be important opportunities to amplify this effect. Our aim was to assess whether there is evidence of a risk signalling effect following the introduction of the Barbados SSB tax. We used process tracing to assess the existence of a signalling effect around sodas and sugar-sweetened juices (juice drinks). We used three data sources: 611 archived transcripts of local television news, 30 interviews with members of the public, and electronic point of sales data (46 months) from a major grocery store chain. We used directed content analysis to assess the qualitative data and an interrupted time series analysis to assess the quantitative data. We found evidence consistent with a risk signalling effect following the introduction of the SSB tax for sodas but not for juice drinks. Consistent with risk signalling theory, the findings suggest that consumers were aware of the tax, believed in a health rationale for the tax, understood that sodas were taxed and perceived that sodas and juice drinks were unhealthy. However consumers appear not to have understood that juice drinks were taxed, potentially reducing tax effectiveness from a health perspective. In addition, the tax may have incentivised companies to increase advertising around juice drinks (undermining any signalling effect) and to introduce low-cost SSB product lines. Policymakers can maximize the impact of risk signals by being clear about the definition of taxed SSBs, emphasizing the health rationale for introducing such a policy, and introducing co-interventions (e.g. marketing restrictions) that reduce opportunities for industry countersignals. These actions may amplify the impact of an SSB tax.

Anthropometric cut-offs to identify hyperglycemia in an Afro-Caribbean population: a cross-sectional population-based study from Barbados.

INTRODUCTION: Body mass index (BMI) and waist circumference (WC) cut-offs associated with hyperglycemia may differ by ethnicity. We investigated the optimal BMI and WC cut-offs for identifying hyperglycemia in the predominantly Afro-Caribbean population of Barbados. RESEARCH DESIGN AND METHODS: A cross-sectional study of 865 individuals aged ≥25 years without known diabetes or cardiovascular disease was conducted. Hyperglycemia was defined as fasting plasma glucose ≥5.6 mmol/L or hemoglobin A1c ≥5.7% (39 mmol/mol). The Youden index was used to identify the optimal cut-offs from the receiver operating characteristic (ROC) curves. Further ROC analysis and multivariable log binomial regression were used to compare standard and data-derived cut-offs. RESULTS: The prevalence of hyperglycemia was 58.9% (95% CI 54.7% to 63.0%). In women, optimal BMI and WC cut-offs (27 kg/m2 and 87 cm, respectively) performed similarly to standard cut-offs. In men, sensitivities of the optimal cut-offs of BMI ≥24 kg/m2 (72.0%) and WC ≥86 cm (74.0%) were higher than those for standard BMI and WC obesity cut-offs (30.0% and 25%-46%, respectively), although with lower specificity. Hyperglycemia was 70% higher in men above the data-derived WC cut-off (prevalence ratio 95% CI 1.2 to 2.3). CONCLUSIONS: While BMI and WC cut-offs in Afro-Caribbean women approximate international standards, our findings, consistent with other studies, suggest lowering cut-offs in men may be warranted to improve detection of hyperglycemia. Our findings do, however, require replication in a new data set.

"We used to get food from the garden." Understanding changing practices of local food production and consumption in small island states.

Many Small Island Developing States (SIDS) lead global rates in obesity and non-communicable chronic diseases (NCDs). Drivers for this are complex and include lack of food sovereignty, evidenced by an increasing reliance on cheap nutrient-poor food imports and a focus on export orientated cash crop production for much local agriculture. To better inform SIDS' policy goals of improving nutrition through increased local food production, we explored in two SIDS current practices of food production and consumption. Teams of researchers from the two main regional universities conducted 28 focus groups in Fiji in the Pacific and Saint Vincent and the Grenadines in the Caribbean with rural and urban communities of different socio-economic or land-owning status. In both countries home gardens were still common, valued as providing staple foods to households and contributing to health and livelihoods. Yet social changes had been experienced over the life course and across generations, such as increased purchase of foods, consumption of processed and often imported foods, and fast foods. While participants associated local foods with better nutrition and health outcomes than imported foods, some local foods were also acknowledged as unhealthy (e.g. locally produced tinned products, pesticide contaminated fresh produce). Finally, as food and related health advice moves globally, crossing national boundaries, and through formal and informal channels, local experiences can be confusing and contested. We suggest the need to understand temporal and spatial aspects of social practices, as social practices and their meaning change over time, travel globally and are experienced locally. To enhance and support re-localising food to counteract unhealthy consumption of ultra-processed, shop-bought, often imported foods, it is vital to understand these lived experiences of changes and resulting uncertainties, and to explicitly build on the longstanding positive relationships that people continue to express about home gardens and local food.

Ultra-processed food consumption in Barbados: evidence from a nationally representative, cross-sectional study.

Our objective was to describe, for the first time in an English-speaking Caribbean country, the contribution of ultra-processed foods (UPFs) to nutrients linked to non-communicable disease. Using a cross-sectional study design, dietary data were collected from two non-consecutive 24-h dietary recalls. Recorded food items were then classified according to their degree of processing by the NOVA system. The present study took place in Barbados (2012-13). A representative population-based sample of 364 adult Barbadians (161 males and 203 females) aged 25-64 years participated in the study. UPFs represented 40⋅5 % (838 kcal/d; 95 % CI 791, 885) of mean energy intake. Sugar-sweetened beverages made the largest contribution to energy within the UPF category. Younger persons (25-44 years) consumed a significantly higher proportion of calories from UPF (NOVA group 4) compared with older persons (45-64 years). The mean energy shares of UPF ranged from 22⋅0 to 58⋅9 % for those in the lowest tertile to highest tertile. Within each tertile, the energy contribution was significantly higher in the younger age group (25-44 years) compared with the older (45-64 years). One-quarter of persons consume ≥50 % of their daily calories from UPF, this being significantly higher in younger persons. The ultra-processed diet fraction contained about six times the mean of free sugars and about 0⋅8 times the dietary fibre of the non-ultra-processed fraction (NOVA groups 1-3). Targeted interventions to decrease the consumption of UPF especially in younger persons is thus of high priority to improve the diet quality of Barbadians.