Food for thought - lessons learned about the eating habits of Barbadian from the Adolescent Health and Fitness study (AHFIT)

OBJECTIVE: To study the eating and exercise habits of adolescent school attenders in Barbados. DESIGN AND METHODS: Four hundred and sixty-two students, randomly selected by class, attending four schools at different points of the "academic rank ladder", were invited to complete a knowledge, attitudes and practices questionnaire, to be measured, and to have their blood drawn. RESULTS: Adolescents whose body mass indices (BMIs) were over 5 kgm-2 were more likely to know of a family member who was overweight or obese (p=0.04) and know of a family member who had diabetes (p=0.03) than were those whose BMIs were less than 25 kgm-2. More of these "bigger" adolescents, compared to their smaller schoolmates, were convinced that they ate in a healthy manner (p<0.001), but did not get enough exercise (p=0.01). CONCLUSIONS: Public health strategies should pay particular attention to the promotion of nutrition and physical activity counselling in adolescents.(Au)

Physical activity in Barbadian secondary school attenders - results from the Adolescent Health and Fitness study (AHFIT)

OBJECTIVE: To study the physical activity habits of adolescent school attenders in Barbados. DESIGN AND METHODS: Four hundred and sixty-two students, randomly selected by school class, attending four schools at different points of the "academic rank ladder", were invited to complete a knowledge, attitudes and practices questionnaire, to be measured, and to have blood drawn. RESULTS: Fifteen percent of these 10-18-year-old students, (males 8 percent, females 20 percent, p<0.001) did not participate in any form of physical activity on a regular basis. The males participated in cycling (54 percent), cricket (52 percent), jogging (50 percent) and football (45 percent), while the females participated in dancing (47 percent) and brisk walking (36 percent). Generally the males were more active than the females. Competing with the physical activity as leisure time activities were more sedentary activities like television viewing, computer and video games, while these adolescents had also experimented with alcohol (60 percent) and cigarettes (9.5 percent). CONCLUSIONS: The role for the health promotion team is clear: to promote increased physical activity in adolescents, to discourage other inappropriate behaviour patterns, and to monitor the influence of adolescent physical activity habits on adult physical activity and ultimately adult disease.(Au)

The hypertensive Caribbean

Caribbean populations demonstrate a dramatic epidemiological transition, with cardiovascular disease the most common cause of death and hypertension the leading risk factor. Epidemiological surveys in the 1980s in Barbados and Trinidad found prevalence rates of 42 percent and 25 percent in population over 40 years and 35 years old, respectively, using the WHO criterion of blood pressure (BP) > 160/95. In a strictly standardised seven country survey carried out in 1992 and 1993 (ICSHIB) prevalence rates (BP>160/95) in the over 25 year old population of Barbados, Jamaica and St. Lucia were 21.5 percent, 17.5 percent and 18.3 percent, respectively, but 50 percent higher for BP>140/90. The gradient correlated closely with body mass index and with economic development and gross national product. In this study, rates of awareness, treatment and control were also highest in Barbados (90 percent, 85 percent, and 72 percent) and lowest in St. Lucia (74 percent, 59 percent and 35 percent). At the 140/90 level these figures were much lower, e.g. 75 percent, 66 percent and 38 percent in Barbados control was lower still, with only 18 percent having a most recent recorded blood pressure of <140/90. Part of the discrepancy may reflect the recognised higher value of "office" versus "home" BP recordings, and a "white coat effect". Nevertheless all studies indicate that the great majority of hypertensives in the Caribbean are not having their blood pressure controlled, with ominous implications for morbidity and mortality in the coming decades. Drugs used in primary care in Barbados conform to current (JNC VI, 1997) recommendations, i.e., frequency of use: thiazide, beta blocker, angiotensin converting enzyme inhibitor and calcium channel blocker, but dietary approaches were documented in only one-third of patients. Greater effort needs to be placed on non-drug therapeutic approaches, and innovative mechanisms need to be developed urgently to achieve this, along with appropriate Caribbean strategies for low cost drug regimens. The Commonwealth Caribbean Medical Research Council has prepared, with wide consultation, regional guidelines for hypertension management.(AU)

Obesity in food handlers

The objective of this study was to determine whether obesity is an occupational hazard in food handlers. 309 persons who presented to two Barbadian group General Practices for food handling certification were studied. The results demonstrate that a majority (55.3 percent) of food handlers had grade 1 obesity or overweight (BMI > 25 kg/sq m). The prevalence in men 67/104 (64.4 percent) was as great as in women 104/175 (59.4 percent). Overweight was high in the relatively young age groups, 30-39 (60.9 percent), 40-49 (75 percent) and 50-59 (69.7 percent). Among the food handlers it was seen more frequently in those with sedentary lifestyles (76/116; 65.5 percent) and in those who had worked more than 10 years in the food handling industry (91/140; 65 percent). No association was found between overweight and use of alcohol or tobacco, but among the food handlers studied were many who demonstrated inaccurate perception of their body image, with 74 of the 190 (39 percent) who thought their weight to be normal, actually classified as overweight. Obesity or overweight is most likely and occupational hazard in food handlers. They work in an industry that is growing rapidly in Barbados as tourism services expand and as the local population adopts the lifestyle of eating out more often. Food handlers are required by law to be certified annually as fit to work. It is important that doctors recognize the threat of obesity and use the opportunity of this annual examination to screen and intervene for this hazard.(AU)

A multifaceted lifestyle intervention in relatives of diabetics; preliminary results from the Barbados Diabetes Intervention Study (BDIS)

This study was designed to determine whether a twelve-week lifestyle intervention programme could improve the risk factor profile, in high risk subjects for the development of non-insulin-dependent diabetes mellitus. A group of volunteer relatives of diabetics were screened for body mass index (BMI), glucose tolerance and other risk factors, as well as for fitness to participate in an exercise programme. Subjects were randomized to a multifaceted lifestyle intervention programme, comprising aerobic exercise sessions, dietary instruction, diabetes-related medical education, motivation and life management skills, or to non-intervention. Results after twelve weeks confirm that impaired glucose tolerance is more likely to be reversed by a lifestyle intervention programme than by non-intervention, and that statistically and clinically significant improvements in BMI could be obtained in over weight and obese relatives of diabetic subjects.(AU)

Exercise - the West Indian experience: Position statement

The lifestyles of Caribbean population have changed dramatically over the last 40 years from predominantly plantation economies with heavy manual labour to predominantly tourism and services industries with a marked reduction of physical activity. Knowledge, attitude and practice surveys indicated that the majority of adults interviewed do not undertake significant physical activity outside of their work. In Barbados 47 percent claimed to do so, but the key activity, brisk walking, was undertaken only by 28 percent: 60 percent of men and 43 percent of women said they never walked. In Trinidad only 17 percent of men and 6 percent of women reported taking regular exercise. In both countries secondary education was associated with a two-to-three fold higher frequency of exercising. In Barbados, with the highest education and literacy rates, a minority of people over 60 have secondary education, and these figures was much lower in other Caribbean countries. The over 60 population, with a 50 percent prevalence of diabetes are at greatest risk of exercise deficiency and constitute a major challenge for lifestyle change which would improve both diabetes control and cardiovascular fitness. The entire population, however, has undergone a socioeconomic and sociocultural transition which has had a dramatic detrimental effect on health. The major thrust for prevention and management of diabetes and related diseases (obesity, hypertension, hyperlipidaemia and cardiac disease), must therefore be the promotion of healthty lifestyles.(AU)

Antihypertensive drugs in primary care in Barbados: used or abused?

An audit of clinic records of 1016 adult Barbadians who attended their public or private primary care practitioners during July 1994 was performed. Non-drug therapy for hypertension was rarely recorded; single drug therapy was the most common regimen employed for 'treating' hypertension. There was fairly liberal use of the most expensive drugs, such as the ACE inhibitors and calcium channel blockers, which may cost up to 200 times more than thiazide diuretics. The clinic records did not indicate why certain regimens were preferred. There was minimal screening for metabolic complications. Only 18 percent of hypertensive patients had blood pressures controlled at the < 140/90 mm Hg level, even though they were all prescribed antihypertensive medication. AU.

Diabetes mellitus in Barbados: an assessment of the CCMRC/Ministry of Health's effort to improve management in the public sector - abstract

The clinic notes of 172 diabetic patients who attended public clinics during a two week period in 1993 were analyzed. Just over one third of the patients had acceptable blood sugars and blood pressures. As a result of this audit, three half-day workshops were held with all the primary health care staff invited. The consultations, along with similar Caribbean-wide workshops eventually lead to the development of new guidelines, 'Managing Diabetes in primary Care' (CCMRC, 1995). A new audit in 1995, targeting the same public clinics as in 1993, found that in the 183 patients who visited these clinics over a comparable period four months after the guidelines were distributed, the diabetic care was only marginally better than in 1993, with still more than half of the patients having uncontrolled disease. (AU).

Healthy male workers? a look at male workers in two occupational settings in Barbados - abstract

Company-sponsored annual examination of 150 workers, from two separate industries, revealed that unhealthy life-styles, in terms of drinking and smoking behaviours, were fairly common. Sixty percent drank alcohol at least every weekend, and 19 smoked at least ten cigarettes daily. Ten percent were obese. Previously undiagnosed diabetes and hypertension were present in 10 and 12 percent of subjects respectively. The workers had very limited contact with health care physicians, for reasons believed in part to be financial. In the circumstances, the physicians had to modify textbook approaches and utilize new approaches to 'opportunistic screening' for chronic disease. None of the problems encountered could be adequately managed on a single annual visit. Family physicians, employers and employees are encouraged to negotiate additional strategies for monitoring and maintaining the health of male workers. (AU)

Diabetes care in middle-income countries: a Caribbean case study

Many middle-income countries now have a high prevalence of diabetes and need to address the problem of providing care for people with diabetes within limited resources. This study evaluated standards of preventive care in primary settings in three Caribbean countries. We studied case records at 17 clinics in 15 government health centres and 17 private general practitioners' offices in Barbados Trinidad and Tobago and Tortola (British Virgin Islands). A census of all attenders over 4 to 7 week period identified 1661 attenders with diabetes mellitus, approximately two-thirds were women with a median age of over 60 years. Overall 676/1342 (50 percent) had 'poor' blood glucose control (> or + 8 mmol 1-1 fasting or > or = 10 mmol 1-1 random). The proportion with BP > or = 160/95 mmHg or receiving treatment for hypertension was 943/1661 (57 percent), of whom 781/943 (83 percent) were prescribed drug treatment. Among those treated for hypertension only 181/781 (23 percent) had blood pressures , 140/90 mmHg. Surveillance for complications affecting the feet (11 percent) or eyes (2 percent) was not performed systematically in any setting. Only 533 (32 percent) had recorded dietary advice and 79 95 percent) had recorded exercise advice in the last 12 months. To begin to address some of these problems at the regional level, we incorporated results from this survey into a series of workshops held in collaboration with health ministries in 10 Caribbean countries, with participants from 13 countries. At these workshops health care workers participated in the process of developing guidelines for diabetes management in primary care. The guidelines have subsequently been widely disseminated through health ministries and non-governmental organizations in the region. Further research is needed to evaluate the effectiveness of this approach, the constraints of diabetes care, and the most cost-effective means of addressing them (Au).

Quality of bloodpressure monitoring and control in primary care in Barbados

This study evaluated the quality of bloodpressure (BP) monitoring and control among primary care attenders 30 years old and over, in Barbados. Data were collected from 1,016 clinic records, 623 (61 percent) from three government polyclinics and 393 (39 percent) from five private general practitioners' (GP) offices. Nine hundred and sixteen (90.2 percent) had BPs recorded at some time, and 89.5 percent within the preceding 18 months. The proportion with no BP measurements was higher for GP patients (16.3 percent) than for polyclinic patients (5.6 percent). GP patients were less likely (OR 0.31, 95 percent CI0.19-0.48) to have their BP measured during a clinic visit. There was a marked digit preference, with BP recordings ending in "0" or "5" in 92 percent of readings. Of 345 patients treated for hypertension, 278 (82.2 percent) had a most recent BP of o 140/90mm Hg, 168 (49.7 percent) of o 160/95mm Hg and seven patients on antihypertensive medication had no BP recordings during the period under review. Hypertensive patients attending GPs were 2.65 times (95 percent CI 1.34-5.31) more likely to have poorly controlled bloodpressures than patients attending polyclinics. Diet therapy and exercise prescriptions were not recorded in the majority of patient notes. Polyclinic and GP patients were in general prescribing the same classes of drugs although more drugs were used in an attempt to control BPs in the polyclinics. In general GPs were less rigorous than health centres in monitoring and treating hypertension, although a couple of individual GPs showed that hypertension could be well managed by them. Even without considering the significant impact of hypertension on national morbidity and mortality, the results of this audit suggest that the standards of monitoring and control of bloodpressure in primary care in Barbados are unsatisfactory for realizing the goal of reducing complications (AU)

Diabetic admissions at the Queen Elizabeth Hospital, Barbados - does the timing of primary care contact make a difference? - abstract

The Queen Elizabeth Hospital (QEH) is the major secondary and tertiary health care facility in Barbados, and patients who reach this hospital either present directly to the Accident and Emergency Department (A+E), or are referred by physicians. Over a six-month period all diabetic admissions to the hospital were identified, each patient was interviewed and examined, and hospital progress and outcome recorded. Of the 539 patients identified, 201 (37 percent) came directly to the A+E, while 338 (63 percent) had been referred to hospital. Three hundred and sixty-two (69 percent) had seen a physician within three months of admission. The main reasons for admission were the diabetic septic foot (33 percent), followed by heart failure (13 percent) and acute myocardial infarct 12.5 percent. Because the diabetic septic foot is considered a largely preventable problem, the high admission rate suggests that preventive care, assessment and management at the primary care level are inadequate. Patients who visited their primary care physicians within three months of admission, but nevertheless ended up in hospital, had lower mortality rates but prolonged hospital stays (AU)

Is preventive medicine a component of the primary care service for diabetes in Barbados? - abstract

Diabetes mellitus is a chronic illness that requires continued medical care and education to prevent acute complications and to reduce the risk of long-term complications. Diabetics should receive care and treatment from a health team with interest and expertise in the management of diabetes. This study aimed to evaluate the quality of care offered to diabetics in three different clinic settings in Barbados. The case notes of 690 diabetic patients attending private practitioner offices, polyclinic general clinics and polyclinic diabetic clinics, were identified during a six-week index period, and a questionnaire was completed for each patient. Although the average number of visits annually was similar in each of the three settings (5-6 visits/year), private practitioners had the lowest percentage of patients (30.7 percent) with poor glycaemic control (defined here as a fasting blood sugar >/=8 mmol/l, or any other blood sugar >/=10 mmol/l. Overall, the glycaemic control was poor in 44.9 percent of patients. Screening for potential long-term complications such as cardiovascular complications, foot problems, eye problems and kidney problems was recorded as being done in a minority of patients, while the concomitant menace of poorly controlled hypertension, which is known to accelerate the progression of diabetic complications, was present in a significant number of patients. While recognising the limitations of the technique of case note review, these results indicate a need for clear concise guidelines for diabetic primary care, with emphasis on prevention and early detection (AU)

Drug prescribing for diabetes mellitus in primary care: a comparison of public and private practice in three Caribbean countries - abstract

Examining the appropriateness of drug prescribing for people with diabetes mellitus in Caribbean countries is important because of the high cost of drug treatment, the potential for improved control of the disease and the possibility of reducing adverse side effects of treatment. This study examined patterns of drug prescribing for diabetes mellitus in public and private sector primary care settings in three Caribbean countries. The sample included 690 patients in Barbados (BDS, 24 percent private), 791 in Trinidad and Tobago (TT, 13 percent private) and 180 in Tortola (BVI, 31 percent private). Patients treated in public health care facilities were prescribed significantly more drugs than those treated in private practice. Few patients had diabetes mellitus managed by diet alone (8 percent public, 15 percent private). Metformin was rarely used as single agent therapy (3 percent public, 6 percent private). Most patients were treated with sulfonylurea drugs alone or in combination with metformin (75 percent public, 67 percent). The proportion of sulfonylurea prescriptions for chlorpropamide varied (Public: BVI 80 percent, TT 60 percent, BDS 10 percent; Private: BVI 41 percent, TT 28 percent, BDS 7 percent) as did prescriptions for gliclazide and glipizide (Public: BDS 41 percent, BVI 3 percent, TT 1 percent; Private: BVI 51 percent, BDS 46 percent, TT 19 percent). A high proportion of patients were treated for hypertension (public 49 percent, private 40 percent). In private practice, ACE inhibitors and diuretics were the most frequently prescribed drugs. In the public sector, Brinderin accounted for 53 percent of prescriptions in TT while thiazides, methyldopa, betablockers and ACE inhibitors were the most frequently prescribed drugs in BDS and BVI. These variations in prescribing practice among countries of the region suggest that factors other than patients' needs or the cost effectiveness of treatment are important in determining prescribing practices. Individual countries should examine how efficiency and effectiveness of drug use could be improved (AU)