Revising primary and secondary school curricula in the Caribbean to enhance education on the risks for noncommunicable diseases.

In the English-speaking Caribbean, an estimated 46% of men and 61% of women are currently overweight or obese, and 8% of children younger than 5 years are also overweight. To combat this worsening epidemic, driven by unhealthy dietary patterns, the Heads of Government of the Caribbean Community (CARICOM) issued the 2007 Port-of-Spain Declaration, which included mandates on the provision of healthy school meals, promotion of healthy dietary patterns, and reintroduction of physical education in schools. These mandates are aligned with evidence-based approaches used in childhood obesity prevention programs. School-based interventions, including curriculum revisions, are part of a multipronged approach to improve nutrition in children and are designed to complement and reinforce other interventions in schools. However, formal evaluation of the Port-of-Spain Declaration showed that most CARICOM member countries had difficulty implementing the mandates related to schools and diet. The Improving Household Nutrition Security and Public Health in the CARICOM project, in collaboration with regional institutions, the CARICOM Secretariat, and the Caribbean Examinations Council, sought to enhance nutrition education through revision of region-wide primary and secondary school curricula to increase the focus on prevention of noncommunicable diseases. This paper describes the process of revising the Caribbean Examinations Council's Human and Social Biology syllabus for secondary schools and the CARICOM Health and Family Life Education Regional Curriculum Framework for primary schools, which was achieved through multisectoral collaboration. We used the Framework for Reporting Adaptations and Modifications-Enhanced model to describe the process through which the modifications were made.

Se calcula que, en el Caribe de habla inglesa, el 46% de los hombres y el 61% de las mujeres tienen sobrepeso o son obesos, así como el 8% de los menores de 5 años. Para combatir esta epidemia creciente, debida a los hábitos de alimentación poco saludables, los Jefes de Gobierno de la Comunidad del Caribe (CARICOM) emitieron en el 2007 la Declaración de Puerto España, que incluía mandatos relativos al suministro de comidas escolares saludables, la promoción de hábitos de alimentación saludables y la reintroducción de la educación física en las escuelas. Estos mandatos están en consonancia con los enfoques basados en la evidencia que se aplican en los programas de prevención de la obesidad infantil. Las intervenciones en los centros escolares, entre ellas la revisión de los planes de estudios, forman parte de una estrategia multidimensional dirigida a mejorar la nutrición infantil, y tienen la finalidad de complementar y reforzar otras intervenciones en las escuelas. Sin embargo, los resultados de la evaluación formal de la Declaración de Puerto España mostraron que la mayoría de los países miembros de la CARICOM tuvieron dificultades para poner en práctica los mandatos relativos a las escuelas y la alimentación. El proyecto "Mejorar la seguridad nutricional de los hogares y la salud pública en la Comunidad del Caribe", en colaboración con instituciones regionales, la Secretaría de la CARICOM y el Caribbean Examinations Council, se propuso mejorar la educación nutricional por medio de la revisión de los planes de estudio de las escuelas primarias y secundarias de toda la región, para prestar mayor atención a la prevención de las enfermedades no transmisibles. En este artículo se describe el proceso de revisión del temario del Caribbean Examinations Council en materia de Biología Humana y Social para las escuelas secundarias, así como del marco curricular regional de educación para la salud y la vida familiar de la CARICOM para las escuelas primarias, que se llevó a cabo mediante una colaboración multisectorial. Para describir el proceso por el cual se realizaron las modificaciones, los autores usaron el modelo ampliado del marco para informar las adaptaciones y modificaciones (FRAME, por su sigla en inglés).

No Caribe anglófono, estima-se que atualmente 46% dos homens e 61% das mulheres estejam com sobrepeso ou obesidade e que 8% das crianças menores de 5 anos também estejam com sobrepeso. Para combater essa epidemia que se agrava, impulsionada por padrões alimentares pouco saudáveis, os chefes de governo da Comunidade do Caribe (CARICOM) emitiram a Declaração de Port-of-Spain de 2007, que incluía mandatos sobre o fornecimento de refeições saudáveis nas escolas, a promoção de padrões alimentares saudáveis e a reintrodução da educação física nas escolas. Esses mandatos são consistentes com abordagens baseadas em evidências usadas em programas de prevenção da obesidade infantil. Intervenções realizadas nas escolas, incluindo revisões curriculares, fazem parte de uma abordagem multifacetada para melhorar a nutrição das crianças, com o objetivo de complementar e reforçar outras intervenções nas escolas. Entretanto, a avaliação formal da Declaração de Port-of-Spain mostrou que a maioria dos países membros da CARICOM teve dificuldade em implementar os mandatos relacionados às escolas e à dieta. O projeto Melhorando a Segurança Nutricional das Famílias e a Saúde Pública na CARICOM, em colaboração com instituições regionais, a Secretaria da CARICOM e o Conselho de Exames do Caribe, buscou aprimorar a educação nutricional por meio da revisão dos currículos do ensino fundamental e médio em toda a região para aumentar o foco na prevenção de doenças não transmissíveis. Este artigo descreve o processo de revisão do programa de Biologia Humana e Social do Conselho de Exames do Caribe (para escolas do ensino médio) e da Estrutura Curricular Regional de Educação em Saúde e Vida Familiar da CARICOM (para escolas do ensino fundamental), que foi alcançado por meio de colaboração multissetorial. Usamos o modelo avançado da Estrutura para Informar Adaptações e Modificações (FRAME) para descrever o processo utilizado para fazer as modificações.

Improving household nutrition security and public health in the CARICOM, 2018-2022.

The Caribbean is experiencing a worsening epidemic of obesity and noncommunicable diseases (NCDs) and it has the worst rates of premature mortality from cardiovascular diseases in the region of the Americas. Creating enabling environments to improve dietary diversity would help reduce obesity and diet-related NCDs. The Improving Household Nutrition Security and Public Health in the CARICOM project aimed to increase dietary diversity in the Caribbean, and to determine and implement effective, gender-sensitive interventions to improve food sovereignty, household food security, and nutrition in CARICOM states. Primary quantitative and qualitative research, scoping reviews, stakeholder engagement, implementation of interventions and dissemination activities were undertaken. This paper describes the overall project design and implementation, discusses challenges and limitations, and presents core achievements to inform further work in Small Island Developing States throughout CARICOM to advance the nutrition agenda in the Caribbean. The results of the project's research activities are presented in other papers published in this special issue on nutrition security in CARICOM states.

El Caribe está registrando un empeoramiento de la epidemia de obesidad y enfermedades no transmisibles (ENT) y presenta las peores tasas de mortalidad prematura por enfermedades cardiovasculares de la Región de las Américas. La creación de entornos propicios para mejorar la diversidad alimentaria contribuiría a reducir la obesidad y las ENT relacionadas con la alimentación. El proyecto "Mejorar la seguridad nutricional de los hogares y la salud pública en CARICOM" tiene por objetivo ampliar la diversidad alimentaria en el Caribe y acordar y ejecutar intervenciones efectivas con perspectiva de género para mejorar la soberanía alimentaria, la seguridad alimentaria de los hogares y la nutrición en los Estados de CARICOM. Se llevaron a cabo investigaciones primarias cuantitativas y cualitativas, revisiones exploratorias, ejecución de intervenciones y actividades de difusión, y se impulsó la participación de las partes interesadas. En este artículo se describen el diseño y la ejecución del proyecto en general, se analizan sus desafíos y limitaciones, y se presentan sus logros básicos para que se tengan en cuenta en la labor adicional que realizan los pequeños Estados insulares en desarrollo de CARICOM con el fin de impulsar la agenda de nutrición en el Caribe. Los resultados de las actividades de investigación del proyecto se presentan en otros documentos publicados en este número especial sobre seguridad nutricional en los Estados de CARICOM.

O Caribe está passando por um agravamento da epidemia de obesidade e doenças não transmissíveis (DNTs) e tem as piores taxas de mortalidade prematura por doenças cardiovasculares na Região das Américas. A criação de ambientes favoráveis para melhorar a diversidade alimentar ajudaria a reduzir a obesidade e as DNTs relacionadas à alimentação. O projeto Improving Household Nutrition Security and Public Health in the CARICOM [Melhoria da segurança nutricional doméstica e da saúde pública na CARICOM] teve como objetivo aumentar a diversidade alimentar no Caribe e determinar e implementar intervenções eficazes e sensíveis ao gênero para melhorar a soberania alimentar, a segurança alimentar doméstica e a nutrição nos estados da CARICOM. Foram realizadas pesquisas quantitativas e qualitativas primárias, revisões de escopo, ações de envolvimento das partes interessadas, implementação de intervenções e atividades de divulgação. Este documento descreve a elaboração e a implementação geral do projeto, analisa seus desafios e limitações e apresenta as principais realizações para informar o trabalho futuro nos pequenos Estados insulares em desenvolvimento em toda a CARICOM, visando a avançar a agenda nutricional no Caribe. Os resultados das atividades de pesquisa do projeto são apresentados em outros artigos publicados neste número especial sobre segurança nutricional nos Estados da CARICOM.

COVID-19 and the social distribution of hunger in three Caribbean Small Island Developing States.

Objectives: To determine changes to income and livelihood, food consumption, and hunger due to coronavirus disease 2019 (COVID-19) in three Small Island Developing States (SIDS) in the Caribbean: Jamaica, St Kitts and Nevis, and St Vincent and the Grenadines. Methods: This was a cross-sectional study conducted in July 2020. Participants were selected using telephone directories and lists of mobile numbers. Data were collected through face-to-face and telephone interviews. Participants rated the impact of COVID-19 on their livelihoods and the Adult Food Security Module was used to assess hunger. To examine how these outcomes varied by sociodemographic group, multivariable logistic regression analysis was used, with odds ratios (OR) and 95% confidence intervals (CI) reported. Results: The analysis included 880 participants. Of these, 40% (344/871) reported some form of hunger, with 18% (153/871) classed as moderate-to-severe hunger. Almost three quarters of households reported some impact on their livelihood (640/880), with 28% (243/880) classifying this impact as moderate to severe. Women were 60% more likely to report that their livelihoods were moderately to severely affected by COVID-19 (OR 1.59; 95% CI 1.09, 2.31) and 70% more likely to experience moderate-to-severe hunger (OR 1.70; 95% CI 1.37, 2.09). The effects of COVID-19 on livelihood and hunger were greater in those with secondary-school and primary-school education compared with tertiary education. Conclusion: The COVID-19 pandemic is disproportionately affecting the most vulnerable segments of the population. Social protection programmes are a key component of efforts to alleviate the pandemic's consequences; however, equitable access must be ensured.

Assessing the determinants of unhealthy dietary habits among a sample of survey participants in Jamaica.

Objective: To identify and assess the determinants of unhealthy dietary habits among a sample of survey participants in Jamaica. Methods: Because of resource constraints, this cross-sectional assessment is based on a three-stage non-probability sample of 374 survey respondents in Jamaica aged ≥18 years. Firstly, three administrative areas (parishes) were randomly selected. Secondly, the main commercial areas within the selected parishes were identified, from which a non-probability sample of establishments was drawn. A broad selection of establishments covering public, private, and nongovernmental organizations was chosen. This array of establishments was selected to capture a sample of respondents that was as representative as possible. Patrons and employees in the selected establishments were asked to complete a questionnaire. Results: Respondents' self-assessment of their general consumption revealed that 48.4% were unhealthy eaters. Among these, the top reasons for generally unhealthy dietary choices were greater accessibility of unhealthy foods (63.5%) and limited time to prepare healthy meals (61.3%). Additionally, 52.5% indicated "unhealthy foods cost less," and 47.0% identified affordability as the main factor in the food choice equation. Findings revealed that the determinants of eating unhealthily tended to vary across income, age, and gender. Female, younger, and lower-income respondents have a higher likelihood of being impacted by the factors. Conclusions: The largest proportions of the sample identified limited time to prepare healthy meals and the ease of access to unhealthy foods as the foremost determinants of unhealthy eating habits. These barriers to healthy eating are more likely to impact survey participants in the 18-34 age group.

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.

Assessing the impact of the Barbados sugar-sweetened beverage tax on beverage sales: an observational study.

BACKGROUND: The World Health Organization has advocated for sugar-sweetened beverage (SSB) taxes as part of a broader non-communicable disease prevention strategy, and these taxes have been recently introduced in a wide range of settings. However, much is still unknown about how SSB taxes operate in various contexts and as a result of different tax designs. In 2015, the Government of Barbados implemented a 10% ad valorem (value-based) tax on SSBs. It has been hypothesized that this tax structure may inadvertently encourage consumers to switch to cheaper sugary drinks. We aimed to assess whether and to what extent there has been a change in sales of SSBs following implementation of the SSB tax. METHODS: We used electronic point of sale data from a major grocery store chain and applied an interrupted time series (ITS) design to assess grocery store SSB and non-SSB sales from January 2013 to October 2016. We controlled for the underlying time trend, seasonality, inflation, tourism and holidays. We conducted sensitivity analyses using a cross-country control (Trinidad and Tobago) and a within-country control (vinegar). We included a post-hoc stratification by price tertile to assess the extent to which consumers may switch to cheaper sugary drinks. RESULTS: We found that average weekly sales of SSBs decreased by 4.3% (95%CI 3.6 to 4.9%) compared to expected sales without a tax, primarily driven by a decrease in carbonated SSBs sales of 3.6% (95%CI 2.9 to 4.4%). Sales of non-SSBs increased by 5.2% (95%CI 4.5 to 5.9%), with bottled water sales increasing by an average of 7.5% (95%CI 6.5 to 8.3%). The sensitivity analyses were consistent with the uncontrolled results. After stratifying by price, we found evidence of substitution to cheaper SSBs. CONCLUSIONS: This study suggests that the Barbados SSB tax was associated with decreased sales of SSBs in a major grocery store chain after controlling for underlying trends. This finding was robust to sensitivity analyses. We found evidence to suggest that consumers may have changed their behaviour in response to the tax by purchasing cheaper sugary drinks, in addition to substituting to untaxed products. This has important implications for the design of future SSB taxes.

Sodium and potassium excretion in an adult Caribbean population of African descent with a high burden of cardiovascular disease.

BACKGROUND: High sodium diets with inadequate potassium and high sodium-to-potassium ratios are a known determinant of hypertension and cardiovascular disease (CVD). The Caribbean island of Barbados has a high prevalence of hypertension and mortality from CVD. Our objectives were to estimate sodium and potassium excretion, to compare estimated levels with recommended intakes and to identify the main food sources of sodium in Barbadian adults. METHODS: A sub-sample (n = 364; 25-64 years) was randomly selected from the representative population-based Health of the Nation cross-sectional study (n = 1234), in 2012-13. A single 24-h urine sample was collected from each participant, following a strictly applied protocol designed to reject incomplete samples, for the measurement of sodium and potassium excretion (in mg), which were used as proxy estimates of dietary intake. In addition, sensitivity analyses based on estimated completeness of urine collection from urine creatinine values were undertaken. Multiple linear regression was used to examine differences in sodium and potassium excretion, and the sodium-to-potassium ratio, by age, sex and educational level. Two 24-h recalls were used to identify the main dietary sources of sodium. All analyses were weighted for the survey design. RESULTS: Mean sodium excretion was 2656 (2488-2824) mg/day, with 67% (62-73%) exceeding the World Health Organization (WHO) recommended limit of 2000 mg/d. Mean potassium excretion was 1469 (1395-1542) mg/d; < 0.5% met recommended minimum intake levels. Mean sodium-to-potassium ratio was 2.0 (1.9-2.1); not one participant had a ratio that met WHO recommendations. Higher potassium intake and lower sodium-to-potassium ratio were independently associated with age and tertiary education. Sensitivity analyses based on urine creatinine values did not notably alter these findings. CONCLUSIONS: In this first nationally representative study with objective assessment of sodium and potassium excretion in a Caribbean population in over 20 years, levels of sodium intake were high, and potassium intake was low. Younger age and lower educational level were associated with the highest sodium-to-potassium ratios. These findings provide baseline values for planning future policy interventions for non-communicable disease prevention.

The 2007 Caribbean Community Port-of-Spain Declaration on noncommunicable diseases: an overview of a multidisciplinary evaluation.

OBJECTIVES: Noncommunicable diseases (NCDs) are a threat to social and economic development, including in the Caribbean. In 2007 the Caribbean Community (CARICOM) held the world's first-ever summit of heads of government on NCD prevention and control and issued the landmark Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs. The objectives of this paper are to provide an overview of a formal evaluation of the Declaration and to highlight key findings that could inform further implementation of the Declaration's 15 mandates. METHODS: The evaluation's six research objectives were decided through stakeholder engagement and assessed by concurrent quantitative and qualitative research methods, using the following four themes: 1) trends in risk factors, morbidity, and mortality; 2) national and Caribbean-wide policy responses, and factors associated with policy successes and difficulties; 3) the international impact of the Declaration; and 4) the potential for raising revenue from tobacco and alcohol taxation in order to support NCD prevention and control. RESULTS: There are marked disparities in NCD mortality and trends among the 20 CARICOM member countries and territories. No CARICOM member had fully implemented all of the Declaration's 15 mandates (which were monitored by 26 indicators), with 10 CARICOM members implementing fewer than half of the indicators, and with most members lacking a well-functioning multisectoral NCD Commission. Larger CARICOM members tended to have higher levels of implementation than did smaller members. Mandates that received active support from regional institutions tended to be better implemented by the CARICOM members than did mandates that lacked that kind of support. Feasible national tobacco and alcohol tax increases could more than cover the cost of implementing the World Health Organization NCD "best buy" interventions in the CARICOM member countries and territories. CONCLUSIONS: Priorities for further implementation of the mandates from the Port-of-Spain Declaration include establishing throughout the CARICOM member countries and territories fully functioning national bodies to support multisectoral action for NCD prevention; greater regional support in policy development and implementation for smaller countries; and greater targeted use of taxes on tobacco and alcohol to support NCD control and prevention.

Premature mortality from cardiovascular disease and diabetes in the Caribbean and associations with health care expenditure, 2001 - 2011.

OBJECTIVE: To examine the historical trends of premature death due to cardiovascular disease and diabetes mellitus (CVD-DM) in the Caribbean and to identify any associations between these trends and health care expenditure. METHODS: Death data were obtained from the World Health Organization Mortality Database; population data, from the United Nations World Population prospects; and health care expenditure data, from the World Bank. In all, 17 Caribbean countries had mortality data; however, only 11 had both mortality and health care expenditure data available. The analyses explored country-level trends in age-standardized CVD-DM mortality rates using 3-year moving averages from 1995 - 2014 for women and men. Associations between secular mortality rate change and health care expenditure were considered. RESULTS: CVD-DM mortality rates ranged from 10.7 - 247.1 per 100 000, with a mean of 92.3 and standard deviation of 47.6. Of the 17 countries, 12 showed a reduction in premature CVD-DM mortality in both men and women, with others either showing no improvement or increases. Mortality rates for men were 1.46 times higher than for women. On average, there was a 68% increase in health care expenditure, with a 15.4% fall in CVD-DM mortality in women and 4.9% in men. Mixed effects modelling demonstrated a weak association between health care expenditure and declining CVD-DM mortality for both women -0.006 (95%CI = -0.014 - 0.001) and men -0.008 (95%CI = -0.017 - 0.001). CONCLUSIONS: Findings suggest that progress has been made to reduce premature CVD-DM related mortality in a number of Caribbean countries. Differences between countries may be partly related to differences in health care system performance, although further research that considers confounders is needed.

Communication strategy to disseminate the results of the evaluation of the Port-of-Spain Declaration (POSDEVAL) across multiple audiences in the Caribbean.

Like many nations in the Americas, the countries of the Caribbean are facing increasing morbidity and mortality associated with noncommunicable diseases (NCDs). In 2007, based on advocacy by Sir George Alleyne and others, the Caribbean Community (CARICOM) convened the first in the world Heads of Government NCDs Summit. This summit issued the Port of Spain Declaration that served not only as a rallying point to accelerate the regional NCDs response, but also as a catalyst for the first United Nations high-level meeting on NCDs in September 2011. In 2014, seven years after the CARICOM NCDs Summit, a formal evaluation of the Port of Spain Declaration (POSDEVAL) was conducted to investigate its impact and learn lessons to support and further accelerate its implementation. One mechanism was to review successes and challenges in the NCDs response and effectively communicate findings to stakeholders and the public. The results of the evaluation and the implementation of the Port of Spain Declaration are presented by other papers in this supplement. The present paper describes the communication and social information process used for sharing POSDEVAL findings across multiple layers of social influence in the Caribbean, primarily in 2016 - 2017. The main steps of the communication process are shared as a possible strategy for disseminating NCDs research information and accelerating control and policy adoption in other Small Island Developing States and middle-income countries.

De modo similar al de otras naciones en la Región de las Américas, los países del Caribe se enfrentan a una morbilidad y mortalidad en aumento asociadas a las enfermedades no transmisibles (ENT). En el 2007, gracias al apoyo de sir George Alleyne, entre otros, la Comunidad del Caribe (CARICOM) celebró la primera cumbre de jefes de Gobierno sobre las ENT. Fruto de esta cumbre fue la Declaración de Puerto España, que supuso un punto de confluencia para acelerar la respuesta regional a las ENT, además de un catalizador para la primera reunión de alto nivel de la Asamblea General de las Naciones Unidas sobre las ENT, que tuvo lugar en septiembre del 2011.En el 2014, siete años después de la cumbre de CARICOM sobre las ENT, se llevó a cabo una evaluación formal de la Declaración de Puerto España para investigar su repercusión y extraer las lecciones que respalden y aceleren en mayor medida su ejecución. Uno de los mecanismos consistió en evaluar los logros y retos en la respuesta a las ENT y comunicar eficazmente los resultados a los interesados directos y el público general.En otros artículos de este suplemento se presentan los resultados de la evaluación y la ejecución de la Declaración de Puerto España. En el presente artículo se describe el proceso de comunicación e información social empleado para divulgar los resultados de la evaluación entre los distintos ámbitos de influencia social en el Caribe, especialmente entre los años 2016 y 2017. A modo de posible estrategia, se describen las principales medidas del plan de comunicación para divulgar la información relacionada con la investigación sobre las ENT y acelerar las medidas de control y la formulación de políticas en los pequeños estados insulares en desarrollo y los países de ingresos medianos.

À semelhança de várias nações nas Américas, os países do Caribe enfrentam um aumento da morbidade e mortalidade associadas às doenças não transmissíveis (DNTs). Em 2007, fundamentada na defesa da causa feita por Sir George Alleyne e outros, a Comunidade do Caribe (CARICOM) convocou a primeira Cúpula de Chefes de Governo sobre DNTs. Esta reunião culminou com a Declaração de Porto de Espanha que serviu não só como um ponto de encontro para acelerar a resposta regional às DNTs, mas também como um estímulo à primeira Reunião de Alto Nível das Nações Unidas sobre DNTs, em setembro de 2011.Em 2014, sete anos após a Cúpula sobre DNTs da CARICOM, foi realizada uma avaliação formal da Declaração de Porto de Espanha (POSDEVAL) para avaliar o impacto produzido e os ensinamentos tirados a fim de subsidiar e acelerar sua execução. Uma das estratégias usadas foi examinar os êxitos e desafios na resposta às DNTs e comunicar de modo efetivo os resultados aos interessados diretos e ao público. Os resultados da avaliação e execução da Declaração de Porto de Espanha são apresentados em outros artigos neste suplemento. O presente artigo descreve o processo de comunicação e informação social usado para divulgar os resultados da POSDEVAL entre as diversas esferas de influência social no Caribe, sobretudo no período de 2016­2017. Os principais passos da estratégia de comunicação são partilhados como uma possível estratégia para disseminar dados de pesquisas sobre DNTs e acelerar o controle e a adoção de políticas em outros Pequenos Estados Insulares em Desenvolvimento e países de média renda.

Validating the self-reported annual monitoring grid for the 2007 Caribbean Community Declaration of Port-of-Spain on noncommunicable diseases.

OBJECTIVES: In 2007, the Caribbean Community (CARICOM) convened the world's first-ever heads of government summit on noncommunicable diseases (NCDs) and issued the landmark Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs. Since then, ministry of health (MoH) focal points in each country have self-reported annually on their NCD efforts, using a 26-indicator grid created to assess implementation of the Declaration. Our objective was to assess the validity of those grid responses, as compared to information from in-depth interviews and document reviews. METHODS: Seven national case studies on policy responses to the Declaration were undertaken in 2015. In-depth, semistructured interviews were conducted with stakeholders from multiple sectors, including the MoH. Policy documents were also identified and reviewed. The results from the 2015 case studies were compared to the 2014 MoH focal point grid responses. Kappa statistics evaluated chance agreement. RESULTS: The information from the grid and from the case studies agreed closely. Out of a total of 182 indicators (26 each for seven countries), there was a lack of agreement on just 9 (4.9%). All the differences were between policy statements and implementation. Except for physical activity, kappa statistics indicated that agreement was good to excellent for all the clusters of the grid and for the grid as a whole, but with wide confidence intervals. CONCLUSIONS: In general, the monitoring grid accurately assessed the national situation, but with a possible tendency to overstate performance in some areas. These findings contributed to the design of a new, 50-indicator monitoring grid in 2016. Alongside these improvements, CARICOM countries face a substantial burden from having to complete many other required NCD reports, mainly for the Pan American Health Organization and the World Health Organization.

Caribbean Wellness Day: promoting a region-wide day of action.

In response to the epidemic of non-communicable diseases (NCDs) in the Caribbean, the Heads of Government of the Caribbean Community (CARICOM) issued the 2007 Port-of-Spain Declaration, "Uniting to Stop the Epidemic of Chronic Non-communicable Diseases" and declared the second Saturday in September to be "Caribbean Wellness Day" (CWD). CWD is a call-to-action for engaging the population of the Member States in confronting NCDs and their risk factors. This report reviews the genesis, implementation, and institutionalization of CWD in CARICOM and beyond. The study used quantitative and qualitative methods, including 29 surveys, 7 in-depth interviews, and analysis of media content. Data was provided by NCD focal points at the Ministry of Health in 15 CARICOM countries, as well as by 7 non-governmental and 4 private organizations. Branding materials were well received and locally adapted; much of CWD media content originated from organization websites and were not community-based. Events typically focused on physical activity and health screenings and were attended by up to 3 000 participants. Though most were held in city centers, some CWD activities have involved rural and indigenous populations. CWD has become a catalyst for multisectoral engagement and health promotion activities. Inspired by CWD, PAHO initiated "Wellness Week in the Americas," which includes CWD and promotes its tenets across the Region of the Americas. As CWD further develops, consideration should be given to reliable, adequate, and sustainable financing; to measuring and evaluating its impact on NCDs; and to widening its reach to include those outside of city centers.

En respuesta a la epidemia de las enfermedades no transmisibles en el Caribe, los jefes de Gobierno de la Comunidad del Caribe (CARICOM) emitieron en el 2007 la Declaración de Puerto España, "Unidos para detener la epidemia de las enfermedades crónicas no transmisibles", y propusieron instaurar el segundo sábado de septiembre como el "Día del Bienestar en el Caribe". Este día es un llamado a la acción para fomentar la participación la población de los Estados Miembros contra las enfermedades no transmisibles y sus factores de riesgo.Este informe examina la génesis, la puesta en marcha y la institucionalización del Día del Bienestar en el Caribe en CARICOM y otros lugares. En el estudio se emplearon métodos cuantitativos y cualitativos, entre ellos 29 encuestas, 7 entrevistas exhaustivas y el análisis del contenido de medios de difusión. Los datos fueron proporcionados por puntos focales para las enfermedades no transmisibles del Ministerio de Salud de 15 países de CARICOM, así como por siete organizaciones no gubernamentales y cuatro organizaciones privadas.Los materiales de imagen institucional fueron bien recibidos y se adaptaron localmente; gran parte del contenido sobre el Día del Bienestar en los medios de difusión provenía de los sitios web de organizaciones y no de las comunidades. Los eventos se centraron generalmente en la actividad física y los exámenes médicos de tamizaje, y asistieron hasta 3 000 personas. Aunque la mayoría se celebraron en el centro de las ciudades, algunas actividades se han realizado con poblaciones rurales e indígenas.El Día del Bienestar en el Caribe se ha convertido en un catalizador para la participación multisectorial y las actividades de promoción de la salud. Inspirada en él, la OPS instituyó la "Semana del Bienestar en las Américas", que incluye a su vez el Día del Bienestar en el Caribe y difunde sus principios en toda la Región de las Américas. Conforme el Día del Bienestar en el Caribe evolucione aún más, debe pensarse en obtener un financiamiento confiable, adecuado y sostenible; en medir y evaluar sus repercusiones en materia de enfermedades no transmisibles; y en ampliar su alcance para abarcar a quienes viven lejos del centro de las ciudades.

Em resposta à epidemia de doenças não transmissíveis (DNTs) no Caribe, os chefes de governo da Comunidade do Caribe (CARICOM) emitiram a Declaração de Porto de Espanha de 2007, "Unidos para deter a epidemia de doenças crônicas não transmissíveis", e declararam o segundo sábado de setembro o "Dia do Bem-estar no Caribe". Trata-se de uma chamada à ação aos Estados Membros para engajar a população a enfrentar as DNTs e os fatores de risco associados.Este informe faz uma análise da origem, implantação e institucionalização do Dia do Bem-Estar no Caribe no CARICOM e outras regiões. Neste estudo foram empregados métodos quantitativos e qualitativos, com 29 inquéritos, 7 entrevistas aprofundadas e uma análise de conteúdo de mídias. Os dados foram fornecidos pelos centros de coordenação de DNTs nos ministérios da Saúde de 15 países da CARICOM, assim como por sete organizações não governamentais e quatro entidades privadas.Os materiais de branding foram bem aceitos e adaptados ao contexto local. Grande parte de conteúdo de mídia do Dia do Bem-Estar no Caribe foi proveniente de sites de entidades e não foram originados nas comunidades. Os eventos normalmente envolveram atividade física e exames de prevenção de saúde, com o comparecimento de até 3.000 participantes. Apesar de a maioria dos eventos ter sido realizada em centros urbanos, ocorreram algumas atividades para populações rurais e indígenas.O Dia do Bem-Estar no Caribe é um incentivador para a participação multissetorial e para atividades de promoção da saúde. Inspirada nesta iniciativa, a Organização Pan-Americana da Saúde (OPAS) instituiu a "Semana do Bem-Estar nas Américas", englobando e promovendo os princípios do Dia do Bem-Estar no Caribe em toda a Região das Américas. Com a expansão deste acontecimento, é preciso considerar como custeá-lo de maneira adequada, segura e sustentável, mensurar e avaliar a repercussão que ele tem e ampliar o seu alcance para chegar às populações fora dos centros urbanos.

An updated systematic review and meta-analysis on the social determinants of diabetes and related risk factors in the Caribbean.

OBJECTIVES: To conduct an analysis of the most recent data on diabetes and its risk factors by gender and other social determinants of health to understand why its prevalence is higher among women than men in the Caribbean; to inform policy agenda-setting for diabetes prevention and control in the Caribbean; and to identify gaps in the evidence that require further research. METHODS: A previous systematic review of the literature describing studies conducted in the Caribbean that presented the distribution of diabetes, its outcomes, and risk factors, by one or more social determinants, was updated to include sources from 1 January 2007 - 31 December 2016. Surveys by the World Health Organization (WHO) were also included. Where data were sufficient, meta-analyses were undertaken. RESULTS: A total of 8 326 manuscripts were identified. Of those, 282 were selected for full text review, and 114, for abstraction. In all, 36 papers, including WHO-related surveys, had sufficient information for meta-analysis. More women compared to men were obese (OR: 2.1; 95%CI = 1.65 - 2.69), physically inactive (OR: 2.18; 95%CI = 1.75 - 2.72), and had diabetes (OR: 1.48; 95%CI = 1.25 - 1.76). More men smoked (OR: 4.27; 95%CI = 3.18 - 5.74) and had inadequate fruit and vegetable intake (OR: 1.37; 95%CI = 1.21 - 1.57). CONCLUSION: Thirty-six papers were added to the previously conducted systematic review; of those, 13 were added to the meta-analysis. Diabetes and its risk factors (primarily obesity and physical inactivity) continue to disproportionately affect women in the Caribbean. Smoking interventions should be targeted at men in this geographic area.

Regulatory measures to fight obesity in Small Island Developing States of the Caribbean and Pacific, 2015 - 2017.

This report examines the experiences of Small Island Developing States in the Caribbean- Barbados, Dominica, Jamaica, and in the Pacific- Fiji, Nauru, and Tonga with specific governmental regulatory measures to reduce the risk of obesity and associated diet-related chronic noncommunicable diseases (NCDs), as well as the obstacles and opportunities encountered. Guided by the diet-related indicators of the World Health Organization (WHO) Noncommunicable Diseases Progress Monitor 2017, the authors reviewed legislation, country reports, articles, and the databases of WHO and the World Trade Organization to identify relevant regulatory measures and to establish the extent of implementation in the selected countries. Obesity prevalence ranged from 25.9% in Dominica to 41.1% in Tonga. The principal diet-related measures implemented by the selected countries were fiscal measures, such as sugar-sweetened beverage taxes and import duties to encourage greater consumption of healthy foods. Governmental action was weakest in the area of restrictions on marketing of unhealthy foods. If they are to reduce their current high rates of obesity and associated NCDs, Caribbean and Pacific states need to intensify implementation of diet-related regulatory measures, particularly in the area of marketing of unhealthy foods and beverages to children. Key implementation challenges include financial and staffing constraints and the need for increased political will to counter industry opposition and to allocate adequate financial resources to keep advancing this agenda.

Este es un informe sobre las experiencias de Barbados, Dominica, Jamaica, Fiji, Nauru y Tonga con medidas gubernamentales regulatorias específicas dirigidas a reducir el riesgo de obesidad y enfermedades no transmisibles relacionadas con la dieta y resaltar los obstáculos y oportunidades relacionados con ellas. Guiados por los indicadores relacionados con la dieta establecidos en el Monitoreo de Avances en materia de las Enfermedades no Transmisibles 2017 de la Organización Mundial de la Salud (OMS) se revisó la legislación, los informes de los países, artículos, y las bases de datos de la OMS y la Organización Mundial de Comercio para identificar las medidas regulatorias pertinentes y establecer el alcance de su implementación en los países seleccionados.La prevalencia de obesidad osciló entre el 25,9% en Dominica y el 41,1% en Tonga. Las principales medidas relacionadas con la dieta implementadas por los países seleccionados fueron medidas fiscales, como los impuestos a las bebidas azucaradas y los aranceles de importación, para alentar un mayor consumo de alimentos saludables. La acción gubernamental fue más débil en el área de restricciones en el marketing de alimentos poco saludables. Para reducir las actuales altas tasas de obesidad y enfermedades no transmisibles asociadas, los estados del Caribe y del Pacífico deben intensificar la implementación de medidas regulatorias relacionadas con la dieta, en particular en el área del marketing de alimentos y bebidas poco saludables para los niños. Los desafíos clave de la implementación incluyen limitaciones financieras y de personal y la necesidad de una mayor voluntad política para contrarrestar la oposición de la industria y asignar recursos financieros adecuados para seguir avanzando en esta agenda.

Este é um relatório sobre as experiências de Barbados, Dominica, Jamaica, Fiji, Nauru e Tonga com medidas específicas reguladoras do governo destinadas a reduzir o risco de obesidade e doenças não transmissíveis associadas (DNTs) relacionados à dieta e destacar os obstáculos e oportunidades que estimulam um maior uso dessas medidas. Guiados pelos indicadores relacionados à dieta estabelecido no Monitoramento de Progresso das Doenças Não Transmissíveis 2017 da Organização Mundial da Saúde (OMS), revisamos a legislação, os relatórios dos países, artigos, e as bases do dados da OMS e da Organização Mundial do Comércio para identificar as medidas reguladoras relevantes, visando reduzir o risco de obesidade e as DNTs associadas, e estabelecer o escopo de sua implementação nos países selecionados.A prevalência de obesidade variou de 25,9% na Dominica a 41,1% em Tonga. As principais medidas relacionadas à dieta implementadas pelos países selecionados foram medidas fiscais, como impostos sobre bebidas açucaradas e tarifas de importação, para incentivar maior consumo de alimentos saudáveis. A ação do governo foi mais fraca na área de restrições à comercialização de alimentos não saudáveis. Para reduzir as atuais altas taxas de obesidade e doenças não transmissíveis associadas, os países do Caribe e do Pacífico devem intensificar a implementação de medidas reguladoras relacionadas à dieta, particularmente na área da comercialização de alimentos e bebidas não saudáveis para crianças. Os principais desafios da implementação incluem restrições financeiras e de pessoal e a necessidade de maior vontade política para combater a oposição da indústria e alocar recursos financeiros adequados para continuar avançando nesta agenda.

Evaluating policy responses to noncommunicable diseases in seven Caribbean countries: challenges to addressing unhealthy diets and physical inactivity.

OBJECTIVE: To identify, assess, and compare existing policies on noncommunicable diseases (NCDs) in the Caribbean, gaps in policy responses, and the factors influencing successful policy development and implementation following the Port of Spain Declaration of 2007. Specifically, to examine policies that target the upstream determinants of two NCD risk factors-unhealthy diets and physical inactivity. METHODS: A total of 76 semi-structured interviews with 80 relevant stakeholders in government, the private sector, and civil society were complemented by policy document analysis. Interviews were analyzed pragmatically, framed by the CARICOM government commitments, the WHO NCD Action Plan, a Multiple Streams framework approach, and realist evaluation ideas. RESULTS: The most widely-reported policy successes involved health promotion activities (e.g., school meal programs) that leveraged multisectoral collaboration among government ministries, such as Health, Education, and Agriculture. Large policy gaps still exist around creating legislative, physical, and social environments to support healthy eating and physical activity at the population level. Multisectoral NCD commissions successfully reached across sectors, but had limited influence on policy development. Different policy levels emerged with national-level policies considered a lengthy process, while "On-the-ground" programming was considered faster to implement than national policies. External barriers included a reliance on food imports enabled by international trade agreements limited availability, quality, and affordability of healthy foods. International pushback limited legislation to reduce food imports and the absence of an international/regional framework, similar to the Framework Convention on Tobacco Control, further impedes efforts. CONCLUSIONS: Regional collaboration and political support across sectors are essential to accelerating the pace of action to support healthy eating and active living environments. Policy "blueprints" could accelerate the process of development. Regional "NCD champions" could spearhead such responses and approaches.

Increased taxation on cigarettes in Grenada: potential effects on consumption and revenue.

OBJECTIVE: To investigate the feasibility of addressing the public health concerns of tobacco consumption through increased taxation, while preserving or augmenting government revenues in Grenada. METHODS: Purposive sampling methods were used to ensure data availability and geographical representativeness. Average price per 20-pack of the most-sold brands of cigarettes was calculated using data from three major supermarkets. The World Health Organization's Tax Simulation Model was used, with excise tax rates adjusted to effect 5%, 10%, and 15% consumption decreases. RESULTS: A 17% to 117% excise tax increase on the cost, insurance, and freight (CIF) value would achieve a 5% consumption decrease. Total government revenues would grow 8.7% and excise tax revenues would increase 11%. The average excise tax per 20-pack would move from EC$ 3.24 (2014 US$ 1.20) to EC$ 3.80 (US$ 1.41), while the average price per pack would increase to EC$ 9.21 (US$ 3.41) from EC$8.48 (US$ 3.14). In the 10% and 15% consumption reduction scenarios, excise taxes would have to be increased by 33% and 50% (to 133% and 150% of CIF, respectively), pushing the average excise tax per pack to EC$ 4.37 (US$ 1.62) and EC$ 4.90 (US$ 1.81), respectively. CONCLUSION: In Grenada, consumption can be reduced alongside growth in government revenues, making available additional resources for health. This aligns with the literature, which indicates that taxation can be effective in pursuing the public health objective of reduced incidence of smoking-related illnesses via reduced consumption.

Trends in beverage prices following the introduction of a tax on sugar-sweetened beverages in Barbados.

A 10% excise tax on sugar sweetened beverages (SSBs) was implemented in Barbados in September 2015. A national evaluation has been established to assess the impact of the tax. We present a descriptive analysis of initial price changes following implementation of the SSB tax using price data provided by a major supermarket chain in Barbados over the period 2014-2016. We summarize trends in price changes for SSBs and non-SSBs before and after the tax using year-on-year mean price per liter. We find that prior to the tax, the year-on-year growth of SSB and non-SSB prices was very similar (approximately 1%). During the quarter in which the tax was implemented, the trends diverged, with SSB price growth increasing to 3% and that of non-SSBs decreasing slightly. The growth of SSB prices outpaced non-SSBs prices in each quarter thereafter, reaching 5.9% compared to <1% for non-SSBs. Future analyses will assess the trends in prices of SSBs and non-SSBs over a longer period and will integrate price data from additional sources to assess heterogeneity of post-tax price changes. A continued examination of the impact of the SSB tax in Barbados will expand the evidence base available to policymakers worldwide in considering SSB taxes as a lever for reducing the consumption of added sugar at the population level.

A cross-sectional study of physical activity and sedentary behaviours in a Caribbean population: combining objective and questionnaire data to guide future interventions.

BACKGROUND: Current understanding of population physical activity (PA) levels and sedentary behaviour in developing countries is limited, and based primarily on self-report. We described PA levels using objective and self-report methods in a developing country population. METHODS: PA was assessed in a cross-sectional, representative sample of the population of Barbados (25-54 years), using a validated questionnaire (RPAQ) and individually calibrated combined heart rate and movement sensing monitors. The RPAQ collects information on recalled activity in 4 domains: home, work, transport, and leisure. Physical inactivity was defined according to World Health Organization (WHO) guidelines; sedentary lifestyle was defined as being sedentary for 8 h or more daily; PA overestimation was defined as perceiving activity to be sufficient, when classified as 'inactive' by objective measurement. RESULTS: According to objective estimates, 90.5 % (95 % CI: 83.3,94.7) of women and 58.9 % (48.4,68.7) of men did not accumulate sufficient activity to meet WHO minimum recommendations. Overall, 50.7 % (43.3,58.1) of the population was sedentary for 8 h or more each day, and 60.1 % (52.8,66.9) overestimated their activity levels. The prevalence of inactivity was underestimated by self-report in both genders by 28 percentage points (95 % CI: 18,38), but the accuracy of reporting differed by age group, education level, occupational grade, and overweight/obesity status. Low PA was greater in more socially privileged groups: higher educational level and higher occupational grade were both associated with less objectively measured PA and more sedentary time. Variation in domain-specific self-reported physical activity energy expenditure (PAEE) by educational attainment was observed: higher education level was associated with more leisure activity and less occupational activity. Occupational PA was the main driver of PAEE for women and men according to self-report, contributing 57 % (95 % CI: 52,61). The most popular leisure activities for both genders were walking and gardening. CONCLUSIONS: The use of both objective and self-report methods to assess PA and sedentary behaviour provides important complementary information to guide public health programmes. Our results emphasize the urgent need to increase PA and reduce sedentary time in this developing country population. Women and those with higher social economic position are particularly at risk from low levels of physical activity.

The association of nutrition behaviors and physical activity with general and central obesity in Caribbean undergraduate students.

OBJECTIVE: To quantify the prevalence of obesity and obesity-related factors in a crosssectional, observational study of Caribbean students using the results of three recent surveys of health behavior among undergraduates in Barbados, Grenada, and Jamaica. METHODS: A total of1 578 Caribbean undergraduate students from Barbados, Grenada, and Jamaica (ages 18-30 years) completed questionnaires and had physical measurements recorded. Multivariable logistic regression was used to estimate odds ratios (ORs) for the association of nutrition behaviors with prevalence of obesity (body mass index > 30 kg/m² ); elevated waist-to-height ratio (W/ht) (> 0.50); and high waist circumference (WC) (> 88 cm in females, > 102 cm in males). Models were adjusted for age, year in university, socioeconomic status, and sex. RESULTS: There was a higher prevalence of obesity (13% versus 10%), high WC (21% versus 7%), and high W/ht (35% versus 25%) in females relative to males. Compared to females, males had reduced odds of obesity (OR 0.46), high WC (OR 0.22), and high W/ht (OR 0.61) (P < 0.05 for all). Both females (46%) and males (24%) reported high levels of physical inactivity. Fruit and vegetable consumption was low (approximately two servings per day). Many students reported avoiding fatty foods (40%); this behavior was associated with high W/ht (OR 1.68), obesity (OR 1.90), and high WC (OR 1.82) (P < 0.05 for all). Irregular breakfast consumption, age, and year of study were also positively associated with obesity. Physical activity was not significantly associated with any obesity measure. CONCLUSIONS: There was a low prevalence of healthy behaviors and a high prevalence of obesity in this sample of Caribbean young adults.