Consumption of sugar-sweetened beverages and T2D diabetes in the Eastern Caribbean.

OBJECTIVE: Sugar-sweetened beverages (SSB) are implicated in the increasing risk of diabetes in the Caribbean. Few studies have examined associations between SSB consumption and diabetes in the Caribbean. DESIGN: SSB was measured as teaspoon/d using questions from the National Cancer Institute Dietary Screener Questionnaire about intake of soda, juice and coffee/tea during the past month. Diabetes was measured using self-report, HbA1C and use of medication. Logistic regression was used to examine associations. SETTING: Baseline data from the Eastern Caribbean Health Outcomes Research Network Cohort Study (ECS), collected in Barbados, Puerto Rico, Trinidad and Tobago and US Virgin Islands, were used for analysis. PARTICIPANTS: Participants (n 1701) enrolled in the ECS. RESULTS: Thirty-six percentage of participants were unaware of their diabetes, 33% aware and 31% normoglycaemic. Total mean intake of added sugar from SSB was higher among persons 40-49 (9·4 tsp/d), men (9·2 tsp/d) and persons with low education (7·0 tsp/d). Participants who were unaware (7·4 tsp/d) or did not have diabetes (7·6 tsp/d) had higher mean SSB intake compared to those with known diabetes (5·6 tsp/d). In multivariate analysis, total added sugar from beverages was not significantly associated with diabetes status. Results by beverage type showed consumption of added sugar from soda was associated with greater odds of known (OR = 1·37, 95 % CI (1·03, 1·82)) and unknown diabetes (OR = 1·54, 95 % CI (1·12, 2·13)). CONCLUSIONS: Findings indicate the need for continued implementation and evaluation of policies and interventions to reduce SSB consumption in the Caribbean.

[Civil society promoting government accountability for health equity in the Caribbean: The Healthy Caribbean CoalitionPromoção, pela sociedade civil, da responsabilização do governo pela equidade em saúde no Caribe: a Coalizão do Caribe Saudável]. / Papel de la sociedad civil en la promoción de la rendición de cuentas de los gobiernos en materia de equidad en salud en el Caribe: la Coalición Caribe Saludable.

Achieving health equity and addressing the social determinants of health are critical to attaining the health and health-related targets of the 2030 Agenda for Sustainable Development and its Sustainable Development Goals. Frameworks for health, including the Sustainable Health Agenda for the Americas 2018 - 2030, emphasize reduction of health inequities and "leaving no one behind" in national sustainable development. Health equity includes advancing universal health and the primary health care approach, with equitable access for all people to timely, quality, comprehensive, people- and community-centered services that do not cause impoverishment. Equally important, and a hallmark of good governance, is accountability for such advances. Governments have primary responsibility for reducing health inequities and must be held accountable for their policies and performance. Civil society has been recognized as a key partner in advancing sustainable and equitable national development. Effective accountability mechanisms should include civic engagement. The Healthy Caribbean Coalition (HCC), the only Caribbean regional alliance of civil society organizations working to prevent and control noncommunicable diseases-a major health priority fueled by inequities-has played a significant role in holding governments accountable for advancing health equity. This case study examines factors contributing to the success of the HCC, highlighting work under its five strategic pillars- accountability, advocacy, capacity development, communication, and sustainability-as well as challenges, lessons learned, and considerations for greater effectiveness.

Conquistar a equidade em saúde e abordar os determinantes sociais da saúde são essenciais para atingir as metas de saúde e as relacionadas à saúde da Agenda 2030 para o Desenvolvimento Sustentável e seus Objetivos de Desenvolvimento Sustentável. As estruturas para a saúde, incluindo a Agenda de Saúde Sustentável para as Américas 2018-2030, enfatizam a redução das iniquidades em saúde "sem deixar ninguém para trás", quando se trata do desenvolvimento sustentável nacional. A equidade em saúde inclui impulsionar a saúde universal e a abordagem da atenção primária à saúde, habilitando o acesso equitativo por todas as pessoas a serviços oportunos, de qualidade, integrais, centrados no atendimento às pessoas e às comunidades de maneira a não causar o empobrecimento. A questão da responsabilidade por tais avanços é igualmente importante, e é um selo de distinção de boa gestão. Os governos são os principais responsáveis pela redução das iniquidades em saúde e precisam ser responsabilizados por suas políticas e por seu desempenho. Reconheceu-se que a sociedade civil desempenha um papel essencial na promoção do desenvolvimento nacional sustentável e equitativo. Para que sejam eficazes, os mecanismos de responsabilização devem incluir a participação cívica. A Coalizão do Caribe Saudável (HCC), a única aliança de organizações da sociedade civil que trabalha na prevenção e no controle de doenças não transmissíveis na região do Caribe ­ uma grande prioridade de saúde movida pelas iniquidades ­ tem desempenhado uma função significativa na responsabilização dos governos pelo avanço da equidade em saúde. Este estudo examina os fatores que contribuem para o sucesso da HCC e destaca o trabalho da perspectiva dos cinco pilares estratégicos ­ responsabilidade, promoção de causa, desenvolvimento das capacidades, comunicação e sustentabilidade ­, bem como os desafios, as lições aprendidas e as considerações para que se torne ainda mais eficaz.

Civil society promoting government accountability for health equity in the Caribbean: The Healthy Caribbean Coalition.

Achieving health equity and addressing the social determinants of health are critical to attaining the health and health-related targets of the 2030 Agenda for Sustainable Development and its Sustainable Development Goals. Frameworks for health, including the Sustainable Health Agenda for the Americas 2018 - 2030, emphasize reduction of health inequities and "leaving no one behind" in national sustainable development. Health equity includes advancing universal health and the primary health care approach, with equitable access for all people to timely, quality, comprehensive, people- and community-centered services that do not cause impoverishment. Equally important, and a hallmark of good governance, is accountability for such advances. Governments have primary responsibility for reducing health inequities and must be held accountable for their policies and performance. Civil society has been recognized as a key partner in advancing sustainable and equitable national development. Effective accountability mechanisms should include civic engagement. The Healthy Caribbean Coalition (HCC), the only Caribbean regional alliance of civil society organizations working to prevent and control noncommunicable diseases-a major health priority fueled by inequities-has played a significant role in holding governments accountable for advancing health equity. This case study examines factors contributing to the success of the HCC, highlighting work under its five strategic pillars-accountability, advocacy, capacity development, communication, and sustainability-as well as challenges, lessons learned, and considerations for greater effectiveness.

Alcanzar la equidad en salud y abordar los determinantes sociales de la salud son aspectos fundamentales para alcanzar las metas en materia de salud y relacionadas con la salud de la Agenda para el Desarrollo Sostenible 2030 y sus Objetivos de Desarrollo Sostenible. Los marcos de referencia para la salud, como la Agenda de Salud Sostenible para las Américas 2018-2030, hacen hincapié en la reducción de las desigualdades en salud y en "no dejar a nadie atrás" en el desarrollo sostenible a nivel nacional. La equidad en salud incluye la promoción de la salud universal y el enfoque de atención primaria de la salud, con un acceso equitativo de todas las personas a servicios de salud oportunos, de calidad, integrales y centrados en las personas y la comunidad que no ocasionen empobrecimiento. La rendición de cuentas por esos avances es igualmente importante, y un signo distintivo de una gobernanza adecuada. Los gobiernos tienen la responsabilidad primordial de reducir las desigualdades en salud y deben rendir cuentas de sus políticas y su desempeño. La sociedad civil es una parte interesada fundamental para promover un desarrollo nacional sostenible y equitativo, y debe formar parte de los mecanismos eficaces de rendición de cuentas.La Coalición Caribe Saludable ­la única alianza regional del Caribe de organizaciones de la sociedad civil dedicada a prevenir y controlar las enfermedades no transmisibles, una prioridad sanitaria importante acrecentada por las desigualdades­ ha desempeñado un papel importante en hacer que los gobiernos rindan cuentas de la promoción de la equidad en salud. En este estudio se examinan los factores que han contribuido al éxito de la Coalición Caribe Saludable, con énfasis en la labor realizada en el marco de sus cinco pilares estratégicos ­rendición de cuentas, promoción de la causa, desarrollo de capacidad, comunicación y sostenibilidad­ así como los retos, las enseñanzas extraídas y otras consideraciones para lograr una mayor eficacia.

Regional Overview on the Double Burden of Malnutrition and Examples of Program and Policy Responses: Latin America and the Caribbean.

BACKGROUND: Hunger, food insecurity, stunting, anemia, overweight, and noncommunicable diseases (NCDs) may coexist in the same person, household, and community in Latin America and the Caribbean (LAC). The double burden of malnutrition (DBM) is an important cause of disability and premature death, which could be addressed with comprehensive policies such as the Plan of Action for the Prevention of Obesity in Children and Adolescents. This paper summarizes the main policies and actions aimed to prevent undernutrition and obesity. SUMMARY: Several countries are implementing the Plan of Action, Caribbean Public Health Agency is actively supporting Ministries of Health, Education, and Sport to develop school nutrition policies and strategies to create health-promoting environments at school and in their surrounding communities. Chile is implementing the comprehensive child protection system "Chile Crece Contigo" that integrates health, social development, and educational activities to optimize growth and childhood cognitive-motor development. Brazil is implementing policies and plans to commit to international targets regarding food and nutrition security, NCDs and their risk factors. Key Messages: The DBM exists in the Americas and contributes to disability and premature death. The Region is making progress implementing policies and actions addressing the DBM. However, stronger political will and leadership are needed to enact legislation and policies that create and support enabling -environments.

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.

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.

[Improved Blood Pressure Control to Reduce Cardiovascular Disease Morbidity and Mortality: The Standardized Hypertension Treatment and Prevention Project]. / Mejor control de la presión arterial para reducir la morbilidad y mortalidad por enfermedades cardiovasculares: Proyecto de Prevención y Tratamiento Estandarizado de la Hipertensión Arterial * Traducción oficial al español efectuada por la Organización Panamericana de la Salud a partir del artículo original publicado en el Journal of Clinical Hypertension, con autorización de John Wiley and Sons. En caso de discrepancia prevalecerá la versión original (en inglés).

Hypertension is the leading remediable risk factor for cardiovascular disease, affecting more than 1 billion people worldwide, and is responsible for more than 10 million preventable deaths globally each year. While hypertension can be successfully diagnosed and treated, only one in seven persons with hypertension have controlled blood pressure. To meet the challenge of improving the control of hypertension, particularly in low- and middle-income countries, the authors developed the Standardized Hypertension Treatment and Prevention Project, which involves a health systems-strengthening approach that advocates for standardized hypertension management using evidence-based interventions. These interventions include the use of standardized treatment protocols, a core set of medications along with improved procurement mechanisms to increase the availability and affordability of these medications, registries for cohort monitoring and evaluation, patient empowerment, team-based care (task shifting), and community engagement. With political will and strong partnerships, this approach provides the groundwork to reduce high blood pressure and cardiovascular disease-related morbidity and mortality.

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

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

Advancing Cancer Control Through Research and Cancer Registry Collaborations in the Caribbean.

BACKGROUND: Few national registries exist in the Caribbean, resulting in limited cancer statistics being available for the region. Therefore, estimates are frequently based on the extrapolation of mortality data submitted to the World Health Organization. Thus, regional cancer surveillance and research need promoting, and their synergy must be strengthened. However, differences between countries outweigh similarities, hampering registration and availability of data. METHODS: The African-Caribbean Cancer Consortium (AC3) is a broad-based resource for education, training, and research on all aspects of cancer in populations of African descent. The AC3 focuses on capacity building in cancer registration in the Caribbean through special topics, training sessions, and biannual meetings. We review the results from selected AC3 workshops, including an inventory of established cancer registries in the Caribbean region, current cancer surveillance statistics, and a review of data quality. We then describe the potential for cancer research surveillance activities and the role of policymakers. RESULTS: Twelve of 30 Caribbean nations have cancer registries. Four of these nations provide high-quality incidence data, thus covering 14.4% of the population; therefore, regional estimates are challenging. Existing research and registry collaborations must pave the way and are facilitated by organizations like the AC3. CONCLUSIONS: Improved coverage for cancer registrations could help advance health policy through targeted research. Capacity building, resource optimization, collaboration, and communication between cancer surveillance and research teams are key to obtaining robust and complete data in the Caribbean.

Management Of Chronic Noncommunicable Diseases After Natural Disasters In The Caribbean: A Scoping Review.

Extreme weather events in the Caribbean region are becoming increasingly severe because of climate change. The region also has high rates of poorly controlled chronic noncommunicable diseases (NCDs), which were responsible for at least 30 percent of deaths after two recent hurricanes. We conducted a scoping review of literature published between 1974 and 2020 to understand the burden and management of chronic NCDs in the Caribbean after natural disasters. Of the twenty-nine articles included in this review, most described experiences related to Hurricanes Dorian (2019) and Irma and Maria (2017) and the Haiti earthquake (2010). Challenges included access to medication, acute care services, and appropriate food, as well as communication difficulties and reliance on ad hoc volunteers and outside aid. Mitigating these challenges requires different approaches, including makeshift points of medication dispensing, disease surveillance systems, and chronic disease self-management education programs. Evidence is needed to inform policies to build resilient health systems and integrate NCD management into regional and national disaster preparedness and response plans.

The Development of Public Policies to Address Non-communicable Diseases in the Caribbean Country of Barbados: The Importance of Problem Framing and Policy Entrepreneurs.

BACKGROUND: Government policy measures have a key role to play in the prevention and control of non-communicable diseases (NCDs). The Caribbean, a middle-income region, has the highest per capita burden of NCDs in the Americas. Our aim was to examine policy development and implementation between the years 2000 and 2013 on NCD prevention and control in Barbados, and to investigate factors promoting, and hindering, success. METHODS: A qualitative case study design was used involving a structured policy document review and semi-structured interviews with key informants, identified through stakeholder analysis and 'cascading.' Documents were abstracted into a standard form. Interviews were recorded, transcribed verbatim and underwent framework analysis, guided by the multiple streams framework (MSF). There were 25 key informants, from the Ministry of Health (MoH), other government Ministries, civil society organisations, and the private sector. RESULTS: A significant policy window opened between 2005 and 2007 in which new posts to address NCDs were created in the MoH, and a government supported multi-sectoral national NCD commission was established. Factors contributing to this government commitment and funding included a high level of awareness, throughout society, of the NCD burden, including media coverage of local research findings; the availability of policy recommendations by international bodies that could be adopted locally, notably the framework convention on tobacco control (FCTC); and the activities of local highly respected policy entrepreneurs with access to senior politicians, who were able to bring together political concern for the problem with potential policy solutions. However, factors were also identified that hindered multi-sectoral policy development in several areas, including around nutrition, physical activity, and alcohol. These included a lack of consensus (valence) on the nature of the problem, often framed as being predominantly one of individuals needing to take responsibility for their health rather than requiring government-led environmental changes; lack of appropriate detailed policy guidance for local adaptation; conflicts with other political priorities, such as production and export of alcohol, and political reluctance to use legislative and fiscal measures. CONCLUSION: The study's findings indicate mechanisms to promote and support NCD policy development in the Caribbean and similar settings.

Improved Blood Pressure Control to Reduce Cardiovascular Disease Morbidity and Mortality: The Standardized Hypertension Treatment and Prevention Project.

Hypertension is the leading remediable risk factor for cardiovascular disease, affecting more than 1 billion people worldwide, and is responsible for more than 10 million preventable deaths globally each year. While hypertension can be successfully diagnosed and treated, only one in seven persons with hypertension have controlled blood pressure. To meet the challenge of improving the control of hypertension, particularly in low- and middle-income countries, the authors developed the Standardized Hypertension Treatment and Prevention Project, which involves a health systems-strengthening approach that advocates for standardized hypertension management using evidence-based interventions. These interventions include the use of standardized treatment protocols, a core set of medications along with improved procurement mechanisms to increase the availability and affordability of these medications, registries for cohort monitoring and evaluation, patient empowerment, team-based care (task shifting), and community engagement. With political will and strong partnerships, this approach provides the groundwork to reduce high blood pressure and cardiovascular disease-related morbidity and mortality.

Evaluating policy responses to noncommunicable diseases in seven Caribbean countries: challenges to addressing unhealthy diets and physical inactivity / Evaluación de las respuestas políticas a las enfermedades no transmisibles en siete países del Caribe: desafíos para abordar las dietas no saludables y la inactividad física / Avaliação de respostas políticas a doenças não transmissíveis em sete países do Caribe: desafios para abordar dietas não saudáveis e inatividade física

ABSTRACT 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.

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RESUMO Objetivo. Identificar, avaliar e comparar as políticas existentes sobre doenças não transmissíveis (DNT) no Caribe, as lacunas nas respostas e fatores que influenciam o desenvolvimento e implementação de políticas bem sucedidas depois da Declaração de Porto Espanha em 2007. Especificamente, examinar as políticas que apontam para dois fatores de risco de DNT: dietas não saudáveis e inatividade física. Métodos. Um total de 76 entrevistas semi-estruturadas com 80 participantes diretos, pertencentes ao governo, ao setor privado e à sociedade civil, foram complementados com a análise de documentos sobre as políticas estabelecidas. As entrevistas foram analisadas pragmaticamente, enquadradas nos compromissos dos governos do CARICOM, no Plano de Ação das DNTs da Organização Mundial da Saúde, numa abordagem do quadro de fluxos múltiplos e em ideias de avaliação realistas. Resultados. Os resultados positivos das políticas mais divulgados incluíram atividades de promoção da saúde (por exemplo, programas de alimentação escolar) que tiveram colaboração multissetorial de diferentes instituições governamentais, como os ministérios da saúde, educação e agricultura. Ainda existem grandes lacunas políticas em torno da criação de ambientes legislativos, físicos e sociais para apoiar a alimentação saudável e a atividade física no nível populacional. As comissões multissetoriais de ENT alcançaram com sucesso todos os setores, mas tiveram influência limitada no desenvolvimento de políticas. Diferentes níveis de políticas foram observados e aqueles em nível nacional foram processos prolongados; os programas "no terreno" foram mais rápidos para implementar. As barreiras externas incluíram a dependência de importações de alimentos permitidas por acordos comerciais internacionais que limitam a disponibilidade, qualidade e acessibilidade de alimentos saudáveis. A legislação internacionalmente limitada para reduzir as importações de alimentos e a ausência de um quadro internacional o regional, semelhante à Convenção-Quadro para o Controle do Tabaco, torna os esforços ainda mais difíceis. Conclusões. A colaboração regional e o apoio político em todos os setores são essenciais para acelerar o ritmo de ação em apoio à alimentação saudável e a ambientes de vida ativa. Os "esquemas" de políticas podem acelerar o processo de desenvolvimento. Os "campeões regionais de ENT" poderiam liderar as estratégias e respostas.

Mejor control de la presión arterial para reducir la morbilidad y mortalidad por enfermedades cardiovasculares: Proyecto de Prevención y Tratamiento Estandarizado de la Hipertensión Arterial / Improved Blood Pressure Control to Reduce Cardiovascular Disease Morbidity and Mortality: The Standardized Hypertension Treatment and Prevention Project

RESUMEN La hipertensión arterial es el principal factor de riesgo corregible de las enfermedades cardiovasculares y, a nivel mundial, afecta a más de mil millones de personas y causa más de diez millones de muertes evitables cada año. Aunque puede diagnosticarse y tratarse de forma satisfactoria, solo una de cada siete personas hipertensas tiene la presión arterial controlada. A fin de abordar este reto, se ha puesto en marcha el Proyecto de Prevención y Tratamiento Estandarizado de la Hipertensión Arterial con el propósito de mejorar el control de la hipertensión, particularmente en los países de ingresos bajos y medianos. Este proyecto consiste en aplicar un enfoque de fortalecimiento de los sistemas de salud que promueva el tratamiento estandarizado de la hipertensión arterial por medio de intervenciones basadas en la evidencia, como el uso de protocolos estandarizados de tratamiento y de un conjunto básico de medicamentos, junto con mecanismos optimizados de compra para aumentar su disponibilidad y asequibilidad, el uso de registros clínicos para el seguimiento y la evaluación de cohortes de pacientes, el empoderamiento de los pacientes, el trabajo en equipo (delegación de tareas), y la participación de la comunidad. Si se dispone de voluntad política y se establecen alianzas fuertes, este enfoque permite sentar las bases para reducir la hipertensión arterial y la morbilidad y mortalidad asociadas a las enfermedades cardiovasculares.

ABSTRACT Hypertension is the leading remediable risk factor for cardiovascular disease, affecting more than 1 billion people worldwide, and is responsible for more than 10 million preventable deaths globally each year. While hypertension can be successfully diagnosed and treated, only one in seven persons with hypertension have controlled blood pressure. To meet the challenge of improving the control of hypertension, particularly in low- and middle-income countries, the authors developed the Standardized Hypertension Treatment and Prevention Project, which involves a health systems–strengthening approach that advocates for standardized hypertension management using evidence-based interventions. These interventions include the use of standardized treatment protocols, a core set of medications along with improved procurement mechanisms to increase the availability and affordability of these medications, registries for cohort monitoring and evaluation, patient empowerment, team-based care (task shifting), and community engagement. With political will and strong partnerships, this approach provides the groundwork to reduce high blood pressure and cardiovascular disease-related morbidity and mortality.

International collaborative project to compare and monitor the nutritional composition of processed foods.

BACKGROUND: Chronic diseases are the leading cause of premature death and disability in the world with overnutrition a primary cause of diet-related ill health. Excess energy intake, saturated fat, sugar, and salt derived from processed foods are a major cause of disease burden. Our objective is to compare the nutritional composition of processed foods between countries, between food companies, and over time. DESIGN: Surveys of processed foods will be done in each participating country using a standardized methodology. Information on the nutrient composition for each product will be sought either through direct chemical analysis, from the product label, or from the manufacturer. Foods will be categorized into 14 groups and 45 categories for the primary analyses which will compare mean levels of nutrients at baseline and over time. Initial commitments to collaboration have been obtained from 21 countries. CONCLUSIONS: This collaborative approach to the collation and sharing of data will enable objective and transparent tracking of processed food composition around the world. The information collected will support government and food industry efforts to improve the nutrient composition of processed foods around the world.

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

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

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