Jamaica Health and Lifestyle Survey 2016 2017 Prevalence

Jamaica Health and Lifestyle Survey 2016 - 2017: Prevalence of NCD Risk Factors and Cardiovascular Disease presented by Trevor Ferguson on behalf of JHLS-III Investigators Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017

Introduction – NCDs and Public Health n n n Noncommunicable diseases (NCDs), including heart disease, stroke, cancer, diabetes, and chronic lung disease remain a global public health problem NCDs are responsible for 71% of deaths globally In Jamaica, NCDs accounted for approximately 62% of deaths among men and 74% of deaths among women in 2016 Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 2

Introduction – NCDs and Public Health n n Data from JHLS-II, completed in 2007 -2008, showed high prevalence of behavioural and metabolic risk factors for NCDs JHLS-III, conducted between 2016 -2017, provides updated estimates on the burden of NCDs and their risk factors Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 3

Content Covered n Obesity n Heart Attack n Diabetes mellitus n Stroke n Hypertension n High Cholesterol Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 4

Study Design n A community based interviewer-administered health examination survey of non-institutionalised Jamaicans, resident in Jamaica, aged 15 years and older n Designed to be nationally representative n Multi-stage sampling design n Randomly selected rural and urban enumeration districts stratified by parish Systematic sampling of households within each ED One participant selected per household – using Kish method Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017

Weighted Analyses n Sampling weights – based on n Probability of selection of dwellings and enumeration districts Adjusted for unit non-response Calibrated using population distribution at parish-level sex-specific by 5 -year age bands Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017

Weighted Estimates n n More conservative estimates of the variability associated with the statistics Description that can be generalised to Jamaican population of 15 years and older Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017

Recruitment Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017

The Recruited Sample Males Kingston Females Total Males Females 74 189 263 St James St. Andrew 125 246 371 St Thomas 66 98 Portland 82 122 St. Mary 70 82 St Ann 57 59 Trelawny 76 135 n Total 73 126 199 60 75 135 52 98 150 109 132 241 152 Manchester 94 118 212 116 Clarendon 70 110 180 211 St Catherine 81 128 209 Hanover 164 Westmoreland 204 St Elizabeth 1089 (38. 8%) males, 1718 (61. 2%) females Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017

RESULTS Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017

Distribution of Nutritional Status by Sex (BMI categories) 54% of persons ≥ 15 yrs were overweight (25% pre-obese; 29% obese) 60. 0 50. 0 40. 0 30. 0 20. 0 10. 0 Underweight Normal Weight Pre-obese Obese Male 8. 3 52. 3 24. 0 14. 9 Underweight Female 4. 6 27. 8 26. 4 41. 2 Normal Weight Pre-obese = BMI 25. 0 -29. 9; Obese = BMI≥ 30 kg/m 2 Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 Both Sexes 6. 4 39. 8 25. 2 28. 6 Obese p<0. 001 for male: female difference 17

Pre-Obesity and Obesity by Age n 38. 7 37. 1 34. 3 32. 7 29. 2 26. 7 28. 4 28. 1 28. 2 27. 4 27. 5 23. 3 15. 515. 0 n n n 15 -24 25 -34 35 -44 45 -54 Pre-obese 55 -64 65 -74 High prevalence of overweight (preobesity and obesity) in all age groups Lowest in 15 -24 age group Highest among those 35 -44 & 45 -54 years Small decrease in the older age groups ≥ 75 Obese Pre-obese = BMI 25. 0 -29. 9; Obese = BMI≥ 30 kg/m 2 Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 18

Prevalence of obesity by sex (BMI ≥ 30 kg/m 2) 55. 1 54. 1 52. 0 48. 0 43. 7 28. 2 20. 6 19. 2 10. 8 15 -24 Male 22. 0 15. 8 13. 8 12. 2 7. 7 25 -34 35 -44 45 -54 Female 55 -64 65 -74 ≥ 75 p=0. 037 for males; p<0. 001 for females Marked sex difference in prevalence of obesity – female >> male Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 19

Prevalence of Obesity (BMI ≥ 30) by Parish (Females) • Highest prevalence: Trelawny (58. 0%) , St James (47. 0%) , Kingston (46. 1%) • Lowest prevalence: Manchester (32. 2%), St Mary (34. 5%), St Ann (36. 6%) Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 21

Prevalence of Obesity (BMI ≥ 30) by Parish (Males) p=0. 064 • Highest prevalence: Hanover (22. 9%) , St Catherine (22. 0%), St Ann (19. 5%) • Lowest prevalence: Westmoreland (2. 0%), Portland (4. 2%), St Thomas (7. 6%) Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 22

Prevalence Diabetes Mellitus (defined as FBS ≥ 7. 0 mmol/l or on medication for diabetes) n 14. 6 11. 9 n 9. 0 n n Male Female Overall diabetes prevalence 11. 9% (95%CI 10. 5 - 13. 4%) Significantly higher prevalence among women 15% vs. 9% (p<0. 001) Prevalence among persons 15 -74 years 10. 2% (95% CI 8. 9 - 11. 7%) Absolute increase of 2. 3% compared to JHLS-II in 2008 Both Sexes Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 24

Prevalence of Diabetes Mellitus by Age 45. 9 40. 3 38. 3 27. 5 23. 3 14. 8 13. 5 5. 3 5. 8 7. 6 14. 7 9. 8 1. 6 1. 5 15 -24 25 -34 35 -44 45 -54 Male 55 -64 65 -74 ≥ 75 Female P<0. 001 for both males and females Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 25

Prevalence of Diabetes by Parish (Females) Female (p=0. 167) • Highest prevalence: Manchester (22%) , Westmoreland (21%), Trelawny (19%) • Lowest prevalence: St Mary (8%), St Ann (9%), Portland (12%) Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 27

Prevalence of Diabetes by Parish (Males) Male (p=0. 038) • Highest prevalence: Hanover (19%) , Clarendon (19%), Kingston (17%) • Lowest prevalence: St Thomas (2%), St Mary (4%), Trelawny (4%) Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 28

Prevalence of Diabetes Mellitus by Rural / Urban Residence 15. 2 12. 3 13. 8 n 11. 4 8. 8 9. 1 n Urban Male Female Rural Both Sexes Rural No significant differences between rural and urban residents 11. 4% among rural vs. 12. 3% among urban residents Urban Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 29

Pre-diabetes by Sex Prediabetes defined as fasting glucose of 5. 6 -6. 9 mmol/l Sex Category Pre-diabetes (%) Male 10. 7 Female 13. 1 Both Sexes 12. 0 p<0. 001 Overall 24% of persons 15 years or older have diabetes or prediabetes Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 30

Definition & Classification of High BP JNC 7 (2003) ACC/AHA 2017 SBP <120 mm. Hg Normal Prehypertension Hypertension & Normal & DBP <80 mm. Hg SBP 120 -139 mm. Hg or SBP 120 -129 mm. Hg or Elevated BP DBP 80 -89 mm. Hg DBP <80 mm. Hg SBP ≥ 140 mm. Hg SBP ≥ 130 mm. Hg or Hypertension DBP ≥ 90 mm. Hg or DBP ≥ 80 mm. Hg JNC 7 = The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 31

Prevalence of Hypertension by Sex using JNC -7 (2003) and ACC/AHA (2017) criteria JNC-7 (SBP ≥ 140 or DBP ≥ 90) Male , 31. 7 Male p=0. 039 Female, 35. 8 Both Sexes, 33. 8 Female Both Sexes Female ACC/AHA 2017 (SBP ≥ 130 or DBP ≥ 80) Male, 58. 3 Female, 57. 0 Both Sexes, 57. 6 Male Female Both Sexes p=0. 506 Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 33

Proportion of Population in Blood Pressure Categories (JNC-7 & ACC/AHA) ACC/AHA 2017 % JNC 7 (2003) % Normal 32. 2 Prehypertension 34. 0 Elevated BP 10. 2 Hypertension 33. 8 Hypertension 57. 6 Only 32% of Jamaican adults have normal blood pressure 2/3 of the population have elevated blood pressure Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 34

Hypertension by Age and Sex (JNC 7) 83. 9 75. 8 75. 5 68. 6 64. 4 67. 1 53. 7 45. 1 31. 5 27. 7 20. 3 16. 1 7. 8 8. 3 15 -24 Male 25 -34 Female 35 -44 45 -54 55 -64 65 -74 ≥ 75 P<0. 001 for both males and females Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 35

Hypertension – Rural vs Urban (JNC 7) Male, 33. 6 Male, 29. 7 Female, Both Sexes, 36. 0 33. 1 Female, Both Sexes, 35. 5 34. 5 Urban Male Female Rural n n Both Sexes Rural Urban No significant rural urban differences in the prevalence of HTN 34. 5% rural vs 33. 1% urban Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 36

Hypertension by Parish (JNC 7) St Thomas 51. 3 Hanover 42. 6 Clarendon 40. 9 St Mary 39. 2 41. 4 St Andrew 41. 2 37. 2 Westmoreland St Ann 37. 0 Trelawny 35. 9 Manchester 33. 3 44. 7 Clarendon Trelawny Kingston 46. 0 St Thomas 40. 6 39. 4 Manchester 38. 0 Portland 37. 9 37. 8 St James 29. 6 Kingston Portland 29. 6 St James 35. 2 35. 1 St Elizabeth 27. 7 St Elizabeth St Andrew 27. 6 St Ann 29. 2 St Mary 28. 9 St Catherine 26. 3 Westmoreland P=0. 014 19. 9 5. 0 15. 0 25. 0 35. 0 45. 0 55. 0 St Catherine P=<0. 001 25. 8 5. 0 Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 15. 0 25. 0 35. 0 45. 0 55. 0 37

Prevalence of High Cholesterol (total cholesterol ≥ 5. 2 mmol/l) n Female, 19. 7 Male, 15. 8 Both Sexes, 17. 8 n Estimated prevalence of high cholesterol = 18% Higher in women compared to men 20% vs. 16%, p=0. 024 Urban vs. Rural n n Male Female Both Sexes Rural prevalence 20%; urban prevalence 16%; p=0. 083 Rural urban difference significant among females: 23% (rural) vs. 17% (urban); p=0. 036 Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 38

Prevalence of High Cholesterol by Age 38. 5 36. 0 33. 6 28. 4 27. 2 25. 9 24. 8 21. 9 18. 9 16. 2 14. 4 11. 6 4. 9 3. 9 15 -24 Male 25 -34 Female 35 -44 45 -54 55 -64 65 -74 ≥ 75 P<0. 001 for both males and females Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 39

Hypertension and Diabetes by BMI Category Hypertension (%) Diabetes (%) 47. 3 p<0. 001 22. 0 p<0. 001 39. 4 22. 9 19. 2 11. 8 5. 0 <18. 5 -24. 9 25. 0 -29. 9 BMI Categories >=30 <18. 5 6. 4 18. 5 -24. 9 25. 0 -29. 9 BMI Categories >=30 BMI categories: <18. 5 = underweight; 18 -5 -24. 9 = normal weight; 25. 0 -29. 9 = pre-obese; ≥ 30 = obese (units = kg/m 2) Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 40

Level of Awareness (%) for HTN & DM Diabetes Hypertension 60 55 42 36 41 26 Male Female Unaware Female Both Sexes Aware Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 Unaware Aware 41

Treatment and Control (%) among Persons Aware of HTN, DM Male % Female % Both Sexes % On Treatment 63. 3 73. 2 70. 2 Controlled 1 26. 0 33. 1 31. 0 On Treatment 91. 3 93. 0 92. 5 Controlled 1 29. 0 27. 5 Hypertension Diabetes 1 Controlled calculated as proportion of those on treatment Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 42

Prevalence of Heart Attack by Sex and Age Male, 0. 52 55 -64, 2. 05 Both Sexes, 0. 42 Female, 0. 31 65 -74, 1. 33 >=75, 1. 34 65 -74 >=75 35 -44, 0. 37 45 -54, 0 Male Female Both Sexes 35 -44 45 -54 55 -64 § Overall prevalence of heart attack 0. 4% (4. 2 per 1000) § Prevalence is lower than 0. 6% seen in 2008 § As expected no cases among persons <35; absence of cases in 45 -54 probably due to chance given the small numbers Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 43

Prevalence of Stroke by Sex and Age Male, 1. 3 Female, 1. 0 Both Sexes, 1. 2 >=75, 6. 77 55 -64, 65 -74, 4. 32 4. 25 45 -54, 25 -44, 35 -44, 0. 36 0. 27 0. 12 Male Female Both Sexes 25 -44 35 -44 45 -54 55 -64 65 -74 >=75 § Overall prevalence of stroke was 1. 2% (10 per 1000) § Prevalence is slightly lower than 1. 4% seen in 2008 § No cases among persons <25; high prevalence among persons ≥ 75 years Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 44

Secular Trends among persons 15 -74 years for 2001, 2008, 2017 2001 % 2008 % 2017 % % Change Pre-obese/Obese 45. 7 51. 8 53. 9 17. 9 Obesity 19. 7 25. 3 28. 9 46. 7 Hypertension 20. 9 25. 2 31. 5 50. 7 Diabetes mellitus 7. 2 7. 9 10. 2 41. 7 High Cholesterol 14. 6 11. 7 17. 1 Condition Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 46

Summary / Key Findings n Prevalence of NCD risk factors remain high and appear to be increasing n More than half of the population is pre-obese/obese n 2/3 have elevated blood pressure n 1/8 have diabetes; ¼ had pre-diabetes or diabetes combined n Just under 1/5 have high cholesterol n 4/10 persons with HTN or DM unaware of their condition n Only 30% of treated persons with HTN or DM are controlled Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 47

Implications n n Jamaica will to continue to face challenges with complications of diabetes & hypertension, particularly heart disease, stroke & chronic kidney disease Health care expenditure is likely to increase May negatively impact economy due to reduced productivity among persons who are ill Likely to see increase in dependency ratio due to more persons being unable to work Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 48

Recommendations n Population wide intervention to reduce obesity, diabetes and hypertension n n Jamaica Moves programme - physical activity, healthy eating; promotion of age-appropriate health checks for NCDs and NCD awareness. Improved socioeconomic circumstances and improved access to care Population wide screening for hypertension, diabetes and high cholesterol to increase awareness and ensure persons are treated Engagement of health care providers in both public and private sector to improve quality of care Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 49

JHLS-III Research Team Rainford Karen Marshall Shelly Andriene Novie Nadia Trevor Tamu Colette Damian Ishtar Suzanne William Wilks Webster Tulloch-Reid Mc. Farlane Grant Younger-Coleman Bennett Ferguson Davidson Cunningham-Myrie Francis Govia Soares-Wynter Aiken Shari Jovan Nicolas Georgiana Tiffany Natalie Georgia Ardene Sharmaine Jamaica Health and Lifestyle Survey (JHLS) III 2016 - 2017 Williams Wiggan Elias Gordon-Strachan Palmer Guthrie Williamson Harris Edwards 50