Sociodemographic and behavioral factors related to obesity among adults in the Republic of Palau based on the WHO STEPwise approach to NCD risk factor surveillance 2011-2013: A cross-sectional study.

BACKGROUND: Pacific islanders face drastic increase of obesity-related noncommunicable disease (NCD) due to lifestyle shifts of unhealthy diets and physical inactivity. To date, however, obesity related factors have not been well elucidated in Republic of Palau. This study aimed to investigate sociodemographic and behavioral factors related to obesity using the national level data in Palau. METHODS: This is a cross-sectional, population-based study analyzing random sampling data of 2133 adults aged 25-64 years (of 20 thousand national population) from the WHO STEPwise approach to NCD risk factor surveillance (STEPS) implemented between 2011 and 2013. Sociodemographic and behavioral factors were obtained by the STEPS standardized questionnaire for NCD risk factors plus the question on betel nut chewing because of its common behavior in Micronesian countries. Logistic regression analysis was performed to estimate multivariable odds ratio (OR) of general obesity (body mass index ≥30.0 kg/m2) and central obesity (waist circumference ≥90 cm in men and ≥80 cm in women). RESULTS: Means of body mass index, prevalence of general obesity and central obesity were higher in women (29.9 kg/m2, 45.5% and 85.4%) than in men (29.3 kg/m2, 40.4% and 67.6%). After adjusted by other potential factors, native Palauan (OR 4.4, 95% CI, 2.7-7.0 for men and 3.6, 2.3-5.6 for women), betel nut chewing (1.5, 1.1-2.1 for men and 1.6, 1.2-2.3 for women), men who work at government office (1.6, 1.2-2.1), women with higher household income (1.4, 1.0-1.8) were positively associated with general obesity, while frequent vegetable intake were inversely associated with it among women (0.71, 0.54-0.93). Similar associations were observed between the aforementioned factors and central obesity. CONCLUSIONS: Native Palauan, people with betel nut chewing behavior, government employment and higher income appeared to be associated with obesity, while frequent vegetable consumption were inversely associated with obesity. Further interventions for prevention and control of obesity are necessary through the enhancing public relation activities to understand harmful health effects on betel nuts chewing and recommending domestic production of vegetables.

Lessons from the Field: Interventions to Improve Health and Quality of Life to Address the NCD Crisis in Palau - Fostering Collaboration Across Sectors within the Government and Civil Society.

The Republic of Palau is a small island nation in the North Pacific with a population of 17,501. The islands of Palau are geographically isolated, considered rural, and medically underserved. The prevalence of non-communicable diseases (NCDs) and risk factors are very high and account for more than 75% of all deaths and disabilities. Recognizing that the high rates of NCDs are undermining health and sustainable development of the nation, Palau declared a state of health emergency due to the epidemic of NCDs. It was recognized during the development of the NCD Prevention and Control Strategic Plan of Action 2015-2020 (Palau NCD Plan) that improved collaboration between government agencies, civil society, and the private sector was needed to address this epidemic. A multi-sectoral solution was needed to address a multi-sectoral problem. Through Presidential Executive Order, the National Coordinating Mechanism for Non-Communicable Diseases (CM) was established to mobilize sufficient resources and coordinate actions to prevent and control NCDs, ensure successful implementation of the Palau NCD Plan, the World Health Organization Framework Convention on Tobacco Control, and other related plans and commitments, align such plans to national policies, ensure a health-in-all-policy approach to address health inequities, and bridge the gap between health and quality of life. Though the CM is young, improved coordination between agencies and accelerated action has taken place. Legislation was enacted that mandates 10% of alcohol and tobacco taxes be directed to NCD prevention through the Coordinating Mechanism, thus ensuring sustainability.

An Evaluation of Infertility Among Women in the Republic of Palau, 2016.

Fertility challenges are a personal and important part of a woman's reproductive health and are associated with health and lifestyle factors. Limited data exist on infertility among women in Palau. We describe the lifetime prevalence of self-reported infertility in a nationally representative sample of women in Palau and investigate the association between tobacco and/or betel nut use and infertility. During May-December 2016, a population-based survey of noncommunicable diseases was conducted in Palau using a geographically stratified random sample of households (N=2409). Men and women ≥18 years of age were chosen randomly from each selected household. The prevalence of a self-reported lifetime episode of infertility (having tried unsuccessfully to become pregnant for ≥12 months) was evaluated among 874 women aged ≥18 years by key health and lifestyle factors. Prevalence ratios (PR) and 95% confidence intervals (CI) were calculated. Of 315 women who ever tried to become pregnant, 39.7% (95% CI: 34.2%, 45.3%) reported a lifetime episode of infertility. Prevalence was higher in women of Palauan vs other ethnicity (PR=1.6, 95% CI: 1.1, 2.3), those who self-reported poor/not good vs. excellent/ very good health status (PR=2.1, 95% CI: 1.4, 3.3), and those with a body mass index (BMI) ≥30 vs <30 (PR=1.7, 95% CI: 1.3, 2.2). Adjusted models showed that tobacco and/or betel nut users were almost twice as likely to report infertility versus non-users (PR=1.8, 95% CI: 1.3, 2.5). More research is needed to understand the infertility experiences of women in Palau and to promote lifestyle factors contributing to optimal reproductive health.

Prevalence and Correlates of Dyslipidemia Among Men and Women in Palau: Findings of the Palau STEPS Survey 2011-2013.

BACKGROUND: Epidemiological evidence of dyslipidemia in Pacific Island countries is limited despite the knowledge that non-communicable diseases have a high burden in the region. We aimed to examine the prevalence and correlates of dyslipidemia among residents of Palau. METHODS: The Palau STEPwise approach to Surveillance (STEPS), which was conducted from 2011 through 2013, comprised three parts: behavioral risk factors; physical measurements; and biochemical tests, covering areas such as blood lipids. We used STEPS-generated data to perform a cross-sectional study of 2,184 randomly selected Palau residents, comprising Palauans and non-Palauans aged 25-64 years. RESULTS: The age-adjusted mean BMI was 29.3 kg/m2 in men and 29.9 kg/m2 in women; age-adjusted mean triglycerides value was 182 mg/dL in men and 166 mg/dL in women; and age-adjusted mean cholesterol was 178 mg/dL in men and 183 mg/dL in women. The prevalence of overweight/obesity (BMI ≥25 kg/m2) was 75% in men and 76% in women, and those of hypertriglyceridemia (triglycerides ≥150 mg/dL) and hypercholesterolemia (total cholesterol ≥200 mg/dL) were 48% in men and 41% in women and 18% in men and 23% in women, respectively. Mean values of total cholesterol were 177 mg/dL in Palauan men and 182 mg/dL in non-Palauan men. Mean values of triglycerides were 171 mg/dL in Palauan women and 150 mg/dL in non-Palauan women. Women living in rural areas showed a higher mean value of total cholesterol than those in urban areas. CONCLUSION: We found a high mean BMI and high prevalence of overweight/obesity and hypertriglyceridemia, but low mean total cholesterol and a low prevalence of hypercholesterolemia in Palau. Lipid profiles varied by age, ethnicity, and living area.

Breast and Cervical Cancer Screening in Palau: Have We Improved Early Detection and Survival?

The Breast and Cervical Cancer Early Detection Program (BCCEDP) was first introduced in Palau in 1997. The program's aim is to recruit and screen women for early detection of breast and cervical cancers. An assessment of this screening program was conducted to evaluate its effectiveness, including impact on stage of diagnosis and survival time of patients diagnosed with breast and cervical cancers through both screening and clinical diagnosis. A retrospective cohort study using secondary data from 2004-2013 was conducted. There were 45 women diagnosed with breast or cervical cancer. Due to the small number of cases, a comparison of two time periods was made (2004-2008) and (2009-2013). There were more cancer cases detected through screening (26%) in the earlier time period (2004-2008), as compared to those diagnosed through screening (8%) in the later time period (2009-2013), though this difference was not statistically significant (P=.09). The proportion of breast and cervical cancers diagnosed at an earlier stage (0-3) may have decreased between the two time periods (42% to 23%, P=.3). A greater proportion of women who were diagnosed between 2004-2008 lived longer than 2 years (58%), than women who were diagnosed between 2009-2013 (39%; P=.23). The screening program has not shown improvement over the years despite the measures taken to detect the early onset of breast and cervical cancer, and survival outcomes in Palau remain poor.

Disparity in metabolic risk factors of non-communicable diseases between Palauans and Filipinos living in Palau.

Non-communicable diseases have been recognized as a serious threat to public health in Palau. To tackle the problem, different strategies might be necessary for populations with different ethnic backgrounds. This study aims to find the differences in the prevalence of metabolic risk factors of non-communicable diseases between Palauans and Filipinos living in Palau, and examine possible determinants of the differences. We selected data of 2,032 participants, including native Palauans and Filipinos, from the Palau STEPS Survey 2011-2013 for this study. Logistic regression models were used to inspect the association of each metabolic risk factor with ethnicity by calculating odds ratios adjusted for potential confounding factors. Palauans had higher age-standardized prevalence of overweight or obesity (84% vs. 45%), hypertension (50% vs. 38%) and diabetes (19% vs. 13%) than Filipinos. However, after adjusting for BMI and various lifestyle related factors, there are no statistical significant differences in the prevalence of hypertension and diabetes between these two ethnic groups. Palauan men were less likely to have elevated total cholesterol, especially after adjusting for BMI (odds ratio=0.55, 95% confidence interval: 0.33-0.91), while Palauan women were more likely to have elevated triglycerides than their Filipino counterparts (odds ratio=1.45, 95% confidence interval: 1.02-2.06). Our findings suggested that Palauans' higher BMI distribution might be able to explain their higher prevalence of hypertension and partially explain their higher diabetes prevalence. Palauans were not consistently more likely to have all metabolic risk factors, namely dyslipidemia were less likely to be observed in Palauan men.

Descriptive Epidemiology of Hypertension and Its Association With Obesity: Based on the WHO STEPwise Approach to Surveillance in Palau.

The rise of noncommunicable diseases is a serious health burden for Palau. This study described the prevalence of hypertension, and assessed its association with obesity. Surveys following the WHO STEPwise approach to surveillance were conducted in 2529 adults. Multivariate prevalence ratios (PR) of hypertension for body mass index (BMI) categories were calculated by logistic regression models using conditional standardization procedure. Age- and sex-specified analyses were performed. Overall prevalence of obesity and hypertension were 40.4% and 46.8%, respectively. Prevalence of hypertension was positively associated with BMI. However, overweight men had as high prevalence of hypertension as the obese (multivariable-adjusted PR was 1.84 for overweight and 1.91 for obese compared with nonoverweight). The association between hypertension and BMI was similar across age groups. The prevalence of hypertension in women increased gradually with the increase of BMI whereas that in men reached a plateau already in the overweight.

Prevalence and predictors of prediabetes and diabetes among adults in Palau: population-based national STEPS survey.

We aimed to investigate the prevalence and predictors of diabetes and prediabetes among adults in Palau. We used data of 1915 adults, aged 25 to 64 years, who participated in the World Health Organization's (WHO) STEPwise Approach to Risk Factor Surveillance (STEPS) study in Palau. Information on behavioral risk factors of NCDs and physical and biochemical measurements were obtained using standard methods of the WHO. The diagnosis of diabetes and prediabetes was based on the recent American Diabetes Association criteria. Predictors of the prevalence of diabetes and prediabetes were identified using multinomial logistic regression analysis. The overall age-standardized prevalence of prediabetes and diabetes were 40.4% (43.6% for men, 37.4% for women) and 17.7% (18.6% for men, 17% for women), respectively. Old age, overall obesity (high BMI), central obesity (large waist circumference or waist-hip ratio), hypertension and hypertriglyceridemia were significant predictors of prediabetes and/or diabetes. Diabetes occurred at a younger age in "obese" individuals than that of their "non-obese" counterparts. We confirmed that prediabetes and diabetes are highly prevalent in Palau affecting 40% and 18% adults, respectively. Introducing public health interventions to reduce and prevent obesity as early as possible could prove useful to curb the problem.

U.S. Associated Pacific Islands Health Care Teams Chart a Course for Improved Health Systems: Implementation and Evaluation of a Non-communicable Disease Collaborative Model.

The burden of non-communicable disease (NCD) is increasing in the U.S. Associated Pacific Islands (USAPI). We describe the implementation and evaluation of a NCD Collaborative pilot, using local trainers, as an evidence-based strategy to systematically strengthen NCD health care quality and outcomes, focusing on diabetes preventive care across five health systems in the region.

Profile of non-communicable disease risk factors among adults in the Republic of Palau: findings of a national STEPS survey.

Palau, similar to other Pacific island countries, is currently highly burdened with non-communicable diseases (NCDs). The WHO STEPS was launched in 2011 to comprehensively survey indicators for NCDs in the country. This paper aims to describe the prevalence of key NCD risk factors assessed by the survey. The WHO instrument, including behavioral, physical and biochemical measurements, was adopted to the nationwide survey for all residents aged 25 to 64 years. A cluster-based sampling method was performed to obtain a national representative data. Valid data from 2,184 individuals were selected for the analyses, of which 75% were Palauans and 19% were Filipinos. Prevalence of current cigarette smoking was 25% in men and 10% in women. Betel nut chewing with tobacco was prevalent particularly among Palauans (58% in men, 69% in women) compared to the other ethnic groups. In terms of all types of tobacco use, 60% of men and 58% of women were current users. Overweight or obesity was very common among Palauans (84% in men, 86% in women) as well as Filipinos (52% in men, 40% in women). Hypertension was found in 55% of men and 49% of women, with the stage 2 hypertension being 21% and 19%, respectively. The prevalence of diabetic level hyperglycemia was more than 20%. Raised total cholesterol was detected in 16% of men and 20% of women. This survey revealed an alarmingly high prevalence of NCD risk factors, especially tobacco use, obesity, hypertension and raised blood glucose. The data would be useful baseline information to develop effective NCD strategies in Palau.

Profile of Non-communicable Disease Risk Factors Among Young People in Palau.

BACKGROUND: Although non-communicable diseases (NCDs) have become the predominant health problems of Palauan society, there have been no comprehensive data on NCD risk factors available to develop effective control strategies. Therefore, the first Palauan national STEPwise approach to risk factor Surveillance (STEPS) was completed in mid-2013 to provide information on its adult population aged 25 to 64 years. This study aims to obtain corresponding data from the younger adults aged 18 to 24 years, who remained to be surveyed. METHODS: We conducted an epidemiological study, targeting the 18- to 24-year-old age group. A survey station and a mobile team were established to recruit voluntary participants dwelling in Koror. A slightly modified WHO STEPS instrument was used, including a structured questionnaire for behavioral risk factors, physical measurements, and blood tests. RESULTS: A total of 356 young people were recruited during the survey. In both sexes, nearly half of the participants were overweight/obese. The prevalence of hypertension was higher in men than in women (17.6% vs 1.7%). Raised blood glucose and impaired fasting glucose were observed in 3.5% and 5.2% of the total participants, respectively. About 36% of the subjects were observed to have raised levels of total cholesterol. More than 70% of the young people were current tobacco users, in terms of all kinds of tobacco products. CONCLUSIONS: The current survey, for the first time, revealed a high prevalence of NCD risk factors, especially overweight/obesity and tobacco use, among young people in Palau. This indicates that swift measures against NCDs are required even in this young age group.