Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697649127467.pdf (Bahamas)
2019 BAHAMAS NCD RISK FACTOR REPORT BAHAMAS NCD RISK FACTOR REPORT The Bahamas 2019 Report of the Pan American STEPS NCD Risk Factor Surveillance Survey All rights reserved.

The publication is available on Ministry of Health & Wellness website (www.bahamas.gov.bs/health) and the Pan American Health Organization (PAHO) website (www.paho.org).

Requests for permission to reproduce or translate this publication should be addressed to the Office of the Chief Medi- cal Officer.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Ministry of Health of the Commonwealth of The Bahamas, or PAHO concerning the legal status of any country, territory, city or area or its authorities, or concerning the delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or rec- ommended by the Pan American Health Organization, in preference to others of a similar nature that are not mentioned.

Errors and omissions except, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the Pan American Health Organization to verify the information contained in this publication.
However, the published material is being distributed without warranty of any kind, either expressed or implied.

The responsibility for the interpretation and use of the material lies with the reader.

In no event shall the Com- monwealth of The Bahamas or the Pan American Health Organization be liable for damages arising from its use.
ii VOLUME 1 Table of Contents SPECIAL NOTES .................................................... iv Global Thinking On Smoking MESSAGE FROM Cessation As A Best Buy .................................. 37 THE MINISTER OF HEALTH & WELLNESS .......... vii Global Thinking On Mental Health MESSAGE FROM THE CHIEF MEDICAL OFFICER .......................... viii MESSAGE FROM THE PAHO/WHO As A Best Buy ................................................... 38 POLICY CONSIDERATION HIGHLIGHTS ............ 41 Upstream Health Policy Innovation ....................... 42 COUNTRY REPRESENTATIVE .............................. ix System Enablers .................................................. 43 ACKNOWLEDGEMENTS .......................................... x Community Empowerment and Innovation ............ 44 ABBREVIATIONS .................................................... xi Research Innovation ............................................. 45 EXECUTIVE SUMMARY ......................................... 1 Rationale ................................................................ 1 STUDY LIMITATIONS ............................................ 47 SNAPSHOT ON NATIONAL ACTIONS Significance Of Steps 2019 .................................... 2 TO PREVENT AND CONTROL NCDS .................. 49 Methodology .......................................................... 2 NATIONAL PROGRESS ON GLOBAL Response Rate ....................................................... 3 INDICATORS AND BENCHMARKS ...................... 50 Synposis Of Key Survey Findings ........................... 3 ANNEXES KEY STUDY FINDINGS AND IMPLICATIONS ....... 7 Sociodemographic Characteristics ..................... 7 ANNEX I – The Bahamas’ Performance (2018) on Port-of-Spain Declaration Indicators ................ 51 Lifestyle Health Risks .......................................... 8 ANNEX II – The Bahamas’ Performance (2020) Non-Communicable Diseases Profile ................ 20 on WHO NCD Indicators ...................................... 53 Health-Seeking Behaviours ............................... 24 ANNEX III – The Bahamas’ Performance on Strength Of The Health System To Health-Related SDGs ............................................. 54 Detect And Appropriately Manage Ncds ........... 26 ANNEX IV – NCD Risk Factor Profile at Oral Health ........................................................ 28 Three Points In Bahamian History ......................... 55 Health Literacy .................................................. 28 AT-A-GLANCE: BAHAMAS STEPS 2019 Health Inequities And Ncds ............................... 29 FACTSHEET .......................................................... 58 NCDS AND GLOBAL THREATS ........................... 30 INACTION, TOO COSTLY A PROPOSITION ....... 32 Value Proposition For Action On Ncds .................. 32 Cost Scenarios ..................................................... 34 Global Thinking On Proper Nutrition And Healthy Diets As A Best Buy ....................... 35 Global Thinking On Reducing Harmful Alcohol Use As A Best Buy ............................... 36 iii BAHAMAS NCD RISK FACTOR REPORT SPECIAL NOTES This publication of the STEPS 2019 Survey findings is presented in two complementary volumes.
The study was executed in 2019 and Report published in 2022.

This delay was the result of shifting priorities due to Hur- ricane Dorian and the Covid-19 pandemic.

iv BAHAMASNCDRISKFACTORREPORT2019 VOLUME 1 Message From The Minister of Health & Wellness Non-Communicable diseases (NCDs) continue to be a challenge both globally and regionally and constitute a significant burden for populations across the globe.
Data from The World Health Organization (WHO) has identified obesity, chronic heart disease, hypertension, dia- betes, and some cancers as the top five causes of death in the region over the past decade.

NCDs have become a major burden on the Bahamian health system with significant economic impact on the public purse.
Not only has the burden of NCDs has been exacerbated during the Covid-19 pandemic, but the implications of the in- creased vulnerabilities and health risks associated with NCDs in individuals have been highlighted through an increased mortality rate.

These realities have once again attracted new attention to NCDs and the need to re-orientate health and other systems to intentionally address the prevention and mitigation of morbidity associated with them.
The United Nations’ Sustainable Development Goal 3 focuses on ensuring healthy lives and well-being for all.

One of the targets of this goal includes reducing by one-third by the year 2030, premature mortality from NCDs through prevention, early identification, and treatment.
Knowing one’s family’s health history, adopting healthy habits such as more water, en- gaging in daily physical activity and getting regular health screenings are just some of the practices that can mitigate the risks of NCDs occurring or progressing to complications, including death.

The health and wellness of the people of the Commonwealth of The Bahamas remains a priority of this Government, and this stewardship has been entrusted to the Ministry of Health & Wellness.
In the 2022-2023 Budget, 2.5 million dollars was allocated to the Ministry to specifically address health and wellness and will be directed at decreasing the incidence of NCDs in this country.

Additionally, improved health infrastructure and the expansion of technology in the public health system will auger well for improved access to quality health services, offering a good return on investment in the pursuit of achieving an overall healthier lifestyle.
The Government is committed to making the decisions, crafting the necessary legislation, and guiding the implementation of the policies that are necessary to reduce the occurrence of NCDs.

The foregoing notwithstanding, the Government can only improve the environment to facilitate a change to healthier personal lifestyle choices.
It is incumbent on individuals to make a determined choice for a healthier existence, and for stakeholders to work collaboratively and cooperatively to reduce NCDs and improve health and wellness across the archipelago.
The conclusions presented in this 2019 STEPS Survey Bahamas Report are fundamental for our country and will guide the way forward for the implementation and sustainability of the strategies, initiatives, and programmes to promote health and wellness and enhance our modalities for healthcare delivery.

The Hon.

Dr. Michael R. Darville, M.P.


Minister of Health & Wellness vii BAHAMAS NCD RISK FACTOR REPORT Message From The Chief Medical Officer Individual and collective health are without doubt the fuel for our pressing onward and march- ing together to loftier goals.

Attaining these goals, are in peril to a magnitude never contem- plated nor seen.
As decades passed, more and more of our people are experiencing and at risk for potentially developing a non-communicable disease (NCD), resulting in disability, reduced quality of life and premature death due to hypertension, diabetes, cardiovascular disease, cancer, and mental health illnesses.

Unhealthy lifestyles are categorically implicated; and are being perpetuated to across generations.
These lifestyle choices include, but are not exclusive to, excess consumption of salt, sugars, and fats; over-indulgence in ultra-processed foods and simple carbohydrates; as well as the harmful use of alcohol and tobacco use.

Addressing lifestyle behaviors do not rest solely with the health sector.
In fact, the co-occurrence of multiple risk factors demands urgent, meaningful, and coordinated action across all sectors to effectively address the social determinants of health, while simultaneously innovating to redesign our health systems.

The new order of the day, to keep more of our people in better states of health and wellness, must also address root causes, or the structural determinants of the social determinants of health inequities.
This requires adopting the Health in All Policies (HiAP) approach with infusion of health considerations in the development of policy in every sector which can potentially affect health and inequities in health.

Di- minished quality of life and increasing premature deaths, that often accompany NCDs will then be in our reach.

The statistics revealed in the STEPS 2019 Report underscore that our nation is at a critical and perilous crossroad.
It is clear, inaction is no longer an option if we are to realize the great potential of our land and our people.

The revelations con- tained in these pages, are envisioned to catalyze a revolution to sharply bend the trajectory of non-communicable diseases and their risk factors in our country.

I commend the work that produced the STEPS 2019 Report.
Profound appreciation is extended to the nearly thirty-nine hundred STEPS survey participants across seven islands; and the almost eighty fieldworkers and supervisors whose work has borne fruit.

Ministry of Finance and the Pan American Health Organization (PAHO) are acknowledged for being trusted partners with the Ministry of Health & Wellness (MoHW) on this and many other endeavors.

I close by paraphrasing the words of William James, we must act as if what we do ‘now’ makes a difference, because it does.
It takes all of us – assuming individual and collective responsibility – to press forward, upward onward together to those loftier goals of better health and well-being for all Dr. Pearl McMillan Ministry of Health & Wellness viii VOLUME 1 Message From PAHO/WHO Country Representative Non-communicable diseases (NCDs) are a major health burden, causing much morbidity, mortality and disability globally.

NCDs are estimated to be responsible for over 70% of all deaths in the world.
NCDs also threaten to overwhelm health systems, and have high socio- economic costs associated with them.

As such the prevention and control of NCDs is vital to sustainable development in all countries.

NCDs tend to be of long duration and are the result of a combination of genetic, physiological, environmental and be- havioural factors.

However, the rise of NCDs has been driven by primarily four major risk factors: tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets.
Persons throughout the life course, from children, to adults, to the elderly are all vulnerable to these risk factors.

The control of these risk factors is therefore an important focus for the prevention and control of NCDs.

Surveillance, particularly measuring and monitoring trends, of these common risk factors for NCDs is essential for guiding policy, priorities and programmes aimed at reducing these common modifiable risk factors.
The World Health Organization (WHO) STEPwise approach to NCD risk factor surveillance (STEPS) is a simple, standardized method for collecting, ana- lysing and disseminating data on key NCD risk factors.

It facilitates routine monitoring of the risk factors within a country over time, as well as comparisons among countries.
The Pan American Health Organization (PAHO)/WHO was pleased to provide technical assistance to The Bahamas when it conducted its first STEPs survey in 2011-2012 and is equally pleased to have been able to provide support for this survey conducted in 2019.

PAHO/WHO congratulates The Bahamas on completing this second STEPS survey and publishing the survey report, which provides important information on the key risk factors for NCDs in the country.
The findings and recommendations will be essential to the development of evidence-based policies, programmes and interventions to combat the increasing health, economic and development burden due to NCDs.

PAHO/WHO is committed to continuing to provide technical cooperation to The Bahamas in this regard and to raising political and public awareness and understanding of the burden of the most common NCDs and their related risk factors.
We look forward to working together with the country across sectors, and in collaboration with other partners, to reduce the risks and burden of NCDs to improve the physical, mental, and social wellbeing for the people of The Bahamas.

Eldonna Boisson PAHO/WHO ix BAHAMAS NCD RISK FACTOR REPORT ACKNOWLEDGEMENTS The Ministry of Health (MOH) is deeply grateful to all Specialist, NCD Monitoring and Surveillance), both of participants in the STEPS Survey.
Without their valuable whom were instrumental in providing direct technical cooperation, this undertaking would not have been a support in the project planning, training, data management success.

and analysis phases.

Current and former executive leaders of the MOH, Planning and executing a survey of this magnitude is no including Dr.

The Hon.

Michael Darville as well as Dr.

The small undertaking, therefore, the work of the planning Hon.

Duane Sands and The Hon.


Renward Wells, present committee is indeed noteworthy.

In this regard, great and immediate past Ministers of Health, respectively, and appreciation is expressed to Dr. Cherita Moxey (Principal Dr. Pearl McMillan, Chief Medical Officer, are commended Investigator/Project Lead); Camille Nairn (Epidemiologist); for their vision and recognition of non-communicable Dr. Keva Thompson (former PAHO NCD Consultant); diseases (NCDs) as an important health concern.
These Britney Jones (former PAHO Consultant); Annouch individuals have demonstrated unrelenting support for Ambrister (Administrative Cadet); Cypreanna Winters, research to better understand the extent of the burden (Statistician, Bahamas National Statistical Institute); of NCDs and their risk factors in The Bahamas.
This is greatly appreciated given that the results will go a long Sincere gratitude is extended for all of the significant work way to increase understanding about these patterns in of the principal writer of the report, Dr. Cherita Moxey, The Bahamas.

Additionally, policies emanating from the as well as contributing writers for Volume II – Cypreanna findings will be targeted toward reducing the impact of Winters and Britney Jones.

Profound gratitude is extended NCDs and related factors in the population.
to Glenise Johnson (Epidemiologist) and Camille Nairn for the additional data analyses performed.

The execution of the 2019 STEPS Survey was made possible through the generous conducting provision of Finally, heart-felt thanks to all of the supervisors, technical and financial support by the Pan American interviewers, support staff, and the entire survey team, Health Organization/World Health Organization (PAHO/ including those whose names may not have been WHO).
We are indebted to the PAHO/WHO Bahamas mentioned specifically, for their much-valued commitment Office under the leadership of Dr. Eldonna Boisson and to the project.

Dr. Esther de Gourville, current and former PAHO/WHO May The Bahamas flourish as a nation rich in good health!

representatives, respectively, for their commitment to this exercise.
Warm gratitude is expressed to PAHO’s NCD Surveillance team at the Washington D.C., U.S.A., office led by Dr. Roberta Caixta (Advisor, NCD Surveillance, Prevention and Control), and Dolores Ondarshu (NCD x VOLUME 1 ABBREVIATIONS ACS ASI BAC American Cancer Society Age-standardized incidence SBP SDH Systolic blood pressure Social determinants of health Blood (or breath) alcohol concentration SDGs Sustainable Development Goals BBSQ Bahamas Bureau of Standards SSBs Sugar-sweetened beverages STEMI ST elevation myocardial infarction TV UN Television United Nations WHO World Health Organization WHR Waist-to-hip ratio BMI CPI CVD CWD DALY DRE DM DSP Body Mass Index Consumer price index Cardiovascular disease Caribbean Wellness Day Disability-adjusted life years Digital rectal examination Diabetes Diastolic blood pressure ESRD End-stage renal disease FCTC Framework Convention on Tobacco Control Gross domestic product Healthy Bahamas Coalition Health-In-All Policies Human papillomavirus Hypertension GDP HBC HiAP HPV HTN mg/dL Milligrams per deciliter MI Myocardial infarction mmHg Millimeters of mercury MoHW Ministry of Health & Wellness NIB National Insurance Board NCDs Non-communicable diseases NPDP National Prescription Drug Plan NHI National Health Insurance PAHO Pan American Health Organization PSA Prostate specific antigen RBPF Royal Bahamas Police Force RTA RR Road traffic accident Risk ratio xi BAHAMAS NCD RISK FACTOR REPORT EXECUTIVE SUMMARY RATIONALE Non-communicable diseases (NCDs) continue to plague societies worldwide, despite the fact that eighty per- Not only are more Bahamians dying today from NCDs than any other disease category, they are dying at younger ages.
There is a twenty percent chance of a cent of these diseases can be prevented1.

NCDs have Bahamian dying early or prematurely from an NCD.

In a long duration and progress slowly; and its burden is fact, for 2019, The Bahamas was identified among the increasing rapidly and has significant social, econom- ic, and health consequences – disproportionately so countries in the Region of the Americas with the high- est probability of dying too young from an NCD.

The in developing countries.
Every minute globally, 28 lives probability in The Bahamas is 19.9% compared to the between the ages of 30 and 70 years are cut short Regional probability average of 14% (Costa Rica, 9.5% because countries have not taken policy, legislative and at low end and Haiti, 31.3% at the high end)7. regulatory measures to respond to the needs of people living with or at risk of cardiovascular diseases, cancers, From a quality of life perspective, the evidence is equally diabetes, chronic respiratory diseases, or mental health clear.
When examined in the context of disability-ad- conditions, including preventive, curative, palliative, and justed life years (DALY), NCDs in 2019 were responsible specialized care2.

The evidence is clear.

In 2005, the major NCDs ac- for 1·62 billion DALYs, an increase from 43.2% in 1990 to 63.8% of total DALYs in 20198.
DALY combines infor- mation about morbidity and mortality to give a measure counted for 60% of all deaths globally, and 47% of the of health burden, including both reduction in healthy global burden of disease3.

By 2019 this rose to 71%4 of years (due to disease or disability) and diminished quality all deaths.

And by 2030, is expected to jump to 75%.

of life.

One DALY is equivalent to the loss of one healthy In fact, deaths due to NCDs and their risk factors have year of living.
It is estimated that, for a person with an increased by 30.8% in the two-decade span between 2000 and 20195.

This upward trend is mirrored in The Bahamas with the proportion of major NCD deaths NCD, three out of every four years lived with the disease will be lived with a disability due to the disease9.

(such as diseases of the heart, cancer, cerebrovascular NCDs also carry economic and societal costs, which are disease, diabetes and chronic lower respiratory disease) borne by the whole of society.
Research contends that compared to all other deaths moved from 51.5% to 55.1% (a 7% increase) for the period 2000 to 20156. the cost of NCDs conservatively represents 48% of the global gross domestic product (GDP) of countries10.

1 https://ncdalliance.org/why-ncds/NCDs#:~:text=An%20estimated%20 80%25%20of%20NCDs,are%20a%20sustainable%20development%20 issue.
https://www.who.int/teams/noncommunicable-diseases/on-the-road-to-2025 2 3 WHO StepWise Implementation Guide 4 https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/ncd-mor tality#:~:text=Noncommunicable%20diseases%20(NCDs)%20kill%2041,71%25%20 of%20all%20deaths%20globally.
5 Source: https://www.who.int/data/gho/data/indicators/indicator-details/GHO/ gho-ghe-ncd-deaths-in-thousands To address the societal threat of NCDs and change 7 https://www.paho.org/en/enlace/risk-dying-prematurely-ncds#:~:text=Saint%20 Vincent%20and%20the%20Grenadines,Bahamas%3A%2019.9%25 8 https://www.healthdata.org/results/gbd_summaries/2019/non-communica ble-diseases-level-1-cause#:~:text=Summary%20Non%2Dcommunicable%20dis eases%20(NCDs,of%20total%20DALYs%20in%202019.
9 https://ncdalliance.org/why-ncds/NCDs?gclid=Cj0KCQjwvZCZBhCiARIsAPXbajuX 7Mq04panWR06pL0Ke_-S5BTpDox2PaiMeDHuMUfWIiTGn_s0jkAaArJgEALw_wcB 10 https://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNon- 6 Health Information and Research Unit, Ministry of Health & Wellness.

CommunicableDiseases_2011.pdf 1 VOLUME 1 course towards improved health and well-being of a sure.
nation, targeted unapologetic interventions and policies c) To measure the prevalence of biological risk driven by current and country-specific evidence is key.
factors (body mass index and sodium intake as The population-based STEPwise survey conducted in well as raised blood pressure, blood glucose 2019 serves as a gateway to understanding the burden and cholesterol) of NCDs in The Bahamas, track NCD risk-factor trends d) To assess effectiveness of the national health and inform NCD policies as well as strengthen linkages system response in terms of early detection, from data to action on NCDs at the country level.

and treatment of targeted CVD risk.


SIGNIFICANCE OF STEPS 2019 The WHO STEPwise approach to non-communicable disease risk factor surveillance provides a standard- ize framework for collecting and reporting on 25 key e) To assess coverage, availability and use of screening for breast, cervical, prostate and colorectal cancers.

f) To assess oral health practices among the adult population.

indicators outlined in the Global NCD Monitoring Frame- g) To assess key suicide-specific indicators.
work, ratified in 2013 by Member States with the goal to achieve those indicators by 2025.

STEPS serves to quantify the direction (trends), magnitude (impact) and h) To assess prevalence and types of violence and injury.

To support targeted planning and objective evaluating of rate of progress on these and other indicators, which NCD policy and programme interventions.

can catalyze the integration of relevant regulatory, legis- lative, policy and multi-sectoral actions.
It also provides insight to the appropriateness and adequacy of the METHODOLOGY The STEPwise Framework to NCD risk-factor surveillance response; as well as the scope, comprehensiveness (abbreviated to STEPS) methodology was used and and applicability of health service delivery along with the adapted.

STEPS is a WHO-developed, cross-sectional, effectiveness of NCD policies and interventions.
population-based, standardized but flexible framework a) Executions of NCD risk factor surveys in The for countries to monitor the main NCD risk factors Bahamas have been cyclical, conducted in through socio-demographic and behavioural risk factors 2005, 2012 and the latest 2019.

The goal (STEP 1); physical measurements (STEP 2); and bio- across cycles is consistently to assess the chemical measurements (STEP 3).
Each step consisted prevalence of selected NCD risk factors among of core mandatory components, which were augmented adults living in The Bahamas.

Specific survey by expanded questions to capture more nuanced infor- objectives include: mation specific to the Bahamian context.
b) To describe the current levels of selected be- havioural risk factors in the population such as The 2019 survey cycle of STEPS in The Bahamas was harmful alcohol consumption, unhealthy diets, carried out from January 2019 to April 2019, across physical inactivity, and tobacco use and expo- seven (7) islands – New Providence, Grand Bahama, Ex- 2 BAHAMAS NCD RISK FACTOR REPORT uma, Abaco, Eleuthera (North), Cat Island, and Inagua.

AID global disease burden at that time11.


Since that time, There was compliance with standard ethical principles, the assault of NCDs (cardiovascular diseases, diabetes, including informed consent for the sample population.

cancer, chronic respiratory, diseases and mental health Data management principles were incorporated; and problems) has been unrelenting.

Now, NCDs account for collected data was weighted and analyzed in accor- 71% of all deaths globally12.
The NCD epidemic is fueled dance with the established methodology, using SPSS primarily by lifestyle choices such as physical inactivity, and programmes developed in EpiInfo version 3.5.4 by unhealthy diets, tobacco use and harmful alcohol use.

WHO for STEPS.
WHO for STEPS.

Of all these lifestyle choices, The Bahamas is showing The 2019 execution of the STEPwise Framework was promising strides in being sufficiently physically active – the first survey cycle to undertake a more detailed explo- with almost 70% meeting the sufficiently active criteria.

ration of the Bahamian diet relative to the prior cycles.
Notwithstanding this, for The Bahamas, the combination It was also the first time intimate partner violence (IPV) of lifestyle choices has catapulted our health standing to related questions were featured.

However, and unfortu- levels comparable with the more unhealthy populations nately, the IPV-specific questions attracted the lowest in the world.

With the STEPS 2019 findings, The Baha- responses.


mas now exceeds the regional prevalence (Region of the Americas) for overweight and obesity prevalence (71.1% RESPONSE RATE There were 2,365 respondents participating in the versus 62.4%), and hypertension prevalence (38.2% versus 18%).

The national prevalence of diabetes is STEPS 2019 Survey in The Bahamas (the sample size 11.5%, but an additional 6.8% are pre-diabetic.

was 3,840).
was 3,840).

The combined response rate for this pop- ulation-based survey was 61.6% for STEPS 1, 2 and 3.

Although tobacco use trends are decreasing in 150 For STEPS 1 and 2 alone, the response rate was 77% countries around the globe13, in The Bahamas tobacco for households.

These rates coupled with the weighting use is an increasing trend – rising by 145% over the of the data confer generalizability of the findings to the almost twenty-year period from 2000 (7.1%) to 2019 Bahamian population.

(17.4%).
(17.4%).

This current tobacco smoking prevalence also SYNPOSIS OF KEY SURVEY FINDINGS Non-communicable diseases (NCDs) were flagged as a public health threat from the mid-2000s; and by 2009 had attracted the attention of regional (Port of Spain Declaration on NCDs) and international (UN resolution on NCDs) health communities.

By 2014, NCDs had overtaken HIV/AIDS, accounting for fifty percent of the global disease burden compared to four percent HIV/ exceeds the regional average of 16.8%.
Diet is a potent driver of health.

Poor diet pave the path- way to malnutrition (in all its forms – including under- weight, overweight and obesity); to the main NCDs; and 11 Luna F, Luyckx VA. Why have Non-communicable Diseases been Left Behind?

Asian Bioeth Rev.

2020 March 20;12(1):5-25. doi: 10.1007/s41649-020-00112-8.
PMID: 33717328; PMCID: PMC7747415 12 https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseas es#:~:text=Noncommunicable%20diseases%20(NCDs)%20kill%2041,%2D%20 and%20middle%2Dincome%20countries.

13 https://www.who.int/about/accountability/results/who-results-rport-2020-2021 3 VOLUME 1 promulgating the obesogenic environment that exists in the point of being harmful to health and well-being.

Of The Bahamas.
Of The Bahamas.

In contrast, healthy diets pave a pathway added interest, females were two-times more likely to to longer lives lived in optimal health without disability engage in the harmful use of alcohol, while males were and with the desired quality; and serves a potent cautery more likely to engage in heavy episodic drinking.

of premature death from NCDs.


Taken together, there is significant co-occurrence of • STEPS 2019 showed that the Bahamian diet is driv- NCD risk factors within the Bahamian population.

Spe- ing the population towards more unhealthy states, cifically, 60.6% have between 1 to 2 NCD risk factors consuming too little fibre, and too much sugar and and an alarming 38.8% (or more than one-third of the salt.

Concretely, population) have 3 to 5 NCD risk factors.
The co-occur- • 85.3% of the population does not meet the mini- rence of risk factors for NCDs is more harmful to health mum daily intake/consumption of fruits and vegeta- than the presence of an individual risk factor.

These data bles; lend to The Bahamas’ population ranking high among • There are high rates of fried food consumption, countries whose population have a greater probability of with more than 50% of the population eating fried dying too young from NCDs.
The Bahamian population foods up to three times each week, and another also exceeded the regional average likelihood of dying 13% eating four or more days each week.

There is a early or prematurely from a NCDs (19.9% versus 14%).
three-times higher frequency in the daily consump- tion of fried foods for males (6.9% C.I 2.6 – 11.2) When disease was already present, STEPS 2019 high- compared to females (2.7% C.I 1.1 – 4.3); lighted that compliance with prescribed medication is • The consumption of free (added) sugars is alarming, low.

Looking across adherence to medication regimes with 60% of the population drinking at least 2 cans/ for diabetes, hypertension and hypercholesterolemia, bottles of a sugary beverage each day.
This is com- the average compliance rate was 43%.

Females are pounded by the practice of adding sugar to tea and/ more compliant than males.

A revelation of concern was or coffee.

Specifically, 53% of the population add that among previously diagnosed diabetics and hyper- between 2 to 3 spoonfuls of sugar; and tensives, and average of 60% sometimes substitute • On average, Bahamians consume double (10.5 their prescribed medication for bush/herbal remedies.
grams) the daily recommended (5 grams) amount of This may contribute to the low control rates for hyper- salt.

tension – less than 20% of known hypertensives on medication are controlled.
It is appreciated though that In addition to consuming diets that are more harmful health system integration, continuity of care, efficacy of to health, Steps 2019 revealed that a sizeable share pharmaceuticals and the role of the social determinants (44%) of the population engages in the use of alcohol to of health may be confounders influencing control rates.
4 BAHAMAS NCD RISK FACTOR REPORT The strength of the health system may also bear insight cent never had a faecal occult blood test; to the finding that 38% of respondents had clinical • Almost 80% of males between ages 45 to 69 years hypertension on physical measurement in STEP 2, but never had a prostate exam.

Admittedly, the survey had gone undiagnosed/undetected (that is, they have did not explore PSA testing prevalence; and hypertension but don’t know).
For respondents with • 43% of females age 45 – 69 years have not had diabetics that had also gone undiagnosed/undetected their breasts examined by a health professional in prior to the biochemical measurements in STEPS 3, it the 24-month period preceeding the survey.

For this was 6%.

STEPS 2019 underscores that there is room same age group and time period, 71% of females for improvement within the health sector to close the had not had a mammogram.
gaps between risk detection and disease confirmation to ensure early detection where prevention was not From a mental health perspective, the findings show that possible; and best control or management of disease.

males were twice as likely to contemplate suicide, but Room for improvement was also noted in maximizing females were four times more likely than males to make medical visits to potential influence health.

On average a suicide attempt.

and across multiple lifestyle modification themes (e.g.
advise to reduce sugar, salt and fat intake; advise to Oral health, though a paramount actor in overall health, maintain a healthy weight; advises to quit or not start had areas of neglect.

Case in point, in the year pre- smoking), less than 35% of STEPS survey respondents ceding the STEPS survey, only 30% of the population reported receiving any lifestyle advise from their health visited a dentist; and of those that did, only 45% was care professional during any visit in the last 12-months.
for a routine dental check-up.

Other reasons for the visit related to some acute dental problem.

And, although Health screening plays a pivotal component of a healthy daily flossing is strongly recommended to maintain good lifestyle and developing healthy habits, as it serves as oral and gum health, less than 50% of the population one mechanism to assessing health status and thereby flossed daily.
signaling when corrective action is needed to prevent onset of disease or for early detection of disease when The window that STEPS 2019 provided into health liter- it has already presented.

Unfortunately, despite the in- acy was small, suggesting a mismatch between health creasing burden of hypertension, diabetes and cancer in knowledge and healthy behaviour practices.

The survey the population, health screening practices do not match however did shed significant light in on the magnitude of the burden.
health inequities in the country.

NCDs risk factors were disproportionately prevalent in the lower income quin- • 91% of respondents between ages 45 to 69 years tiles as well as among the less educated, unemployed never had a colonoscopy and a similarly high pre- and married.

By way of example, statistical relation- 5 VOLUME 1 ships were found between biological sex and number of NCD risk factors.

Females (44.3%) more so than males (32.8%) have the co-existence/co-occurrence of 3 to 5 NCD risk factors.
More males (66.4%) than females (55.2%) have 1 to 2 NCD risk factors.

Based on risk calculation from the STEPS 2019 data, nearly 10% of the Bahamian population between ages 40 to 69 years have a 30% or higher chance of a car- diovascular event (heart attack or stroke) in the next 10 years.

This, coupled with the NCD risk factor profile and trends, makes clear that the health of the nation is off course and headed in the wrong direction.
Using current-state disease prevalence rates, preliminary cost scenarios estimate a conservative lifetime price tag of $8.6 billion to manage NCDs and their downstream complications.

This price tag along with the indirect costs, mortality and reduced quality of life associated with NCDs represent real threats to national develop- ment.

The STEPS 2019 survey findings give the eviden- tiary footing to prioritize upstream strategies to prevent the onset of NCDs.
Prevention through bold and target- ed policies and interventions is a more cost-effective and sustainable approach to disrupt the trajectory of NCDs in The Bahamas.

This report is being published at a time when inflationary pressures in the country are at an all-time high, and the country is recovering from two historical shocks – Hurri- cane Dorian and the COVID-19 pandemic.
6 BAHAMAS NCD RISK FACTOR REPORT KEY STUDY FINDINGS AND IMPLICATIONS SOCIODEMOGRAPHIC CHARACTERISTICS The average respondent was an employed, never married, Bahamian female between the ages of 18 to 44 years who has achieved at least a high school/sec- ondary education.

85.5% of respondents indicated The Bahamas as country of birth.

Key demographic data are presented in Image 1.

The male to female sex distribution in the study popula- tion is 1 :1.5.
In the general population this distribution is approximately 1:1.

Of note, more males (62.5%) than females (57.9%) reported ‘high school’ as the highest level of educational achievement.

The study did not further distinguish between high school diploma versus high school leaving certificate.

Image 1: Socio-demographic Characteristics of STEPS Respondents 7 VOLUME 1 The majority of respondents had never been married.
tion), from 92.46 in 2009 to 108.17 in 201915, suggests Marriage in the Bahamian society is not as common as that even employed persons may have reduced discre- it once was, and this is borne out in the STEPS 2019 tionary income and financial capacity to afford healthier data.
An examination of marriage and divorce by notable food options; co-pay or deductible for the cost of medi- psychologist, Barrington Brennen, highlighted that the cation to manage their diagnosed NCD conditions; or to number of people getting married each year from 1975 afford life-saving procedures – to name a few.

to 2005 had not grown despite population growth.


During this period, the marriage rate was incrementally A little over a third (34.1%) of respondents have private declining (from 5.6 per 1,000 to 5.3 per 1,000).

The health insurance – more females (35.4%) than males divorce rate was travelling in the opposite direction – (32.7%).
To ensure a wider segment of the population from 0.5 per 1,000 in 1975 to 2.1 per 1,000 in 200514. has access to health services they need, when and In 2010, twenty percent of marriages ended in divorce.
where they need them and without financial hardship, This family dynamic reality may have implications for National Health Insurance (NHI) – the national equiv- household income; stability of support systems; avail- alent of universal health coverage – was legislatively ability of time for food preparation and physical activity introduced in 2017.

From enrolment to the date of this and so much more.
report, about 30% of the population has enrolled with NHI and has access to a standard package of health Three-quarters (75.8%) of respondents are employed (in benefits.

2019, the Department of Statistics reported a national employment rate of 82.9%).

Seventy percent of re- The study sample drew from seven islands across the spondents self-reported annual household incomes of archipelago, representing the northern, central and $40,000 or less.
The paradox and confounder is, The southern Bahamas aligned with island poverty groupings Bahamas is one of the most expensive countries to live and the population density distribution of the country.

in worldwide.

It is widely accepted that the higher the cost of living, the lower the purchasing power.

Cost- of-living index for The Bahamas is 100.68.


Meaning, it is 68% more expensive to live in The Bahamas than a LIFESTYLE HEALTH RISKS Bahamians engage in health behaviours that carry higher risks for disease.

The leading four behavioral (also typical city.


And, the purchasing power is 71.40 – mean- called modifiable or lifestyle) risk factors for NCDs are ing persons living in The Bahamas with average salaries tobacco use, harmful alcohol consumption, physical can expect to buy approximately 30% less goods and inactivity, unhealthy diet (including low nutritional intake services.
This coupled with the year-on-year increases in and poor dietary habits) which can lead to overweight the national consumer price indices (a measure of infla and obesity.

These behaviours are predictable and prov- 14 The Bahamas Department of Statistics, re-named the Bahamas National Statistical Institute en precursors to raised blood pressure (hypertension), raised blood glucose (diabetes), and abnormal blood 15 The Bahamas Department of Statistics Consumer Price Index Report (2019).
8 BAHAMAS NCD RISK FACTOR REPORT lipid profile (dyslipidemia).

It is well established that up simultaneous increases in the population’s average to eighty percent of CVD, Type 2 Diabetes Mellitus, and body mass index (BMI) across the region19,20.

A recent over one-third of cancers can be prevented by reducing survey21 in the Region shows that 50%–60% of respon- or eliminating these four modifiable shared risk factors16.
dents who reported consuming ultra-processed snacks in the past month did so for meal replacement, suggest- The extent to which these health-risk behaviours are ing displacement of traditional diets.

This is worrisome being practiced make the Bahamian adult population because population-based studies undertaken in the more unhealthy than healthy.

Findings from STEPS Region show that traditional diets (based on fresh or 2019 support this claim.
Less than one percent (0.7%) minimally processed foods, and dishes made from those of the population have no NCD risk factor, while 60.6% foods, plus culinary ingredients) have a lower content have between 1 to 2 NCD risk factors; and 38.8% of sodium, unhealthy fats, and free sugars and a higher (more than one-third of the population) have 3 to 5 NCD content of fiber, vitamins, and minerals than average risk factors.

The data confirms that, for the Bahamian ultra-processed products.
Additionally, traditional diets population, the older one gets the more likely he/she is tend to have better nutrient profiles than processed and to develop multiple NCD risk factors.

The greater share ultra-processed food products.

(51.9%) of those with 3 to 5 NCD risk factors was 45 to 69 years.

This is compared to those 18 to 44 years who An inverse relationship between dietary risk factors and bear the greater share (69%) of those with 1 to 2 NCD NCDs22.
Diets low in fibre, whole grains, legumes, fruits risk factors.

Statistical relationships are demonstrated and vegetables as well as diets high in salt/sodium, between number of NCD risk factors and education unhealthy fats, added (free) sugars and processed foods levels and employment (see Health Equity section).

are considered high dietary risks.


Dietary Risk Factors In the Region of the Americas there has been a rapid replacement of unprocessed or minimally processed foods and freshly prepared dishes by ultra-processed products.

For example, the relative contribution of Fruits and vegetables are deemed good sources of fibre and other essential minerals and vitamins.

To achieve the benefits of these food items, it is recommended that a minimum of 5 servings be incorporated into daily meals.
Very few Bahamians come close to this.

Specifi- ultra-processed products to the overall energy supply of cally, families increased from 19% to 32% in Brazil between 1987 and 200817; and from 24% to 55% in Canada between 1938 and 200118.

These changes parallel the 16 World Health Organization .

Action Plan for the Global Strategy for the Preven- tion and Control of Non-communicable Diseases The six objectives of the 2008- 2013.

2008. p. 48.

17 Martins AP, Levy RB, Claro RM, Moubarac JC, Monteiro CA.
Increased contribu- tionof ultra-processed products in the Brazilian diet (1987–2009).

Rev Saude Publica.2013;47(4):656–65.

tionof ultra-processed foods and likely impact on human health: evidence from Brazil.

Public Health Nutr.

2011;14(1):5–13.

19 Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA.

Consump tion of ultra-processed foods and likely impact on human health.

Evidence from Canada.

Public Health Nutr.

2013;16(12):2240–8.


20 Crovetto MM, Uauy R, Martins AP, Moubarac JC, Monteiro C. [Household avail ability of ready-to-consume food and drink products in Chile: impact on nutri- tional quality of the diet].

Rev Med Chil.

2014;142(7):850–8.

21 Nielsen.

Snack attack: what consumers are reaching for around the world [In ternet].

New York: Nielson; 2014.

Available from: http://www.nielsen.


com/ us/en/insights/reports/2014/snack-attack-what-consumers-are-reaching-for- around-the-world.html 18 Monteiro CA, Levy RB, Claro RM, de Castro IR, Cannon G. Increasing consump- 22 https://onlinelibrary.wiley.com/doi/epdf/10.1111/jhn.12904 9 VOLUME 1 • 23.2% of respondents eat no fruits and/or limiting consumption of processed foods (52.8%); and vegetables using spices other than salt when cooking (61.2%).
A • 45.6% of respondents eat 1 to 2 servings daily component of STEPS 3 entailed the collection of 24- • 16.5% of respondents eat 3 to 4 servings daily hour urinary samples to analyze urinary sodium levels • 14.7% of respondents eat at least 5 servings (an objective biochemical measured).

Although the sam- daily.

ple was small, the test revealed that the average amount of salt consumed by each person, each day was 10.5 In other words, 85.3% of respondents do not meet the grams of salt.
This is double the WHO recommended daily recommendation for eating at least 5 servings of daily consumption of 5 grams of salt (2 grams of sodi- fruits and/or vegetables.

There was age disparity in this um) per day per person.

This equates to less than one finding.

Younger respondents (those 18 – 44 years) eat (1) teaspoon of salt per day.

The physiologic requirement less daily servings when compared to older respondents for salt is less than one (1) gram per day23.
who eat at least 3 to 4 servings of fruits and/or vegeta- bles each day.

Latin American and Caribbean (LAC) countries con- sume excess dietary sodium.

The major food culprits STEPS 2019 found that a statistical relationship exists were identified in a 2019 study24 within selected LAC between income and adequacy of fruit and vegetable in- countries.

Specifically, the highest median sodium levels take.
Ninety-two percent (92%) of persons with income in packaged foods were among condiments (7778 less than or equal to $20,000 eat fewer than 5 servings mg/100 g), processed meats (870 mg/100 g), mayon- of fruits and vegetables per day, compared to 80% of naise (755 mg/100 g), bread products (458 mg/100 g), persons with income over $60,000.

Additionally, there cheese (643 mg/100 g), and snack foods (625 mg/100 was an observed statistical relationship between income g).
Diets high in sodium and low in potassium are linked and average number of meals eaten each day.

As in- with greater incidence of hypertension, heart disease come level increase so did the likelihood of eating three and stroke.

meals per day.

Those who earn $20,000 or less eat on average two meals each day.

More important than the number of meals is the nutritional quality of the meal(s) eaten.

However, this was not assessed in the survey.

Most of the sodium consumed comes from salt.


Seventy percent (70%) of respondents self-reported consum- ing ‘just the right amount’ of dietary salt, while 24.8% reported consuming far too much and too much salt.

Respondents also self-reported taking measures to con- trol salt intake/consumption.

These measures included 23 Webster J, Trieu K, Dunford E, Hawkes C. Target salt 2025: a global overview of national programs to encourage the food industry to reduce salt in foods.

Nu- trients.
Nu- trients.

2014 Aug 21;6(8):3274-87. doi: 10.3390/nu6083274.

PMID: 25195640; PMCID: PMC4145308.

24 Arcand J, Blanco-Metzler A, Benavides Aguilar K, L’Abbe MR, Legetic B.

Sodium Levels in Packaged Foods Sold in 14 Latin American and Caribbean Coun- tries: A Food Label Analysis.

Nutrients.

2019 Feb 11;11(2):369. doi: 10.3390/ nu11020369.

PMID: 30754646; PMCID: PMC6412284.


10 BAHAMAS NCD RISK FACTOR REPORT Not all dietary fats are created equal – some are healthy In addition, studies have associated the consumption of and others are harmful.

Good fats include monounsat- TFAs with an increased risk for other noncommunicable urated and polyunsaturated fats (e.g.

avocado, fish, diseases (NCDs) and related conditions such as ovarian sardine, and nuts are good sources of omega 3 fats).
cancer29, infertility, endometriosis, Alzheimer’s disease, Saturated fats (e.g.

red meat, cheese and coconut oil) diabetes, and obesity30.

Although the STEPS survey did fall somewhere in the middle.

Bad fats include industri- not investigate these specific types of dietary fats, it did ally made trans fats25 (e.g.

solid margarines and partially exam the frequency with which fried foods were con- hydrogenated vegetable oils).

Trans fats can be naturally sumed.


Fifty-five percent (55%) report eating fried foods occurring or can be industrially-produced.

Industrially-pro- 1 to 3 times each week compared to 8.3% who eat it duced trans fats are formed when fats or oils are modified 4 to 6 times each week; and 4.7% who eat fried foods by partial hydrogenation and, hence, occur in partially hy- daily.

What is also known is that healthy fat options can drogenated fats or oils (PHOs).
PHOs are used by manufac- be price prohibitive for the vast majority of the society.

turers to enhance the texture and to increase the shelf life of The measured average total blood cholesterol level of processed foods in an inexpensive way.

STEPS respondents was 153.1 mg/dL (discussed fur- Trans fats is characterized as the single most harmful fat in our diets26, and can harm health even in small amounts.
Consumption of trans fats significantly in- creases the risk of death from coronary heart disease by 28 percent27 because trans fats impact cholesterol level, through the primary mechanism of increasing LDL (bad cholesterol) and decreasing HDL (good cholester- ol).

For every 1% increase in daily energy obtained from TFAs, coronary heart disease mortality rises by 12%28.

ther under cardiovascular diseases).

The Bahamas is net importer of goods, importing more than 90% of its food supply.
The alarm in this statistic is not only around food security and sovereignty, but also a food quality.

Imported foods are currently not subject to routine standard controls for quality, acceptability nor nutritional value.

This current state, may compromise public assurances.

A recent independent study con- ducted in Jamaica tested for industrially produced trans- fat and saturated fats in foods.
The results of 300 25 Trans fats are harmful because they increases the amount of harmful LDL choles- terol in the bloodstream and reduces the amount of beneficial HDL cholesterol.

Trans fats create inflammation, which is linked to heart disease, stroke, diabetes, and other chronic conditions.

They contribute to insulin resistance, which increases the risk of developing type 2 diabetes.
26 http://www.wphna.org/htdocs/downloadsaug2012/12-08%20WN3%20Govt%20 action%20pdf.pdf 27 https://www.health.harvard.edu/staying-healthy/the-truth-about-fats-bad- and-good#:~:text=For%20long%2Dterm%20health%2C%20some,fall%20some- where%20in%20the%20middle.

28 Pearson-Stuttard J et al.

Cost-effectiveness analysis of eliminating indus- trial and all trans fats in England and Wales: modelling study.

J Pub Health 2017;39(3):574-582. doi: 10.1093/pubmed/fdw095.

11 29 Yammine S et al.


Dietary and circulating fatty acids and ovarian cancer risk in the European Prospective Investigation into Cancer and Nutrition.

Cancer Epidemiol Biomarkers Prev 2020;29:1739-49. doi: 10.1158/1055-9965.EPI-19- 1477.

30 Downs SM, Bloem MZ, Zheng M, et al.

The Impact of Policies to Reduce trans Fat Consumption: A Systematic Review of the Evidence.

Curr Dev Nutr.

2017;1(12):cdn.117.000778.

Published 2017 Nov 13. doi:10.3945/ cdn.117.000778.
VOLUME 1 samples tested showed that 40% had trans fats, and Globally, 63 countries have adopted iTFA regulations, half of those with trans fats were labelled by the manu- of which 46 are best practice policies (dark green areas facturers as trans-fat free.

in Image 2) – indicating that the elimination of iTFAs is economically, politically and technically feasible.

The Bahamas currently has no iTFA regulation or policy.

Image 2: Map of Countries with iTFA Regulations.


Source: WHI TFA Country Scorecard31 31 https://extranet.who.int/nutrition/gina/en/scorecard/TFA 12 BAHAMAS NCD RISK FACTOR REPORT In exploring dietary sugar intake, the STEPS 2019 gave can Heart Association has an even lower threshold: important insights on quantity and frequency of added • For men, no more than 9 teaspoons (36 grams or (free) sugar32 consumption – that is, sugar not naturally 150 calories) per day occurring in foods.
• For women, no more than 6 teaspoons (25 grams • 53.1% of respondents added between 2 to 3 kitch- or 100 calories) per day en spoons of sugar when preparing a hot beverage (e.g.

tea and coffee); and an additional 7% added Just one (1) sugary drink easily puts an individual at or four or more spoons; over this 10% threshold35.

Given that the Bahamian diet • 33.2% of respondents eat sweets (e.g.
baked is traditionally energy (calorie) dense and nutrient poor, goods, pastries, chocolate, candies, ice-cream) a it begs that many far exceed this recommended 10% minimum of two days each week; threshold.

Literature creates a profile of adults and ado- • 92.7% of respondents consume sugary sweetened lescents who are more likely to be frequent consumers beverages (SSBs).

This consumption occurs with of sugary drinks.


The profile that emerges is adults and varying frequency – 30.7% of respondents drink adolescents who smoke, don’t get enough sleep, don’t SSBs everyday, and an additional 28.5% drink exercise much, eat fast foods often and who do not eat SSBs between 2 to 3 days each week; and fruits regularly drink more sugary beverages36.

• Between 1 to 3 bottles or cans of a sugary drink are consumed on a daily by 92% of respondents.
SSBs are a leading source of added (free) sugars and accounts for at least half of the discretionary calories in today’s diet33,34.

Generally, every 8 ounce of an sugary drink contains 26 grams of added sugar.

It is worth noting that the SSB cans/bottle sizes predominantly available in the Bahamian market are at minimum of 12 ounce, which approximates 39 grams of added sugar for each 12 ounce can/bottle.

Data from the Department of Customs brings further illumination on SSBs in The Bahamas.
Between 2007 The national sugar consumption pattern emerging from and 2018, the annual average import volume of the STEPS data becomes worrisome particularly in view • Non-alcoholic beverages (specifically, fruit juices, of WHO recommendations that sugar consumption in malt beverages and other fermented beverages adults (from all sources) should be no more than 10% of such as cidar) was 5.31 million gallons.
This means total energy (or calories) consumed each day (which is every individual in the Bahamian society consumed equivalent to no more than 10 teaspoons).

The Ameri- 32 Free sugar refers to all sugar added to foods or beverages (WHO).
33 https://www.cdc.gov/nutrition/data-statistics/sugar-sweetened-beverages-in- take.html 34 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228983/ an average of 14 gallons (or 1,792 ounces) of SSBs 35 WHO recommended energy (calorie) intake for males is 2,500 and females is 2,000.

36 Park S, Pan L, Sherry B.

Consumption od sugar-sweetened beverages among US adults: Behavioural Risk Factor Surveillance, 2011.

Prev Chronic Disease 2014;11:E65.


13 VOLUME 1 each year which equates to 5,824 grams of added ages and ‘sweets’.

These habits are disproportionately sugar37 to the dietary intake.

This per person yearly skewed more towards males than females.

volume may be lower given the country’s tourist numbers.

Nutritional practices as early as infancy and through • Breads, pastry and cookies was 2.51 million childhood and adolescence are shapers of one’s health pounds; profile in adulthood.
Breastfeeding, though not explored • Candy and gum were 1.32 million pounds; and in STEPS, have been associated in cohort studies with • Chocolate bars were 385,093 pounds.

reduced adult serum cholesterol concentrations, isch- Notwithstanding SSB consumption and consumption of ri infection38.
Breastfed babies have a reduced likelihood other food items with added sugar, water intake among of obesity, type-2 diabetes39 and reduced odds of hav- STEPS respondents was encouraging with 79.1% of re- ing more severe depressive symptoms in adulthood40.

spondents drinking at least seven glasses of water daily.

Globally, only 38% of infants aged 0 to 6 months are aemic heart disease mortality and Helicobacter pylo- exclusively breastfed41.
The global target is to reach 50% There was noteworthy contrast in data available on by 2025.

In the Bahamas, the exclusive breastfeeding meals prepared in the home versus meals eaten from rate for the first four months of life was 2% in 1998; and a fast-food or restaurant.

Respondents in STEPS 2019 7% in 2001.

In 2022, the national breastfeeding rate indicated that 87% of their meals eaten are prepared at (whether exclusive or not) was 18.7%42.

home – there were no age or sex variances.


This was an unexpectedly high percentage given the visibly mush- rooming fast-food industry, road-side and pop-up food Tobacco Use As A Risk Factor Although the Region is observing that smoking is no vendors.

The Bahamas Household Expenditure Survey longer a male-dominated practice, in The Bahamas ten (2013) reflected 64.1% of the population ate from a fast- times more males (32.4%) smoke than females (3.6%).
food eatery between 1 to 3 times per week – the poor The prevalence of current tobacco smoking among (77.9%) more so than the non-poor (62.4%).

STEPS 2019 respondents was 17.5%.

In 2005 (STEPS 2005) the current tobacco prevalence of 7.1%.

There Diets (what we eat) are potent drivers of health.
Poor are only five (5) countries in the Region of the Americas diets pave pathways to malnutrition and disease; while with higher current tobacco smoking prevalences than healthy diets pave pathways to enhanced quality of life The Bahamas – United States (20.3), Argentina (21.9), and cauterizes premature death.
What comes into sharp Uruguay (22.5), Cuba (27.8) and Chile (49.0)43. focus from the STEPS 2019 data is that Bahamians have unhealthy/poor dietary habits characterized by too little fruits and vegetables, too much salt, too much fat and too much consumption of sugar-laden bever- 37 One (1) gram of sugar contains four (4) calories and no nutritional value.
38 https://fn.bmj.com/content/87/3/F193 39 Kelishadi R., Farajian S. The protective effects of breastfeeding on chronic non-communicable diseases in adulthood: a review of evidence.

Adv.

Biomed.

Res.

2014;3:3.

40 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4957542/ 41 Exclusive breastfeeding is defined as the practice of only giving an infant breast- milk for the first 6 months of life (no other food or water).
42 https://bit.ly/3s4lMWH 43 PAHO Core Indicators 2019 14 BAHAMAS NCD RISK FACTOR REPORT Among current smokers participating in the STEPS In the 1930’s, the electronic cigarette (e-cigarettes) 2019 survey, smoking initiation was at age 19 years; was patented but not commercialized.

E- cigarettes and 44% smoke everyday.

Almost seventy percent were introduced to the China, U.K. and U.S. markets (67.3%) of current smokers smoke at least five (5) cig- in 2003, 2006 and 2007, respectively.
Although e-cig- arettes on a daily basis; and 32.8% smoke four or less arette smoking has become increasingly more popular cigarettes each day (Image 2).

The literature points to than conventional/combustible cigarettes (c-cigarettes) increased risk of ischemic heart disease, cancers oral in these markets, uptake has been slower in the Ba- disease, death and other health consequences with hamian adult population.

Almost two percent (1.5%) of smoking 1 to 2 cigarettes per day.
Relative risk in- respondents report using e-cigarettes and/or vaporizers creases with the amount smoked, duration of smoking, (males,2.5%; females,0.5%).

This low prevalence may earlier starting age and tar level44.The highest proportion be a reflection of the age range of the sample population of current daily smokers was in the lowest income level.
(18 to 69 years) given that global studies suggest that However, the difference by income level was not statis- e-cigarette smoking is more popular among person 18 tically significant.

Forty-five percent of current smokers years or less.

have tried to quit smoking but have not yet achieved success.
Image 3: Daily Quantity of Cigarettes Smoked 44 https://bmccancer.biomedcentral.com/articles/10.1186/1471-2407-12-385#ci- teas 15 VOLUME 1 Seventy-one percent (71%) of respondents report have never smoked tobacco or tobacco products.

Yet, an in- Harmful Alcohol Use As A Risk Factor Those who have ever consumed alcohol (65.6%) are creasing number of persons are being exposed to SHS.

more than double those who are life abstainers (29.3%).
In The Bahamas, secondhand smoke (SHS) exposure Almost half (49.5%) of those who have consumed alco- between 2012 and 2019, increased from 7.7% to 12.1% hol classify as current alcohol drinkers46.

This represents in homes; and from 11.3% to 17.4% in workplaces.

an 8.8 percent point increase from the STEPS 2012 Numerous studies have concluded that SHS is harmful findings for current alcohol drinkers.

Major shocks such to non-smokers.


Using statistical modeling, estimates as Hurricane Dorian, public health threats and life crises of relative risk of the health consequences from SHS could impact this prevalence in future studies.

have been documented.


Pregnant women exposed to SHS are at 57% higher risk of premature delivery; and if Current drinkers convey drinking a maximum of four the pregnancy is carried to term, at 38% higher risk of standard drinks on each occasion they consumed delivering a low birth weight newborn.

Infants exposed alcohol.


One standard drink is 10 grams of pure alcohol, to SHS are at a 55% increased risk for developing acute which is equivalent to 250ml of beer, 230ml of alcoholic lower respiratory infections requiring hospitalized in the cider or 100ml wine or 31ml of distilled spirits.

first two years of life.


Non-smoking females exposed to SHS are at a 68% increased risk of developing breast Current drinkers were grouped as follows depending on cancer before menopause; and for any breast cancer their reports of alcohol consumption – type, the risk is 25% higher.
In the adult non-smoking • Category I47 drinkers accounted for 56% of current population exposed to SHS there is a 82% increased drinkers, risk of stroke and 27% increased risk of ischemic heart • Category II48 drinkers accounted for 33.6%, and disease.

SHS worldwide contributes to 0.7% of the total • Category III49 drinkers accounted for 10.5%.

burden of disease, and represents about 12% of deaths and 19% of DALYs45.
The Bahamas signed the Framework Convention for Tobacco Control (FCTC) on 29th June 2004 and ratified it on 3rd November 2009.

The Tobacco Control Bill was initial drafted in 2014 and underwent revisions in 2018; it remains in draft.

Categories II and III are associated with harmful use of alcohol.

This means that 44.1% of current drinkers consume alcohol to a point it is considered harmful.
Although a male is 1.4-times more likely to be current drinker than a female, a female is 2-times more likely to consume alcohol to the point it is considered harmful (males, 29.9%; females, 62.6%).

46 ‘Current’ the last 30 days.

47 Category I, low-level drinking, is defined as drinking <40g of pure alcohol on average per day for men and <20 for women.
48 Category II, intermediate-level drinking, is defined as drinking 40-59.9g of pure 45 https://apps.who.int/iris/bitstream/handle/10665/44426/9789241564076_eng.

alcohol on average per day for men and 20-39.9g for women.

pdf 49 Category III, high-level drinking, is defined as drinking ≥60g of pure alcohol on average per day for men and ≥40g for women.
16 BAHAMAS NCD RISK FACTOR REPORT Eighteen percent of drinkers meet the definition of a heavy episodic drinker (they drink at least 5 drinks per Physical Inactivity As A Risk Factor To maintain good health, WHO recommends adults con- occasion at least monthly).

The sex variance is reversed sistently engage a certain level of activity52 each week: for heavy episodic drinking (males, 23.1%; females, • 150 minutes of moderate-intensity physical activity; 12.5%).
OR • 75 minutes of vigorous-intensity physical activity.

Of all drinkers, 85.7% reported being able to self-regu- late and control the amount of alcohol consumed; and STEPS 2019 revealed that 30.2% of respondents did with the vast majority (94.7%) never needing a first drink not engage in sufficient physical activity (i.e.

were not during the morning hours to get their day started.

active or active for less than 150 minutes) to promote Only 6% indicated that on a weekly or monthly bases good health.
There was a noted sex variance – females they were unable to do expected tasks/responsibilities (39.5%) compared to their male counterparts (20%).

because of their alcohol intake, compared to 92.4% who were able to perform and do what was expect- ed despite their intake.

But, alcohol consumption has the potential to impact more than just the user.
One- fifth (21.6%) of respondents drove a vehicle under the The usual amount of time (median) engaged in physical activity each day by males was almost 5-times that of the median for females – 180 minutes (males) versus 40 minutes (females).

The vast majority of the physical activity done was work-related, accounting for 49.4% of influence of alcohol.

Between 2017 and 2018, fatal road total activity.

A large proportion of respondents (74.3%) traffic accidents (RTAs) in The Bahamas rose by 29%50.
were employed as public servants, which represents an In this period, more than three times more males were opportunity for government agencies to set the pace killed than females.

Local studies to describe role of alcohol in fatal RTAs were constrained by the lack of breath and/or blood alcohol level testing at the time of the accident51.

Respondents reported relationship problems never and be forerunners in creating workplace policies that are conducive to health and well-being.
A similar performance is mirrored for vigorous-intensity activity, with 57.9% of respondents (males, 40.4% com- pared to females 73.9%) not meeting the recommended arose (95.5%), arose on frequencies less than monthly threshold.

This performance category represents a 20% (4.1%) and arose monthly or more frequently (0.5%) improvement over the STEPS 2012 level of 72.6%.

because of someone else’s drinking problem.

Respondents reported sleeping an average of 7.1 hours each day53, leaving 16 waking hours.
In those waking hours, they spent up to 24% of that time (or 231.4 minutes of the total 960 minutes) engaged in sedentary 52 This is the combination of all activity including work, organized sports, exercise 50 https://ewnews.com/29-increase-in-traffic-fatalities 51 https://journals.sfu.ca/cob/index.php/files/article/view/59/91 routines, activities during transport and leisure time.

53 STEPS 2019 Databook 17 VOLUME 1 activities.


Sedentary behaviour is defined as the amount Unhealthy body mass index (BMI) is another known con- of time spent sitting at work, during recreation and while tributing risk to poor health and poor health outcomes.

commuting.

Sedentary behaviour is inversely proportion- Height and weight, inputs for calculating BMI, were ate to health and well-being.

It has been documented measured in STEP 2.


And, an average BMI of 29.8 kg/ by Australian researchers that every hour spent watch- m2 was recorded.

A BMI equal to or greater than 30 kg/ ing TV is linked to an 18% increased risk of dying from m2 is classified as obese.

Further disaggregation shows: cardiovascular disease.
In a 2011 meta-analysis relative • 4.6% respondents being underweight risks (RR) of 1.20 for Type 2 Diabetes, 1.15 for cardio- • 23.8% respondents with normal body weight vascular disease, and 1.13 for all-cause mortality were • 27.9% respondents overweight (BMI 25 to observed for every 2-hour increase in TV viewing per 29.9 kg/m2) day.
In other words, every 2-hours of TV watching (sed- • 43.7% respondents obese (BMI greater than or entary behaviour) increases the risk of Type 2 Diabetes equal to 30 kg/m2).

and premature death by 20%, cardiovascular disease by 13%, and all-cause mortality by 20%54.

Further research Interestingly, sex variances were observed among the underscored those who watched more than 4-hours BMI categories.
For the overweight category, more of TV per day were at greatest risk for heart disease, males (30.2%) than females (25.8%) were overweight.

regardless of risk score and genetic predisposition55.

The converse was true for the obese category – females The Bahamas’ Household Expenditure Report (2013) (54.8%) versus males (31.8%).
The combined preva- noted that persons in The Bahamas spent on average lence of overweight and obesity in adults for The Baha- 3.1 hours per day during weekdays watching TV; and mas is 71.7% which exceeds the average prevalence of 3.7 hours per day on weekends.

It is possible that 62.4% for the Region of the Americas57.
these amounts may have increased since 2013 with the increasing appeal and popularity of other screen-time Waist and hip circumferences were also measured in activities such as gaming, YouTube, TikTok and online STEP 2.

For males, these measured 36.7 inches and self-help tutorials.

40.9 inches, respectively.

And, for females these mea- sured 37.6 inches and 43.6 inches, respectively.
The Unhealthy Weight As A Risk Factor waist-to-hip ratio (WHR), a modifier for cardiovascular Obesity prevalence in The Bahamas for 1989 and 2001 heart disease risk, averaged at 0.9 for both sexes.

were 21.3% and 30.9%, respectively56.

Twenty years Given that a healthy WHR for males is 0.9 or less; and later, the obesity prevalence has more than doubled.

for females 0.85 or less, female respondents were at a nominally higher risk for a cardiovascular event than male respondents.
54 https://jamanetwork.com/journals/jama/fullarticle/900893 55 Medical Research Council and Universities of Cambridge and Hing Kong - https:// scitechdaily.com/one-in-ten-cases-of-coronary-heart-disease-could-be-preven- ted-by-watching-tv-less-than-one-hour-a-day/ 56 Ministry of Health.

The National Health and Nutrition Survey (1988-1989).

57 Pan American Health Organization Core Health Indicators Data Tables, 2019.
18 BAHAMAS NCD RISK FACTOR REPORT Co-occurrence of NCD Risk Factors Taking all risk factors together, the image emerging is than male counterparts, with resultant better disease control.

Second, females tend to engage in less risky that a healthy Bahamas remains a conceptual ideal with behaviours.

Third, estrogen is a protective factor.

Fourth, only 0.7% having no NCD risk factors.

The co-occur- death due to violence is higher for males than females.
rence of risk factors for NCDs is more harmful to health than that of individual risk factor effects when they are added independently58.

There is a high prevalence of Regarding females, it is important to note that the single most prevalent risk factor was overweight/obesity.

This co-occurrence of NCD risk factors in The Bahamas with is particularly alarming as obesity has been observed as 60.6% having 1 to 2 risk factors; and 38.8% having 3 to a strong risk factor for multi-morbidity.
5 NCD risk factors.

The presence of 3 or more lifestyle risk factors was more is outpacing the Regional average for many of these frequent in women, older age groups (45-69 years), the behavioural risk factors (Image 3).

As an overview of all NCD risk factors, The Bahamas unemployed and those with a secondary education or less.

From STEPS 2019, the co-occurence of 3 or more NCD risk factors was higher in females (44.3%) than for males (32.8%).
This finding is inconsistent with what has been described in other countries, where men have more combined (or co-occurrent) risk factors59,60.

The higher prevalence of co-occurrent NCD risk factors among females is interesting, especially when Baha- mian women live longer than Bahamian men.

In the study year, life expectancy for females in The Bahamas was 76.1 years, compared to 71.7 years for males61.

A confluence of factors may account for this.


First, and as a sweeping generalization, females have better health-seeking behaviours than males; and tend to be more compliant with NCD management regimes 58 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6647087/ 59 Kelley, E. et al.

Cardiorespiratory fitness is inversely associated with clustering of metabolic syndrome risk factors: The ball state adult fitness program longitudinal lifestyle study.

Mayo Clin.

Proc.

Innov.

Qual.


Outcomes 2, 155–164 (2018).

60 Zwolinsky, S., Raine, G. & Robertson, S. Prevalence, co-occurrence and clustering of lifestyle risk factors among UK men.

J. Mens.

Health 12, 15–24 (2016).


61 PAHO Core Health Indicators (2019) 19 VOLUME 1 Image 4: Overview of NCD Risk Factor Prevalence in The Bahamas Compared to the Region of the Americas NON-COMMUNICABLE DISEASES PROFILE The constellation of NCD conditions are commonly referred to as the 5x5 diseases – cancer, cardiovascu- lar disease, diabetes, chronic respiratory diseases and mental health.

Insights on all, except chronic respiratory diseases, will be elaborated on in this section.
Cardiovascular Disease [Raised Blood Pressure and Raised Blood Cholesterol] Sodium is essential to human life., but its overconsump- tion (primarily through salt) carries substantial public health complications.

Recall, on 24-hour urinary sodium collection, readings showed that participants consumed double the amount of recommended salt in any giv- en day.

Layered on this, is the admission by 25.7% of respondents to ‘always or often’ eating processed, high salt content foods.
The additive effect likely contributes to the combined raised blood pressure prevalence62 of 38.2% - disaggregated as: • 29.4% have reading of SBP ≥ 140mmHg and/ or DSP ≥ 90 mmHg, and are classified as Stage I Hypertension.

The sex variance is males 33.1% to females 26%.

62 The JNC7 definition of hypertension (greater than 140/90 mmHg) was use in this survey.
It is appreciated that the ACC (American Academy of Cardiology) has a lower definition threshold for hypertension which is greater than 130/80 mmmHg.

20 BAHAMAS NCD RISK FACTOR REPORT • 8.8% have readings of SBP ≥ 160mmHg and/or In addition to those who have already had a cardiovas- DSP ≥ 100 mmHg, and are classified as Stage II cular disease (CVD) event, there are those at risk for Hypertension.

The sex variance is males 9.4% to experiencing a CVD event in the future.

STEPS 2019 females 8.3%.


calculated (using the WHO/ISH risk prediction) the The direct and indirect costs of increasd blood pressure 10-Year CVD risk ≥ 30%.

Nearly ten percent (8.2%) of are estimated to consume 5–15% of the gross domestic respondents between 40 to 69 years have a predicted product in high-income countries and 2.5–8.0% in Latin 30% or more chance of having a fatal or non-fatal car- America and the Caribbean63.
diovascular event (heart attack or stroke) in the next 10 The average total blood cholesterol level among respon- years.

This risk is higher for males (10.4%) than females dents measured 153.1 mg/dL.

The ideal total choles- (6.8%).

But, only 5.6% of respondents take aspirin terol targets levels lower than 200 mg/dL.

Twenty-four regularly to prevent or treat heart disease.
A little more percent (24.2%) of respondents have levels ≥ 190 mg/ than half (57.6%) of persons eligible64 for receiving drug dL; and another 4.3% have levels ≥ 240 mg/dL.

More therapy and counselling to prevent heart attacks and meaning could have been derived had the study budget strokes are actually receiving it.

permitted the measurements of LDL and HDL levels.

CVD accounts for 31 percent of all global deaths.


Poor cardiovascular health can cause heart attacks, Diabetes This survey examined and gave insight to impaired fast- ing glycaemia and raised blood glucose levels among strokes, heart failure, chronic kidney disease, peripheral participants.

Respectively, these are 6.8% and 11.5% arterial disease, and the onset of vascular dementia.
Nowadays, there is broad scientific consensus that high intakes of trans fats increase the risk of CVD which can - with no significant male to female differences.

Impaired fasting glycaemia (IFG) signals that the body may not be using the available glucose as efficiently as it should.

IFG eventually cause heart attacks, stroke and death.
Trans fat is also known as pre-diabetes – a prelude to diabetes if is an artificial compound that can be found in cakes, cookies, biscuits, packaged foods, cooking oils and corrective lifestyle changes are not employed.

The aver- age fasting blood glucose reading among participants is spreads.

WHO estimates that consumption of these fats 88.1 mg/dL.

Normal fasting levels blood glucose level is cause around 500,000 deaths per year due to coronary between 70 mg/dL to 100 mg/dL.
Raised blood glucose heart disease.

is consistent with the disease diabetes mellitus.

Almost ten percent (9.8%) of respondents had a person- al history of a heart attack or stroke – males, 12.2% and females, 7.6%.

This history was more prevalent in the 18 to 44 age group than the 45 to 69 age group.

Cancer STEPS 2019 explored cancer from a screening (dis- cussed later) and family history perspective rather than from a prevalence perspective.

Data from the National 63 World Health Organization.
Scaling up Action against NCDs: How much will it 64 Eligible is defined as age 40-69 years with a 10-year CVD risk ≥ 30%, including cost?

[Internet].

WHO; 2011, p. 17.

[cited 28 May 2021].

Available from: http:// apps.who.int/iris/bitstream/ handle/10665/44706/9789241502313_eng.pdf those with existing CVD.

21 VOLUME 1 Cancer Registry informs that the combined cancer prev- the rest of the world67.

WHO admonishes all countries alence (2019) was 182.4 per 100’000.
Stated differently, to accelerate action toward eliminating cervical cancer approximately 1 in every 500 Bahamians have been and to reach an incidence rate not greater than 4 per diagnosed with a cancer.

The individual prevalence of 100,000 population.

nationally tracked cancers is listed in Table 1.

A ready tool to eradicate cervical cancer is the HPV vaccine, which was introduced into the Bahamian im- munization schedule since 2015.
The vaccine is doc- umented to have exceptional protection (high efficacy and effectiveness) against HPV infection, genital warts, high-grade cervical lesions (CIN2+ and CIN3+)68 and invasive adenocarcinoma, more so when the vaccine is administered before sexual debut69.

The HPV virus does not only cause health problems in females, it can also cause genital, anal and oropharyngeal cancers in males.
Mental Health Human flourishing is a multi-variant theoretical construct based on five central domains – happiness and life Table 1: Cancer Prevalence in The Bahamas In The Bahamas, deaths from cancers (all types) have satisfaction; mental and physical health; meaning and been increasing year-over-year.

In 2000, the cancer mortality rate was 71.5 per 100,000 (or 13.6% of deaths).

In 2015, this rate stood at 111.7 per 100,000 (or 18.6%).
Cancer mortality rates are not available for 2019. purpose; character and virtue; and close social relation- ships70.

Stressors such as emotional exhaustion, rela- tionship strain and financial woes, among others, can manifest as new and exacerbate existing mental health illness, thereby diminishing the human flourishing index.

Special note is made of cervical cancer, which carries an unacceptable and disproportionately high disease burden65 considering 92% HPV-associated cancers are preventable66.
In the Bahamas in 2018, the age-stan- dardized incidence (ASI) of cervical cancer was 10.9 per 100,000, compared to an ASI of 13.1 per 100,000 for 65 Cervical cancer is the second most common female cancer in the Bahamas among those 15 to 44 years of age.

67 George C, Roberts R, Brennen D, Deveaux L, Read SE.

Knowledge and awareness of Human Papillomavirus (HPV) and HPV vaccines among Caribbean youth: the case of the Bahamas.

Hum Vaccin Immunother.


2020 Mar 3;16(3):573-580. doi: 10.1080/21645515.2019.1661205.

Epub 2019 Sep 23.

PMID: 31464555; PMCID: PMC7227632.

68 https://www.nejm.org/doi/full/10.1056/NEJMoa1917338 69 Kamolratanakul S, Pitisuttithum P. Human Papillomavirus Vaccine Efficacy and Effectiveness against Cancer.

Vaccines (Basel).

2021 Nov 30;9(12):1413. doi: 10.3390/vaccines9121413.

PMID: 34960159; PMCID: PMC8706722.


66 http://www.tribune242.com/news/2020/feb/25/hpv-guide-men-bahamas/ 70 https://hfh.fas.harvard.edu/measuring-flourishing 22 BAHAMAS NCD RISK FACTOR REPORT STEPS 2019 gives a small window into mental and Although there was a weak statistical relationship be- physical health domain; and an even smaller peak into tween educational level and having either considered, the social relationships domain.
Six percent (6.3%) of planned or attempted suicide, a stronger relationship respondents reported seriously contemplating suicide exists between income and having a history of planned within the 12-month period preceding the study.

Of or attempted suicide.

Weighted analysis indicates that these, 34.4% sought professional help.

More males 5.6% of persons with income level of $20,000 or less (8.7%) than females (4.1%) contemplated suicide.
In have had these suicidal tendencies compared to 1.4% other words, for every one female who considers sui- of persons with income greater than $60,000.

cide, there are two males with a similar consideration.

However, in moving from contemplation/consideration to Additional light is shed on mental states in the context making a plan to commit suicide, the observation is re- of binge or uncontrolled alcoholic drinking.
Respondents versed and for every one male who makes a plan, there who engaged in this practice cited an array of moods/ are seven females who do the same.

Once planned, feelings before taking the first drink on the binge oc- females are four times more likely to make a suicide at- casion – felt fine (63.2%), felt stressed/overwhelmed tempt than males.

Overall, 1.8% of STEPS respondents (27.4%) and lonely/unimportant (7.7%).
None of the (or close to 7,000 persons) shared having attempted respondents selected the ‘hopeless’ response option.

suicide at some point during their lives.

And, the same percentage had a close family member who died as the The quality and frequency of social relationships and result of suicide.

interactions (e.g.

family) impact mental well-being.


Family meal times should not simply be an event where WHO’s Suicide In the World (2019) reports a global food is prepared and consumed, but also a time for talk, age-standardized suicide rate of 10.5 per 100,000 bonding with and interaction between family members.

population.

The crude suicide rate in Bahamian society Having regular family meals has consistently been for 2019 was 3.5 per 100,00071.
Generally, males have associated with emotional health (e.g., lower depres- been found to have a disproportionately lower rate of sive symptoms) as well as better dietary intake (e.g., suicide attempts and an excessively higher rate of sui- increased fruit and vegetable intake), weight-related cides compared to females72.
The global age-standard- outcomes (e.g., lower weight status, less unhealthy ized suicide rate was 1.8 times higher in males than in weight control behaviors) in children and adolescents75.

females73.

According to the RBPF statistics, in 2020 the Additionally, a recent literature review on family meals male to female suicide ratio was 10:174.
71 https://www.macrotrends.net/countries/BHS/bahamas/suicide-rate 72 Freeman A, Mergl R, Kohls E, Székely A, Gusmao R, Arensman E, Koburger N, He- gerl U, Rummel-Kluge C. A cross-national study on gender differences in suicide intent.

BMC Psychiatry.

2017 Jun 29;17(1):234. doi: 10.1186/s12888-017-1398-8.

PMID: 28662694; PMCID: PMC5492308.


73 https://apps.who.int/iris/bitstream/handle/10665/326948/WHO-MSD-MER- 19.3-eng.pdf 74 https://thenassauguardian.com/suicides-rose-by-38-percent-in-2020/ 23 75 Fulkerson Ja, Larson N, Horning M, Neumark-Sztainer D. A review of associations between family or shared meal frequency and dietary and weight status out- comes across the lifespan.

J Nutr Educ Behav.

2014;46(1):2–19.

doi: 10.1016/j.

jneb.2013.07.012.


VOLUME 1 suggested that people benefit from family meals across then cancer (43.1%), stroke (28.9%), raised cholesterol the lifespan76.

(28.8%) and early81 heart attack (9.5%).

STEPS 2019 uncovered that respondents eat meals with other household members on average three (3) days each week.

This finding may give an indirect qualitative dimension to shifts in intergenerational family meal practices.
Opportunities for families to have meals together have been negatively affected by changes in our society and the frequency of family meals may be declining77, likely due to changes in parenting styles, limited time/busy schedules78 and low enjoyment of cooking79 - to name a few.
Family History of Chronic Diseases Family history (or health status of close relatives) reflects social, behavioural, and environmental factors that influ- ence health; and provides insights into the genetic risk of disease [as well as knowledge, attitude and practice predispositions]80.

Epidemiological studies show that a family history is a strong and independent risk factor for cardiovascular diseases, Type 2 Diabetes, and many cancers.
HEALTH-SEEKING BEHAVIOURS Theories on health seeking behaviours have evolved from the original focus of how the individual engages with services to how the individual engages with the sys- tem.

A widely held premise is that providing knowledge about causes of ill health and choices available, will go a long way towards promoting a change in individual behaviour – towards more beneficial health seeking behaviour.
However, there is growing awareness, in both developed and developing countries, that providing education and knowledge at the individual level is not sufficient in itself to promote a change in behaviour.

Preventive health screening is an example of health seeking behaviour.

Screenings (along with vaccinations) have long been advocated as one of the most important (and effective) health care strategies to facilitate early diagnosis and treatment, improve quality of life, and pre- vent premature death.
Case in point, some of the most common cancer types, such as breast cancer, cervical cancer and colorectal cancer, are largely curable if they Data from STEPS 2019 show that a family history of hy- are detected early and treated appropriately.

STEPS pertension ranked highest (72.1%) among respondents 2019 sheds new knowledge on health-seeking (screen- followed by family history of diabetes (51.6%), and ing) behaviours in the Bahamian population.

76 Skeer MR, Ballard EL.


Are family meals as good for youth as we think they are?

A review of the literature on family meals as they pertain to adolescent risk pre- vention.

J Youth Adolesc.

2013;42(7):943–963.

doi: 10.1007/s10964-013-9963-z.

77 https://southbahamasconference.org/newsblogpost.php?permalink=lo- gos-get-your-kids-moving-1665156629634046154ebfd634046154ec10 78 Fulkerson Ja, Kubik MY, Rydell S, et al.
Focus groups with working parents of school-aged children: what’s needed to improve family meals?

J Nutr Educ Behav.

2011;43(3):189–193.

doi: 10.1016/j.jneb.2010.03.006.

79 Neumark-Sztainer D, MacLehose R, Loth K, Fulkerson Ja, Eisenberg ME, Berge J. What’s for dinner?

Types of food served at family dinner differ across parent and family characteristics.

Public Health Nutr.

2014;17(1):145–155.

doi: 10.1017/ S1368980012004594.


Cancer Screening Forty-three percent (43%) of female respondents in STEPS 2019 between the ages of 45 – 69 years either never had a breast exam by a health professional or haven’t had one in more than two years (between 2018 80 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5257240/ 81 Early is defined as less than 55 years for males, and less than 65 for females.

24 BAHAMAS NCD RISK FACTOR REPORT and 2019).


For this same age group, 70.9% have either of men may facilitate informed decisions about prostate never had a mammogram or the last mammogram was cancer screening and improve patient satisfaction and more than two years ago.

outcomes82.

For cervical cancer, two-thirds (67.5%) of all female Regarding alternate screening options for prostate respondents (18 to 69 years) had been screened for cancer, STEPS 3 methodology did not require PSA cervical cancer.
For those specifically between the ages measurements, but it is believed to be more effective at 30 – 49 years, the rate for ever screened is 76.6%.

prostate cancer detection than DREs, though nuances Though cervical cancer screening rates are the highest do apply.

A meta-analysis showed overall sensitivity, of all cancer screening rates.
The uptake of the HPV specificity, and positive predictive value for PSA were vaccine in The Bahamas among males and females, is higher (72.1%, 93.2% and 25.1%, respectively) than not as encouraging.

The HPV vaccine was developed in those for DRE (53.2%, 83.6% and 17.8%, respective- 2006; and introduced into the national vaccine sched- ly) when used as a screening tool to detect prostate ule in 2015.

The availability and efficacy of this vaccine cancer83.
means that cervical cancer can be essentially eliminated and that death from cervical cancer can be a thing of Colon cancer screening rate among respondents the past.

aged 45 – 69 years is 8.6% (males, 5.3% and females, 12.5%).

Faecal occult blood screening prevalence for Nearly 80% of male respondents aged 45 – 69 years the same age group is 20.8% (males, 22% and females, never had a prostate exam (DRE or digital rectal exam- 19.5%).

Dimensions related to awareness of and cost ination).
Of the 21.5% that had the exam, many report accessibility for colonoscopy screening would need the exam was performed within the last two years.

interrogating.

Underlying this observation may be issues related to acceptability of DRE among men as well as the exis- Collectively, these sub-optimal cancer screening rates tence of other clinical screening options, specifically could reflect a disconnection between current lifestyle PSA blood testing.
Regarding acceptability, a systematic practices and the risk they pose as well as a disconnec- review found that men (3,029 men aged 18-89 years) tion between one’s family history and personal genetic are willing to participate in prostate cancer screening to predisposition; or health system accessibility challenges prevent cancer and gain reassurance about their health, (which are discussed later).

particularly when supported or prompted by their social networks or healthcare providers.
However, to do so they needed to mentally overcome fears of losing their masculinity and accept the intrusiveness of screening, the ambiguities about the necessity and the potential for substantial costs.

Addressing the concerns and priorities 25 82 James LJ, Wong G, Craig JC, Hanson CS, Ju A, Howard K, Usherwood T, Lau H, Tong A. Men’s perspectives of prostate cancer screening: A systematic review of qualitative studies.

PLoS One.

2017 Nov 28;12(11):e0188258.

doi: 10.1371/jour- nal.pone.0188258.


PMID: 29182649; PMCID: PMC5705146.

83 Mistry K, Cable G. Meta-analysis of prostate-specific antigen and digital rectal examination as screening tests for prostate carcinoma.

J Am Board Fam Pract.

2003 Mar-Apr;16(2):95-101. doi: 10.3122/jabfm.16.2.95.

PMID: 12665174.
PMID: 12665174.

VOLUME 1 Biochemical Screening Taking into account the total study sample, Bahamas; 145,347 adult hypertensives; 37,288 at risk increased for a stroke or heart attack; and a significant • 40% (equates 152,196 adults) never had their blood number who remain undiagnosed or, if diagnosed, not cholesterol measured (male, 44.1% and females, in care or adequately managed84.
Of males whose blood 36.1%); • 22.7% (equates 86,371 adults) never had their blood glucose measured (males, 27.6% and fe- males, 18.2%); • 6.9% (equates 22,254 adults) never received dental pressure measured and recorded at or above 140/90 mmHg (as per STEPS 2 protocol of clinical diagnosis), 41.7% had no clue – they had not been previously diag- nosed with hypertension.

For females, this was 34.6%.


care (males, 7.4%; females, 6.5%); Data on NCD detection rate show that 5.9% of respon- • 6.6% (equates 25,112 adults) never had their blood dents with diabetes went undetected/undiagnosed, pressure measured (males, 10.5% and females, 3%).

Taken together, the screening data for cancers and and were only alerted to having raised fasting glucose because of the biochemical tests done as part of the STEPS 2019 survey.
A significantly higher percentage (38%) of respondents with hypertension went unde- biomarkers suggest there is room for improvement.

The tected/undiagnosed prior to physical blood pressure data bolster the claim that men are less likely than wom- measurements done as part of the study (18-44 years, en to seek help from health professionals for diverse 53.9% and 45-69 years, 28.7%).

This means that health problems.


The study was not designed to explore almost 4 in 10 persons with raised blood pressure level factors that may impede men’s acceptability of or nor had gone undetected.

accessibility to available health screening services.

STRENGTH OF THE HEALTH SYSTEM TO DETECT AND APPROPRIATELY MANAGE NCDs Preventing disease onset is the guarantor of good phys- ical health.
In scenarios where disease is present, pre- mature deaths and disability from NCDs can be mitigat- ed through timely disease detection, treatment and care.

It reasons then that gaps in care are a prominent factor for undetected or poorly controlled disease conditions.

Translating the STEPS 2019 prevalence rates, there are 43,756 adults living with diabetes currently living in The Complications of disease are more likely to manifest when there are delays in diagnosis and/or control is not achieved.
Thirty percent (32.5%) of respondents diag- nosed with diabetes and/or hypertension experience complications, including circulation problems and limb amputations as well as kidney, eye, heart and sexual problems.

Data on compliance with NCD medication regime es- tablished by a doctor or other health provider show that 44.7% of known diabetics currently follow the regime.
For previously diagnosed hypertensives, the compliance 84 The Department of Statistics Projected Mid-Year Population Estimate (Low Estimate) for 2019 of 380,490 was used in this calculation.

26 BAHAMAS NCD RISK FACTOR REPORT rate with prescription medication is 57.9%.

For those A multiplicity of factors can converge to result in un- previously diagnosed with high cholesterol levels, 25.1% controlled blood pressure levels.
But, a strengthened, were compliant with medication prescribed by a doctor integrated health system may be at the core of address- or health worker.

In all three disease conditions, females ing many (not all) of those factors.

are 1.5-times and 2-times, respectively, more likely to be compliant than males.

HbA1c levels were not measured in the study.


Nonethe- less, the presence or absence of NCD sequelae is a rea- The degree of compliance with prescription medication sonable indicator of disease control.

Thirty-two percent may be influenced by advice sought from traditional (32%) of known diabetics and hypertensives self-report healers and/or the use of bush/herbal remedies in lieu complications of their illness, including diabetic retinop- of prescription medicines.
12.8%, 13.7% and 7% of pre- athy and peripheral neuropathy.

Best practice guidelines viously diagnosed (known) diabetics, hypertensives and recommend that all patients with diabetes have yearly persons with raised cholesterol, respectively, have ac- screening of feet and eyes to reduce the risk of blind- tively sought the advice of a traditional healer for manag- ness and avoidable limb amputations.

STEPS 2019 data ing these conditions.


Whether advice was sought from show that among known diabetics, 32.7% had an eye a traditional healer or not, 54.5% of known diabetics examination; and 23.9% had a diabetic foot screening in and 66% of known hypertensives sometimes take bush/ the last 12-months.

herbal remedies instead of medication(s) prescribed by a doctor.

There are greater personal and societal gains when NCD can be prevented.
When this is not the prevailing reality, Revelations from the STEPS 2019 survey on the degree health maintenance and management of NCDs and their of clinical control show that of the known hypertensives risk factors become essential to minimizing negative 15.3% are not taking any medication, and 26.9% are sequalae including disability, reduced quality of life and taking prescribed medication but their blood pressure is premature death.

Health and care providers have a role not controlled.
This could be a reflection of sub-optimal to play in lifestyle, awareness management and health medication adherence, medication quality and/or even maintenance.

STEPS 2019 explored whether providers interactions with other medicines and bush remedies.

advised respondents on any of the NCD risk factors Only 19.8% of known hypertensives on medication have during any visit in the 12-month period prior to the their blood pressure controlled.

Clinical blood pressure study.

Image 4 shows the findings.


In general, less than control among both sexes was glaringly low.

What 35% of respondents received any advice.

causes even more disquiet is that, for known hyperten- sives on medication, almost triple the amount of females compared to males achieved control (females, 28.3%; males, 10.6%).

That is, for every three females achieving blood pressure control, only one male achieved control.
27 VOLUME 1 Image 5: Lifestyle Advise from A Healthcare Provider ORAL HEALTH A significant proportion of respondents (66.2%) meet the could be tooth fracture or teeth grinding).

Noteworthy are the primary reasons for missing natural teeth – peri- ADA’s recommendation of brushing teeth twice a day.

odontal disease and cavities.

Twenty-three percent 22.8% brushed 3 or more time per day.

Less than 50% (46.3% ) flossed daily (males, 39.8% and females, 50.7%).
Seven percent (6.9%) of respondents have never re- ceived dental care.

Of those who have visited a dentist, only 30.3% had a visit in the last year – with top three reasons for the visit being routine dental check-up (45%), pain in teeth or gums (27.5%) and follow-up for a recent treatment/procedure (13.9%).

The majority (97.9%) of respondents perceive the state of their gums to be ‘very good’ or ‘good’.
However, 56.8% have natural teeth missing; 10.9% have dentures or dental implants; and 35.8% teeth filling.

Generally, the most HEALTH LITERACY The STEPS study was not explicitly designed to mea- sure/assess health literacy in the population.

None- theless, the study provided for proxies to gain some preliminary understanding on the level of health literacy in society.
Health literacy is the ability to obtain, read/ process, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment85.
popular reason for fillings are tooth decay/cavity (others 85 https://www.nih.gov/institutes-nih/nih-office-director/office-communica- tions-public-liaison/clear-communication/health-literacy 28 BAHAMAS NCD RISK FACTOR REPORT The data highlights that almost all respondents (98%) able difference(s) in health status or health resources believe too much sugar in the diet could cause a health between different social groupings of people.
Social problem; and 94.3% believe that too much salt in the factors (equity stratifiers) such as sex, age, education, diet can cause a health problem.

These beliefs howev- employment status and income have discernible effect er, did not parallel with the practice of reading nutrition on how healthy a person is.

The lower an individual’s facts on food labels when shopping.

In fact, 42.7% of socio-economic status, the higher their risk of poor respondents never read nutrition labels compared to health86.
17.7% who often read them and 16.6% who always read them.

Reading food labels is only one component of health literacy.

Whether respondents understood what was read was not examined, especially noting that not all products available in local grocery stores are printed in English or in units that are familiar.

For those who do read nutrition labels, 68.8% relay that the information Income There was no statistical relationship between blood pressure status and income.
However, a relationship was indicated between high BMI and income.

Specif- ically, 78.3% of persons with annual income $20,000 or less had high BMI, compared to 53.9% of persons on salt and/or sugar content does influence purchasing with annual income over $60,000.

Similarly, there was decisions (females more than males).
In May 2019, The Bahamas Department of Statistics reported households were predominantly headed by a relationship between insufficient physical activity and income – insufficient physical activity levels were observed in 34% of persons with income less than or equal to $20,000, compared to 45% with income above males – 58% compared to the 42% headed by females.

$60,000.

This observation is contrary to intuition.


But, In that same report, the Department noted that the greatest share of household income came from males it is appreciated that those who earn more can afford more conveniences that promote a sedentary lifestyle (64%) versus females (36%).

An implication of this data such as a vehicle.


And therefore, walking to public is, although females exhibit promising health behaviours, transportation, food supply, work, school et cetera is not they may not be sufficiently financially empowered to act a routine and necessary element of a day.

Also, persons on their nutrition knowledge.


with income over $60,000 were 2.5 times more likely to approach the recommended 5 or more servings of On the flip side, 61.2% use spices other than salt when fruits and vegetable each day, compared to those with cooking.

But when asked how often salt, salty season- income $20,000 or less.

ing or a salty sauce is added when cooking or preparing meals at home, 64.9% responded ‘always’ or ‘often’.
HEALTH INEQUITIES AND NCDs Equity is critically important for health, as both a princi- ple and as an outcome.

Health inequity refers to avoid- Education Lower educational attainment was associated with the presence of more NCD risk factors.

Expressly, among 86 https://www.who.int/news-room/facts-in-pictures/detail/health-inequi- ties-and-their-causes 29 VOLUME 1 persons with the highest attainment level at senior high respectively.
It is worth repeating that males are more or lower, the largest proportion (51.3%) had 3 to 5 likely than females to having a fatal or non-fatal cardio- NCD risk factors.

This contrasts with persons having a vascular event (heart attack or stroke).

tertiary education or higher, where the largest proportion (55.5%) of persons in this group had 1 to 2 NCD risk factors.
Educational attainment was also associated Marital Status A statistical relationship was found between marital with the reported average number of meals eaten a day.

status and having at least one NCD.

Fifty-four percent Those with lower attainment ate two meals, compared (54%) of married persons had at least one NCD, com- with those attaining tertiary education who at 3 meals.

pared to 41% of non-married persons.


Unemployment Unemployment was also associated with the presence Needless to say, when multiple equity stratifiers are at play for any one person, the degree of health inequity of more NCD risk factors.

Among persons unemployed, experienced by that person is compounded.

the largest percentage (55.5%) had 3 to 5 NCD risk fac- tors, compared with the employed who for the largest percentage (52.4%) had 1 to 2 NCD risk factors.
Super- NCDS AND GLOBAL THREATS Political instabilities, economic crises and public health imposed on this the sex variance – an unemployed male threats negatively correlate with NCD prevention and and an unemployed female are more likely to have more control.

Post-STEPS 2019, the world was shaken by NCD risk factors than their employed counterpart.

Hurrican Dorian, and the COVID-19 pandemic which has been prolonged, problematic and paused the de- Sex Sex is another equity stratifier.
In 2019, the age-adjusted livery of essential health services.

From these, coupled with disruptions to supply chains and reduced purchas- mortality rate from NCDs was 525.4 per 100 000 popu- ing powers, there is a yet realized NCD toll of death, lation (623.8 per 100 000 in men and 446.5 per 100 000 disability and reduced quality of life.

Subsequent national in women).

NCD studies may reveal the magnitude of this impact.
The STEPS 2019 data reveals a statistical relationship between biological sex and having a history of at least one NCD.

Forty-seven percent (47%) of males had a history of at least one NCD, compared to 43% of fe- males.
The probability of dying prematurely from an NCD in The Bahamas is 19.9% - with significant sex variance for males and females being 23.6% and 16.6%87, 87 https://www.who.int/data/gho/data/indicators/indicator-details/GHO/proba- bility-of-dying-between-exact-ages-30-and-70-from-any-of-cardiovascular-dis- ease-cancer-diabetes-or-chronic-respiratory-(-) 30 BAHAMAS NCD RISK FACTOR REPORT 31 INACTION, TOO COSTLY A PROPOSITION VOLUME 1 VALUE PROPOSITION FOR ACTION ON NCDs Non-communicable diseases (NCDs) are the invisible epidemic which has become a mounting threat – ef- fecting everyone, everywhere.
They have human, social, and economic consequences that are felt by all.

NCDs continue to be the biggest killers worldwide and in The Bahamas.

Globally, NCDs are responsible for 71% 88of all deaths.

Regionally, they are responsible for 81%89 of all deaths.

Nationally, they are responsible for 74% of all deaths.

A singular message from the STEPS 2019 data is that The Bahamas is headed in the wrong direction in its NCD trajectory.
Additionally, in the study year, the adjust- ed rate of potentially avoidable premature mortality in The Bahamas was 324.5 deaths per 100,000 popula- tion, a decrease of 26.9% from a rate of 443.9 in 2000.

This meant that, in 2019, the avoidable mortality in the country was 43.1% higher than the average rate report- ed for the Region of the Americas as a whole.
Among potentially avoidable premature mortality, the rate for preventable causes was 171.5 per 100 000 popula- tion in 2019, which is 25.1% higher than the regional average rate; and the rate for treatable causes was 153 per 100 000 population, above the regional average of 89.690.

These data reflect the ultimate toll of NCDs, death.

There are however, other tolls that NCDs exert.

Health is an indispensable precursor for a number of economic outcomes.
Over time, NCDs reduce the qual- ity and quantity of a country’s labour force (both skilled 88 WHO Key NCD Facts (2018) 89 PAHO NCDs At-A-Glance (2019) 90 https://hia.paho.org/en/countries-22/bahamas-country-profile and unskilled), which lowers the national income91.

The ripple effect is, workers with NCDs are more likely to get regularly sick and have NCD-related disabilities, which in turn reduce their efficiency and productivity as well as influence early labour force exits.
NCD mortality will reduce the size of skilled and unskilled labour essential for long run economic growth92.

Additionally, NCD-relat- ed morbidity will reduce the capital stock since potential savings will be re-directed to the treatment of NCDs instead of investment purposes.

Consequently, NCDs have the effect of widening the health iinequality gap (World Health Organization, 2013); and hindering the potential achievement of the SDGs.

Gross domestic products (GDP) do not go untouched.


Global studies reveal that NCDs comprise a significant proportion of a country’s GDP.

In 2010, that projection was calculated at 48% of the global GDP.

Simply put, NCDs are growth-retarding factors.

The global economic cost of NCDs (including mental health) is estimated at US$ 30 trillion for the period 2011 – 203093 (or US$ 1.55 trillion annually).
This starkly con- trasts with the estimated cost of US$ 2 billion annually (equivalent to less than US$ 0.30 per person) to imple- ment a set of cost-effective interventions to address NCD risk factors.

Moreover, every US$ 1 invested in these interventions will yield a return of at least US$ 7 by 2030 (Image 5).

91 Bloom D, Chen S, McGovern M. The economic burden of noncommunicable diseases and mental health conditions: results for Costa Rica, Jamaica, and Peru.

Revista Panamericana de Salud Pública.


2018;42(18):1–27.

92 Abegunde D, Mathers C, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries.

The Lancet.

2007;370(9603):1929–38.

93 https://www.paho.org/en/topics/economics-ncds 32 BAHAMAS NCD RISK FACTOR REPORT Image 6: Return on Investment for Investing in NCDs.
Source: WHO website These ‘Best Buys’ seek to combat the common and an increasing burden of disability, premature death, pov- preventable risk factors which underlie most NCDs – all erty and ill health.

Reducing their burden should be an of which set in motion cascades that lead to unhealthy overriding priority and necessary condition for sustain- weight, hypertension, high cholesterol and the known able development (World Health Organization, 2014).

5x5 NCD diseases.
5x5 NCD diseases.

Altogether, these are responsible for 33 VOLUME 1 The more healthy a people, the greater their social par- Buys’ were implemented in 2016.

Sobering is that in ticipation; the more productive they are; the more they 2015 alone, 1,222 persons died from an NCD in The are able to contribute to the development of the nation’s Bahamas.

economy across generations.


The degree to which The Bahamas is able to successfully implement the ‘Best Buys’ and make in-roads in its health promotion and COST SCENARIOS International studies have been undertaken to quantify disease prevention strategies, will have explicit implica- the lifetime cost specific NCDs and risk factor.
The aver- tions on counteracting the costs (direct94, indirect95 and age lifetime cost after diagnosis98 for: intangible96) of delayed action or inaction at the individu- • heart failure (hospital care) is US$ 73,762 per al, societal and national levels.
person • heart failure (outpatient care) is Whether viewed through the Sub-regional, Regional, or US$ 22,032 per person global lens, it is apparent that the non-communicable • stroke is US$ 103,576 (an average of the three diseases (NCDs) continue to apply an exacting and increasing burden on individuals, families, societies, systems and economies.

The Global Status Report stroke types) • overweight is US$8,120.
Current estimates reveal that total annual medical expenditures would be 9% on Non-Communicable Diseases (2014) compared 53 lower in the absence of overweight and obesity high-income countries on many of the modifiable NCD • obesity is US$ 25,50599 risk factors.

Despite its developing nation status, The Bahamas ranked high – 4th , 12th and 36th in its preva- These estimations form the bases for cost scenarios the lence of obesity, diabetes and hypertension.

context of The Bahamas (Table 2).


Table 2: Cost Scenarios for Selected Conditions In 2016, WHO statistical modelling estimated that 2,000 The US$ 8.6 billion probably represents a starting and Bahamian lives could be saved by 202597 if the ‘Best 94 Direct costs refer to costs falling on the health sector in relation to prevention, diagnosis and treatment.

95 Indirect costs typically measure the lost productivity potential of patients who are too ill to work or who die prematurely.
There is no concise on the measure- ment to be applied for estimating indirect cost.

96 Intangible costs capture the psychological dimensions of the illness to the indi- vidual (and their family) – particularly pain, bereavement, anxiety and suffering; and is usual hard to measure.
97 https://cdn.who.int/media/docs/default-source/country profiles/ncds/bhs_ en.pdf?sfvrsn=5c3e9988_38&download=true 34 likely under-estimated lifetime cost of persons impact- ed by these four selected conditions reflected in Table 98 https://onlinelibrary.wiley.com/doi/epdf/10.1038/oby.2008.290 99 Although obesity increases the likelihood of diseases and treatment that results in higher annual medical spending, for the same reasons it also results in a shorter life expectancy, especially for high BMI values (4–6).
Depending on which effect is larger, the expenditure effect or the mortality effect, some levels of obesity may actually reduce lifetime medical spending.

BAHAMAS NCD RISK FACTOR REPORT 2.

Primarily because the cost of living in The Bahamas It is contended that with a lower and decreasing chronic is high with resultant higher healthcare cost and other disease burden, resources could be available for other indirect costs in the Bahamian context.

Notwithstanding national and health issues.


the limitations and imperfect parallel, the value of these scenarios is the rudimentary understanding it lends to the cost of inaction or stagnated action in The Bahamas’ fight on NCDs; and doubles down on the reality that the Bahamian economy will be challenged to support expenditure even at this level in the long run.

All-in-all, investing in the ‘Best Buys’ is a much more attractive proposition.
A CARICOM initiative to develop a strategy100 to reduce mortality due to acute myocardial infarction (MI) events in the sub-region quantified the average annual cases of MI for participating countries.

The report noted that on average The Bahamas had 236 STEMI cases per year at a cost of $25,399 per case.

End-stage renal failure (ESRD) becomes an unfortu- nate reality for many persons with longstanding and/or uncontrolled hypertension and diabetes mellitus.
Part of the clinical management of ESRD involves dialysis.

In the Bahamian public health sector, an average of 474 per- sons required dialysis in each year between 2017 and 2020101.

The attended cost was $388.67 per person per treatment102.

Typically, treatment guidelines for ESRD call for at least three (3) treatment sessions each week (or 156 treatment sessions per person each year).
On an annual basis then the direct cost for dialysis for these persons is in excess of $28.7 million (or $60,632.52 per patient per year).

This cost of dialysis is another financial GLOBAL THOUGHTS Global Thinking On Proper Nutrition And Healthy Diets As A Best Buy Over the last century, there has been a substantial change in the lifestyle and dietary habits of people worldwide, creating an imbalance between calorie intake and energy expenditure.
Clear evidence of this is that obesity is almost tripled since 1975103.

Unhealthy diets are drivers of malnutrition and NCDs.

In a study that looked at global deaths from 1990 to 2017, it was found that one in every five deaths were the result of poor nutrition104.

High intake of sodium coupled with low intake of whole grains and fruits are leading risks for deaths and DA- LYs worldwide.
In 2019, almost 8 million deaths (28% of all deaths) and 190 million DALYs were attributable to dietary risk factors105.

Now, more than ever, nutrition interventions are essential in managing the risk of NCDs.

Generally, healthy diets contain: • Total fat intake of less than 30% of total energy.

These should be mainly unsaturated fats, with less from saturated fats (less than 10%).
Trans fats should not be consumed, but if consumed, less than 1% of total energy intake which translates to less than 2.2 grams per day with a 2,000 calorie outlay to consider in the case for no action or sluggish diet106.

action.

100 Dr. Ronald Henry serves as focal point for this initiative.

101 Source: Public Hospital’s Authority Statistics Unit 102 Source: Princess Margaret Hospital Finance Department 103 Nutrients.
2019 May; 11(5): 1074 104 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30041-8/ fulltext 105 https://onlinelibrary.wiley.com/doi/epdf/10.1111/jhn.1290 106 https://www.who.int/news/item/09-09-2020-more-than-3-billion-people-pro tected-from-harmful-trans-fat-in-their-food 35 VOLUME 1 • Free sugar intake of less than 10% of total energy, All these dimensions must therefore be contemplated in but preferably less than 5%.

the implementation of healthy diets as a ‘Best Buy’.
• Salt intake of less than 5g per day.

• Fruit and vegetables intake at least 400g per day.

Global Thinking On Reducing Harmful Alco- Evidence is mindful though of current challenges pop- ulation’s face in enjoying healthier diets.

Chief among these: 1.

The high availability of low-cost foods and bev- erages that are also high in calories, fat, salt and sugar by commercial food industry; 2.

The easy access to modern technology; 3.

Nutritional information that is difficult to under- stand and apply; 4.
Misleading health claims on foods; 5.

Eating patterns have shifted to eating out, and increased food portion sizes, combined with a lower intake of fruit, vegetables, and high-fibre foods; and 6.

Healthy diets are less affordable for the poor in every region of the world and people are increasingly exposed to ultra-processed, unhealthy foods and diets that lead to poorer health.

Researchers also contend that food choices aren’t just about health.
A host of different factors, from health to convenience to habit, taste and price drive the consum- er mind.

And while researchers are finding that health is one driver, especially in the grocery store, it’s far from the only one.

Coupled with these socio-cultural factors along gender lines relating to cultural expectations about the body and beauty ideals107 also play a role.

107 Poitier F, Kalliecharan R, Ebenso B.


Impact of sustained health policy and popu- lation-level interventions on reducing the prevalence of obesity in the Caribbean Region.

Frontiers in Public Health (2019).

36 hol Use As A Best Buy Globally, the harmful use of alcohol contributes to 3 million deaths yearly or 5.3% of all deaths.99 Besides premature mortality, behavioural disorders (e.g.
alcohol dependence), liver cirrhosis, cancers and cardiovascu- lar diseases, unintentional injuries, violence, road traffic accidents, and suicide are health concerns of harmful alcohol use.

Fetal alcohol syndrome and complications with pre-term birth are also of concern.

Harmful alco- hol consumption is also linked to the transmission of infectious diseases like HIV/AIDS.108 The impact that alcohol has on health outcomes are determined by the total consumer volume and the pattern of drinking.
Risk factors for harmful alcohol consumption are age, gender, familial context, and socioeconomic status.

Societal risk factors include the culture of drinking, availability of al- cohol, and the extent of comprehensive alcohol policies and their enforcement.25 In the Americas in 2016, persons age 15 and over con- sumed 8 litres of alcohol per capita, and in The Baha- mas, persons age 15 and over consumed 4.4 litres of alcohol per capita.
Additionally, in 2016 in the Americas, 8.2% and 4.1% of persons over age 15 had an alcohol use disorder and alcohol dependence respectively.
This is compared to The Bahamas where 6.7% and 2.8% of persons over age 15 had an alcohol use disorder and alcohol dependence respectively.109 108 Alcohol Fact Sheet https://www.who.int/news-room/fact-sheets/detail/alcohol 109 WHO Global Alcohol Report: Bahamas Country Profile https://www.who.int/ substance_abuse/publications/global_alcohol_report/profiles/bhs.pdf BAHAMAS NCD RISK FACTOR REPORT The WHO emphasizes the country’s responsible for formulating, implementing, monitoring and evaluating public polices to reduce the harmful consumption of alcohol.
The recommended strategies include regulat- ing the marketing of alcoholic beverages, particularly in youth; restricting availability; implementing taxing and price mechanisms; raise awareness of the harmful use of alcohol; provision of treatment for people with alcohol use disorders; and implementing screening and inter- vention programs in health services.9999 The WHO best buys for reduction of harmful alcohol use are increased excise taxes, enactment of bans on advertising across multiple media platforms, and enactment and enforcement of regulations on availabil- ity.101 The health sector has the responsibility to detect, prevent and treat those suffering from or impact by alcohol-related disorders.
It also plays a pivotal role in community education, advocacy and support to reduce the harmful use of alcohol particularly among youth, unemployed and other vulnerable populations.
Gov- ernments may also facilitate mass media campaigns on drink-driving and introduce and enforce legislation for: blood alcohol concentration retail licensing; location requirements; hours of sale; age; regulation of content, volume, sponsorship, promotion, marketing; and public consumption.110 These policies must be sufficiently funded and with intersectoral responsibility and support to be effective.
Global Thinking On Smoking Cessation As A Best Buy Globally, tobacco smoke contributes to more than 5 mil- lion deaths per year and without radical intervention by 2030, could rise to more than 8 million deaths annual- ly.111 Tobacco smoking gradually kills half of its users13 and contributes to the development of ischaemic heart disease, cerebrovascular diseases, lower respiratory in- fections, chronic obstructive pulmonary disease, trache- al, bronchial and lung cancers and increases suscepti- bility of developing tuberculosis.112 Second-hand smoke is similarly harmful as it can result in cardiovascular and respiratory health challenges in adults, sudden death in infants, and low birth weight for pregnant women.102 In the Americas the prevalence of current tobacco smoking in adults in 2017 was 16.8% and 11% in The Bahamas.
Tobacco smoke continues to be a major public health concern because of the increasing attractiveness of prod- ucts to new and existing users through enhanced palat- ability, increases in addictive properties, and increases in toxicity levels.113 The tobacco industry has interfered with tobacco control measures by using misleading messag- es, funding political campaigns in exchange for legislative favours, lobbying to influence political processes, funding research to create doubt about the evidence of health effects of tobacco, and employing tactics of philanthropy and intimidation among others.114 111 Tobacco Fact Sheet https://www.paho.org/sur/index.php?option=com_con- tent&view=article&id=151:tobacco-factsheet&Itemid=477 112 PAHO/WHO 2018 Report on Tobacco Control in the Region of the Americas file:///C:/Users/jonesbri/Downloads/9789275120156_eng%20(1).pdf 113 WHO Factsheet on Tobacco Ingredients https://www.who.int/tobacco/industry/ 110 10 Areas Governments could work with to Reduce the Harmful use of Alcohol product_regulation/factsheetingredients/en/ https://www.who.int/news-room/feature-stories/detail/10-areas-for-nation- al-action-on-alcohol 114 Tobacco Industry interference with tobacco control https://www.who.int/tobac- co/publications/industry/interference/en/ https://apps.who.int/iris/bitstream/ handle/10665/83128/9789241597340_eng.pdf?sequence=1 37 VOLUME 1 The WHO best buys recommend taxation on tobacco In 2019 the Bahamas’ Ministry of Health developed a products; printing of graphic health warnings on packag- policy that designated all its premises smoke-free envi- es; banning of tobacco advertisements, promotions and ronments, with appropriate signage and entrances and sponsorships; promoting smoke-free environments; and exits of buildings.117 While the ban demonstrates neces- implementing mass media educational campaigns on the sary action that should be replicated in other government health hazards of tobacco smoke exposure115.
buildings, there is no legislation for smoke-free health centres, schools, universities, offices, casinos, restau- In 2003, the World Health Organization adopted the rants, bars and public transportation.

Additionally, al- Framework Convention on Tobacco Control (FCTC) the though the country levies import taxes (customs duty and first global public health evidence-based treaty developed 33.52% excise tax) and 12% value added sales tax on in response to the global tobacco epidemic.
It calls for the tobacco products118 there is a need to pass the Tobacco raising of political commitment for multisectoral and coor- Control legislation.

The price for a pack of 20 cigarettes dinated action to implement taxation measures to reduce in 2018 in The Bahamas was $8.97 which is higher than tobacco demand, protect populations from exposure in $8.12 maximum price for the region of the Americas in indoor and public settings, and to raise public awareness the same year119.
on health effects among other actions.116 Global progress since implementation of each FCTC Article is illustrated in Image.

Generally, implementation rates of 65% or greater were obtained in Articles 8 (protection from exposure); Article 11 (packaging and labelling tobacco products); Article 12 (education and communication); Article 16 (sales to and by minors); Article 5 (establishment of focal points and national coordinating mechanisms); and Ar- ticle 6 (price and tax measures to reduce demand).
The lowest implementation rates are Articles for protection of the environment and the health of persons; and liability and support for economically viable alternative activities.

The Bahamas has not achieved any of the Articles.

It has drafted a Tobacco Control Bill in 2014, which was revised in 2018; and still awaits enactment.

Global Thinking On Mental Health As A Best Buy Mental health conditions represent a significant cause of morbidity and premature mortality in the Americas.
De- pressive disorders and anxiety disorders are the 2nd and 4th leading causes of years lived with disability respec- tively, and suicide mortality, which rose 17% between 2000 and 2019 in the Region, claims nearly 100,000 lives annually.

One in five adults experience some form of men- tal illness.
However, the vast majority of people with mental health conditions will not received treatment; the Region’s mental health treatment gap reaches as high as 90% for some conditions, with marginalized pop- 117 The Nassau Guardian https://thenassauguardian.com/2019/11/15/sugary-drinks- ban-at-all-min-of-health-facilities/ 115 https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI- 118 At the time of this report writing, VAT had been reduced to 10% for all goods and 17.9-eng.pdf;jsessionid=477FEB7F701DDCB28EB17E92A69767E0?sequence=1 services.
116 The WHO Framework Convention on Tobacco Control: An Overview https:// 119 PAHO WHO 2018 Report on Tobacco Control in the Region of the Americas www.who.int/fctc/about/WHO_FCTC_summary_January2015.pdf?ua=1&ua=1 38 BAHAMAS NCD RISK FACTOR REPORT ulations and people living in conditions of vulnerability experiencing significant barriers to care.
Unaddressed poor mental health compromises the overall health and well-being of individuals and is linked to broader health and social consequences for communities and society.

This is magnified and exacerbated in times of crises – be they disasters, political unrest or tragedy.

39 POLICY CONSIDERATION BAHAMAS NCD RISK FACTOR REPORT POLICY CONSIDERATION HIGHLIGHTS It is worth underscoring that NCDs represent more than demic, save thousands of Bahamian lives and bolster just a health problem.
NCDs are a sustainable develop- the economy by redirecting dollars that would have ment issue120, as well as a social, economic and political been spent on healthcare to other economy-expanding issue.

The Bahamas is not only ‘off course’, but headed programmes.

While prevention is the holy grille, systems in the wrong direction relative to its health and well-be- and policies must simultaneously provide a response to ing.

The country is likely not to meet the global nutrition those with NCDs.
targets and the health-related SDG targets if the ur- gency for action does not gain traction at the highest Superimposed on this, is the reality that the Bahami- political levels and at the grass roots.

STEPS 2019 gives an population is an aging one (Image 6), which brings the justification for bold action to accelerate and bridge unique opportunities to implement health-promoting the gap between promise to priority to progress.

strategies across the life cycle.
Image 7: Population Pyramid of The Bahamas Given 80% of NCDs can be prevented, early, evi- Given the preponderance of the evidence; recognizing dence-based and coordinated action can mitigate the that NCDs have their origin at young ages with an un- common modifiable lifestyle drivers of the NCD epi- healthy childhood being fertile ground for unhealthy adult 120 https://ncdalliance.org/why-ncds/NCDs?gclid=Cj0KCQjwvZCZBhCiARIsAPX- bajuX7Mq04panWR06pL0Ke_-S5BTpDox2PaiMeDHuMUfWIiTGn_s0jkAaArJ- gEALw_wcB years; and appreciating that action taken to reduce NCD risk factors can save lives and prevent 80% of prema- 41 VOLUME 1 ture heart disease, stroke and diabetes, policy consider- Mandate nutrition and caloric information for all ations are proposed under four thematic areas to get the country back on course: 1.
Proactive Policy Innovation 2.

System Enabling Environments 3.

Community Empowerment and Innovation 4.

Research Innovation Upstream Health Policy Innovation Health policy goes beyond health care policy.

By ad- dressing the drivers of health, public health policies can have significant positive health impact.

There is urgency in addressing economic diversity, the learning gap and climate change.
Successes on these fronts will be irre- versibly diluted if the health of our people is not elevated to a similar level of urgency.

Change comes when a sense of urgency is present.

a. b. c. d. The highest political commitment expressed through a proclamation declaring NCDs a na- tional emergency.

Enact legislation that are health enabling and reduce demand for unhealthy food products.
Specifically, elimination of trans fats legislation (REPLACE strategy) and taxation of sugary bev- erages; and earmarking these taxes to support wellness.

Example, evidence shows that a tax on SSBs that increases retail price by 20% can reduce consumption by approximately 20%.

Review, table and enact the draft Tobacco Control Bill.
Revisit and modernize legislation on access to as well as sales and promotion of alcohol with increased penalties and fines for infractions, with fines earmarked for programmes geared at harmful alcohol use reduction.

e. f. g. h. i. j. k. meals sold in restaurants as well as fast foods, pop-up, side-of-the-road franchises.
Require grocery stores to organize/group products and erect visible shelf markers such as green for healthy, yellow for less healthy and red for not healthy; as a precursor to legislation on front-of-package labelling.

Prohibit children from purchasing junk food and outlaw junk food in schools and vending ma- chines.

Lessons can be learnt from Mexico who implemented this in 2020121.
Complete the work of the Breadbasket revision initiative to remove grossly unhealthy items and include more healthy options and mitigate sub-optimal dietary intake, particularly for the vulnerable.

Renew, cost and implement the Wellness in The Nation: National NCD Strategy and Plan of Action (2023 – 2030).

The current plan expires December 2022.


Formalize health-in-all-policies and intersectoral strategy with explicit objectives and goals to address social determinants of health to reduce social inequities for better health outcomes.

Fashion legislation similar to Food Labeling Modernization Act of 2021, to set quality standards for an array of food imports; and to strengthen regulatory mechanisms to iden- tify and prohibit entry of food products with substandard quality and/or misleading health claims.
The legislation should speak t properly resourcing a food laboratory for sample analy- ses.

121 https://youtu.be/cgbxCJ_ZxJ4 42 BAHAMAS NCD RISK FACTOR REPORT Modernize, with practical age-specific applica- fine and publicize which locally available food tion, the National Dietary Food-based Guide- products are high in sugars, fats, saturated fats, lines.

trans fats and salt.


Require all public policies to apply the Health Develop, where needed, and update clinical l. m. Impact Assessment tool (HIA) – a practical approach used to judge the potential health effects of a policy, programme or project on a population.

e. f. g. h. i. j. management guidelines for primary health care settings; and conduct training sessions for healthcare professionals.
Develop and cost national action plans along with defined performance indicators for mental health, elimination of cervical cancer, salt re- duction, oral health and a national alcohol plan/ policy.

Re-orient health and care providers to their role in disease prevention and early detection.

Complement passive NCD screening (done within the walls of medical facilities and offices) with proactive screening through systemized community screening strategies.
Expand NHI’s standard benefits package to include nutrition education and counselling; and pre-qualified medical wearable devices for con- tinuous monitoring of HbA1c, total cholesterol, LDL and blood pressure122.

The latter recogniz- ing that patient engagement in chronic disease self-management is an essential component of chronic disease models of health care.
Prioritize the introduction and implementation of Innov8 in national health programmes, Healthy Bahamas Coalition, and other relevant stake- holders.

Innov8 is a WHO approach involving an 8-step review process aimed towards support- ing health programmes better address equity, human rights and SDH.
Fast-track implementation of telemedicine and 122 https://www.frontiersin.org/articles/10.3389/fendo.2022.848695/full k. 43 System Enablers Enabling environments are required across all ministries and sectors to address the complex and multi-variant issues of NCDs.
Prioritize the integration of behavioural sciences, through the engagement of behavioural change specialists, into work on health promotion and NCD prevention, recognizing that health-re- lated (and other) decision-making process are multi-variant and complex; and that health-relat- ed behaviours (at individual, community and na- tional levels) are essential for achieving desired health outcomes.
Fund and execute a well-conceived, nation- wide public education campaigns to promote wellness and to magnify the harms of unhealthy lifestyle practice, which are diversified and take into account the socio-demographic variations in health risks.

Implement cardiovascular disease risk screen- ing using validated and agreed scoring instru- ment(s)/calculators in the NHI benefits package and at the primary care level.
Advocate for the implementation of the PAHO Nutrient Profile Model within BBSQ to de- a. b. c. d. VOLUME 1 l. m. n. o. p. q. r. s. an information system for health.

the pilot to guide accelerated implementation of Employ an intermediary NCD surveillance and the framework in all schools by 2025. monitoring system to facilitate mandatory re- Scale-up and resource in-country capacity for porting by all providers, clinics and laboratories to Ministry of Health & Wellness.
Conduct a mid-point evaluation of progress on the National Food Security and Nutrition Policy; t. u. food quality analysis.

Augment capacity and resource law enforce- ment and healthcare settings to perform and document breath and blood alcohol testing in and devise strategies to recover progress on these respective settings; and especially at the the lines of action that are lagging.

time of all RTAs.
time of all RTAs.

Deepen collaborations between MOHW and the Sufficiently capacitate the Price Commission to Ministry of Agriculture and Marine Resources to leverage, optimize and catalyze synergies on common touchpoints for accelerating move- ment toward food security.

Revitalize and make impactful media campaigns v. w. proactively regulate and set standardization of food pricing.
Explore the utility and implementation of WHO Innovation Scaling Framework to guide the in-country scaling up of NCD prevention and to increase awareness on benefits of breast- control feeding.

Create built environments and policies that pro- mote breastfeeding in the society.
Accelerate action to scale-up HPV vaccination and screening for HPV infection and cervical cancer through effective programming, surveil- lance, monitoring and evaluation; and well as Community Empowerment and Innovation Complex health problems require actions beyond the Ministry of Health and the health sector, that extend to the wider community, through intersectoral and in- ter-ministerial action and a Health in All Policies (HiAP) approach.
This requires a commitment that goes be- public awareness campaigns targeted at males yond specific government administrations and political and females.

cycles, creating, strengthening, and institutionalizing Engage a collaborative process with Ministry of existing intersectoral mechanisms, organizational struc- Education and other stakeholders to strengthen tures, and alliances.
the Family Life; and Consumer Science curricula with an intentional and deepened focus on culti- vating healthy habits at early ages and through- out the formative educational years.

Achieve buy-in for the ‘Health-Promoting School’ framework.

Identify schools (public, pri- vate and home schools) to pilot the ‘Health-Pro- moting School’ framework.

Use lessons from 44 Increase health literacy and foster health citizen- ship.
Formalize and resource institutional structures to lead the charge, coordinate and implement a comprehensive approach to tackling NCDs.

Re-envisage new leadership models within and beyond the health sector that favor collabora- tion and that recognize that the leading role can a. b. c. BAHAMAS NCD RISK FACTOR REPORT lie with the health sector or with other sectors (academia, civil society, and the private sector) depending on the nature of the problem to be addressed.
This requires joint work in planning Research Innovation Social determinants of health (SDH) influence these health problems and as such deliberate action should be taken to link these SDH to well-being through research and evaluation based on a shared analysis of and innovation.

Undertake a national study to give novel and baseline data on nutritional deficiencies among children between 5 and 10 years; and to inform tailored nutrition catch-up programmes for this age grouping across the country.
Encourage and allocate funding for research that will address unmet questions arising from STEPS 2019 as well as add new knowledge to the NCD space.

Engage in-depth health equity analyses to understand both the magnitude and gradient of equity gaps.

Augment capacity to better position the MoHW to take advantage of grant funding for priority NCD-related research, inclusive of grant writing capacitation.

Establish a knowledge repository on NCDs.

a. b. c. d. e. the health situation.


Re-imagine and re-introduce the community health council concept.

Develop interventions to target co-occurrences of risk factors rather than emphasizing individual risk factors for NCDs Engage persons affected by NCDs to serve as champions in the fight against NCDs.

Advocate for workplace policies that encourage wellness and opportunities for being physically active during the work-day.

Design and launch a ‘Live Well Bahamas’ campaign.


Features of this campaign may include Podcast and YouTube ready ‘Well-Being Lessons’ aimed at teaching the population how to plan for and prepare healthy meals; tips on navigating food labels; de-mystifying the back- yard garden; and mental health check-in tips.

Collaborate with faith-based organizations to develop a Bible Study Series on Health & Nutrition to be incorporated into mid-week, chil- dren’s church and other teaching opportunities.
Incorporate Pahola, PAHO’s digital health tool to facilitate better access to strategies for reducing harmful alcohol consumption.

Engage key stakeholders to maximize the power of media to mainstream conversations on intimate partner violence and empower the voices of those impacted.
d. e. f. g. h. i. j. k. 45 STUDY LIMITATIONS BAHAMAS NCD RISK FACTOR REPORT STUDY LIMITATIONS Reliance on persons to provide information on Cost was a limiting factor to the inclusion of their own health behaviours and conditions.

1.

Respondents may have been reluctant to report behaviours that are considered undesirable such as drinking, smoking and poor nutritional practices; or behaviours associated with shame and discrimination such as sexual abuse and intimate partner violence.
Consequently, the HbA1c, LDL and HDL measurements.

Data on intimate partner violence should be in- terpreted with caution as respondents were less likely to respond to the more sensitive questions in that section.

In assessing salt intake, the study question was not formulated to 6.

7.

8. prevalence of these behaviours may be under- quantify salt added during the estimated by the survey.

Respondents may also cooking process.


have had limited recall about past behaviours or Island-specific risk prevalence was not ana- may recall them imprecisely.

lyzed.

9.

The culturally pervasive belief that confidentiality The new digital data collection platform neces- is not as valued as it should be, may have influ- enced respondents’ candor with some ques- tions.
In contrast, the close-knit communities within the country may have given the impres- sitated a steep learning curve for field enumer- ators.

The inconsistent public relations may have negatively impacted the ground swell needed 10.

11. sion that confidentiality could be preserved and to secure public enthusiasm, support for and may have influenced the level of truthfulness on participation in the survey field work.

some questions.
some questions.

Inclusion of country-specific questions extended to overall length of the questionnaire and time respondents needed to be engaged, which may have resulted in some degree of rushed re- sponses or less thought-out responses – partic- ularly towards the end of the question period.

Both competing priorities of some respondents as well as less conducive household settings for others negatively impacted participation in STEPS 3.
Budget constrained the number of enumerators engaged for the administration of the survey which contributed to the 4-month fieldwork period.

47 2.

3.

4.

5.

NATIONAL NCD ACTION BAHAMAS NCD RISK FACTOR REPORT NATIONAL NCD ACTION SNAPSHOT ON NATIONAL ACTIONS TO PREVENT AND CONTROL NCDS The public health policy responses to NCDs have adapted to the changing heath landscape of the coun- try.

Between 1970 and 1989, policy responses primarily focused on the issue of undernutrition in all age groups.
In contrast, between 1990 and 2000, the focus was in- telligence gathering on population nutritional status and promotion of breastfeeding123.

Between 2000 to 2019, policy interventions were fashioned to address climbing obesity and physical inactivity to stem the tide of the ever-increasing threat of NCDs.

A hallmark of national action on NCDs is the devel- opment in 2017 of the Ministry of Health’s National Non-Communicable Diseases Strategic Plan 2017-2022 entitled Wellness in the Nation.
This work was the culmi- nation of a series of planning meetings, workshops and consultations with various partner agencies and stake- holders across the private, public, civil, health and non- health sectors.

An accompanying implementation plan was crafted and costed by the summer of 2019.

Unfor- tunately, The Bahamas has had a cascade of national disasters since then which has significantly impacted the availability of funds and personnel to ap propriately engage the plan.
Several initiatives have been Image 8: Milestones for National NCD Policies and Initiatives 123 Poitier F, Kalliecharan R, Ebenso B.

Impact of sustained health policy and popu- lation-level interventions on reducing the prevalence of obesity in the Caribbean Region.

Frontiers in Public Health (2019).

49 VOLUME 1 implemented at the programme level, and through 1.
Greater shifts toward normal weight should be bilateral discussions and arrangement with responsible prioritorized (Annex IV – Graph 1); executing agencies.

But without an organizational struc- 2.


The pre-diabetic portion of the population can ture to appropriately administer the Plan, and to endow benefit from more aggressive screening, lifestyle the necessary authority required to successfully advance interventions and public education (Annex IV – the ideals included therein, there is suboptimal progress Graph 3) to prevent the transition to diabetes; been made with respect to the implementation on the 3.
Exposure to secondhand smoke is a real phe- strategies envisioned.

nomenon in The Bahamas (Annex IV – Graph 4); Throughout this time (1999 – 2019) the Ministry has 4.

Inadequate physical activity may not be the core relied on clinical and population-based data to shape issue or contributor to ill-health in the country its NCD-related policies and initiatives.

For the latter, (Annex IV – Graph 5); and three population-based NCD risk factor surveys have 5.
The risk of having a stroke or heart attack has been conducted.

Namely, in 2005, 2012 and 2019.

The doubled from 2005 to 2019 (Annex IV – results of these three surveys are not automatically com- Graph 6).
NATIONAL PROGRESS ON GLOBAL INDI- CATORS AND BENCHMARKS There have been a series of political commitments made to curb the NCD epidemic These include the landmark Declaration of Port-of-Spain (2007), the United Nations High Level Political Declaration on NCD Prevention and Control (2011), and the WHO Global NCD Action Plan 2013-2020 and NCD targets, as well as Sustainable Development Goals (2015).
Annex I (Port-of-Spain in- dicators), Annex II (WHO indicators) and Annex III (SDG targets) sheds light on The Bahamas’ progress.

parable for two main reasons.

First, the STEPS method- ology has been modified over the years, with changes in the age range of the target for each cycle.
Specifically, • In 2005, the study targeted individuals between ages 15 and 74 years; • In 2012, the study targeted individuals between ages 25 and 65 years; • In 2019, the study targeted individuals between ages 18 and 69 years.

Second, response rates met or exceeded the WHO threshold to allow generalizability of findings for only the 2005 (79.4%) and 2019 (61.6%) cycles of the STEPS study.
Therefore, although insights into keys findings from each of these years/cycles are reflected in Annex IV (Graphs 1 to 6), caution is advised in making direct com- parisons; and particularly for the 2012 cycle when the response rate threshold was not acheived.
That said, the salient points that may be drawn are from these three population-based risk factor cycles are: 50 BAHAMAS NCD RISK FACTOR REPORT ANNEXES ANNEX I – The Bahamas’ Performance (2018) on Port-of-Spain Declaration Indicators POS NCD Summir Evaluation GA-CDRC, UWI 51 VOLUME 1 POS NCD Summir Evaluation GA-CDRC, UWI 52 BAHAMAS NCD RISK FACTOR REPORT ANNEX II – The Bahamas’ Performance (2020) on WHO NCD Indicators 53 ANNEX III – The Bahamas’s Performance on Health-Related SDGs124 VOLUME 1 124 https://dashboards.sdgindex.org/profiles/bahamas-the/indicators 54 BAHAMAS NCD RISK FACTOR REPORT ANNEX IV – NCD Risk Factor Profile at Three Points In Bahamian History Graph 1: Graph Showing BMI Prevalence Obtained From Periodic Studies Graph 2: Graph Showing Hypertension Prevalence Obtained From Periodic National Studies 55 VOLUME 1 Graph 3: Graph Showing Diabetes Prevalence Obtained From Periodic Studies Graph 4: Graph Showing Smoking Prevalence From Periodic Study 56 BAHAMAS NCD RISK FACTOR REPORT Graph 5: Graph Showing Prevalence of Sufficient Physical Activity From Periodic Studies Graph 6: Changes in Stroke and Heart Attack Prevalence Between 2002 and 2019 57 AT-A-GLANCE: BAHAMAS STEPS 2019 FACTSHEET VOLUME 1 58 BAHAMAS NCD RISK FACTOR REPORT 59 BAHAMAS NCD RISK FACTOR REPORT 61 Ministry of Health & Wellness