National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC

 
National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC
National Survey of Noncommunicable Diseases in
         Seychelles 2013‐2014 (Seychelles Heart Study IV):
                          main findings

This report focuses on selected main findings from the 2013 National NCD Survey and these findings are compared,
            whenever possible, with results from previous national NCD surveys in 1989, 1994 and 2004.

A technical report presenting crude results for all the variables assessed in the 2013 NCD survey entitled “National
 Survey of Noncommunicable Diseases in Seychelles 2013‐2014 (Seychelles Heart Study IV): Methods and Overall
 Findings” was produced by the Public Health Authority, Ministry of Health, Seychelles (2nd version, 10 November
2014). These findings were discussed in two half‐day meetings in the presence of Minister of Health, officials and
                             interested persons on 31 October & 4 November 2014.

      Detailed analysis of specific issues and related recommendations will be available in separate reports.

                                            Public Health Authority
                                         24 February 2015 (version 2)
National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC
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          National Survey of Noncommunicable Diseases in Seychelles 2013‐2014
                        (Seychelles Heart Study IV): main findings

Pascal Bovet, Bharathi Viswanathan, Meggy Louange & Jude Gedeon, on behalf of the Survey Team

Unit of Prevention and Control of Cardiovascular Diseases (UPCCD)
Public Health Authority
Ministry of Health
Victoria
Republic of Seychelles

Survey team
   Pascal Bovet, MD, NCD consultant, Ministry of Health, Seychelles & associate professor, Institute of Social and
    Preventive Medicine, University of Lausanne, Switzerland
   Bharathi Viswanathan, RN, program manager, UPCCD
   Barbara Fock Tave, RN, UPCCD
   Juddy Labiche, RN, UPCCD
   Gaynor Mangroo, health promotion officer, UPCCD
   Romena Maria, RN, UPCCD
   Vanessa Lafortune, UPCCD
   Gina Michel, RN, program manager, Cancer and Other NCDs Unit
   Daniel Belmont and colleagues, Public Health Laboratory
   Maygane Jean and colleagues, Clinical Laboratory, Seychelles Hospital
   Meggy Louange, MD, Director General, NCD Section, MOH
   Jude Gedeon, MD, Public Health Commissioner, Public Health Authority, MOH

Funding
   Ministry of Health, Republic of Seychelles (staff, laboratory and partial direct funding)
   World Health Organization (core methodology of survey [STEPS] and partial direct funding)
   University Institute of Social and Preventive Medicine, Lausanne, Switzerland (technical support and partial
    direct funding)
   Seychelles Trading Company (STC), Seychelles (unconditional vouchers to all participants)
   Seychelles Petroleum (SEYPEC), Seychelles (unconditional partial funding)
National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC
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Acknowledgements

Grateful thanks are expressed to the following institutions and persons who have been instrumental in the organization of the survey:

    Public Health Authority, Ministry of Health, Seychelles, particularly Mitcy Larue (minister), Jude Gedeon (public health
     commissioner), Shoba Hajarnis (director general), and Meggy Louange (director of the NCD section)
    All the staff members of the Unit of Prevention and Control of Cardiovascular Disease (UPCCD), Public Health Department,
     including Bharathi Viswanathan (program manager); Barbara Fock Tave; Juddy Labiche; Gaynor Mangroo; Vanessa Lafortune;
     Romena Marie and Maria Omath; and Gina Michel (program manager) from Unit of Other NCDs
    Clinical laboratory, Seychelles Hospital, particularly Prosper Kinabo (director), Maygane Jean (senior technician) and colleagues
    Public Health Laboratory, Ministry of Health Seychelles, particularly Philip Palmyre (director), Daniel Belmont (senior technician)
     and colleagues
    Praslin Hospital, particularly Dina Hibonne (coordinator) and Logan Hospital, particularly Pamela Dubignon (coordinator)
    National Bureau of Statistics (NBS), particularly Laura Ahtime (CEO) and Helena Deletourdis (principal statistician)
    Ministry of Administration and Community Services (MACS), particularly Denis Rose (principal secretary), Dan Frichot (director
     general), and all the district administrators and their staff
    Seychelles Broadcasting Company (SBC), particularly Antoine Onesime (CEO), Cindy Wirtz (sales manager) and the journalists
     involved in several programs on TV and radio on the survey
    World Health Organization, particularly Cornelia Atsyor (local liaison officer) and the WHO AFRO office
    Institute of Social and Preventive Medicine, University Hospital Center, Lausanne, Switzerland, particularly Fred Paccaud
     (director), Brigitte Santos Eggimann (advisor on questionnaire sections related to frailty and aging) and Samuel Hirsiger for
     contribution to preliminary analysis of the overall results
    Seychelles Trading Company (STC), particularly Patrick Vel (CEO up to 2013) and Veronique Laporte (CEO 2014), for providing a
     large non conditional grant (vouchers to all participants)
    Seychelles Petroleum (SEYPEC), particularly Conrad Benoiton (CEO) and Sarah Romain (commercial manager) for providing a large
     non conditional grant
    OMRON Healthcare Europe, The Netherlands, particularly Dounia Benjelloun (Sales Manager Africa) for supplying free or charge
     equipment to perform ECG and bioimpedance
    Bayer Consumer Care AG, Switzerland, particularly Konstantin Tselikas (country manager NaOC) for providing discounted prices on
     diagnostic equipment for diabetes, including A1c

                    Minister of health, high officials and survey team at the opening ceremony of the Seychelles
                         NCD Survey (Seychelles Heart Study IV) on 23 September 2013
National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC
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Table of contents

Summary and recommendations .............................................................................................................................4
Context of NCDs globally and in Seychelles .............................................................................................................6
Objectives of the 2013 survey ..................................................................................................................................7
Methods and participants for the 2013 survey ........................................................................................................7
Population and mortality, Seychelles, 1989‐2013.........................................................................................................8
Participation to Seychelles NCD surveys ..................................................................................................................9
Body mass index (BMI) .............................................................................................................................................9
Tobacco use ........................................................................................................................................................... 11
Alcohol use ............................................................................................................................................................ 13
Dietary habits ........................................................................................................................................................ 16
Physical activity (PA) .............................................................................................................................................. 18
High blood pressure (HBP) .................................................................................................................................... 19
Blood cholesterol................................................................................................................................................... 22
Diabetes ................................................................................................................................................................. 24
Trends in risk factors between 1989 and 2013 ..................................................................................................... 26
Socio demographic variables (2013 Survey).......................................................................................................... 27
Perceived health status ......................................................................................................................................... 28
Utilization of health care services ......................................................................................................................... 28
Screening of selected cancers ............................................................................................................................... 30
Communication, mass media, and exposure to health programs ........................................................................ 31
Appendix 1. Tabulation of selected findings by sex and survey year .................................................................... 33
Appendix 2. Questionnaire in English.................................................................................................................... 38
Appendix 3. Data entry form for measurements .................................................................................................. 52
National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC
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Summary and recommendations                                               selected days in study centers located in Mahé, Praslin, and La
                                                                          Digue. All the eligible participants who did not attend were
This report provides information on selected summary results of           actively traced using (telephone, local administration,
the National Survey of Noncommunicable Diseases in Seychelles             announcements on radio, etc) and invited to attend the survey.
in 2013‐2014 (Seychelles Heart Study IV). The survey is also              Since participants were randomly selected from the general adult
referred shortly as the “2013 Survey” in this report. Overall crude       population, findings of the survey can be inferred to the general
results were reported in a comprehensive report in November               adult population of Seychelles.
2014. Further detailed analyses and recommendations on
particular topics will be performed separately.                           The survey included a questionnaire and clinical and biological
                                                                          tests including anthropometrics, bioimpedance, blood pressure,
The survey 2013 Survey addressed the following objectives:                blood tests, urine tests, one lead ECG, bone ultrasound, and
                                                                          selected functional tests to assess frailty.
Primary objectives
                                                                          Main findings and global recommendations
a) Distribution of the main modifiable risk factors of
   noncommunicable diseases (NCD), particularly blood                     Pending further analysis, and based on preliminary analysis
   pressure, adiposity markers, diabetes and blood lipids                 reported in this report and the overall report produced in
b) Distribution of health behaviors related to NCDs, particularly         November, the following general findings can be formulated:
   tobacco use, alcohol drinking, and physical activity
c) Rates of awareness, treatment and control of hypertension,             a) The prevalence of tobacco use decreased between 1989‐and
   diabetes and dyslipidemia                                                 2013, reflecting strong tobacco control programs and policy
d) Comparison of findings in survey in 2013‐2014 with results in             in the interval. Data also show that the general public largely
   previous surveys in 1989, 1994, 2004                                      supports the tobacco control legislation implemented a few
e) Dietary patterns                                                          years ago in Seychelles.
f) Knowledge, attitudes and practices related to NCDs and NCD                Tobacco control needs to be strengthened including strict
   risk factors                                                               enforcement of current legislation and need to address new
Secondary objectives                                                          issues, e.g. electronic cigarettes, shisha, measures targeting
                                                                              smoking among youth, etc.
g) Assessment of indicators of quality of health (e.g. SF‐12)
h) Assessment of psychological stress and relation with NCD               b) Blood pressure (BP) tended to decrease over time, consistent
i) Assessment of indicators of frailty (e.g. handgrip strength               with improved awareness, treatment and control rates
   test, chair strand test, questions on functional limitations)             between 1989 and 2013. Favorable trends likely reflect socio‐
j) Assessment of knowledge and level of agreement with                       economic development, increasingly diverse nutrition, and
   current policies on tobacco control                                       improved medical care. However, the level of control of BP
k) Use of public and private health care services, particularly for          among persons with HBP and knowledge on hypertension is
   NCDs                                                                      far from optimal.
l) Exposure to advice on health behaviors given by health                    There is a need to improve health care for patient with HBP,
   professionals at health care level                                         including updated guidelines for detection and treatment of
m) Burden of chronic diseases not related to the main NCDs (e.g.              hypertension, training of health professionals, extended use
   musculoskeletal, mental health, etc)                                       of home BP monitoring, etc. There is also a need to improve
n) Screening of selected cancers                                              population‐based interventions, including awareness
o) Assessment of the kidney function in the population                        campaigns (“know your number”, “reduce your salt”, etc) and
p) Frequency of heart arrhythmias (one‐lead ECG) and heart                    structural measures in all sectors to improve choices for
   murmurs (auscultation)                                                     healthy products and regular physical activity (e.g. reduction
q) Assessment of bone mineral density (ultrasound of                          of salt in locally made or imported manufactured foods).
   calcaneus)
r) Exposure of the population to the mass media, particularly in          c) The prevalence of overweight/obesity and diabetes has
   relation to health programs, and use by the population of                 markedly increased between 1989 and 2013, consistent with
   new communication technologies                                            worldwide upward trends and increasingly globalized food
s) Assessment of social variables and their association with the             markets. The survey provides information on dietary patterns
   variables measured in the survey                                          in the population, which is useful to guide individual‐based
t) More generally, the survey provides broad information                     and population‐based interventions.
   (medical, social, environment, etc) that can be useful for
                                                                             Need to develop structural interventions in all sectors to
   tailoring NCD prevention and control programs.
                                                                              improve the availability of, and access to, healthy foods for all
Overall methods of the survey                                                 people and in different settings (schools, workplaces, etc),
                                                                              including adequate food labeling, ban on advertising of
The survey was performed in a sex and age stratified random                   unhealthy foods in mass media, subsidies/taxes on
sample of all adults aged 25‐64 years of Seychelles between                   healthy/unhealthy foods, food labeling, etc. Interventions in
October and December 2013 on Mahé and during 2 weeks in                       all sectors are also needed to promote physical activity in
February 2014 in the islands of Praslin and La Digue. These three             different settings. Health education programs are helpful to
islands account for >98% of the total population of Seychelles.               raise awareness on healthy lifestyles and should target all
The eligible sample was extracted from the population registry.               population sub‐groups. The school setting is particularly
The survey was attended by 1240 adults, with a participation rate             important to empower healthy choices at a young age and
of 73%. Participants were invited to attend the survey on                     specific measures include water fountains in all schools,
National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC
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    healthy food menus in canteens, compulsory 2 or 3 hours of               Global targets for NCD prevention and control
    physical activity per week, etc.
                                                                             All WHO member states, including the Seychelles, agreed at the
d) Knowledge on NCDs is fairly good in the population, reflecting            World Health Assembly in 2014 on 9 targets to be achieved by
   the impact of continued health education programs in the                  2025 (compared to baseline in 2010):.
   mass media in Seychelles and through other avenues over the               1) 25% reduction of NCD
   past 2‐3 decades. Yet several areas of knowledge about NCDs               2) 10% reduction in alcohol use
   should be improved. The survey also provides information on               3) 10% reduction in prevalence of insufficient physical activity
   how people are exposed to different mass media in                         4) 30% reduction in mean population salt intake
   Seychelles and how people use electronic communication                    5) 30% reduction in the prevalence of tobacco use
   devices: this provides useful information on how these mass               6) 25% reduction in the prevalence of raised blood pressure
   media and new technologies could be used to strengthen                    7) 0% increase in obesity and diabetes
   new NCD awareness campaigns.                                              8) At least 50% of eligible people receiving drug therapy and
                                                                             counseling to prevent heart attack and stroke (this includes
   Need to brainstorm ways to enhance health education
                                                                             hypertension and diabetes treatment)
    programs, including through targeted use of mass media and
                                                                             9) At least 80% availability of the affordable technologies and
    new communication technologies.
                                                                             essential medicines, including generics, required to treat major
e) Many people report less than optimal exposure to advice on                NCDs on both public and private facilities
   healthy lifestyle and nutrition by health professionals at the
                                                                             Next national NCD surveys & WHO Global Status Reports
   level of health care.
                                                                             The WHO 2014 Global Status Report on NCDs provides
   Need to brainstorm efficient and innovative mechanisms to                population levels of selected indicators related to the 9 targets in
    provide health education at the level of health care services            2010 and 2014 for all countries, based on actual data or
    (to target patients) and through other channels (to target the           estimated using statistical models. For Seychelles, levels of risk
    general public).                                                         factors of NCDs appearing in the WHO Global Status Report 2014
f) The survey provides information on frequency of screening                 on NCDs come from the 2013 survey.
   for several priority cancers.                                             Within the WHO Global Monitoring Framework and the WHO
   Need to brainstorm the design, implementation and                        Global Plan of Action for the Prevention and Control of NCDs
    monitoring of screening programs for priority cancers in                 endorsed by all countries in 2013 and 2014, all countries are
    Seychelles.                                                              expected to report population levels of these 25 NCD indicators
                                                                             and updated national data will be published in updated versions
g) Several characteristics related to NCDs (health behaviors, risk           of the Global Status Report on NCDs in 2020 and 2025. This
   factors, knowledge, exposure to information, use of health                implies that each country should perform national surveys of
   care services, etc) were less favorable among lower socio‐                NCD risk factors, similar to the 2013 Survey. On these premises, a
   economic groups.                                                          next survey in Seychelles could be organized in 2018‐2019 and, in
   Need to brainstorm these results and consider social factors             all cases, in 2023‐2024 in order to assess achievement of the 9
    when designing interventions to address the prevention and               priority targets.
    control of NCDs.
The following data collected in the 2013 Survey will be examined
in separate report: quality of life; stress and NCDs; frailty & aging;
kidney function; heart arrhythmias & murmurs; bone mass
density; A1c vs. blood glucose for the diagnosis of diabetes, etc.
Of note, the WHO 2014 NCD Status Report (available on www‐
who.int) provides lists of most cost‐effective population wide and
high risk interventions to reduce the burden of NCDs.
National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC
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Context of NCDs globally and in Seychelles                                 past 2‐3 decades in the Seychelles to address NCDs, particularly
                                                                           strong tobacco control measures (e.g. comprehensive tobacco
Global burden of NCDs                                                      control legislation in 2009), improved nutrition (i.e. increasingly
                                                                           diverse food available) and free health care allowing all high risk
Cardiovascular diseases (CVD) and other main noncommunicable
                                                                           persons to receive treatment.
diseases (NCD) such as cancer, diabetes, and obstructive
pulmonary disease account for more than 70% of all premature               However, Seychelles experiences a rapid demographic transition
deaths in most middle income countries, including in Seychelles.           so that the total number of NCD patients (which tend to occur at
The burden of NCD is largely attributable to 4 “physiological”             middle or older age) will rise over time, even if interventions to
main risk factors (body mass index, blood pressure, blood lipids           prevent and control NCDs are successful.
and diabetes) which are themselves largely determined by 4
major modifiable risk behaviors (smoking, insufficient physical            NCD risk factors in previous surveys in Seychelles
activity, unhealthy diet, and excess alcohol intake).                      The key information needed to guide interventions for NCD
Main risk factors of NCDs                                                  prevention and control is the current levels of risk factors in the
                                                                           population. Population‐based surveys require that participants
The focus on 4 main modifiable behaviors to reduce the NCD                 are randomly selected from the general population. Previous
burden is encapsulated in the so called “4*4 strategy”, advocated          population‐based surveys of NCD risk factors were conducted in
in the Political Declaration on NCD Prevention and Control                 1989, 1994 and 2004. Results of these surveys have been widely
adopted [1] and in the WHO 2013‐2020 Global Plan of Action for             reported in overall reports [7‐9] and through more than 50
the Prevention and Control of NCDs adopted by all member                   publications that have focused on special NCD issues [10‐15]. The
states in May 2013 [2]. From a clinical perspective (i.e. the health       existence of data from 4 national surveys between 1989 and
care response) the emphasis is on the main physiological risk              2013 is unique and no country in the African region has
factors (blood pressure, blood lipids, and blood glucose                   performed more than2 NCD surveys recently, except Mauritius.
impairment), which are amenable to screening and control
through cost effective treatment.                                          Results from the past surveys (i.e. 1989, 1994, and 2004) have
                                                                           shown divergent trends of NCD risk factors over time: downward
WHO targets to reduce the burden of NCDs                                   trend for smoking (good news), unchanged or decreasing trends
                                                                           for high blood pressure and high blood cholesterol (good news)
The “Global Action Plan for the Prevention and Control of NCDs,
                                                                           but largely upward trends for diabetes and obesity (bad news)
2013‐2020 (3) adopted by all WHO member states in May 2013
                                                                           [13,14,15]. Findings of these previous surveys have been
[3] defines 9 voluntary national targets to be achieved by 2025
                                                                           instrumental to guide prevention and control programs in
and 25 indicators to monitor progress towards meeting these
                                                                           Seychelles since the early 1990s.
targets.
                                                                           The NCD survey in 2013‐2014 was therefore timely to update the
The 9 targets to be achieved by 2025, compared to baseline in
                                                                           situation of NCD risk factors which was last surveyed in 2004.
2010, are:
                                                                           Information in 2013‐2014 will be important to guide and adjust
1) 25% reduction of NCD
                                                                           clinical and public health responses to address NCDs, including
2) 10% reduction in alcohol use
                                                                           useful information to guide the Seychelles NCD strategy.
3) 10% reduction in prevalence of insufficient physical activity
4) 30% reduction in mean population salt intake                            References
5) 30% reduction in the prevalence of tobacco use                          1) UN General Assembly. Political declaration of the high‐level meeting
6) 25% reduction in the prevalence of raised blood pressure                    of the General Assembly on the prevention and control of non‐
7) 0% increase in obesity and diabetes                                         communicable diseases. A/66/L.1. 16 September 2011.
                                                                                  th
8) At least 50% of eligible people receiving drug therapy and              2) 65 World Health Assembly closes with new global health
                                                                               measures.www.who.int/mediacentre/news/releases/2012/wha65_cl
counseling to prevent heart attack and stroke
                                                                               oses_20120526/en/index.html
9) At least 80% availability of the affordable technologies and            3) Global Action Plan for the Prevention and Control of NCDs, 2013‐2020,
essential medicines, including generics, required to treat major               WHO, Geneva, 2013, www.who.int/nmh/events/ncd_action_plan/en/
NCDs on both public and private facilities                                 4) World Health          Organization. Global status report on
                                                                               noncommunicable diseases 2014. WHO, Geneva, 2015
All WHO Member States have committed to report national                        www.who.int/nmh/publications/ncd_report2014/en
levels of NCD risk factors on a regular basis. A first report (WHO         5) Annual Health Statistical Report. Ministry of Health, 2013.
Global Status Report on NCDs was published in 2011 (WHO                    6) Stringhini S, Sinon F, Didon J, Gedeon J, Paccaud F, Bovet P. Declining
Global Status Report on NCDs 2014) and an updated report was                   stroke and myocardial infarction mortality between 1989 and 2010 in
published in 2015 (WHO Global Status Report on NCDs 2014)                      a country of the African region. Stroke 2012; 43: 2283‐88.
[16]. Updated versions of this report will be published by WHO in          7) Bovet P, Rosalie D, Shamlaye C, Darioli R, Paccaud F. The Seychelles
2021 and in 2025. This implies that a next survey in Seychelles                Cardiovascular Diseases Survey 1989: methods and results. Sozial &
                                                                               Praeventivmedizin 1991;36 (Suppl 1):S1‐89.
should possibly take place before 2019 or and/or before 2024.
                                                                           8). Bovet P, Perret F, Shamlaye C, Darioli R, Paccaud F. The Seychelles
Overall trends of NCDs in Seychelles                                           Heart Study II. Methods and selected basic findings. Seychelles
                                                                               Medical & Dental Journal 1997;5:8‐24.
Vital statistics in Seychelles show that CVD and cancer account
for the largest share of premature mortality and morbidity in
Seychelles [5]. The good news is that the age‐standardized rates
of CVD are decreasing in Seychelles [6], consistent with trends in
high income countries. This favorable downward trend in is likely
related to the many programs and policies implemented over the
National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC
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Objectives of the 2013 survey                                             from the general adult population, findings can be inferred to the
                                                                          general adult population of Seychelles.
The 2013 survey addressed the following objectives:
                                                                          Instruments used in the survey to collect data
Primary objectives
                                                                          The survey included a questionnaire and several examinations
a) Distribution of the main modifiable risk factors of                    including anthropometrics, bioimpedance, blood pressure, blood
   noncommunicable diseases (NCD), particularly blood                     tests, urine tests, one lead ECG, bone ultrasound, and selected
   pressure, adiposity markers, diabetes and blood lipids                 functional tests.
b) Distribution of health behaviors related to NCDs, particularly
   tobacco use, alcohol drinking, and physical activity                   Detailed information on methods are described in the report
c) Rates of awareness, treatment and control of hypertension,             entitled “National Survey of Noncommunicable Diseases in
   diabetes and dyslipidemia                                              Seychelles 2013‐2014 (Seychelles Heart Study IV): Methods and
d) Comparison of findings in the survey in 2013‐2014 with                 Overall Findings, Public Health Authority, Ministry of Health,
                                                                                       nd
   results in previous surveys in 1989, 1994, 2004                        Seychelles, 2 version, 10 November 2014”).
e) Dietary patterns                                                       Further analyses will be performed to allow detailed description
f) Knowledge, attitudes and practices related to NCDs and NCD             of the findings and to formulate specific recommendations in
   risk factors                                                           different health areas.
Secondary objectives                                                      Approval of the survey
g) Assessment of indicators of quality of health (e.g. SF‐12)                The protocol of the survey was approved by the Health
h) Assessment of psychological stress and relation with NCD                   Research and Ethics Committee.
i) Assessment of several indicators of frailty (e.g. handgrip                The objectives of the survey were guided by the
   strength test, chair strand test, functional limitations)                  recommendations of the WHO Global Monitoring to
j) Assessment of knowledge and level of agreement with                        countries to regularly conduct population surveys on the 25
   current policies on tobacco control                                        priority NCD markers.
k) Use of public and private health care services, particularly for          A large part of the survey followed standard methods for
   NCDs                                                                       NCDs advocated by WHO (i.e. STEPS).
l) Exposure to advice on health behaviors given by health
   professionals at health care level                                     Consent form
m) Burden of chronic diseases not related to the main NCDs (e.g.
                                                                             Upon arrival to the study center, the aim and procedures of
   musculoskeletal, mental health, etc)
                                                                              the survey was explained to each participant separately and
n) Screening of selected cancers
                                                                              each participant was invited to sign an informed consent
o) Assessment of the kidney function
                                                                              form.
p) Frequency of heart arrhythmias (one‐lead ECG) and heart
                                                                             Participants were asked to separately sign a consent form for:
   murmurs (auscultation)
                                                                              1) consent to participate in the survey along modalities stated
q) Assessment of bone mineral density (ultrasound of
                                                                              in the invitation letter (no participant declined); 2) consent
   calcaneus)
                                                                              for blood to be used for genetic tests, and 3) consent to be
r) Exposure of the population to mass media, particularly in
                                                                              possibly contacted in the future for possible follow up related
   relation to health programs, and use by the population of
                                                                              to any possible follow up of the survey.
   new communication technologies
                                                                             All participants retained the right to decline any question or
s) Assessment of a number of social variables and their
                                                                              any test.
   association with the variables measured in the survey
t) More generally, the survey provides broad information                     The original paper consent forms will be kept for 5 years in a
   (medical, social, environment, etc) that can be useful for                 locked room and a scanned copy of all consent forms will be
   tailoring NCD prevention and control programs.                             kept for at least 10 years.
                                                                          Communication of results to the participants

Methods and participants for the 2013 survey                                 Before being discharged from study centers, participants
                                                                              received information on their own results, with relevant
Selection of participants                                                     advice, from the medical doctor of the survey.
The survey was performed in a sex and age stratified random                  Participants with a newly found abnormal medical condition
sample of all adults aged 25‐64 years of Seychelles between                   received a referral form signed by the doctor of the survey (a
October and December 2013 on Mahé and during 2 weeks in                       copy of which is kept at UPCCD) and were advised to go to a
February 2014 in the islands of Praslin and La Digue. These three             health center or to a specialist clinic to confirm or manage
islands account for >98% of the total population of Seychelles.               the condition.
The eligible sample was extracted from the population registry.              Participants who presented a serious medical condition were
                                                                              sent to the casualty for further diagnosis or care.
The survey was attended by 1240 adults, with a participation rate            A letter with selected results was sent to each participant
of 73%. Participants were invited to attend the survey on                     shortly after the visit to the survey center.
selected days in study centers located in Mahé, Praslin, and La
Digue. Non participants were actively traced (telephone, local
administration, announcements on radio, etc) and invited to
attend the survey. Since participants were randomly selected
National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC
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Population and mortality, Seychelles, 1989‐2013                                                                              health care occurring in the interval. Decreased age‐specific
                                                                                                                             mortality is consistent with substantially increased life
These data are compiled from Seychelles vital statistics of the                                                              expectancy in Seychelles over the past 25 years.
Ministry of health and from the National Bureau of Statistics.
Data on health outcomes in relation to CVD shown in this page                                                                Figure 3. Total numbers of cardiovascular disease, cancer and
help put results of the 2013 and other surveys in context.                                                                   other broad causes of deaths between 1989 and 2013
                                                                                                                                                                 800
Figure 1. Population of Seychelles between 1989 and 2013                                                                                                                                                          669
                                                                                                                                                                                                      651
                                                                                                                                                                 700
                                    100'000                                                                                                                                543          559
                                                                                         7.0k
                                                                           6 .5k         7.8%                                                                    600
                                                                           7.8%
                                                                                                                                                                                                                  272              Other

                                                                                                                              Deaths per year
                                                              5 .1k                                                                                                                                   276
                                     80'000        4.2k       7.0%
                                                                                                                                                                 500
                                                   6.4%                                                                                                                   233           235                                        Cancer
                                                                                                                                                                 400
 Population (k)

                                     60'000                                35k           49k                                                                                                                                       CVD other
                                                              32k          49%                             65+                                                                                                    118
                                                   25k                                   55%                                                                     300                                  115
                                                   37%        43%                                                                                                          80            96                                        Stroke
                                                                                                           25‐64
                                     40'000                                                                                                                      200                                  121         139              MI
                                                                                                                                                                           96           102
National Survey of Noncommunicable Diseases in Seychelles 2013 2014 (Seychelles Heart Study IV): main findings - WHO FCTC
9

Participation to Seychelles NCD surveys                                   are less older than young people in the population, the sampling
                                                                          strategy was designed to include similar numbers of participants
Table 1. Participation to the 2013 NCD Survey by age and sex              in each of four 10‐year age categories (i.e. random sex and age
                                                                          stratified sample from the total population aged 25‐64 years).
                     25‐34     35‐44     45‐54    55‐64     Tota l        The sample sizes in each of the four surveys are sufficiently large
 Men                                                                      to provide sufficient statistical power to assess the main
 El i gi bl e         196       202       217       215      830          objectives of the surveys, i.e. the prevalence of risk factors and
 Pa rti ci pa nts     111       109       150       161      531          their trends over time.
 Participation (%)    56.6      54       69.1      74.9        64
                                                                          Of note, similar methods were used in all four surveys in relation
 Women
                                                                          to the sampling strategy (sex and age stratified random samples
 El i gi bl e         204       216       222       230      872          of the total population aged 25‐64), questionnaires used (a
 Pa rti ci pa nts     162       168       183       196      709          majority of questions were identical in each survey) and methods
 Participation (%)    79.4      77.8     82.4      85.2      81.3         used to assess risk factors (blood pressure, BMI, etc). This allows
 Tota l                                                                   both inferring results to the general population of Seychelles and
 El i gi bl e         400       418       439       445      1702         directly comparing results across different survey.
 Pa rti ci pa nts     273       277      333       357       1240
 Participation (%)    68.3      66.3     75.9      80.2      72.9

Participation in the 2013 survey was lower among men (64.0%)
                                                                          Body mass index (BMI)
than among women (81.3%) and lower among young men than                   Figure 1. Mean BMI by sex, age and survey year, age 25‐64
older male participants (55.6% among men aged 25‐34 and 54%
among men aged 25‐44).           These findings are frequently                                                             32
                                                                                                                                       Men                   Women
encountered in surveys in all countries.                                                                                   30
With regards to non participation, we were able to compare
                                                                            Body mass index (kg/m2)

                                                                                                                           28
education status among eligible participants who did not                                                                                                                        1989
participate and eligible participants who participated in the 2013                                                         26                                                   1994
Survey, as Information on education was available in the sample                                                                                                                 2004
of eligible participants provided by National Bureau of Statistics.                                                        24
                                                                                                                                                                                2013
Education was not different in participants and non‐participants,
                                                                                                                           22
which gives reasonable assurance that participants and non‐
participants did not differ substantially in terms of socio‐                                                               20
economic status.
Table 2. Participants in surveys in 1989, 1994, 2004 and 2013.
                                                                          Mean BMI is higher in women than men, in young than older
                     25‐34     35‐44    45‐54     55‐64     Tota l
                                                                          persons, particularly in women. Mean BMI increased markedly
 Men
                                                                          between 1989 and 2013 in all sex and age categories. The
 El i gi bl e         196       202      217      215        830          increase of mean BMI between 1989 and 2013 is particularly
 Pa rti ci pa nts     111       109      150      161        531          striking in young women aged 25‐34.
 Participation (%)    56.6      54       69.1     74.9       64
                                                                          Figure 2. Age‐standardized prevalence of overweight and obesity
 Women
                                                                          by sex and survey year, age 25‐64
 El i gi bl e         204      216       222      230       872
 Pa rti ci pa nts     162      168       183      196       709                                                            100
                                                                                  Prevalence of overweight & obesity (%)

 Participation (%)    79.4     77.8      82.4     85.2      81.3                                                                           Men               Women
 Tota l                                                                                                                     80

 El i gi bl e         400      418       439      445       1702
                                                                                                                            60
 Pa rti ci pa nts     273      277       333      357       1240                                                                                                       39    Obese
                                                                                                                                                                  35
 Participation (%)    68.3     66.3      75.9     80.2      72.9                                                                             15   22         28              Overweight
                                                                                                                            40                          23
                                                                                                                                       8
The four surveys included similar total numbers of participants,
                                                                                                                                  4
i.e. 1081 in 1989, 1067 in 1994, 1255 in 2004 and 1240 in 2013.                                                             20               36   35
                                                                                                                                       30                    32   33   33
Participation rates in the surveys in 1989, 1994 and 2004                                                                         24                    28

exceeded 80% and participation in 2013 was 73%. These                                                                        0
participation rates are excellent for such exanimation surveys,                                                                  1989 1994 2004 2013   1989 1994 2004 2013
and allow generalizing findings to the entire population of
Seychelles. Participation to examination surveys, for which               Between 1989 and 2013, the prevalence of combined overweight
                                                                                                                         2
participants have to come to designated study centers, is often           (i.e. slight excess of weight, BMI: 25‐29 kg/m ) and obesity
                                                                                                                 2
lower than 50% in high income countries.                                  (marked excess of weight, BMI ≥30 kg/m ) doubled in men (from
                                                                          28% to 57%) and also markedly increased in women (from 51% to
To maximize the statistical power of estimates of the variables           72%).
assessed in the survey in all age categories considering that there
10

Figure 3. Total numbers of overweight and obese persons by sex                                                                                                             aged 26‐64 in 2013). This predicts high numbers of persons with
and survey year, age 25‐64                                                                                                                                                 complications in near, middle and long terms.
  30'000                                                                                                                                                                   Figure 6. Mean BM by sex, socio‐economic status and survey
                                                                       Men                                          Women                                                  year, age 25‐64
  25'000
                                                                                                                                                                                                                      32
                                                                                                                                        8'070
  20'000                                                                                                                                                                                                                           Men                Women

                                                                                                                                                                             Mean body mass index (kg/m2)
                                                                                             8'673                                                                                                                    30
                                                                                                                              6'662
  15'000                                                                                                                                                Obese
                                                                                  7'466
                                                                                                                                                                                                                      28
                                                                                                                                                        Overweight
                                                                                                                    4'195                                                                                                                                              Non manual
  10'000
                                                                                                                                       17'822
                                                                     4'757                                                                                                                                            26
                                                                                           14'015      2'828                 13'664
                                                                                                                                                                                                                                                                       Manual
                    5'000                               2'932                     10'569
                                                                                                                    8'546                                                                                                                                              Unskilled
                                                                     6'107                                                                                                                                            24
                                                                                                       5'453
                                                        3'496
                                                0
                                                                                                                                                                                                                      22
                                                        1989 1994 2004 2013                            1989 1994 2004 2013

                                                                                                                                                                                                                      20
Because of the increasing and aging population between 1989                                                                                                                                                                1989 1994 2004 2013   1989 1994 2004 2013
and 2013, the increasing prevalence of overweight and obesity
over time results in increasing numbers of overweight and obese                                                                                                            There is a strong sex‐specific social patterning of body weight in
persons in the population (48’830 aged 25‐64 in 2013).                                                                                                                     all surveys. BMI is higher among women of low than higher SES
Figure 4. Age‐standardized prevalence of categories of BMI, age                                                                                                            while BMI is markedly higher in men of higher than lower SES.
25‐64                                                                                                                                                                      Figure 7. Perceived ideal body shape by sex, BMI and SES
                                                                            Men                                             Women                                                                                    5.0
                                                        0.3           0.0           0.9         1.5
                                       100
                                                                                                                                                                            Perceived ideal body shape (scale 1‐9)

                                                         0             1                                   1.8
                                                         4             7
                                                                                     2           4          6
                                                                                                                            4.0
                                                                                                                             5
                                                                                                                                      4.5         6.7                                                                           Men                   Women
                                                                                    12                                                 11                                                                            4.5
                                                                                                16                                                10
                                                        24                                                     15
 Age standardized prevalence (%)

                                              80                                                                            18
                                                                      30                                                               20                   ≥40
                                                                                                                                                  22                                                                 4.0
                                                                                    36                                                                      35‐39
                                                                                                35             28
                                              60                                                                                                            30‐34
                                                                                                                            32                                                                                       3.5                                                Manual
                                                                                                                                       33                   25‐29
                                                                                                                                                  33                                                                                                                    Non manual
                                              40        66
                                                                                                                                                            18.5‐24                                                  3.0
                                                                      57
11

Figure 9. Men taking currently concrete measures to control their            Tobacco use
body weight by age and SES indicators, (green: yes; red: some effort;        Figure 1. Age standardized prevalence of occasional and daily
blue: no)
                                                                             smokers by sex, age and survey year, age 25‐64

                                                                                                                    60
                                                                                                                                            Men                                Women
                                                                                                                             3.2
                                                                                                                    50

                                                                                       Prevalence of smoking (%)
                                                                                                                    40                4.6
                                                                                                                                              7.7
                                                                                                                    30                                     5.9                                         Occasional
                                                                                                                             50.3                                                                      Current
                                                                                                                    20                36.5
                                                                                                                                             30.8      28.3          0.8
                                                                                                                                                                               1.3
                                                                                                                    10
                                                                                                                                                                                               2.6
                                                                                                                                                                     9.8              2.0
                                                                                                                                                                               6.8             5.1
                                                                                                                                                                                      3.9
                                                                                                                    0
Substantial proportions of men, with a marked difference                                                                    1989 1994 2004 2013                     1989 1994 2004 2013
according to higher vs. lower SES; take measures to control
weight in the total population.                                              The prevalence of daily smokers is much higher in men than
                                                                             women. The prevalence decreased between 1989 and 2013 in all
Comments                                                                     age categories in men. The prevalence tended to increase in
BMI (i.e. body weight) largely increased over time in Seychelles in          women between 2004 and 2014.
all sex, age and SES categories. High BMI is associated with many            Figure 4. Age‐standardized number of cigarettes smoked per day
detrimental heath conditions, including diabetes, high blood                 among daily smokers, by sex and survey year, age 25‐64
pressure, dyslipidemia, osteoarticular problems, etc. It is the
main cause of the increasing prevalence of diabetes in the                                                          14

population (“diabesity”).
                                                                              Number of cigarettes smoked per day

                                                                                                                    12

The 2013 Survey identified marked differences in men vs women,                                                      10
                                                                                     among daily smoker

and differ SES categories, in relation prevalence of obesity and in
associated factors, such as perception of ideal body weight, and                                                        8                                                                            Men
attitudes (efforts to lose weight). These variables will be analyzed                                                    6      12.7                 12.3                                             Women
in further detail as they bear important significance in terms of                                                                                                 10.4
                                                                                                                        4                                                8.1
cultural, social incentives/disincentives for people to gain or lose                                                                  6.7
                                                                                                                                                           7.3                       7.2 6.8
weight.                                                                                                                 2

The WHO member states, including Seychelles, have agreed in                                                             0
2014 on the target of 0% increase of the prevalence of obesity                                                                      1989             1994          2004               2013
and diabetes between 2010 and 2025.
                                                                             The number of cigarettes smoked by daily smokers, which was
Interventions to reduce body weight at the individual level often            much higher in men than women in the past, has decreased in
have little efficacy, except for bariatric surgery. Therefore, weight        male smokers, but not in female smokers.
control interventions should address the societal causes of the
obesogenic environment and involve population‐based                          Figure 3. Prevalence of smoking by sex, socio‐economic status,
interventions in all sectors (education, agriculture, finance,               and survey year, age 25‐64
transports, nutrition, food industry:) to enable people to chose
                                                                                                            100
healthier diets through awareness campaigns, food labeling,                                                                             Men                              Women
tax/subsided on healthy/unhealthy foods; ban on advertising of
                                                                                                                   80
unhealthy foods, healthy food in canteens of schools/workplaces,
                                                                                Prevalence of smoking (%)

etc, and in population‐based strategies to engage people to have
more physical activity in their daily lives (e.g. bus/cycling lanes,                                               60
                                                                                                                                                                                                     Laborer
safe sidewalks, public transports, disincentives to use private                                                                                                                                      Manual
cars, etc).                                                                                                        40
                                                                                                                                                                                                     Non manual

The WHO 2014 NCD Status Report lists cost‐effective
                                                                                                                   20
interventions in many sectors to help reduce weight and promote
physical activity in the population.
                                                                                                                    0
                                                                                                                            1989 1994 2004 2013                  1989 1994 2004 2013

                                                                             The prevalence of smoking was higher in all surveys in lower vs.
                                                                             higher SES groups, particularly in men.
12

Figure 4. Numbers of regular and occasional smokers by sex and                   Figure 7. Did anyone smoke in your home when you were
survey year, age 25‐64                                                           present in the past 7 days? (yes: red)
 10000
                 Men                        Women
  8000
                              1369
                       1657
          468
                771
  6000
                                                               Occasional

                                                               Current
  4000
         6545                 6830
                5887   6313

  2000
                                      97    212         617
                                                  428
                                     1070   930   796   1206
     0
         1989 1994 2004 2013         1989 1994 2004 2013

                                                                                 Nearly 20% of all adults report are exposed to smoke at home,
Even if the prevalence of smoking has markedly decreased in
                                                                                 slightly less often in higher than lower SES households.
men and not markedly increased in women, the total numbers of
smokers has increased over time because of the largely                           Figure 8. Do you agree with the ban on smoking in enclosed
increasing population between 1989 and 2013.                                     public places, including work places and restaurants? (blue: fully
                                                                                 agree)
Figure 5. Use of pipe, cigars, cigarillos, hand rolled cigarettes and
shisha (n=17) among 354 ever smokers (yes: red)

                                                                                 The prohibition on smoking in enclosed places by law is very
                                                                                 largely supported, including by a large majority of smokers.
The use of tobacco products other than cigarettes is very
uncommon. In addition, most users of other products also smoke                   Figure 9. Did anyone smoke in enclosed areas in your workplace
cigarettes (data not shown here).                                                when you were present in the past 7 dayss, by sex, age and SES
                                                                                 categories (red: yes)
Figure 6. Proportion of daily smokers who tried to quit in past 12
months in 2013, by sex, age and SES categories (yes: red)

                                                                                 Around 10% of participants report exposure to indoor smoke in
A large proportion of smokers wish to quit. This proportion is                   the workplace, which suggests the need to improve enforcement
higher among higher than lower SES, consistent with high                         of the legislation.
prevalence of smokers among low than higher SES. Of note,
attempt to quit are often not successful because of the addictive
nature of nicotine, which emphasizes the need to focus on
measures to prevent smoking uptake at the first place.
13

Figure 10. Received advice on smoking cessation from a health              areas that need be improved so that the prevalence of smoking
officer in past 12 months, among 127 smokers who visited a                 keeps decreasing in Seychelles and the target of a 30% decrease
doctor in past 12 months (yes: blue)                                       between 2010 and 2025 can be achieved.
                                                                           As the first country to have ratified the Framework Convention
                                                                           for Tobacco Control in the African region, Seychelles should aim
                                                                           at implementing best practices in tobacco control in the region.

                                                                           Alcohol use
                                                                           Figure 1. Mean daily intake of ethanol by sex, age and survey
                                                                           year, age 25‐64
                                                                                                                   100
                                                                                                                    90             Men                  Women

                                                                                 Ethanol per day on average (ml)
                                                                                                                    80
                                                                                                                    70
Only a third of smokers receive advice to quit smoking during
                                                                                                                    60                                                       25‐34
medical visits. This advice should be repeated at all visits as
                                                                                                                    50                                                       35‐44
studies show that advice to quit smoking by doctors is cost
                                                                                                                    40                                                       45‐54
effective.
                                                                                                                    30                                                       55‐64
Comments                                                                                                            20
                                                                                                                    10
The age‐adjusted prevalence of smoking decreased over time as
                                                                                                                     0
well as the number of cigarettes smoked per day in male
                                                                                                                         1989 1994 2004 2013      1989 1994 2004 2013
smokers. This decrease is one factor that underlies the marked
decrease in the age‐adjusted mortality rates of cardiovascular             Volume of drinking (ml ethanol per day and per capita on average
diseases and lung cancer between 1989 and 2013. Decreasing                 = alcohol intake per capita) is much lower among women than
prevalence of smoking (men) likely reflects the high profile               men and has decreased markedly over time in men. Consumption
tobacco control program in Seychelles since the late 1980s, which          was not assessed in 1994 for persons drinking alcohol less than
includes continued awareness programs, fairly high tax on                  weekly but this has little impact on mean drinking volume.
tobacco products (>65% of total cost of cigarette packet in 2014),
and impact of comprehensive legislation on tobacco control in              The decrease in mean alcohol intake per capita over time in men
2009 (i.e. total ban on smoking in enclosed public places an               is likely largely driven by the marked decreased consumption of
selected open public spaces, total ban on tobacco advertising,             homebrews over time, which accounted for as much as 50% of
promotion and sponsorship, etc).                                           the total ethanol intake in 1989 (mainly among men) but is only
                                                                           minimal in 2013. The decrease is also driven by the decrease over
However, the total numbers of smokers in the population is still           time of heavy drinkers (>75 ml/day), which also used to be
both high and increasing over time, which emphasizes the need              strongly associated with homebrew drinking.
to further strengthen tobacco control program as a main public
health priority.                                                           Figure 2. Mean alcohol intake by sex, socio‐economic status and
                                                                           survey year, age 25‐64
This emphasizes that interventions to reduce tobacco use should
be strengthened. This includes ensuring complete enforcement                                                       120
of the ban on smoking in public places with regular monitoring by                                                               Men                 Women
inspectors and spot fining smokers and managers when smokers                                                       100
                                                                            Mean ethanol per day (ml)

smoke in non authorized areas, as prescribed by the law; swift
                                                                                                                    80
implementation of rotating health warnings on tobacco packets
as requested by the law and the FCTC; further tax increases at                                                                                                          Laborer
                                                                                                                    60
regular intervals at greater pace than inflation, so that the ratio                                                                                                     Skilled manual
of tax/total cost is larger than 75%); and continued health                                                         40
                                                                                                                                                                        Non manual
education programs in all settings.
                                                                                                                    20
It is also necessary that a cessation smoking program is provided
by health services to help smokers who wish to quit, including
                                                                                                                     0
free provision of nicotine replacement medications.                                                                      1989 1994 2004 2013   1989 1994 2004 2013

The WHO member states, inclusive Seychelles, have agreed on a
                                                                           Ethanol intake differed largely by socio‐economic status (SES) in
30% relative reduction in the prevalence of smoking between
                                                                           men, with much higher intake of alcohol in low than higher SES
2010 and 2025. The WHO 2014 NCD Status Report provides a list
                                                                           men. However, the difference decreased markedly over time,
of cost‐effective interventions for tobacco control.
                                                                           likely driven by the marked decrease in homebrew drinking. It
All tobacco control interventions and policies implemented in              was mostly person of lower SES who used to drink inexpensive
Seychelles are reported in the Reporting Instrument submitted              homebrews, and drank it in large amounts, in past surveys (as
every 2 years to the Conference of Parties to the Framework                found in past surveys). Homebrew drinking has virtually
Convention of Tobacco Control. It is necessary to address all              disappeared in recent years and consumption now almost
14

entirely relies on commercial beverages, highly taxed. High price                                               and moderate drinkers, and the increasing population between
of alcohol beverages is an effective measure against heavy                                                      1989 and 2013, result in largely increasing numbers of light and
drinking and one could even expect a reversal of the social                                                     moderate drinkers over time, both male and female.
gradient in heavy drinking (as already apparently seen, at a small
scale, with higher alcohol intake in women of higher vs. lower
SES.                                                                                                            Figure 5. Number of drinks on a typical week day by sex, age and
                                                                                                                socio economic indicators (orange: 3; grey: 4; red:5+)
Figure 3. Age‐standardized prevalence of categories of drinkers,
age 25‐64 (1‐29 ml/day = 1‐2 drinks per day on average; 30‐75 ml/day =
3‐ 5 drinks; ≥75 ml/day >5drinks)
                       100
                                            Men                       Women

                              80
 Prevalence of drinkers (%)

                                                        11
                              60    34                                                        >75 ml/d
                                                 14
                                                                                              30‐75 ml/d
                                                        28
                                                                                              1‐29 ml/d
                              40          22                                           1
                                                                                       6
                                                 24
                                    22
                                                                3
                                                                5
                              20          17
                                                                               1
                                                        34                     3      35
                                    19           22             20
                                          11                                   14
                                                                       2
                                                                       1
                              0                                        3
                                   1989 1994 2004 2013         1989 1994 2004 2013                              Figure 6. Number of drinks on a typical Friday (orange: 3; grey: 4;
                                                                                                                red: 5‐10: blue grey: 11‐20)
The prevalence of heavy drinkers (≥5 drinks per day on average),
which was high in men in early surveys (1989, 1004) has
decreased over time but is still substantial (nearly 11% of men in
2013). However, the prevalence of both moderate drinkers (1‐2
drinks per day) and marked drinkers (3‐5 drinks per day) has
increased over time in both men and women.
Of note, alcohol intake was not assessed in 1994 for persons
drinking less than once weekly and the prevalence of category 1‐
25 ml/day is underestimated in 1994. This has impact on
estimation of the frequency of light drinkers but only little impact
on the estimation of on total alcohol consumption.
Figure 4. Total number of drinkers of light, moderate, marked
and heavy amounts of alcohol by sex and survey year, age 25‐64
30'000
                                                                                                                Figure 7. Number of drinks on a typical Saturday, (orange: 3; grey:
                                               Men                   Women
                                                                                      237                       4; red: 5‐10: blue grey: 11‐20)
25'000
                                                                                      1422
                                                        2698
                                                                              132
20'000                                                                         645
                                                 2814                  247            8496    >75 ml/d
                                                        6735                  2894
                                                                       220                    30‐74 ml/d
15'000                                    3532   4916                  433
                                                                497                           1‐29 ml/d
                                          2671                  361
                                   4403          4605   8294
10'000                                    1967                 2316                           0 ml/d
                                                                              16713
                                   2967                               14461           14259
     5'000                         2389   8460                 8506
                                                 8046
                                                        6381
                                   3380
                               0
                                   1989 1994 2004 2013         1989 1994 2004 2013

Note: 1‐29 ml/d = 1‐2 drinks/d; 30‐75 ml/d =3‐5 drinks/d; >75
ml/d, >5 drinks/d. Alcohol consumption was not assessed in 1994
for persons drinking alcohol less often than once weekly, hence
the frequency of drinking 1‐25 ml/day is under‐estimated and the
category of 0 ml/day is overestimated in 1994.
Although the prevalence of heavy drinkers (>5 drinks per day on
average) has decreased over time, the total number of heavy
drinkers remains high with nearly 3000 male heavy drinkers in
2013. The cumulating effect of the increasing prevalence of light
15

Figure 8. Number of drinks on a typical Sunday (orange: 3; grey: 4;        Figure 10. Number of days drinking more than 4 (women) or 5 (men)
red: 5‐10: blue grey: 11‐20)                                               drinks per month (orange: 5‐10; grey: 11‐15; red: 16+)

                                                                           Around 20% of all adults drink vey high amounts of alcohol on
Few adults drink on workdays but high proportions drink on                 more than 5 days per month and around 10% of all adults drink
Fridays and Sundays with even higher proportions drinking on               excessive alcohol amounts of alcohol on more than 10 days per
Saturdays. This suggests binge drinking patterns in many                   month. Binge drinking is more frequent in male vs. female and in
drinkers.                                                                  persons of lower vs. higher SES. There was little difference
                                                                           between young and older persons. Overall, these figures show
Figure 9. Proportion of persons drinking homebrews (kalou, baka,
                                                                           high frequency of binge drinking, with many men and women
lapire) among 665 current drinkers (yes: blue)
                                                                           drinking in excess on many days per month.
                                                                           Comments
                                                                           Ethanol consumption per capita decreased over the past 25
                                                                           years, largely driven by both a marked decrease of heavy drinking
                                                                           among men and a largely decreasing consumption of homebrews
                                                                           between 1989 and 2013.
                                                                           However, while the prevalence of heavy drinking (>5 drinks per
                                                                           day on average) has decreased, the frequency of light and
                                                                           moderate drinking has increased among both men and women.
                                                                           Because the population has largely increased, the total numbers
                                                                           of heavy drinkers in the population (mainly men) remains high,
                                                                           and the numbers of drinkers of 1‐2 and 3‐5 drinks per day on
Homebrew drinking was very low in 2013, and was higher in male             average have largely increased. This implies large and further
vs. female, older vs. young, and lower vs. higher SES persons.             increasing numbers of health, social and other alcohol‐related
Figure 10. Number of drinks (any type) in a single day on special          problems, e.g. larger numbers of drunk drivers on the roads.
occasions (green: 6‐10, orange: 11‐15; grey: 16‐20; red: 21+)              A further important problem is that alcohol is often consumed
                                                                           along a binge drinking pattern (i.e. high intake on few occasions).
                                                                           Binge drinking (as compared to regular low intake) is associated
                                                                           with many health and social problems (heart attack, drunk
                                                                           driving, violence, etc).
                                                                           Findings in the different surveys between 1989 and 2013 confirm
                                                                           that alcohol misuse remains a main public health issue in
                                                                           Seychelles and requires a strengthened public health response,
                                                                           e.g. frequent random alcohol checks of all drivers in sensitive
                                                                           points (discotheques, social gatherings at night, etc), high taxes
                                                                           on alcohol beverages on a basis of alcohol content of beverages,
                                                                           severe penalties for drunk driving, ban on advertisements of
                                                                           alcohol beverages in public mass media, awareness campaigns,
                                                                           etc).
Around 20% of all adults report drinking >10 drinks on single
special occasions. This proportion is higher in male vs. female,           The WHO member states, inclusive Seychelles, have agreed on a
young vs. old, and lower vs. higher SES persons. Binge drinking            10% relative reduction of the prevalence of harmful use of
(irregular drinking with high amounts on drinking sessions) has            alcohol between 2010 and 2025. The WHO 2014 NCD Status
numerous health and social detrimental outcomes.                           Report provides a list of cost‐effective interventions in multiple
                                                                           sectors to reduce alcohol misuse in the population.
16

Dietary habits                                                                                        The proportion of people drinking full cream milk is high and
                                                                                                      does not differ according to SES categories. Awareness
Figure 1. Patterns of dietary habits, based on food frequency                                         campaigns should encourage people drinking semi‐skimmed milk.
questionnaire, age 25‐64
                                                                                                      Figure 4. Number of spoons of sugar added in tea or coffee, (blue
                                  daily   5-6 d/wk      3-4d/wk       1-2 d/wk
17

Figure 7. Do you use olive oil when cooking or to add in salad,            Taking vitamin supplements has been associated with adverse
(blue: never; red: rarely, green 1‐2 times/wk, orange: ≥2 times/wk)        health effects in many studies.
                                                                           Figure 10. Do you read labels on food packages to help you
                                                                           decide, e.g. to look for salt, sugar or fat content (blue: never; green:
                                                                           sometimes; red: rarely; orange: often)

The consumption of olive oil (a healthy oil rich in mono‐
unsaturated fatty acids) is unexpectedly high in the population
and likely a new trend, likely reflecting health consciousness,
impact of health education programs, and recent decrease in the
price of olive oils. Consumption of olive oil is markedly higher in        Few people read food labels, and many of those who read labels
higher v. lower SES persons, possibly reflecting both a cost issue         said they read mostly expiry dates. There is a need for health
and better health awareness.                                               education programs to raise this issue, as well as policy measures
                                                                           to regulate the content and format of food labels so most people
Figure 8. How Important to you is lowering the salt content in             can understand them and help them chose healthy products.
your diet (blue: not; red: a bit important; green: very important)
                                                                           Comments
                                                                           Fish, unpolished rice and sugared tea continue to be the staple
                                                                           diet in Seychelles. Of note, these items do not include a number
                                                                           of nutrients so the trends towards a more diverse diet are
                                                                           welcome to provide healthy micronutrients and vitamins.
                                                                           A few other items are consumed frequently in 2013, e.g. bread,
                                                                           vegetables, fruit, lentils, breakfast cereals, milk, and cheese.
                                                                           Intakes of meat, processed meat, potatoes, potato chips, and
                                                                           pasta are still low (although likely largely increased compared to
                                                                           past years). Consumption of poultry is more frequent. Intake of
                                                                           salted and sweet snacks is substantial.
                                                                           The data do not provide information on portion sizes. Therefore
The proportion of people reporting paying attention to salt
                                                                           high frequency of eating an item per week (e.g. “vegetables”)
reduction (a main measure for reducing blood pressure) is high in
                                                                           does not necessarily mean that a product is consumed in large
the population, likely reflecting ongoing awareness campaigns on
                                                                           amounts. For example, a large proportion of people report eating
this issue. This proportion of persons trying to reduce salt intake
                                                                           salad on most days of the week, but the amount of salad actually
is higher among female vs. male, older vs. young, and higher vs.
                                                                           found in plates in Seychelles (in grams) is often very low.
lower SES persons.
                                                                           Overall, a more varied diet, as found in the 2013 survey, has
Figure 9. Took vitamins during last 4 weeks (red: yes)
                                                                           advantages in providing a broader range of nutrients and
                                                                           vitamins (e.g. bread, cheese, milk, breakfast cereals,) which are
                                                                           not present in rice and fish. However, the current diet also
                                                                           includes substantial intake of nutrient poor and energy rich food
                                                                           items (e.g. large amounts of sugar added in tea/coffee, soft
                                                                           drinks, juices in packets, salted and sweet snacks, processed
                                                                           meat, etc). These nutrients contribute large amounts of sugar,
                                                                           salt, saturated fats or trans fats, which are main causes of
                                                                           cardiovascular disease. Sugared drinks have little nutritional
                                                                           value and contribute large energy intake and, therefore, fuel the
                                                                           raising prevalence of obesity.
                                                                           There is a need to sustain health education campaigns on healthy
                                                                           nutrition, e.g. emphasizing on five portions of vegetables and
                                                                           (fresh) fruit a day, need to prefer water (including tap water),
The proportion of adults taking vitamins is high, possibly
                                                                           semi‐skimmed milk and fresh fruit juices to soft drinks of packets
reflecting health concerns. Yet, there is no medical reason for
                                                                           of fruit juices.
healthy people having a proper diet to take vitamin supplements.
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