Chronic Disease In St Lucia Health And Social Care Essay

Chronic disease is a disease of a long duration and generally slow progression (WHO, 2010). The U.S. National Center for Health Statistics states that a chronic disease is one lasting 3 months or more. These chronic diseases normally cannot be prevented by vaccines or cured by medication, nor do they just vanish. Chronic diseases are mainly caused by three major risk factors – tobacco use, poor eating habits and physical inactivity. Majority of these risk factors are themselves worsened by poor socioeconomic determinants, such as lack of education and poverty. Most often these determinants are a indication of the main forces driving social, economic and cultural transition, including globalisation, urbanisation and an aging populations.

Chronic diseases are affecting population health as the epidemiological transition progresses and are the lead cause of mortality worldwide and pose increasing problems for the burden of disease and quality of life in developed and developing countries (WHO, 2003). Non communicable diseases include a broad range of conditions, including cardiovascular disease, diabetes, cancers, chronic respiratory disease, mental-health problems and musculo- skeletal disorders. The first four mentioned above account for approximately 50% of mortality globally, and share behavioural risk factors, such as excess calorie consumption, diets high in saturated and transfatty acids, excessive intake of alcohol, physical inactivity, and tobacco smoking. Approximately 35 million people have died from heart disease, stroke, cancer and other chronic diseases in the year 2005. The burdens of these diseases are equally shared among men and women, and are more prevalent in people under the age 70 (WHO, 2004). 80% of chronic disease deaths occur in low and middle income countries.

Figure 1: Global distribution of total deaths (58 million) by cause in 2005.

The age-specific death rates between the years 2005 – 2015 are projected to fluctuate slightly, Nevertheless, the ageing populations will result in an overall increase in chronic disease death rates for all ages combined. In 2005, all chronic diseases account for 72% of the total global burden of disease in the population aged 30 years and older. The total lost years of healthy life due to chronic diseases, as measured by DALYs, are greater in adults aged 30-59 years than for ages 60 years and older. More than 80% of the burden of chronic diseases occurs in people under the age of 70 years.

Table 1: Projected global deaths and burden of disease due to chronic disease by age 2005- 2015

Deaths (Million) DALYs (millions) Deaths per 10000 DALYs per 100000

2005 2015 2005 2015 2005 2015 2005 2015

0-29 years 17 15 220 219 48 40 6320 5994

30-59 years 7 8 305 349 311 297 13304 13375

60-69 7 8 101 125 1911 1695 27965 26396

≥70 20 24 99 116 6467 6469 32457 31614

All ages 35 41 725 808 549 577 11262 11380

World Health Organization projects that, globally, NCD deaths will increase by 17% over the next ten years. The greatest increase of 27 %and 25 % respectively will be seen in the African region and the Eastern Mediterranean region (WHO,)

1.2 Types of chronic diseases

1.2.1Cardiovascular disease

Cardiovascular disease CVD is the term used by the scientific community to embrace not just conditions of the heart [ischemic heart disease (IHD), valvular, muscular, and congenital heart disease but also hypertension and conditions involving the cerebral, carotid, and peripheral circulation. The risk of CVD is related to diet, physical activity, and body ( ). The patterns of food supplies and of food and nutrition that modify the risk of CVD are also well known.

Whereas CVD was once largely confined to high-income countries, it is now the number one cause of death worldwide as well as in low- and middle-income countries, where 80 percent of the world’s 13 million annual CVD deaths occur. And at least 21 million years of disability-adjusted life years (or DALYs, a measure of future productive life) are lost globally because of CVD each year. The vast majority of CVD can be attributed to conventional risk factors such as tobacco use, high blood pressure, high blood glucose, lipid abnormalities, obesity, and physical inactivity.

Cardiovascular diseases are major cause of chronic disease death and were accounted for of 17 million deaths in 2002. It is estimated that by the year 2030, 24 million will die of CVD, of which 80% will occur in low and middle income countries (5).

1.2.2 Cancer

Cancer is a major and growing disease burden worldwide. The number of new cancer cases is projected to increase from 10 million in 2000 to 15 million in 2020, 9 million of which would be in developing countries. The epidemiology of cancer in developing countries clearly differs from that in developed countries in important respects. While developed countries often have relatively high rates of lung, colorectal, breast, and prostate cancer (some of which is tied to tobacco use, occupational carcinogens, and diet and lifestyle), up to 25% of cancers in developing countries is associated with chronic infections. Seven types of cancers account for approximately 60 percent of all newly diagnosed cancer cases and cancer deaths in developing countries: cervical, liver, stomach, esophageal, lung, colorectal, and breast.

1.2.3 Respiratory Diseases

Chronic adult respiratory diseases-such as chronic obstructive pulmonary disease (COPD) and asthma-are a major and growing burden in terms of morbidity and mortality in the developing world. COPD (which includes emphysema, chronic bronchitis, and obstructive airways disease) is largely linked with cigarette smoking as well as exposure to unvented coal-fired cooking stoves; it accounts for 2 percent of lost DALYs on a worldwide basis.

1.2.4 Diabetes Mellitus

Diabetes affects people worldwide and is one of the oldest diseases known. There are two common types of this disease: type 1and type 2 diabetes. Type-1 diabetes accounts for 5-10% of all diagnosed diabetes. Type-2 diabetes is the most common form of diabetes. It accounts for 90-95% of diagnosed diabetes.

The World Health Organization (WHO) estimated the worldwide prevalence of diabetes in adults to be around 173 million in 2002 and predicted that there will be at least 350 million people with Type 2 diabetes by 2030. At present about two-thirds of persons with diabetes live in developing countries and the majority of new cases will originate from these areas. The global increase in the incidence of diabetes is related to high levels of obesity associated with a change from traditional diets, diminishing levels of physical activity, population ageing and increasing urbanization.

Diabetes Mellitus is the most prevalent form of diabetes on the global scale (6). For the past few decades, Diabetes Mellitus has reached epidemic proportions in many parts of the world. The World Health Organization (WHO) has predicted the global prevalence of all Diabetes will increase from 194 million in 2003 to 330 million in the year 2030 (7).

1.2.5 Hypertension

Another commonly occurring chronic disease is hypertension. High blood pressure increases the risk of heart disease and stroke. Hypertension is sustained high blood pressure (≥140/90mmHg).

Blood pressure itself is the pressure exerted by the blood on the walls of the blood vessels. Each time the heart beats (about 60-70 times a minute at rest), it pumps blood into the arteries. Blood pressure is at its highest when the heart beats, pumping the blood. This is called systolic blood pressure. When the heart is at rest, between beats, blood pressure falls. This is diastolic pressure. Blood pressure itself is not harmful – it is essential as it is the force that drives blood through the blood vessels to supply oxygen and nutrients to the body’s organs and tissues and carry away waste materials. However, when blood pressure becomes too high it has damaging effects on almost every

part of the body and can lead to serious illness and death. Hypertension is an important public health challenge worldwide because of its prevalence and its role as a risk factor for cardiovascular disease. Some of the risk factors of hypertension include obesity, alcohol, family history, and smoking.

There are two types of hypertension, namely primary hypertension and secondary hypertension. Primary hypertension is more common, occurring in 90-95% of the hypertension population. There is no identifiable cause and it develops gradually over many years. Secondary hypertension occurs in 5-10% of the hypertension population. ()

In the year 2000 it was estimated that the total number of adults with hypertension was 972 million. Of these, 333 million were estimated to be in developed countries and 639 million in developing countries (0). Kearney PM et al., predicted that by the year 2025, the number of people with hypertension will increase by approximately 60% to a total of 1.56 billion. (Kearney PM et al., 2005) the reasons are the continuing population increase and changes in lifestyle, which includes a diet high in sugar and high-fat processed foods and sedentarism.

1.3 Impact of chronic disease in the Caribbean

Caribbean countries are in epidemiological transition, where not only nutritional deficiencies have considerably declined but infectious diseases have also been disappearing. However, over the last thirty years, nutrition-related chronic non-communicable diseases have slowly emerged as the major public health problems. Non-communicable diseases (NCDs) have gradually displaced communicable diseases in the Caribbean. Rates of chronic non-communicable disease such as diabetes, hypertension, cardiovascular disease and cancer have been increasing in the Caribbean and are the leading cause of mortality and mobility in the region (Ragoobirsinghet al., 1995, 2002; Wilkset al., 1998, 1999; Figueroaet al., 1999; Rotimi et al., 1999; Cruickshanket al., 2001, Figueroa, 2001; Sargeantet al., 2001; Henniset al., 2002a,b; Corbinet al., 2004; Wolfeet al., 2006). Of concern is the fact that while the prevalence and mortality rates of these diseases are highest in the elderly, they are not restricted to any one age group. An estimated 10% to 20% of the Caribbean population over 20 years of age suffers from diabetes and hypertension, respectively, with prevalence more than doubling at older ages (Hennis et al., 2002a, b). Hypertension and diabetes rank as the two leading chronic disorders among Caribbean populations and are also major risk factors for other diseases such as cerebrovascular disease (stroke) and coronary heart disease.

Prevalence of chronic diseases in the Caribbean region over the pass 3 decades

Another striking epidemic among the Caribbean population is the high prevalence of overweight [body mass index (BMI) >25 kg m−2] and obesity (BMI >30 kg m−2). Approximately half of the adult Caribbean population is overweight and 25% of adult Caribbean women are obese (Henry, 2004). The escalating trend in obesity is considered to be a major causative factor in chronic disease prevalence in the region. The increasing obesity levels, mainly among women, maybe associated with the changes in traditional diets and the adoption of sedentary lifestyles. In some the islands more than half of adult women are reported to be obese. Data from Barbados highlights the importance of obesity as a risk factor in chronic diseases. Based on available evidence, obese persons, (BMI>30) of 40-79 years had a 2.6 times greater risk of hypertension than persons with BMI<25, and obese women had 5.2 times the risk of developing diabetes. It is estimated that reducing obesity in the Barbadian population could reduce hypertension and diabetes by 30% and 33% respectively.

1.4 Impact of chronic disease in St. Lucia

St. Lucia has undergone a significant demographic transition in the last 3 decades (Wilks, et al., 1998). Some features of this transition include the rise in the median age of the population from 20 years to 15 years between 1970 and 2010, the doubling of the proportion of persons older than 60 years old from 5000 to over 17,000 and the increase in life expectancy at birth from less than 50 years in 1950 to greater than 73 years in 2010 (World population prospectus, 2008). As a result, the main causes of illness and death in St. Lucia and many other Caribbean islands and regions at a similar state of development are the chronic non-communicable diseases (Sargeant et al., 2001). There is an increased prevalence of diet-related chronic non-communicable diseases, such as cardio-vascular diseases, diabetes and obesity. (Wilks et al., 1998). Between 1992-1999 in St. Lucia, preventable chronic diseases such as cardiovascular and circulatory systems accounted for 20.8% of deaths, with the major causes being cerebrovascular disease, ischemic heart disease, and hypertensive disease. Other major causes of death were cancers (14.5%), disease of the digestive system (8.7%), and diabetes (7.2%) (8). Approximately 1,304 deaths were due to diseases of the circulatory system and was accounted for 33% of all reported deaths, death due to cerebrovascular was (35.9%), hypertensive disease (14.8%), and ischemic heart disease (13.6%) (Health in America, 1998).

There were 731 deaths due to cardiovascular disease from 1996 to 1999, accounting for 19% of all deaths and 53 % of deaths ratio of 5.8:1. Most (21 or 62%) occurred in the 15-44 years age group, and had a male-female ratio of 9.5:1. Cardiac arrest caused 268 cardiovascular deaths (37%), ischemic heart disease 174 (24%), pulmonary circulation and other forms of heart disease 134 (18%), and heart failure 153 (21%). Females accounted for 359 (49%) of deaths due to cardiovascular disease, and persons 60 years of age or older accounted for 588 deaths (80%). (WHO statistics). Based on PAHO statistic St. Lucia is the tenth leading island in the Caribbean with high rates of non- communicable chronic disease, accounting for approximately 63%.

Over the years prevalence of non communicable diseases have been increasing, in a survey done by the Kairi consultants limited in association with the national assessment team of St. Lucia concluded the following findings for the year 2005 to 2006 for the distribution of chronic disease in St. Lucia. Irrespective of per capita consumption quintile, high blood pressure was the most prevalent lifestyle disease affecting persons with diseases in St. Lucia. In every quintile group, it also shows that the prevalence of diabetes ranks second to high blood pressure as a life time disease affecting persons with diseases in St. Lucia. In each of the quintile groups, more than three fifths of the persons with diseases reported suffering from high blood pressure while more than one quarter reported suffering from diabetes.

In the year 2007 diabetes and Hypertension were the two the most pervasive and worsening health problems facing the island of St Lucia. The diseases afflict a broad swath of people, young and old.

St. Lucia has a population of approximately 160,000 thousand people, and of this 28.1%of the population have abnormal blood glucose or high blood sugar and 8.1% have diabetes (Graven et al., 2007). 20% of people over 40 years of age suffer with the disease (the ministry of health 2007). At least 35% of those with Type 2 Diabetes Mellitus do not know that they have the condition (The Ministry of Health, 2008). In rural area of St. Lucia the proportion with undiagnosed diabetes is considerably higher (St. Lucia Diabetic Society, 2008). At the time of diagnosis, every tenth person with diabetes has already developed one or more micro- or macro-vascular complications (Ministry of Health, 2008).

Diabetes is among the leading cause of death. If inadequately treated, diabetes can cause blindness, kidney disease, nerve disease, amputations, heart disease, and stroke. Even conscientious and well-treated diabetics frequently suffer from these complications and have above-average medical costs.

If observed, the Native St. Lucian has many barriers to health education, which basically involves their culture, lifestyle, accessibility and socio-economic status. For instance, St. Lucian is currently experiencing a crisis of poverty. People from lower socioeconomic status have poorer health than those in higher socioeconomic positions. Various studies have reported the relationship between low socioeconomic status and the development of chronic disease ((Lynch et al, 2000; Stelmach et al, 2009; Supriya et al, 2009).

Recent poverty assessments in St. Lucia estimate that 18.7% of households and 25% of the population live in poverty. Income inequality is high, with 26% of the population characterized as chronically poor (MPDEH, 2003). That same report estimated that a decade later in 2005/06 the poverty rate had increased to 28.8% of the population( Government of St. Lucia( GOVST), The assessment of Poverty volume1, 2006) .The highest poverty rates in2005/06 were in the districts of Anse La Raye/Canaries (44.9%), Micoud (43.6%),Soufriere (42.5%) and Laborie (42.1%). The poverty gap and poverty severity also occurred in these same districts (GOVST, 2006)

Furthermore, because of poverty and living in rural areas, most people consume less expensive and often high fat foods, and less fruits and vegetables (Henchy et al, 2000). Brown et al, (2005) described how socioeconomic position influences health among persons with diabetes. Diabetes is twice more prevalent in low income populations compared to wealthy populations (Stelmach W et al; 2009). Some explanations for this increased risk among people of low-income or resource-poor areas include increased stress, low access to medical and preventive care, and poor environment.

1.5 Diet, nutrition and chronic diseases

There are clear associations between the various biomedical and behavioural chronic disease risk factors, and it is well established that diet quality and healthy eating practices play an important role in both preventing and managing chronic diseases and the factors that increase their risk (Kant A.K, 2004). The links with food and nutritional status are especially strong in the case of cardiovascular disease, diabetes and their risk factors (metabolic syndrome, obesity, hypertension and hyperlipidaemia). The food we eat, in all cultural selection, defines one’s health, growth and development. Risk behaviours, particularly smoking and sedentarism, alter the result (). All this takes place in a social, cultural, political and economic environment that can exacerbate the health of populations.

Diet is a key component in predisposing to chronic disease, mainly where diet is energy dense causing positive energy balance and obesity. Adoption of western diet which are high in fats , aminal protein, refined carbohydrates and low in fibre, fruits and vegetable can further increase one risk of developing no of more chronic disease(). Several studies have demonstrated a prudent diet rich in fruits, vegetables, fish and wholegrain to be associated with a decline in chronic disease risk such as diabetes (Van Dam et al., 2002; Anne-Helen Harding et al., 2004)

Carbohydrates

Carbohydrates food source are the most important source of calories for the world’s population mainly because of their low cost and wide availability (). Although Carbohydrates is easily accessible and widely eaten carbohydrate is a key dietary component affecting insulin secretion and postprandial glycemia and is implicated in the etiology of many chronic diseases (Brand-Miller JC et al., 2004). Both the quantity and type of carbohydrate eaten have consequences on insulin secretion and postprandial glycemia. Foods with a rich glycemic index (or glycemic load) produce high rates in blood glucose. Diets including large quantities of high GL foods increase the risk of diabetes, breast cancer, colorectal cancer, endometrial cancer, and overall chronic disease (Barclay AW et al., 2008).

Dietary fibres

Epidemiological evidence has shown that foods rich in fibre help glycaemic control in diseases such as type 2 diabetic patients(). A diet high in fibre helps in control blood sugar levels in those with type 2 diabetes. It also helps with colon health as the high fibre diet with smoothing the stool and facilitates to weight loss ().

Fats

Dietary fat is one of the most influential nutrients in health. Fats has many functions in the human body, As well as to providing more than twice the energy supplied by carbohydrates and proteins and supplying essential fatty acids, fats slows digestion of carbohydrates in order to fuel the brain he fats serve as carriers for fat soluble vitamins (A, D, E and K) and as parts of cell membranes().

The overconsumption of fat, mainly saturated fat, has been linked to six of the 10 leading causes of death worldwide ().Coronary heart disease and cancer ().There is a strong link between dietary fat consumption and risk of chronic diseases such as cancer, such as colon, breast, prostate, and ovary cancer (). Several studies over the past 30 years have verified the relationship of high dietary fat intake with higher mortality due to various cancers (). Some saturated fatty acids raise blood cholesterol levels and, thus, increase the risk of atherosclerosis (). High fat, intake is a main cause of obesity, hypertension, diabetes, metabolic syndrome and gallbladder disease ().

Studies have show that countries with higher per capita intakes of fat, especially animal fat, have higher incidence rates of certain cancers, including breast, colon, prostate, and pancreas.[41] Migrational studies show that when individuals move from a country of low fat intake to one of high fat intake, the risk of some cancers increases [42] .

Vitamins

Vitamins are essential nutrients hey are required in small amounts, but have important and specific functions such as promoting growth, reproduction and the maintenance of health. Nutritionally, they form a cohesive group of organic compounds that are required in the diet in small amounts (micrograms or milligrams per day) for the maintenance of normal health and metabolic integrity. They are thus differentiated from the essential minerals and trace elements (which are inorganic) and from essential amino and fatty acids, which are required in larger amounts.

Vitamin deficiency however, may increase the risk of chronic diseases (). Suboptimal folic acid levels, along with suboptimal levels of vitamins B(6) and B(12), are a risk factor for cardiovascular disease, neural tube defects, and colon and breast cancer() and low levels of the antioxidant vitamins (vitamins A, E, and C) may increase risk for several chronic diseases. .

Nutritional Transition

There are now approximately 350 million obese and more than 1 billion overweight people in the world, living in both developed and developing nations. Previously, underdeveloped nations grappled with undernutrition. Now many of these countries like St. Lucia are in a transitional state and are dealing with the twin evils of under- and over nutrition. In the Caribbean nations between the 1970s and 1990s, the prevalence of overweight/obesity increased from 7% in men and 20% in women in the 1970s to 22% in men and 58% in women (Ragoobirsingh D et al., 2004).

The global prevalence of overweight amongst preschool children is estimated at 3.3%. Within the Caribbean region and St. Lucia has one of the highest incidences for this age group with St. Lucia having 2.5% of the 0-5 yr. population ( De Onis M et al.,October 2000) .Obesity in children and adolescents is known to have significant impact on both physical and psychosocial health, these soaring rates of obesity leads to an increase in hyperlipidaemia, hypertension, insulin resistance and abnormal glucose tolerance later in life (Reilly et al., 2003; Weiss et al., 2004).

Urbanization, industrialization and transformation processes have been the main cause of this public health accomplishment. In modern cultures, demographic factors interact with social and economic factors and lead to changes in the patterns of health and diseases as hypothesized by Omran’s epidemiological transition theory in the early 1970s (Orman et al., 1971). Omran’s theory describes the changing pattern of mortality from the predominant communicable diseases to the emerging non-communicable diseases. In his study, Omran defined three stages of epidemiological transition, i.e. ‘the age of pestilence and famine’, ‘the age of receding pandemics’, and ‘the age of degenerative and man-made diseases’ (Orman et al., 1971).

1.6 Dietary habits of St. Lucians

Food habits reflect the plantation past: the typical diet contains a lot of starches, animal protein content that varies by location, and until recently, little in the way of green vegetables. Starches include various kinds of yams, dasheen, eddos, bananas and plantains, sweet potatoes, cassava and breadfruit. Most of these are boiled, served with some kind of stewed fish or meat, and accompanied by a sauce. Pepper (capsicum) sauce is always present at the table, as most dishes are not prepared spicy hot. Animal protein sources reflect the historical scarcity of this element: pork hocks, pig tail (fresh and salted), chicken back, and saltfish, (cod) salted beef, fish (tuna, flying fishing, red snapper, barracuda, sharke, sardines, jack fish). Most of the dishes are prepared with fats such as; coconut oil, lards, yellow butter. As much as St. Lucia has a wide variety of fruit they are only eaten Fruits such as; mangoes, golden apple, papaya, grapefruit, oranges, cherries, cashew, sugar apple(love apple).Main dishes are accompanied by vegetables such as, avocado, calaloo, spinach, tomatoes, okras, carrots, pigeon peas and lentils,

Imported processed foods have been available for decades, but more recently account for larger parts of many meals. Foods such as pasta, rice,

1.7 Cause for chronic non-communicable diseases in St. Lucia

Chronic diseases have numerous risk factors, which function at different levels, from the most proximal (i.e. biological), to the most distal (i.e. structural). These risk factors can be classified as ‘modifiable’ and ‘non-modifiable risk factors’. Modifiable determinants include factors that can be altered, such as individual and community influences, living and working conditions and socio-cultural factors, non-modifiable determinants include those factors that are beyond the control of the individual, such as age, sex and hereditary factors.

1.7.1 Biological factors

Some populations are susceptible to chronic disease because of inherited genes. In a south Africa a tribal group “Afrikaners” have been found to have familial hypercholesterolemia, a rare genetic disorder, characterised by very high low-density lipoprotein, cholesterol and early cardiovascular disease.( Steyn K et al.,1996). Genetic and lifestyle factors are considered to be the main contributors in causing type 2 diabetes (O’Rahilly et al; 2005). The genetic makeup of a person is as essential to the development of the disease but a person lifestyle and environmental factors can contribute significantly. Some of the major contributing factors include overweight, abdominal obesity and physical inactivity and to lesser extent intrauterine and early childhood factors (Alberti et al, 2007)

1.7.2 Early life origin

The time between intrauterine growth and the development is the most vulnerable period in the life cycle and places major physiological, metabolic and psychological demand on the mother to support the growth and the development of the fetus (Allen, 2001). Good growth and development is dependent on a sufficient supply of energy and nutrients. Under nourishment during pregnancy is linked with poor pregnancy and neonatal outcomes which can have negative long term implications for the infant such as a reduction in intelligence, growth disorder, low immunity, increased morbidity, mortality and the development of a range of diseases during adulthood (Rasmussen, 2001)

It is proposed that type 2 diabetes results from relative intrauterine malnutrition and the latter leads to lifelong programming (Baker et al; 1986). Children with low birth weight are most likely to experience growth restraint, whether due to intrauterine nutritional restriction or genetic predisposition to low birth weight; similar associations of low birth weight have been made for the development of diabetes (Lindsay et al; 2001). Babies who are born low birth weight tend to grow fast after birth ‘catch-up growth’, often become overweight as young children. They are most likely to develop high blood pressure and abnormal blood glucose level early in life, which future increase their risk of developing chronic diseases, such as heart disease and diabetes (Barkeret al., 1997). The prevalence of Low Birth Weight (LBW) is approximately 6 and 9% in the Caribbean. The association between low birth weight and adult disease makes urgent the concern of these high LBW prevalence rates in the Caribbean (Henry; 2000).

An under-nourishes child is normally a smaller and shorter child (0) Stunting is an indication of long standing mal and under-nutrition and is often accompanied by fat deposition, particularly around the abdominal section when faced with food in abundance. Predisposing individuals to obesity in adulthood. ()

Likewise children who are born to large mother and are large for their gestational age are most likely to induce insulin resistance and type 2 diabetes later in life (Bennett et al; 2002). In Jamaica children shortness at birth and increased current weight are independent predictors of insulin resistance (Bennett et al; 2002).

There is significant amount of evidence, mainly from developed countries, that states intrauterine growth retardation is connected with an increased risk of coronary heart disease, stroke, diabetes and elevated blood pressure (WHO, 2002; Godfrey et al., 2000; Forsé et al., 2000). It may be the pattern of growth, i.e. restricted fetal growth followed by very fast postnatal catch-up growth that is vital in the underlying disease pathways. Likewise, large size at birth is also associated with an increased risk of diabetes and cardiovascular disease (McCance DR et al., 1996; Leon DA et al., 1998).

Behavioural risk factors (lifestyle factors)

Lifestyles play an important role in determining chronic diseases and lifestyle changes are likely to be responsible for a significant proportion of their increase over time.

1.7.3 Poor diet

Nutrition is a major modifiable determinant of chronic diseases, with scientific evidence supporting the view that modifications in diet have effects on health outcome of a person. Non-communicable diseases are linked to high consumption of energy dense foods, made of animal origin and of foods processed or prepared with added fat, sugar and salt.()

St. Lucia is undergoing rapid nutritional transition (Boyne, 2008). There has been an increase of fast-food restaurants, and an increased in the consumption of meals high in fat, sugar, and salt and a reduction in the consumption of cereals, grains, fruits, vegetables, tubers, and legumes (Jacoby et al.,2008). The increased consumption of imported foods high in fat and sodium has led to a decline of the health status of people throughout the region, with an increase in health problems such as obesity and diabetes (Report from WHO, 2003).

1.7.4 Physical inactivity

Physical inactivity and sedentary lifestyle is linked with increased levels of obesity, breast cancer, colon cancer, osteoporosis, stress, anxiety and depression (Hardman et al., 2001; Warburton et al., 2001), and one of the main underlying causes of mortality in the world.

1.7.5 Smoking

Smoking of tobacco is one of the most modifiable risk factors and preventable causes of death in the world. The World Health Organization (WHO) attributes to approximately 4 million deaths a year to tobacco use. It has been responsible for 22% of cardiovascular diseases in industrialized countries, and for the vast majority of some cancers and chronic respiratory diseases (WHO, 2002). It is projected by the 2030 smoking will kill one in six people globally, if the present trends persist. (WHO, 2002). This prediction of death will include about 7 million people in developing countries (Mackay, WHO; 2002) Smoking has been linked with premature mortality amongst users, with cardiovascular disease (i.e. stroke and heart attack) causing most deaths and is closely followed by chronic lung diseases, such as chronic bronchitis, emphysema and lung cancer.

(Bjartveit et al., 2005).

Alcohol abuse is deemed to be the source of 8%-18% of the total burden of disease in men and 2%-4% in women. The Rate of smoking in among men in St. Lucia is at its highest therefore increase the risk of chronic diseases.

1.8 Social determinants of health

The social determinants of health incorporate underlying causes of health problems which includes environmental factors, working status and housing and living conditions and socio-cultural factors that have an effect on the health of a population. These factors also increase the risk of an individual developing non-communicable disease.

1.8.1 Urbanisation and globalisation

Urbanisation is a key risk factor in the development of non-communicable diseases epidemic, as the economy grows and develops into a more ‘modernised’ society and the populations slowly migrate from rural to urban areas.

In St. Lucia, the percentage of people living in urban areas has increased from 43.3% in 1996 to 47.5% in 2001, (). Studies have shown that urbanisation leads to dietary changes towards adoption of the so-called ‘western diet’, which is high in animal proteins, fat and sugar.(20)This is often accompanied by lifestyle changes including alcohol consumption, cigarette smoking and physical inactivity increasing the population’s risk for non-communicable diseases.(34)

1.8.2Environmental factors

1..8.3 Obesogenic environment

The role of the media plays a very crucial role in advertising, marketing and promoting the consumption of high energy dense foods and fast foods outlets with large portion sizes. In a study to identify major sources of nutritional information among urban Black South African women, found that television was the most highly credible source of information. This influenced food choices based on taste, family preferences and price.35

Other factors associated to poor eating practices include, easy access to cheap unhealthy foods compared to the high prices of healthy foods.

1.8.4 Structural environmental factors

Structural environmental factors include environmental factors that might act as an obstacle to participating in physical activity, such as a lack of playing fields, parks, proper sidewalks and exercise facilities, as well as the existence of crime and violence on the streets.

1.8.5 Socio-cultural factors

Beliefs and attitudes about body image of some individuals have been found to increase the risk for developing non communicable diseases. The belief that thinness is associated with personal problems and sickness, especially HIV and AIDS, seems to be a barrier to maintaining normal body weight in some individuals ( ). Accompanying beliefs about body weight are socio-cultural factors related to food intake, which partly contributes to obesity in some individuals.()

1.9 The economic impact of chronic diseases in ST. Lucia

Chronic diseases have had and continue to have a major economic impact on individuals, families, and the health system in St.Lucia (). Since chronic diseases affect the young and people in their productive years, they reduce productive labour and earning capacity at a household level. Treatment of chronic diseases puts much strain on the already overburdened health system, because of the additional resources required. The burden is not only on the health care system but also but also indirectly causes loss of productivity from the disable, absenteeism and early death.

Rationale

Chronic diseases such as heart disease, cancer and diabetes negatively affect the general health status and quality of life of individuals, and there is an absence in the literature of studies looking at the health status of persons in St. Lucia with chronic non-communicable diseases. It is against this background that this study was undertaken. This study is designed to explore and review the association between diet, lifestyle and chronic non-communicable disease in St. Lucia.

This comprehensive systematic review seeks to examine the association between diet, lifestyle and risk of chronic disease among St. Lucians.

Objectives

To analyze the pattern of chronic disease risk factor distribution in a well defined population in St. Lucia

To analyze or critically evaluate the 30 most commonly food eaten in St. Lucian

To examine dietary patterns, food choices and habits of St. Lucian

To synthesize qualitative findings diet, lifestyle and chronic diseases

Research Question

The Prevalence and incidence of chronic diseases is very high in St. Lucia and is the main cause of death in the island. Does St. Lucian diet and lifestyle contribute to increases number of chronic diseases in the country?

Hypotheses

Null hypothesis:

St. Lucian diet and lifestyle has no direct impact on the prevalence of chronic diseases in St. Lucia

Alternative hypothesis:

St. Lucia diet and lifestyle has an impact on the prevalence of chronic disease

CHAPTER 2

2.0 Methodology

.

This research will be bаѕed on ѕecоndаry data collected from various authentic sources and used to generate new data as a basis for analyzing the lifestyle and 30 most commonly eaten foods in St. Lucia in relation to chronic diseases. This type of research will not involve human subject.

The literature search strategy is described in a summary in Figure.

The data was taken from journal articles and published bооkѕ. By definition, secondary research describes information gathered through literature, publication, broadcast media, and other non-human sources.

Literature search strategy

Figure 1 Literature search strategy and study design

The search, covered publications between the years 1985 to 2009. The following sources were included in the search process.

Electronic library databases

To increase the comprehensiveness of the research and reduce the ambiguity, key words were used only when mapped subject headings and the Thesaurus were not available for a particular search database. Chronic disease was used as the main search term and combined with additional terms deemed relevant to the key questions. These additional terms were identified, nutrition, diet, lifestyle. Databases searched included the following: MEDLINE, PreMEDLINE, CINAHL (Cumulative Index for Nursing and Allied Health Literature), CDSR (Cochrane Database of Systematic Reviews), ACP Journal Club (American College of Physicians Evidence Based

Medicine), CCTR (Cochrane Central Registry of Controlled Trials) Health Star, PAIS (Public Affairs Information Service), Proceedings First, Population Index, Proquest Digital Dissertations, Science direct, Pub Med.

Hand searches

A hand search of the International Journal of Chronic disease for the years 1985 to July 2009 was conducted. Reference lists from reports were hand searched for other eligible reports.

Internet

The internet search. first, involved using the search engine, Google, with the terms ‘Chronic disease’ and ‘diet ‘ and either ‘lifestyle’, ‘prevalence ‘.To eliminate irrelevant sites, the research was limited to searches using predefined criteria based on several guides for finding reliable information from trustworthy sources on the Internet . Sites were eliminated if (i) they were clearly just commercial; (ii) they did not seem to be trustworthy or reliable sources (i.e. personal homepages); and/or (iii) had little to no relevant information.

Inclusion/exclusion criteria

The search was limited to English reports, which included editorials, and theoretical reviews, PhD thesis and other degree works, summaries of conferences, historical papers and book reviews. Letters to the editor, editorials were excluded. Papers selected for retrieval were assessed in a two-stage process. In the first stage, papers were selected based on reading of title and abstract. The second stage involved reading of the full text of the articles selected, to establish the degree to which the paper satisfies inclusion/exclusion criteria.

Critical Appraisal:

The researcher used the QARI (Qualitative Appraisal and Review Instrument) critical appraisal instrument from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information package (SUMARI) (see Appendix 1 for hard copy).

Data extraction:

Data was extracted from papers using the QARI data extraction process which aggregated findings and seeked to categories and synthesis. Data was extracted manually using the standardized data extraction tool in QARI (see Appendix 1 for hard copy of extraction tool) and contained within the Joanna Briggs Institute System for the Unified Management, Assessment and Review the Information package (SUMARI).

Where meta-synthesis was possible, qualitative research findings were pooled using the Qualitative Assessment and Review Instrument (QARI). This process involved the aggregation of findings and categorized to generate a set of synthesized statements that represent such aggregation.