RESUMO

Diabetes and obesity present a high and increasing burden of disease in the Caribbean that have failed to respond to prevention policies and interventions. These conditions are the result of a complex system of drivers and determinants that can make it difficult to predict the impact of interventions. In partnership with stakeholders, we developed a system dynamics simulation model to map the system driving diabetes and obesity prevalence in the Caribbean using Jamaica as a test case. The study aims to use the model to assess the magnitude changes necessary in physical activity and dietary intake to achieve global targets set by the WHO Global Action plan and to test scenarios for interventions to reduce the burden of diabetes and obesity. Continuing current trends in diet, physical activity, and demographics, the model predicts diabetes in Jamaican adults (20+ years) to rise from 12% in 2018 to 15.4% in 2030 and 20.9% by 2050. For obesity, it predicts prevalence to rise from 28.6% in 2018 to 32.1% by 2030 and 39.2% by 2050. The magnitude change necessary to achieve the global targets set by the World Health Organization is so great as to be unachievable. However, a combination of measures both upstream (including reducing the consumption of sugar sweetened beverages and ultra processed foods, increasing fruit and vegetable intake, and increasing moderate-to-vigorous activity) at the population level, and downstream (targeting people at high risk and with diabetes) can significantly reduce the future burden of diabetes and obesity in the region. No single intervention reduces the prevalence of these conditions as much as a combination of interventions. Thus, the findings of this model strongly support adopting a sustained and coordinated approach across various sectors to synergistically maximise the benefits of interventions.

RESUMO

The World Health Organization (WHO) Global Action Plan on Physical Activity recommends adopting a systems approach to implementing and tailoring actions according to local contexts. We held group model-building workshops with key stakeholders in the Caribbean region to develop a causal loop diagram to describe the system driving the increasing physical inactivity in the region and envision the most effective ways of intervening in that system to encourage and promote physical activity. We used the causal loop diagram to inform how the WHO Global Action Plan on Physical Activity might be adapted to a local context. Although the WHO recommendations aligned well with our causal loop diagram, the diagram also illustrates the importance of local context in determining how interventions should be coordinated and implemented. Some interventions included creating safe physical activity spaces for both sexes, tackling negative attitudes to physical activity in certain contexts, including in schools and workplaces, and improving infrastructure for active transport. The causal loop diagram may also help understand how policies may be undermined or supported by key actors or where policies should be coordinated. We demonstrate how, in a region with a high level of physical inactivity and low resources, applying systems thinking with relevant stakeholders can help the targeted adaptation of global recommendations to local contexts.

Le Plan d'action mondial pour l'activité physique élaboré par l'Organisation mondiale de la Santé (OMS) recommande d'adopter une approche systémique pour la création et le déploiement d'actions adaptées aux contextes locaux. Nous avons organisé des ateliers de construction de modèles regroupant divers acteurs clés de la région Caraïbes. Objectif: développer un diagramme de boucles causales afin d'identifier le système à l'origine de la sédentarité croissante dans cette région, mais aussi de concevoir les moyens les plus efficaces pour s'immiscer dans ce système en vue d'encourager et de promouvoir l'exercice physique. Nous avons employé le diagramme de boucles causales pour définir comment le Plan d'action mondial pour l'activité physique de l'OMS peut être adapté au contexte local. Bien que les recommandations de l'OMS se rapprochent considérablement de notre diagramme, ce dernier illustre aussi l'importance du contexte local dans la manière dont les interventions sont censées être coordonnées et mises en œuvre. Certaines de ces interventions prévoyaient d'ouvrir des espaces sécurisés dédiés à la pratique sportive pour les deux sexes, de lutter contre les attitudes négatives vis-à-vis de l'activité physique dans des situations spécifiques, notamment à l'école et au travail, et de rendre les infrastructures compatibles avec les modes de transport actifs. Le diagramme de boucles causales permet en outre de mieux comprendre comment les acteurs clés peuvent soutenir ou au contraire discréditer les politiques en la matière, et de voir où ces politiques ont besoin de coordination. Nous démontrons comment, dans une région marquée par un taux de sédentarité élevé et de faibles ressources, l'adoption d'une approche systémique impliquant les principaux intervenants peut contribuer à ajuster avec précision des recommandations mondiales à des contextes locaux.

El Plan de acción mundial sobre actividad física de la Organización Mundial de la Salud (OMS) recomienda adoptar un enfoque sistémico para implementar y adaptar las acciones según los contextos locales. Celebramos talleres de construcción de modelos de grupo con las principales partes interesadas en la región del Caribe para desarrollar un diagrama de circuito causal para describir el sistema que impulsa la creciente inactividad física en la región y prever las formas más eficaces de intervenir en ese sistema para fomentar y promover la actividad física. Utilizamos el diagrama de circuito causal para informar sobre cómo se podría adaptar el Plan de acción mundial sobre actividad física de la OMS a un contexto local. Aunque las recomendaciones de la OMS se ajustaban bien a nuestro diagrama, este también ilustra la importancia del contexto local a la hora de determinar cómo deben coordinarse y aplicarse las intervenciones. Algunas intervenciones incluyen la creación de espacios seguros para la actividad física para ambos sexos, la lucha contra las actitudes negativas hacia la actividad física en determinados contextos, incluidos los colegios y los lugares de trabajo, y la mejora de las infraestructuras para el transporte activo. El diagrama de circuito causal también puede ayudar a entender cómo las políticas pueden ser socavadas o apoyadas por actores clave o dónde deben coordinarse las políticas. Demostramos cómo, en una región con un alto nivel de inactividad física y pocos recursos, la aplicación del pensamiento sistémico con las partes interesadas pertinentes puede ayudar a la adaptación específica de las recomendaciones globales a los contextos locales.

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[Extract]. To the Editor, Small Island Developing States (SIDS) are highly dependent on food imports from larger nations, with the Caribbean Community (CARICOM) and Pacific islands combined importing almost $5 billion in food in 2018, and more than half of SIDS countries importing more than 80% of their food, much of it nutritionally poor and highly processed. This has been an important driver of high levels of obesity (>30% of adults), food insecurity, and noncommunicable diseases (NCDs) (between 10-30% of adults) in these countries. The susceptibility of the SIDS food system to shocks in the supply chain of imported foods has been dramatically exposed in recent weeks through the growing COVID-19 pandemic with discussions focused on food security and vulnerability to climate change. The current crisis has accelerated the discourse on increasing food security, particularly in the CARICOM, as the region–which consists of 15 nations with a combined population of over 18 million–braces for a disruption in food imports from larger economies, and also due to border closures. Food security in the context on COVID-19 was high on the agenda at the Ninth Special Emergency Meeting of the Conference of Heads of Government of CARICOM on April 15, 2020, focusing on a regional approach instead of individual country approaches.

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Many Small Island Developing States of the Caribbean experience a triple burden of malnutrition with high rates of obesity, undernutrition in children, and iron deficiency anemia in women of reproductive age, driven by an inadequate, unhealthy diet. This study aimed to map the complex dynamic systems driving unhealthy eating and to identify potential points for intervention in three dissimilar countries. Stakeholders from across the food system in Jamaica (n = 16), St. Kitts and Nevis (n = 19), and St. Vincent and the Grenadines (n = 6) engaged with researchers in two group model building (GMB) workshops in 2018. Participants described and mapped the system driving unhealthy eating, identified points of intervention, and created a prioritized list of intervention strategies. Stakeholders were also interviewed before and after the workshops to provide their perspectives on the utility of this approach. Stakeholders described similar underlying systems driving unhealthy eating across the three countries, with a series of dominant feedback loops identified at multiple levels. Participants emphasized the importance of the relative availability and price of unhealthy foods, shifting cultural norms on eating, and aggressive advertising from the food industry as dominant drivers. They saw opportunities for governments to better regulate advertising, disincentivize unhealthy food options, and bolster the local agricultural sector to promote food sovereignty. They also identified the need for better coordinated policy making across multiple sectors at national and regional levels to deliver more integrated approaches to improving nutrition. GMB proved to be an effective tool for engaging a highly diverse group of stakeholders in better collective understanding of a complex problem and potential interventions.

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[ABSTRACT]. Objectives. To conduct an analysis of the most recent data on diabetes and its risk factors by gender and other social determinants of health to understand why its prevalence is higher among women than men in the Caribbean; to inform policy agenda-setting for diabetes prevention and control in the Caribbean; and to identify gaps in the evidence that require further research. Methods. A previous systematic review of the literature describing studies conducted in the Caribbean that presented the distribution of diabetes, its outcomes, and risk factors, by one or more social determinants, was updated to include sources from 1 January 2007 – 31 December 2016. Surveys by the World Health Organization (WHO) were also included. Where data were sufficient, meta-analyses were undertaken. Results. A total of 8 326 manuscripts were identified. Of those, 282 were selected for full text review, and 114, for abstraction. In all, 36 papers, including WHO-related surveys, had sufficient information for meta-analysis. More women compared to men were obese (OR: 2.1; 95%CI = 1.65 – 2.69), physically inactive (OR: 2.18; 95%CI = 1.75 – 2.72), and had diabetes (OR: 1.48; 95%CI = 1.25 – 1.76). More men smoked (OR: 4.27; 95%CI = 3.18 – 5.74) and had inadequate fruit and vegetable intake (OR: 1.37; 95%CI = 1.21 – 1.57). Conclusion. Thirty-six papers were added to the previously conducted systematic review; of those, 13 were added to the meta-analysis. Diabetes and its risk factors (primarily obesity and physical inactivity) continue to disproportionately affect women in the Caribbean. Smoking interventions should be targeted at men in this geographic area.

[RESUMEN]. Objetivos. Analizar los datos más recientes sobre la diabetes y sus factores de riesgo desglosados por género y otros determinantes sociales de la salud para comprender por qué su prevalencia en el Caribe es mayor en las mujeres que en los hombres, fundamentar la definición de la agenda de políticas para la prevención y el control de la diabetes en el Caribe, y determinar las brechas en la evidencia que requieren mayor investigación. Métodos. Se actualizó una revisión sistemática anterior de la bibliografía que describe los estudios realizados en el Caribe acerca de la distribución de la diabetes, sus resultados y sus factores de riesgo por uno o varios determinantes sociales, con el objetivo de incluir otras fuentes publicadas en el periodo comprendido entre el 1 de enero del 2007 y el 31 de diciembre del 2016, además de encuestas realizadas por la Organización Mundial de la Salud (OMS). En los casos en los que se contaba con datos suficientes, se emprendieron metanálisis. Resultados. Se encontró un total de 8.326 artículos, entre los que se seleccionaron 282 para llevar a cabo un examen del texto íntegro y 114 para realizar un resumen. En conjunto, 36 artículos, entre los que se incluyen las encuestas relacionadas con la OMS, disponían de la información suficiente para su metanálisis. En comparación con los hombres, un mayor número de mujeres eran obesas (razón de posibilidades [OR]: 2,1; IC de 95% = 1,65 – 2,69), físicamente inactivas (OR: 2,18; IC de 95% = 1,75 – 2,72) y tenían diabetes (OR: 1,48; IC de 95% = 1,25 – 1,76). Un mayor número de hombres eran fumadores (OR: 4,27; IC de 95% = 3,18 – 5,74) y presentaban un consumo insuficiente de frutas y verduras (OR: = 1,37; IC de 95% = 1,21 – 1,57). Conclusiones. Se agregaron 36 artículos a la revisión sistemática realizada con anterioridad y, de ellos, se añadieron 13 al metanálisis. La diabetes y sus factores de riesgo (fundamentalmente, la obesidad y la inactividad física) siguen afectando desproporcionadamente a las mujeres en el Caribe. En esta zona geográfica, las intervenciones contra el tabaquismo deben dirigirse a los hombres.

[RESUMO]. Objetivos. Examinar os dados mais recentes sobre diabetes e fatores de risco relacionados por gênero e outros determinantes sociais da saúde para entender por que a prevalência da doença é maior no sexo feminino que no masculino no Caribe; obter subsídios para estabelecer a agenda de políticas para prevenção e controle da diabetes no Caribe; e identificar as lacunas nas evidências que precisam de uma investigação mais aprofundada. Métodos. Uma revisão sistemática anterior da literatura de estudos realizados no Caribe que apresentavam dados da distribuição da diabetes, desfechos e fatores de risco relacionados a esta doença, por um ou mais determinantes sociais, foi atualizada com a inclusão de novas fontes de informação para o período de 1o de janeiro de 2007 a 31 de dezembro de 2016. Foram incluídas também pesquisas feitas pela Organização Mundial da Saúde (OMS). Meta-análises foram conduzidas quando havia dados suficientes. Resultados. Ao todo, 8.326 manuscritos foram identificados. Destes, 282 foram selecionados para leitura completa de texto e 114 foram separados para a coleta de dados. Trinta e seis artigos, incluindo as pesquisas da OMS, continham dados suficientes para uma meta-análise. Verificou-se uma proporção maior de mulheres em comparação aos homens com obesidade (OR 2,1; IC95% 1,65–2,69), inatividade física (OR 2,18; IC95% 1,75–2,72) e diabetes (OR 1,48; IC95% 1,25–1,76). Observou-se também que uma proporção maior de homens era fumante (OR 4,27; IC95% 3,18–5,74) e tinha consumo inadequado de frutas e verduras (OR 1,37; IC95% 1,21–1,57). Conclusões. Foram acrescentados 36 artigos à revisão sistemática anteriormente realizada. Destes, 13 foram incluídos na meta-análise. A diabetes e fatores de risco relacionados (sobretudo obesidade e inatividade física) continuam afetando de forma desproporcional as mulheres no Caribe. Intervenções para combater o tabagismo devem ser dirigidas ao sexo masculino nesta região geográfica.

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RESUMO

OBJECTIVES: To conduct an analysis of the most recent data on diabetes and its risk factors by gender and other social determinants of health to understand why its prevalence is higher among women than men in the Caribbean; to inform policy agenda-setting for diabetes prevention and control in the Caribbean; and to identify gaps in the evidence that require further research. METHODS: A previous systematic review of the literature describing studies conducted in the Caribbean that presented the distribution of diabetes, its outcomes, and risk factors, by one or more social determinants, was updated to include sources from 1 January 2007 - 31 December 2016. Surveys by the World Health Organization (WHO) were also included. Where data were sufficient, meta-analyses were undertaken. RESULTS: A total of 8 326 manuscripts were identified. Of those, 282 were selected for full text review, and 114, for abstraction. In all, 36 papers, including WHO-related surveys, had sufficient information for meta-analysis. More women compared to men were obese (OR: 2.1; 95%CI = 1.65 - 2.69), physically inactive (OR: 2.18; 95%CI = 1.75 - 2.72), and had diabetes (OR: 1.48; 95%CI = 1.25 - 1.76). More men smoked (OR: 4.27; 95%CI = 3.18 - 5.74) and had inadequate fruit and vegetable intake (OR: 1.37; 95%CI = 1.21 - 1.57). CONCLUSION: Thirty-six papers were added to the previously conducted systematic review; of those, 13 were added to the meta-analysis. Diabetes and its risk factors (primarily obesity and physical inactivity) continue to disproportionately affect women in the Caribbean. Smoking interventions should be targeted at men in this geographic area.