non - communicable diseases ( ncds ) have undoubtedly become a major challenge in the pacific islands , which account for around 70% of all deaths in the region , including a high percentage of premature deaths ( before the age of 60 ) .
the republic of palau bears a high burden of ncds , as well as other pacific island countries and territories . according to the data released by the ministry of health in 2011 , cardiovascular disease ( 24.3% ) , cancer ( 21.4% ) , chronic respiratory diseases ( 12.7% ) , and diabetes ( 9.8% ) are the leading four causes of death in the country .
palau is a micronesian island country , located east of the philippines , west of the federated states of micronesia ( fsm ) and northeast of indonesia .
it is classified as an upper middle income country by the world bank and has relatively high living standards in comparison with other island countries in the region . according to the latest national population and housing census conducted in 2005 ,
the total population is about 20,000 , of which 73% are of palauan descent and foreign nationals comprise the rest .
filipinos , estimated at 16% to roughly 20% of the total population , are the largest group of the foreign residents , and most of them are migrant workers from the philippines after the 1990s , with a relatively young age distribution compared to local palauans .
being aware of the seriousness of the burden of ncds , the president of republic of palau signed an executive order declaring a state of health emergency on ncds in 2011 .
however , the authorities did not have valid population baseline data of key indicators for ncds to establish evidence - based strategies for controlling ncds .
although several previous population - based surveys were conducted in palau , none of them could provide complete information , including behavioral and biological risk factor of ncds .
for example , the palau health survey in 1991 or the palau community health assessment in 2003 did not include blood tests , and the behavioral risk factor surveillance system ( brfss ) in 2010 and 2012 did not include either physical or biochemical measurements .
the ministry of health , therefore , collaborated with the world health organization ( who ) to start the who stepwise approach to risk factor surveillance ( steps ) in late 2011 , which would be the first comprehensive national survey for ncd risk factors in palau .
this paper aims to perform an initial analysis before looking further into associations among various factors on the population representative dataset , and describe the prevalence of each major common risk factor for ncds .
a population - based survey for ncd risk factors , referred to as palau ncd steps survey , was started in september 2011 by adopting the who steps instrument , and the data collection was completed in june 2013 .
based on the 2009 household survey , two - stage cluster random sampling was designed to cover the entire 16 states of palau .
firstly , 75 enumeration areas ( eas ) were selected using probability proportional to size ( pps ) as the primary sampling units , followed by randomly selecting 2,807 households from them as the secondary sampling units .
one resident aged 25 to 64 years within each of the households was recruited for the survey using the kish method , which provides for random selection of one individual from a household . the required sample size to detect statistically significant differences between eight sex - age groups
were calculated as 2,807 individuals , within a margin of error of 5% and an anticipated 80% response rate .
as detailed below , there are three component parts , called " steps " , of the survey instrument , i.e. behavioral , physical and biochemical measurements .
( 1 ) apart from questions for basic demographic information , a structured questionnaire was used to assess four common behavioral risk factors of ncds by face - to - face interviews .
participants were asked about personal dietary habits , particularly fruit and vegetable intakes , as well as tobacco use , alcohol consumption and physical activity in their daily lives .
( 2 ) the second step consisted of measurements of height , weight , waist and hip circumferences , and resting blood pressure .
the anthropometric measurements were taken in light indoor clothing , and without shoes or other heavy accessories .
waist circumference was measured at the midpoint between the lowest rib and the iliac crest .
blood pressure in the sitting position was measured three times in the upper arm , using an electronic sphygmomanometer ( omron hem-7200 ) .
three measurements of blood pressure were taken for each participant in the survey , and the arithmetic mean of the second and third readings were used . ( 3 ) biochemical blood tests were performed in the morning after roughly 10 to 12 hours of fasting .
fresh capillary whole blood samples were drawn from the fingertip , followed by biochemical tests on portable devices , namely accu - chek performa system ( roche diagnostics , north america ) for fasting blood glucose and accutrend plus system ( roche diagnostics , north america ) for blood levels of total cholesterol and triglycerides .
data were entered by using the epidata software and categorized into different groups for the analysis based on well - defined criteria .
body mass index ( bmi ) is defined as the weight in kilograms divided by the square of the height in meters . as the current who classification ,
cutoff points of 18.5 , 25 and 30 kg / m were used to define underweight , normal weight , overweight and obesity .
hypertension was defined as having a systolic blood pressure 140 mmhg , a diastolic blood pressure 90 mmhg , or currently being on antihypertensive medication .
people with systolic blood pressure 160 mmhg or diastolic blood pressure 100 mmhg were grouped as stage 2 hypertension , by applying the criteria of the seventh report of the joint national committee on prevention , detection , evaluation , and treatment of high blood pressure ( jnc 7 ) . according to the recommendations by the who and american diabetes association ( ada ) , values of fasting blood glucose 126 mg / dl or those on diabetic treatment were categorized as diabetic .
two values for the upper limit of normal fasting blood glucose were used : 110 mg / dl by the who or 100 mg / dl by the ada criteria .
the levels of blood lipids were classified as follows : normal ( < 150 mg / dl ) , borderline - high ( 150199 mg / dl ) and high ( 200 mg / dl ) for triglycerides , and desirable ( < 200 mg / dl ) , borderline - high ( 200239 mg / dl ) and high ( 240 mg / dl ) for total cholesterol . to test the differences among ethnic groups on each categorical data ,
we conducted all aforementioned data analyses using the statistical software , ibm spss statistics for windows , version 22.0 ( ibm corp , armonk , ny , usa ) . the survey proposal was reviewed and approved by the who and institutional review board of the ministry of health , republic of palau prior to implementation ( july , 2010 ) .
written informed consent was obtained from all of the participants after adequate explanations of the objectives and procedures of the project .
data analysis of this study is also included in a joint research project between palau and japan , which was designed to investigate ncd risk factors among the younger adults aged 18 to 24 years .
the relevant research project was approved by the bioethics review committee of nagoya university school of medicine ( july , 2012 ) .
from the selected 2,807 households ( 71% of the total households nationwide ) , 2 , 212 individuals participated in this survey and completed all of the three steps giving a response rate of 79% .
valid data of 2,184 individuals were finally selected for the analyses in this study , excluding those who were not within the target age range of 2564 years , who did not give a clear answer of sex , and women who were pregnant at the moment of the survey .
about 75% of the subjects were palauans and 19% were filipinos , the main foreign population in the country .
the mean age of the palauan participants was 46.6 years ( standard deviation , 10.2 ) , while the mean age of the filipinos was 42.4 years ( standard deviation , 9.5 ) .
table 1 shows the characteristics of participants by gender and age group , and table 2 shows that by ethnic background .
characteristics of participants aged 2564 years in palau ncd steps survey 20112013 , valid %   usd indicates united states dollar characteristics of participants by ethnic background , valid % ( age  standardized % )    based on the age distribution of the whole population from 2005 census of population and housing   usd indicates united states dollar a quarter of male participants were current cigarette smokers , but female smokers were less than 10% .
betel nut with tobacco chewing was a common practice among palauans , as 58% of men and 69% of women had the habit . in the total participants , 60% of men and 58% of women reported current use of any kind of tobacco products , including smoking and chewing .
infrequent fruit intake , namely one day or less per week , occurred in 44% of men and 32% of women .
as for infrequent vegetable intake ( 1 day / week ) , it was observed in 15% and 9% of men and women , respectively .
most of palauan males ( 84% ) and females ( 86% ) were overweight or obese ( bmi  25 kg / m ) , with the mean bmi being 30.8 kg / m and 31.3 kg / m in males and females , respectively .
filipino residents also had a high prevalence of overweight or obesity , i.e. 52% in males and 40% in females , and the mean bmi was 25.4 kg / m in males and 24.5 kg / m in females .
as for percentage of obesity alone ( bmi  30 kg / m ) , it is much higher among palauan residents ( 51% in males and 55% in females ) than that among filipinos ( 9% in males and 10% in females ) .
approximately 8% of males and 14% of females among the total adult subjects reported that they had taken antihypertensive medication during the past two weeks .
including those who were on medication , more than half of palauan males ( 60% ) and females ( 54% ) were considered hypertensive , followed by 46% of males and 34% of females in the filipino population .
moreover , 20% of the total participants were stage 2 hypertensive (  160/100 mmhg ) .
the prevalence is higher in the older age group , e.g. 29% of males and 35% of females were diabetic among the oldest age group of 5564 years . borderline - high or high levels of triglycerides
were found in 48% of men and 41% of women in the total subjects , whereas borderline - high or high levels of total cholesterol including those on medication were observed among 16% of men and 20% of women .
this is the first comprehensive population based survey on risk factors of ncds among adults in palau , which included physical and biochemical measurements .
the results revealed a high percentage on each of the major risk factors , especially tobacco use , overweight or obesity , hypertension , and raised blood glucose .
findings of this survey confirmed that cigarette smoking was more prevalent among men than women in palau ( 25% vs. 10% : p < 0.001 ) .
the prevalence was almost the same as that reported in the palau community health assessment , a national household survey in 2003 , indicating that smoking rate of adults had hovered during the past decade in this country . compared with the other pacific island countries , the prevalence of smoking in palau was not high .
for instance , it was much lower than the findings from a previous survey carried out in the adjacent micronesian country , federated states of micronesia ( fsm ) , in which 42% of men and 32% of women were reported as current smokers .
however , cigarette smoking solely can hardly illustrate the fact of tobacco use in palau .
chewing betel nut with tobacco , smokeless tobacco , is a broadly acceptable practice within all sectors of the population in palau . according to the results , palauan adults , especially women ,
had an extremely high proportion of betel nut with tobacco chewing , which was not commonly observed in other ethnic groups living in this country .
although the neighboring country , fsm , has the same tradition of betel nut chewing , the percentage of smokeless tobacco users was significantly lower in comparison to palau , namely 22% in men and 3% in women .
as regards the gender difference in betel nut and tobacco chewing , cambodia is the other country in the who western pacific region which reported women had a significantly higher prevalence than men .
three reasons for the use of chewing tobacco and betel nut among cambodian women were suggested in a previous study : ( 1 ) as an addictive stimulant , ( 2 ) as part of a female rite of passage into adulthood and reproductive age , and ( 3 ) as a remedy to relieve pregnancy - related symptoms .
however , the reasons for the high prevalence of chewing betel nut with tobacco among palauan women are still not clear .
based on the findings in this survey , the palauan government may have to develop gender- and ethnic - specific tobacco control measures for the population .
more than half of adult population in each of the pacific island countries are observed to be overweight or obese ( bmi  25 kg / m ) , with the exception of papua new guinea .
likewise , about three in four participants were considered as overweight or obesity in this survey . with regard to the difference by ethnic background ,
more than half of palauan adults were obese ( bmi  30 kg / m ) , whereas the proportions of obesity in both filipino men and women were less than 10% . even after adjusting for age ,
palauans have a higher obesity prevalence than filipinos either in men or in women ( p < 0.001 for both ) . since most of the filipinos living in palau are migrant workers engaged in physical labors and having lower income levels than palauans .
( see table 2 ) . considering the socio - economic background , lower prevalence of obesity among filipinos than among palauans might be attributable to the differences in dietary habits , physical activities , working conditions , etc . in comparison with the data reported from the palau health survey in 1991 ,
the mean bmi of adults aged 3564 years had increased from roughly 27.6 to 29.6 kg / m for men and 29.6 to 30.1 kg / m for women over the past two decades .
dietary patterns and lifestyle changes with the economic growth in palau might explain the increased bmi .
subsequent analyses or further studies are required to investigate the factors contributing to overweight or obesity in the population .
this survey revealed an alarmingly high prevalence of hypertension in palau , of which more than half of the adults had a raised blood pressure , particularly among ethnic palauans . even the youngest age group ( 2534 years ) demonstrated a high percentage of hypertension ( 36% in men and 25% in women ) .
however , the proportion of participants who were on antihypertensive medication was relatively low ( 8% in men and 14% in women ) . as hypertension rarely causes symptoms in the early stages , those who have undiagnosed hypertension or ignore self - management of blood pressure
should be targeted first in ncd control policies . among published data of who steps surveys for pacific island countries and territories , palau has the highest prevalence of hypertension in both sexes ( 55% in men and 49% in women ) , even though the prevalence of obesity is not noticeably high compared to the others .
factors might contribute to this result , such as salt intakes , need to be investigated further .
palau was the only country in oceania which did not have any available data concerning the population prevalence of raised blood glucose prior to the present survey , despite the fact that pacific island countries have some of the highest rates of diabetes in the world .
this survey showed that more than 20% of the participants had diabetic level hyperglycemia , and more than 60% of the participants had ada - defined impaired fasting glycemia ( ifg ) or diabetes ( 100 mg / dl ) .
it is known that diabetes , if untreated for years , causes serious complications such as diabetic retinopathy , nephropathy , and neuropathy , as well as ischemic cardiac diseases .
urgent actions are needed to screen and control blood glucose of the population in palau .
although the evidence of health impacts of the given risk factors has been identified around the world , a limited number of those studies were conducted in the pacific islands . as of today
, most of the countries and territories in the pacific region have accessible data of the key ncd risk factors for their population , such as those from the who steps surveys .
all of these data could be potentially used for further studies to investigate local characteristics of ncds for the islanders .
in addition , comparisons across the island countries have also become possible , because of the standardized methodology used for the data collection .
we could not obtain valid variables on fruit and vegetable intakes by servings , standard amounts of alcohol consumption , and quantity of physical activity due to inappropriate methods of the interviews . regarding blood tests ,
capillary whole blood samples were applied to the dry chemistry method . although the device has been calibrated for plasma automatically
, the results might not correspond to those done by venous plasma samples at the laboratory , the standard method for measuring and reporting glucose concentrations in blood .
accordingly , the criteria of appropriate cutoffs might be different from those we adopted in this article . in conclusion , this survey has provided useful baseline epidemiological data on the major ncd risk factors , with very high prevalence on both behavioral and biological risk factors . on the basis of this survey
, policymakers could develop more effective and efficient ncd prevention or control strategies for the public .
the authors wish to thank staff members of the bureau of public health , ministry of health , republic of palau for the data collection .
appreciation is also given to the regional office for the western pacific , who for the full financial and technical support during the survey .
the content is solely the responsibility of the authors and does not necessarily represent the official views of the palauan government or the who .
data analysis of this paper is part of a joint research project between palau and japan , supported by the health and labour sciences research grants for research on global health issues ( h24-chikyukibo - ippan-004 ) to a.a . from the ministry of health , labour and welfare , government of japan .
 abstractpalau , similar to other pacific island countries , is currently highly burdened with non - communicable diseases ( ncds ) . 
 the who steps was launched in 2011 to comprehensively survey indicators for ncds in the country . 
 this paper aims to describe the prevalence of key ncd risk factors assessed by the survey . the who instrument , including behavioral , physical and biochemical measurements , 
 was adopted to the nationwide survey for all residents aged 25 to 64 years . 
 a cluster - based sampling method was performed to obtain a national representative data . 
 valid data from 2,184 individuals were selected for the analyses , of which 75% were palauans and 19% were filipinos . 
 prevalence of current cigarette smoking was 25% in men and 10% in women . 
 betel nut chewing with tobacco was prevalent particularly among palauans ( 58% in men , 69% in women ) compared to the other ethnic groups . in terms of all types of tobacco use , 60% of men and 58% of women were current users . 
 overweight or obesity was very common among palauans ( 84% in men , 86% in women ) as well as filipinos ( 52% in men , 40% in women ) . 
 hypertension was found in 55% of men and 49% of women , with the stage 2 hypertension being 21% and 19% , respectively . 
 the prevalence of diabetic level hyperglycemia was more than 20% . 
 raised total cholesterol was detected in 16% of men and 20% of women . 
 this survey revealed an alarmingly high prevalence of ncd risk factors , especially tobacco use , obesity , hypertension and raised blood glucose . 
 the data would be useful baseline information to develop effective ncd strategies in palau . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ACKNOWLEDGMENTS
CONFLICTS OF INTEREST