1. Introduction

Chronic non-communicable diseases (CNCDs) are viewed to be the leading causes of global death and disability in the not so far off 2030 and are predicted to cause three quarters of all deaths [1]. Cardiovascular disorders, chronic obstructive pulmonary disease, asthma, diabetes, obesity, some cancers and disabling mental illness are included under the umbrella of this acronym. CNCDs have dominated the global health burden in recent years, and poorer countries seem to have provided the model for this observation. Evidence clearly points to CNCDs as disproportionately affecting the poor [2]. In low- and middle-income countries, chronic disease is the current cause for an estimate of more than 80% of deaths [1,3]. Countries economically not on par with the developed nations bear the biggest brunt of these diseases, and Caribbean territories with less than enviable economies are significantly saddled with this health encumbrance. In 1990 non-communicable diseases surpassed maternal, peri-natal, communicable, and nutritional disorders in the Caribbean [4]. More than a decade later the health scenario suggests these diseases are still the leading causes of morbidity. The Caribbean has the highest prevalence of CNCDs in the region of the Americas [5]. In the twin-island republic of Trinidad and Tobago, the mortality rates from diabetes and cardiovascular disease are higher than in North America (United States and Canada) [5].

The epidemiologic transition to CNCDs has been well documented in Trinidad and Tobago [6,7]. The first survey of a stratified random sample of the entire population of Trinidad screened 24,069 persons in the 1960s and reported that 1.89% of the sample satisfied the criteria for diabetes [8], which was one of the highest reported prevalence for this disease in the region. In a second study conducted between 1977 and 1985 of 2491 persons in an urban setting, the incidence rates of hypertension in men were 37 per 1000 person-years and 29.5 per 1000 person-years in women. The incidence of diabetes (per 1000 person-years) in Indians was 23.5/1000 and was significantly higher than in Africans [9]. However, following these two early population-based epidemiologic studies, more recent data on the epidemic have been based on self-reporting of the CNCDs. Thus, the 2005 Survey of Living Conditions reports that 10.4% of the poorest and 17.6% in the richest of 2086 community dwelling respondents had self-reported diabetes. In this survey no information was provided for hypertension [10]. These data provide an insight into the evolution of the diabetes epidemic in Trinidad and Tobago. The death rate from diabetes in the country is ten times higher than in the United States of America, and the age-adjusted, gender-specific mortality rates from heart disease and all cardiovascular diseases rank among the highest in the Caribbean [11].

Although population-based epidemiologic surveys are the gold standard, information derived from self-reporting of diabetes in a Taiwanese population has been found to be accurate in determining disease prevalence [12]. Further, in a USA study of 2037 persons self-reporting of diabetes when compared with a review of their medical records revealed a specificity of >90% but with lower (66%) sensitivity [13]. The self reported prevalence of diabetes, hypertension and heart disease in a large population of individuals from the lower socioeconomic group who applied for State-sponsored welfare grants was studied. The determined prevalence rates of these conditions, particularly diabetes and hypertension – the two most common chronic non-communicable diseases in Trinidad and Tobago – will contribute to the health care system planning over the next decade.

2. Materials and methods

3. Results

4. Discussion

Successful management of CNCDs is dependent on social and environmental influences beyond the scope of the health care system. The increase in chronic diseases in developing countries is consequent to the increasing prevalence of risk factors, such as increased alcohol consumption, smoking, obesity, physical inactivity and low fruit and vegetable intake. Poverty is closely linked with social determinants of chronic disease, such as poor education [14], ethnicity [15], age, poor diet and tobacco use [16]. In this report, a higher prevalence of hypertension in females was found compared with the PAHO/WHO National STEPS Survey. Subjects in this study who had received a primary education only were at greatest risk for all three diseases compared with other degrees of education. An education enables people to rise beyond the limitations of poverty and is capable of curbing the rising prevalence rates of CNCDs. In a nationally represented cohort from the United States, education and income were important determinants in diabetes-related mortality [17]. In another study from India, educated parents made decisions which positively affected the health of their children [18].

More Trinidadians of East Indian ethnicity suffered from all three conditions in this cohort. In the United States the disproportionate sufferers of heart disease, cerebrovascular disease, and type 2 diabetes, which were ranked in 2000 as first, third, and sixth, respectively, among the leading causes of death and disability were racial and ethnic communities comprising the African Americans, Hispanic-Latino Americans, Native Americans and Alaska Natives, and Asian Americans and Pacific Islanders [19] From Jamaica, another Caribbean nation, hypertensive heart disease was predominant in Afro-Caribbean populations, and ischemic heart disease and acute myocardial infarction though highly prevalent appeared to have been missed and not recognized [20]. It appears that people of Indian heritage are more susceptible to these three disease entities of the metabolic syndrome.

The World Health Organization estimates that chronic disease accounts for 60% of deaths worldwide and has given precedence globally to the prevention and treatment of chronic diseases [21]. Among hypertension, heart disease and diabetes, hypertension has been cited as the most frequently reported condition [22]. This observation has implications for health and longevity in Trinidad, if this research is to be guided by data showing hypertension, like diabetes, has a rising prevalence [23] and is an alert to its etiological health burden for cerebrovascular accidents, which were the second leading cause of death a decade ago [4].

All three conditions showed a peak prevalence in subjects aged 51–60 years and 46.8% of these had hypertension. One study from Sweden showed that the prevalence of co-morbidity in older persons ranges from 55% to 98% [22]. Co-morbid chronic disease conditions are common in elderly patients and are significantly associated with higher mortality, particularly in patients between the ages of 65 and 89 years. Co-morbid diabetes, hypertension and cardiac disease were found to be the most prevalent in subjects between the ages of 61 and 70 years. Authors of a study from three European countries in men with chronic disease between 65 and 84 years reported co-morbidity was relatively common and could explain a large proportion of excess in all-cause mortality in 10 years of follow-up [24]. The age dependency of multi-morbidity in individuals studied illustrated a significant rising prevalence in both women and men from 18.5% to 44.0% and 28.6% to 58.0%, respectively [25]. Over the age of 51, women demonstrated a higher prevalence of cardiovascular/metabolic disease than did men. In cross-sectional studies, older age, female gender, and low socioeconomic status were associated with multi-morbidity [22]. The higher prevalence of chronic conditions in women in this study established a gender difference which is strengthened by the findings of Marengoni et al. [22]. However, other studies found gender differences that were either smaller [26] or larger in men [27].

One interesting observation was that 35.1%, 51.7% and 16.4% of diabetics, hypertensive and heart disease patients respectively were widowed. These categories represented the highest marital status proportion for all three diseases and may have important policy implications. It is well recognized that widowhood is associated with poverty [28]. A household loses much of its earning potential or pensions with the death of the male breadwinner, or the long-term caring for a chronically disabled male wage earner. The well-documented longer life expectancy of women taken together with men marrying younger women in general, means that women often may live their later years without their life partner and thereby get a reduced income.

The association between poverty and chronic disease is interesting and has been described. Poverty contributes to CNCDs, and CNCDs contribute to poverty. The poor are more likely to smoke, have high levels of alcohol intake, have diets high in unsaturated fats, have low fruit and vegetable intake and enjoy a more sedentary lifestyle [29], all of which are risk factors for the development of non-communicable diseases. Where the literature is not as clear is in the status of widowhood and poverty and the relationship with the development of CNCDs. One could speculate if it is widows that suffer from chronic disease and are subjected to relative poverty as a result of the loss of their partner, or does losing a life partner lead to poverty which in turn results in chronic metabolic disease? This dilemma is worthy of exploration.

The burden of cardiovascular disease, specifically hypertension, diabetes and dyslipidemia in the Caribbean, portrays that which is reported in sub-Saharan African countries [30] considering both regions experience changing lifestyles with advancing urbanization. Wellbeing in both regions is influenced by a lack of infrastructural healthcare support, rapid urbanization, inadequate finances and insufficient and inefficient government programs that focus on disease prevention.

The recognized drivers of the health threat viz. diet, obesity, lack of exercise and smoking collectively fuel cardiovascular disease. Gender specificity is emergent; for example obesity is a major risk factor in women, but smoking continues to predominate as a cardinal risk factor in men. The impact of low socioeconomic influences on obese women and male smokers put them at increased risk for developing or experiencing poor outcomes of metabolic and cardiovascular disease. These findings highlight the need to explore the nature and magnitude of CNCDs and identify a pressing need for interventions which prevent these illnesses in Trinidad and Tobago.

This study has prompted further work with the Government of Trinidad and Tobago to mount surveillance studies to detect cases of diabetes, hypertension and the metabolic syndrome in families of patients being treated at primary health centers. This research agenda also aims to explore prospectively in schoolchildren and adolescents the prevalence of obesity and pre-diabetes.

Notwithstanding data collection in 2008–2009 and the results under publication in 2012–2013 may limit the representation of current data, we believe the situation in this twin island republic of 1.3 million people has not significantly changed. Factors which contributed to the delay are the extensive population strength of 21,790 respondents in 23 centers that were screened across the country. Data collection by interview was entered manually on forms and later transcribed into an electronic database, and cross-checked with manual records to ensure an error-free file.

5. Conclusion

Hypertension, type 2 diabetes and cardiac disease are highly prevalent in individuals seeking State-funding in Trinidad and Tobago, and Indo-Trinidadians are the most affected ethnic group among these individuals. The peak prevalence of these conditions is between 51 and 60 years, particularly for hypertension. Hypertension is significantly more prevalent in females, while diabetes and cardiac disease are not gender specific. Low socioeconomic status and lower standards of education favor these conditions. Preventive measures to contain, and elucidate surveillance systems to detect these diseases are needed to form necessary features of the country’s research agenda.