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MEOR Flash: News you can use Nepal STEPS Survey 2019 The Nepal Health Research Council (NHRC) in collaboration with the World Health Organization, Nepal has disseminated the full report on Noncommunicable Disease Risk Factors: STEPS Survey 2019. The key findings of the report have also been released, national as well as those of Province 1, Province 2, Bagmati Province, Gandaki Province, Lumbini Province, Karnali Province, Sudurpashchim Province. In addition, factsheets on alcohol and tobacco consumption have also been made available in the website of NHRC. The survey collected socio-demographic and behavioural information as well as physical and biochemical measurements related to non-communicable diseases (NCDs) risk factors. The survey was a population-based household survey conducted among 5,593 adults aged 15-69 years selected through multistage sampling process. This is the third phase of the nationwide STEPS survey. In 2003, a subnational STEPS survey was conducted in Kathmandu followed by another subnational survey in 2005 covering Ilam, Lalitpur and Tanahun districts. The first national level STEPs survey was carried out in 2007 with only socio- demographic, behavioural information and physical measurements. This was followed by the second national survey in 2012-13 that included biological measurements as well, which was the first time the country measured biological risk factors across the nation. MEOR found this study useful and thought we would share it with you all. STEPs survey The STEPwise approach to noncommunicable disease risk factor surveillance–STEPS, is a simple, standardized method developed by the World Health Organisation (WHO) for collecting, analysing and disseminating data on the established risk factors that determine the major disease burden of NCDs in WHO member countries. STEPs focuses on obtaining information on four major modifiable behavioural risk factors including unhealthy diet, tobacco use, harmful alcohol consumption, and inadequate physical activity and four major biological risk factors that include overweight and obesity, high blood pressure, elevated blood glucose, and abnormal blood lipids (including raised cholesterol). Key findings in Nepal 1. Behavioural risk factors i. Salt intake: At the national level, mean intake of salt per day (in grams) is 9.1g. This average figure is approximately twice the WHO recommended salt consumption for adults, which is less than 5g (just under a teaspoon) per day. The highest provincial mean salt intake per day was found at Karnali Province with 9.5g. Additionally, at the national level, almost one in five adults (19.5%) always or often eat processed foods high in salt. Policy response: If WHO recommendation of salt consumption level is achieved, an estimated 2.5 million deaths could be prevented each year globally as salt consumption is associated with risk of hypertension and cardiovascular diseases. WHO has also listed a range of strategies ranging from Page | 1 government policies to consumer awareness for reduction in salt consumption. These strategies can be stepping-stone for the government of Nepal in the initiatives to reducing salt consumption. On an average, 2 servings of fruit and vegetables are consumed per day in Nepal while the WHO recommends consumption of 5 servings per day. The proportion of adults who eat less than 5 servings of fruits or vegetables on average per day is 96.7%. Policy Response: Low intake of fruit and vegetables is a risk factor for mortality and morbidity associated with micronutrient deficiency and non-communicable diseases. Therefore, increasing the intake of fruits and vegetables is one of the policy options included in the WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013-2020 to implement as appropriate in the national context, and Nepal has also adopted the same in Multisectoral Action Plan for the Prevention and Control of Non-Communicable Diseases (2014-2020). ii. Tobacco use The survey showed that approximately three in ten adults currently use tobacco of any kind, with about 17% of adults smoking tobacco currently and about 18% using smokeless tobacco product. About 6.5% use both forms of tobacco products currently. Province 5 had the highest prevalence of current tobacco use of any kind (36.4%) and smokeless tobacco use (26.9%). Sudurpashchim Province had the highest prevalence of current tobacco smoking (26.6%). The survey also reported a decline in tobacco use with increasing wealth quintile and educational level. The average age of initiation of tobacco use was 17.8 years. Policy Response: Tobacco use is a leading modifiable behavioural risk factor contributing to NCDs. WHO has set a voluntary global target of a 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years. Nepal has also adopted this target in its Multisectoral Action Plan for the Prevention and Control of Non-Communicable Diseases (2014-2020) iii. Harmful alcohol consumption The survey indicated that one in every five adults currently drink alcohol, while 7% were involved in heavy episodes of drinking. The highest percent of adults involved in drinking currently were found in Bagmati Province (27.5%) followed by Karnali Province (27%) and Gandaki Province (24.1%). The highest prevalence of heavy episodes of drinking was found in Karnali Province (8.8%), followed by Bagmati Province (8.7%) and Gandaki Province (8.5%). Policy Response: Harmful use of alcohol is a major risk factor for adverse health outcomes: morbidity, premature mortality and disability. The overall burden of disease and injuries attributable to alcohol consumption remains unacceptably high. WHO is currently in the process of developing action plan (2022-2030) to implement the global strategy to reduce the harmful use of alcohol effectively. In line with the voluntary global target recommended by the WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013-2020, Nepal has also set a target to reduce harmful alcohol consumption by 10% by 2025. iv. Physical activity The survey showed that 7.5% adults had insufficient physical activity, which is defined as < 150 minutes of moderate-intensity activity per week, or equivalent. GPAQ Analysis Guide provides a complete definition of insufficient physical activity. The percentage of adults with insufficient activity varied from 3.6 in Province 1 to 10.3 in Bagmati Province. Page | 2 Policy Response: Physical inactivity has a major health impact over the world. It is a leading risk factor for rising prevalence of NCDs. WHO Global Action Plan for prevention and control of Non- Communicable Diseases 2013-2020 has set a voluntary global target of a 10% relative reduction in insufficient physical activity. Nepal has also adopted this target in its Multisectoral Action Plan for the Prevention and Control of Non-Communicable Diseases (2014-2020). 2. Biological risk factors i. Overweight and Obese The survey showed that almost a quarter of the adult population (24.3%) was overweight (20%) and obese (4.3%). The highest percentage of overweight and obese people reside in Bagmati Province (42.6%) followed by Gandaki Province (34.6%) and Province 1(22.9%). Only around 11% of adults were overweight and obese in Karnali and Sudurpashchim Provinces. One fifth of the adults had an increased risk for disease based on the body mass index and waist circumference. Similarly, 7.5% had high risk and 3.3% had very high risk. About 10% of adults were underweight too. Policy Response: The double burden of malnutrition is characterised by the coexistence of undernutrition along with overweight and obesity and is often associated with nutrition transition. In addition to underweight, overweight and obesity is rapidly becoming a major public health concern and is also associated with many NCDS. WHO has set a global target to globally stop the rise in obesity. Similar target has also been adopted by the Government of Nepal. ii. Raised blood pressure The survey revealed that about one-fourth of the adult population (24.5%) have raised blood pressure (BP), based on the criteria of systolic BP≥140 mmHg or diastolic BP≥90 mmHg, or currently under medication for raised BP. Among the 7 Provinces, Gandaki province had the highest percentage of adults with raised BP (30%), followed by Province 5 (28.2%) and Province 1 (26.6%). Almost 4 of 5 adults were not aware about their raised BP. About 12% of adults were aware of their raised BP but not on treatment. Policy Response: Raised BP significantly increases risk of diseases related heart, brain, kidneys, and others. WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013- 2020 has set a voluntary global target of a 25% relative reduction in the prevalence of raised BP, Nepal has also adopted this target in its Multisectoral Action Plan for the Prevention and Control of Non- Communicable Diseases (2014-2020) iii. Raised blood glucose The survey revealed that almost 6% of adult population had raised blood glucose, based on the percentage with raised fasting blood glucose (≥126mg/dl). Among the 7 Provinces, Province 2 had the highest percentage of raised blood glucose (11.3%), followed by Province 5 (6.4%) and Province 1 (4.4%). Almost 1 in 4 adults were not aware about their raised blood glucose. About 6% of adults were aware of their raised blood glucose but not on treatment. Policy Response: WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013-2020 has set two voluntary global targets: i. 25% relative reduction in the risk of premature mortality of NCDs including diabetes and ii. halt the rise of diabetes. Both of these targets have been adopted by the Government of Nepal in its multisectoral action plan. This action plan also includes a target of 50% for eligible people receiving drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes Page | 3 iv.