2010 Cancer & Health in American Samoa Factsheets by Sara Krosch Consulting

What we know about cancer incidence & prevalence in American Samoa Cancer is the second leading cause of death in American Samoa (1).

Incidence

K nown Cancer Incidence 2004-09*

Cancer incidence is the number of new cases in a population in a certain period of time. Data from the American Samoa Cancer Registry captures cases of cancer diagnosed in the Territory and some cases of off-island diagnosis where the patient expires in American Samoa. Preliminary data from 2004 -2009 shows 223 new cases of cancer were diagnosed in 134 women and 89 men (2). Many patients with findings ’suspicious of cancer’ go off-island, usually to Hawai’i, for further testing and are not currently captured in the Registry (3).

Source: American Samoa Cancer Regisitry * preliminary data as of 4/8/2010

0 2004

2005

2006 all

2007 females

2008

2009

males

2004 and 2008 saw the most new cases of cancer over the six-year period, with a sharp drop in 2009. Cancer diagnoses in women saw the greatest number of cases detected in 2007 and 2008 with a significant decrease in 2009. Cancer diagnoses amongst men steadily decreased between 2004 and 2007, increased in 2008 and dropped dramatically again in 2009. There is little reason to believe less people developed cancer in 2009. It is more likely fewer people were screened or those with suspicious findings went off-island. Most Common Female Sites

Most Common Male Sites

# cases

breast

prostate

uterine/endometrial

lung/bronchus

colon/rectal

stomach

colon/rectal

cervical

ovarian

brain/other nervous system lymphoma

Age at Cancer Diagnosis 2004-09* Source: American Samoa Cancer Registry *preliminary data as of 4/8/2010

35 30 25 20

Females

Males

10 5 0 <20

20‐29 30‐39 40‐49 50‐59 60‐69 70‐79

≥80

Cancer was found in more than 20 different sites. The most common cancer sites for the population as a whole are 1) breast, 2) uterine/endometrial, 3) stomach, 4) colon/rectal, 5) prostate, and 6) lung/bronchus (2), reflecting little change compared to 1998-2002 statistics (1, 4). Many of the most common cancers found in American Samoa are gender specific with a particular burden on women. Based on data from the past 6 years, the average incidence of cancer in the population was 37 new cases per year--22 in women and 15 in men.

Age at cancer diagnosis ranged from 13 to 90 years with a median age of 56 for women and 67 for men. Cancer diagnoses peak in women two decades before men pointing to an urgent need to early screening for women (1). Cancer screening is often not found in medical records so overall screening rates are unknown. And because most cancer cases are cared for offisland, treatment records of individuals diagnosed in American Samoa are usually incomplete (3).

American Samoa Comprehensive Cancer Control Factsheet Series 2010 Centers for Disease Control and Prevention Cooperative Agreement Grant #U58DP000777-03

What we know about cancer incidence & prevalence in American Samoa Prevalence Prevalence refers to the current number of people diagnosed in prior years who are still living with the disease. The total cancer prevalence for American Samoa is unknown. Of the 223 cases of cancer diagnosed between 2004-2009, as many as 94 people (42%) are believed to have died from the disease, 41 women and 52 men. As many as 129 patients (58%) are currently cancer survivors, 93 women and 37 men however, some patients diagnosed in American Samoa have likely expired off-island (2,3). Although more women were diagnosed with cancer, 69% are cancer survivors compared to 42% of men (2). Life after a cancer diagnosis is alarmingly short; 88% of women and 92% of men are thought to have died from the disease in the same year of diagnosis or the in following calendar year (2). Males are more likely to be diagnosed with cancer after metastasis (4).

Sources (1) Cancer in American Samoa. Pacific Health Dialogue. 11(2). 2004. (2) American Samoa Cancer Registry April, 2010 (3) personal correspondence with Cancer Registrar, Angelina Stevens April 9, 2010 (4) Mishra, SI et al. Cancer among Indigenous Populations: The Experience of American Samoans. Cancer. 78(8):1553-1557. 1996.

What we know about cancer beliefs in American Samoa Beliefs Research conducted by the American Samoa Community Cancer Network 2006-08 and by the American Samoa Community Cancer Coalition in 2009 confirmed what others have previously found and uncovered several new beliefs and misconceptions American Samoans hold about cancer. Cancer was not amongst the most important health issues.

“Cancer is a disease people hardly get. We should be afraid of diabetes.” “We should pity those who have cancer because there is no testing and no cure.”

Exercise, diet and diabetes rank highest (1, 2) Cancer is believed to be a new disease because many never heard of it when they were younger (1, 3) Cancer is not a Samoan illness; there is no word for the disease (1, 3, 4) Cancer is associated with hopelessness, worry, and a fear that death is near(1, 4) There was widespread knowledge of smoking leading to cancer (1) Cancer may be caused by  not taking local herbal medicine in time when feeling ill (1)  a punishment from God or God’s will (1, 3, 5, 6)  spirit possession (1)  germs or uncleanliness (1)  a shift in diet from traditional foods to processed foods

“If you have cancer you should not tell another person because they can’t help.” “…if women don’t live healthy it will lead to cancer.” “Because the disease is new we go to the doctor or to the Lord. The Lord is the only cure. The Father in Heaven is the Doctor of all doctors.” “If I were diagnosed I would rely on God.” “[If diagnosed], all we can do is pray.” (1)

containing “chemicals and preservatives”(1, 3) The mystery surrounding what causes cancer lead many towards religious comfort (1) Older women and men are more likely to believe cancer can be treated or cured by a traditional Samoan healer (2, 4) Older women and men are more likely to recommend a cancer patient see a traditional Samoan healer (2, 4) Cancer patients are sometimes treated for mumu (swelling) or oloa (persistent ulcer) by traditional Samoan healers (4) People get most cancer information from the hospital, Samoan healers (Taulasea/Fofo), church pastors, and cancer survivors (1) Cancer has identifiable symptoms such that you can tell if someone is sick (1, 2, 4) Both men and women can have prostate cancer (2) You can get prostate cancer from sexual intercourse (2) Sources (1) Krosch S. Men’s Health Awareness & Prostate Cancer Screening Clinic Program Evaluation. The American Samoa Community Cancer Network. July 2008. NCI Grant #U01CA114590 (2) Krosch S. Men’s Prostate Cancer Screening Clinic Program Impact Evaluation Results. The American Samoa Community Cancer Network. August 2008. NCI Grant #U01CA114590 (3) Hubbell FA, et al. Exploring beliefs about cancer among American Samoans: focus group findings. Cancer Detection and Prevention. 2005;29:109-115. (4) Krosch S and Tuitoelau V. Complementary and Alternative Medicine for Cancer in American Samoa. Pacific-CEED Legacy Project formative research for the development of a radio serial drama. April 2009. CDC #5U58DP000976-03 (5) Mishra SI, et al. Knowledge of and Attitudes about Cancer among American Samoans. Cancer Detection and Prevention. 2000; 24:186-95. (6) Ishida D et al. Beliefs and Attitudes of Samoan Women toward Early Detection of Breast Cancer and Mammography Utilization. Cancer. 2001;91(1) 262-266.

American Samoa Comprehensive Cancer Control Factsheet Series 2010 Centers for Disease Control and Prevention Cooperative Agreement Grant #U58DP000777-03

What we know about barriers & predictors of cancer screening in American Samoa American Samoans often say they do not want to know they have cancer. “I’m scared to go to the hospital. It is best to stay at home and if I die then I’ll die. I don’t want to know whether I have cancer. I will worry and I might die sooner and yet my children are very young. That is why I resist going to the hospital. I don’t what to hear that my days are numbered because there is no treatment for my cancer. A lot of programs about cancer are being advertised. I never thought of joining.”

-breast cancer survivor utilizing traditional Samoan healing instead of hospital care 2009 interview for the development of the radio drama “Tasi le Ola”

Barriers to Cancer Screening Screening is not a priority (1, 2) Disease prevention is not part of the Samoan way of life (fa’aSamoa) (3, 4) Belief that cancer can be treated or cured by traditional Samoan healers (1, 2, 4-8) Culture-specify beliefs about health an illness that can lead to misinterpretation of symptoms and misdiagnosis of illness (6, 7, 8) Modesty, concern about body being touched, and reluctance to discuss personal issues (1-4) Distrust of Western medicine and medical doctors (4, 7, 8) Unfamiliar with screening tests (6-8) Men associate masculinity with not appearing sick or weak (7) Fear of cancer (1, 2, 9) Pain, actual or perceived (1, 2) Cancer is God’s will (1, 2, 5, 9)

Predictors of Cancer Screening Higher education, beyond high school (4, 8) Higher income (4) Higher acculturation--bilingual, bicultural, Western assimilation (4) Family history of cancer (4) Doctor’s recommendation (1, 2) Fear of cancer (1, 2) Belief screening will not be painful (4)

Knowledge about cancer and awareness of cancer screening services are neither strong barriers nor predictors of cancer screening (1, 2). Sources (1) Hubbell FA, et al. Exploring beliefs about cancer among American Samoans: focus group findings. Cancer Detection and Prevention. 2005;29:109-115. (2) Ishida D et al. Beliefs and Attitudes of Samoan Women toward Early Detection of Breast Cancer and Mammography Utilization. Cancer. 2001;91(1) 262-266. (3) Puaina S, et al. Impact of traditional Samoan lifestyle (fa’sSamoa) on cancer screening practices. Cancer Detection and Prevention. 2008;32S:S23-S28. (4) Mishra SI, et al. Breast Cancer Screening among American Samoan Women. Preventative Medicine. 2001;33:9-17. (5) Mishra SI, et al. Knowledge of and Attitudes about Cancer among American Samoans. Cancer Detection and Prevention. 2000; 24:186-95. (6) Mishra SI, et al. Results of a Randomized Trail to Increase Mammogram Usage among Samoan Women. Cancer Epidemiology Biomarkers and Prevention. 2007;16(12):2594-2604. (7) Krosch S. Men’s Prostate Cancer Screening Clinic Program Impact Evaluation Results. The American Samoa Community Cancer Network. August 2008. NCI #U01CA114590 (8) Krosch S and Tuitoelau V. Complementary and Alternative Medicine for Cancer in American Samoa. Pacific-CEED Legacy Project formative research for the development of a radio serial drama. April 2009. CDC #5U58DP000976-03 (9) Krosch S. Men’s Health Awareness & Prostate Cancer Screening Clinic Program Evaluation. The American Samoa Community Cancer Network. July 2008. NCI #U01CA114590

American Samoa Comprehensive Cancer Control Factsheet Series 2010 Centers for Disease Control and Prevention Cooperative Agreement Grant #U58DP000777-03

What we know about tobacco use in American Samoa Tobacco smoke contains 4,000 chemicals, 50 of which are known to be carcinogenic (1). Smoking and exposure to second-hand smoke has been linked to cancer of the lung, oral cavity, bladder, liver and cervix, respiratory infections, and adverse effects on infant and child development (1,4). Current smoker:

smoked any tobacco products (cigarettes, cigars or rolled tobacco) in the past 12 months

Non-daily smoker:

Daily smoker:

smoked any tobacco product in the past 12 months but not every day Secondhand Smoke:

smoked any tobacco product every day in the past 12 months

smoke from the burning of a tobacco product or exhaled from a smoker

Adults Percent Adult Current Smokers (n=2,072) Source: NCD STEPS Report, 2007 50 40

38.1%

30 21.6%

females males

The 2004 STEPS assessment of noncommunicable disease risk factors in American Samoa found 29.9% of adults are ‘current smokers’—21.6% of females and 38.1% of males (2). This rate has remained stable for the past two decades with a slight increase in female smokers (2,3).

Amongst current smokers, the majority, 77.8%, are daily smokers. Most male smokers start the 25‐34yrs 35‐44yrs 45‐54yrs 55‐64yrs 25‐64yrs habit before more women and smoke more. The mean initiation age for males who smoke daily is 20 and they smoke an average of 14.2 manufactured cigarettes a day. The mean age for a female to start daily smoking is 21 and women smoke an average of 12.4 manufactured cigarettes a day. Smoking also appears to be a lifelong behavior as current daily smokers report smoking an average of 19.9 (males) and 17.4 (females) years (2). According to a 2002 Behavioral Risk Factor Survey of 752 adults, 80% of current smokers report trying to quit in the last 12 months and 65% would accept free cessation treatment (3). 0

Smoking is more common amongst Samoans residing in American Samoa than in Hawaii or Los Angeles. The strongest predictors of smoking include being younger, male, married, less educated, with lower income and more acculturated--having adopted more Western ways. Adult Smoking Status Current smokers are less likely than non-smokers to identify Source: Mishra et al., 2005 smoking as a risk factor for developing cancer or to agree that most 3% deaths from lung cancer are caused by cigarette smoking. But the 29% majority of both smokers and non-smokers feel smoking while pregnant may harm the baby and even if a person has smoked for more than 20 years there is a health benefit to quitting (4). Overall smoking cessation rates are low (4). But a survey of 179 American Samoan women age 40 or older found 18% were former smokers (49% non-smokers, 33% current smokers). Women with 4 or more years college education were the most likely to have quit smoking (5).

68%

Non‐smoker

Current smoker

American Samoa Comprehensive Cancer Control Factsheet Series 2010 Centers for Disease Control and Prevention Cooperative Agreement Grant #U58DP000777-03

Quit Smoking

What we know about tobacco use in American Samoa College Students A survey of 100 American Samoa Community College students ages 18-24 found 65% had tried smoking and 33% are current daily smokers. The majority recall seeing anti-tobacco use media messages and no smoking signs, but three-quarters have seen a smoker in a restricted area and have asked a friend or a family member to not smoke near them. College students feel secondhand smoke exposure is equally as harmful as firsthand smoking. The majority (70%) report being exposed to secondhand smoke daily. More than half (57%) of college students live with at least one smoker and 95% have at least one friend who smokes. College students are primarily exposed to secondhand smoke from their peers on campus or in popular public ‘hangouts’ such as stores, parks, parking lots, and bus stops. Most (71%) are in favor of a smoking ban especially on buses and around schools and the hospital (1).

Youth The 2007 American Samoa Youth Risk Behavior Survey of 3,625 public high school students grades 9-12 revealed that 57% have tried cigarette smoking. In the past 30 days, 24% have used cigarettes or cigars and 5% have used smokeless tobacco. Nine percent (9%) of youth appear to be ‘regular smokers’, consuming cigarettes 20 or more days in the past 30 days. Boys are twice as likely as girls to be current regular smokers, often buying their own cigarettes at a store or gas station. Among students who currently smoke cigarettes, 84% tried to quit in the past year. Students are receiving mixed messages about tobacco use. Nearly all (94%) college students recall being taught about the dangers of smoking in high school, but 81% remember seeing a teacher smoking on campus (1) because only 4% of high schools prohibit all tobacco use, by all persons, at all times, in all campus locations (6). Tobacco-free school zone signs are posted at 42% of schools but enforcement appears to be lacking with 10% of students reporting smoking cigarettes and 3% using smokeless tobacco on school property in the last 30 days. Males are nearly 3 times more likely to have used chewing tobacco on school property one or more days in the past month (6).

Student Smoking Status Sources: YRBS, 2007 & S. Faaiuaso, 2009 65% 57%

33% 24%

high school

ever smoked current smoker

college

Sources (1) Faaiuaso S. Youth exposure to secondhand smoke. Presentation given at the American Samoa Community Cancer Investigator Program Community Forum, May 13, 2009. American Samoa Community College. NCi # U01CA114590 (2) American Samoa NCD Risk Factors STEPS Report. World Health Organization. March 2007. (3) American Samoa Behavioral Risk Factor Survey, 2002. Centers for Disease Control and Prevention. (4) Mishra SI, Osann K, Luce PH, Prevalence and predictors of smoking behavior among Samoans in three geographical regions. Ethnicity & Disease 15:2,305-15. 2005. (5) Krosch S and Tuitoelau V. Complementary and Alternative Medicine for Cancer in American Samoa. Pacific-CEED Legacy Project formative research for the development of a radio serial drama. April 2009. CDC #5U58DP000976-03 (6) American Samoa Youth Risk Behavior Survey Summary, 2007. Centers for Disease Control and Prevention and American Samoa Department of Education.

What we know about overweight & obesity in American Samoa Obesity is caused by an energy imbalance: consuming more calories than are used up. Our rapidly changing society has allowed us to live comfortably by eating more and expending less energy (1). A United Nations World Health Organization 2005 ranking of overweight in countries and territories found that American Samoa's population, with 93.5% being overweight or obese, ranks a close second to Nauru (94.5%). Independent Samoa ranks 7that 80.4%, and the United States comes in 9th at 74.1% (2). Adults Overweight and obesity are the norm for adults in American Samoa. Based on 1,995 BMI scores:  The average BMI for men is 33.7 and 36.2 for women  93.5% of adults ages 25-64 are overweight or obese, with little difference between age groups  18.9% are overweight  74.6% are obese  94.4% of women ages 25-64 are overweight or obese  14.2% are overweight  80.2% are obese  92.7% of men ages 25-64 are overweight or obese  23.4% are overweight  69.3% are obese (3) 100

Abdominal fat is the most clinically relevant (1). Exceeding waist circumference cut offs of 35 inches for women and 40 inches for men indicates an increased risk of cardiovascular disease. The average waist circumference for both women and men in American Samoa is 41 inches (3).

Body Mass Index = weight (lb) [height (in)]2 x 703 CDC BMI Scale Normal weight

19 -25

Overweight

≥25 – 30

Obese

≥ 30 - 40

Morbidly Obese

> 40

Pacific Islander BMI Scale Normal weight

23-27

Overweight

≥28-32

Obese

≥ 32

Percent Female Population Source: McGarvey, 1991

80 60 40 20 0

McGarvey suggests efficient fat-producing metabolisms would Upolu (n=89) Manu’a (n=238) Tutuila (n=848) Oahu (n=290) have increased survival among the first Polynesians who overweight obese settled in the Samoan islands. But Samoans in the late 20th Percent Male Population century did not have the prevalence of overweight and obesity 100 seen in today’s population. This suggests it is not simply an 80 ethnic group trait but an interaction between genetics, the 60 modern environment, and individual dietary and physical activity patterns. The affects of a modern lifestyle, especially 40 rapid dietary and physical activity changes, along food20 centered cultural activities in a population with a genetic 0 disposition for overweight have exacerbated the prevalence of Upolu (n=78) Manu’a (n=137) Tutuila (n=624) Oahu (n=222) obesity in Samoans, especially females. This modernization idea is supported by the steady increase in BMI for both genders and all age groups in Samoa, to American Samoa to Samoan immigrants to Hawaii (4).

College Students ASCC Student BMI Categories Source: S. Samoa, 2009

29%

34%

32%

28%

39%

38%

all

females

19% 22% obese overweight 59%

healthy weight

A sample of 114 students ages 18-24 attending the American Samoa Community College found 62% of females and 41% of males are overweight or obese, despite using the more liberal Pacific Islander BMI scale. Waist circumference scores show an even greater gender difference. Forty-one percent (41%) of female college students are at-risk compared to 15% of males. Students with high BMI and high waist circumference are more likely to report feeling unhealthy with at-risk waist circumference being the strongest predictor of poor health perceptions (5).

males

American Samoa Comprehensive Cancer Control Factsheet Series 2010 Centers for Disease Control and Prevention Cooperative Agreement Grant #U58DP000777-03

What we know about overweight & obesity in American Samoa Youth The number of fat cells is set during childhood and adolescence and the most important factor in determining adult BMI is previously developed fat cells (1). Research in 1978 and 1982 showed consistent obesity rates of 8% of girls and 4% of boys (6). Today, the average American Samoan youth is overweight and 35% are obese and 40% have at risk waist circumference scores. Studies conducted 2006-09 on the prevalence of overweight and obesity amongst school children show that as students get older they are more likely to be at an unhealthy weight. Although most students remained in the same weight category over a two-year period, average BMI percentiles within weight groups increased over time showing an average overall weight gain exceeding age associated average height gain (1).

Boys Weight Catagories (n=2,795)

Girls Weight Catagories (n=2,621)

Source: D. Vargo, 2007 17.9%

17.4%

32.8%

33.5%

40.9%

19.5%

20.5% 18.2% 20.9%

overweight at risk for overweight

62.6%

49.0%

ages 5‐6

38.2%

ages 7‐13

19.8% 26.5% 62.1%

healthy weight

ages 14‐18

44.2%

46.7% 29.3%

ages 5‐6

ages 7‐13

ages 14‐18

A gap exists between perceptions of healthy weight and actual BMI scores for youth. The majority of high school juniors feel they are at a healthy weight despite this being true for only a quarter of this population (1). The 2007 Youth Risk Behavior Survey of 3,625 public high school students found only 27% of girls and 18% of boys describe themselves as overweight. A survey of 108 girls ages 13-18 attending 4 public high schools, including Manu’a High School, revealed that weight satisfaction decreases with age; 70% of girls ages 13-14 are happy with their weight compared to 55% of girls ages 17-18. The majority of girls recognize that obesity is a problem for people their age and feel overweight or obese females are stigmatized more than male counterparts (8). Sixty-one percent (61%) of female high school students and 48% males report trying to lose weight (7).

Young Children Large birth weight and large weight gains from birth to 6 months are common for American Samoan infants, and children are significantly heavier and taller than in Samoa (4, 9). However, children as young as 5 years appear to be progressing towards overweight and obesity. Height and weight measurements of 4,225 2-5 years olds accessing the American Samoa Women Infants and Children (WIC) program in 2009 found 34% to be overweight or obese using a CDC age-specific BMI scale. Weight category percentages appeared stable from ages 2-4, but significant shifts towards obesity are visible between ages 4 and 5 years for both girls and boys (10). Obese children tend to be come obese adults who are more likely to require costly health care (1). Bo y s Weight Categories ages 4-5 (n=888)

Girls Weight Catagories ages 4-5 (n=929)

Source: AS WIC, 2009 15.4%

18.2% 18.4%

40.5% 13.5%

61.5% 45.9%

Sources

obese overweight healthy weight under weight

19.3%

63.8%

27% 8.1%

62.2%

obese overweight healthy weight

(1) Vargo D. Prevalence of Obesity Amongst American Samoa School Children 2008/2009 School Year: Report to the Directors Department of Health and Department of Education. May 2009. (2) www.epidemiologic.org/2007/02/most-overweight-countries-in-world.html (3) American Samoa NCD Risk Factors STEPS Report. World Health Organization. March 2007. (4) McGarvey S. Obesity in Samoans and a perspective on its etiology in Polynesians. American Journal of Clinical Nutrition. 1991;53:1586S-94S. (5) Samoa S. Motivations and barriers of college student healthy eating habits for a healthy weight. American Samoa Community Cancer Network Community Cancer Investigator Program presentation given May 13, 2009. American Samoa Community College. NCI # U01CA114590 (6) Vargo D. Prevalence of Overweight in American Samoan Schoolchildren, 2007/2008 School Year: Report to the Directors Department of Health and Department of Education. June 2008. (7) American Samoa Youth Risk Behavior Survey summary, 2007. Centers for Disease Control and Prevention and American Samoa Department of Education. (8) Faaiuaso G. Obesity in American Samoa’s female adolescents. Community Cancer Network Community Cancer Investigator Program presentation given May 13, 2009. American Samoa Community College. NCI # U01CA114590 (9) Galanis, DJ, et al. 1999. Dietary Intake of Modernizing Samoans: Implications for Risk of Cardiovascular Disease. Journal of American Diet Association, 99,184-90. (10) American Samoa Women Infant and Children (WIC) Program data, 2009.

What we know about physical activity in American Samoa A low level of physical activity is a common and critical risk factor for developing non-communicable diseases such as heart disease, diabetes and cancer. Physical activity can be measured in Metabolic Equivalent minutes or METS (1). Physical Activity Scale in Metabolic Equivalent Minutes (MET) for ≥10 minutes activity 1 MET=

Energy spent sitting still

2-3METS=

Transportation by walking or cycling

4 METS=

Moderate physical activity (cleaning, farming, climbing stairs)

8 METS=

Vigorous physical activity (carrying heavy loads, strenuous sport)

Inactive

Moderately Active

Vigorously Active

<600 MET mins/week

600-1,500 MET mins/week

>1,500 MET mins/week

Adults A survey of 2,072 adults ages 25-64 found that the majority have low levels of activity--66% of women and 59% of men. The average daily MET minutes for an adult is 69, or 483 MET per week. However, the median daily MET minutes is an alarming 13, or 91 per week showing a large portion of the population with extremely low levels of physical activity. Men get nearly twice as much physical activity as women each week. Men are physically active mostly during work hours (45 minutes/day) while women get most of their exercise during transportation (27 minutes/day). Adults are less physically active in leisure time then at work (1).

A verage Weekly M ET Minutes Source: WHO STEPS, 2007 1500 1300 1100 900 women 700

men

500 300

Inactive

100 25‐34 yrs

35‐44 yrs

45‐54 yrs

55‐64 yrs

Youth A survey of 3,625 public high school students found 18% of girls and 28% of boys are physically active for at least 60 minutes a day on 5 or more of the past 7 days. About one third of students watch 3 or more hours of television and play video games or used a computer for something other than school work for 3 or more hours on the average school day (2). Studies conducted 2006-09 on the prevalence of overweight and obesity amongst school age youth found 1 in 9 girls and 1 in 5 boys engage in some sort of outdoor play on a typical school day, and only 5% of girls and 10% boys participate in some sort of strenuous after school sports activity (3). Most students feel they get an adequate amount of physical activity. However, boys in general are more likely to feel they are in need of more physical activity followed by obese girls (4). Most elementary students rely on the bus and high school students usually take a car to and from school. As walking decreases and car use increases so to do student BMI scores rise (4). Students who perform more afterschool chores are less likely to be overweight (3), but it is friends rather than family who are more likely to encourage physical activity (5). Sources (1) American Samoa NCD Risk Factors STEPS Report. World Health Organization. March 2007. (2) American Samoa Youth Risk Behavior Survey summary, 2007. Centers for Disease Control and Prevention and American Samoa Department of Education. (3) Vargo D. Prevalence of Overweight in American Samoan Schoolchildren, 2007/2008 School Year: Report to the Directors Department of Health and Department of Education. June 2008. (4) Vargo D. Prevalence of Obesity Amongst American Samoa School Children 2008/2009 School Year: Report to the Directors Department of Health and Department of Education. May 2009. (5) Faaiuaso G. Obesity in American Samoa’s female adolescents. Community Cancer Network Community Cancer Investigator Program presentation given May 13, 2009. American Samoa Community College. NCI # U01CA114590

American Samoa Comprehensive Cancer Control Factsheet Series 2010 Centers for Disease Control and Prevention Cooperative Agreement Grant #U58DP000777-03

What we know about nutrition in American Samoa Adults Not consuming enough daily fruits and vegetables is a common and critical risk factor for developing noncommunicable diseases such as heart disease, diabetes and cancer. Nearly half of American Samoa’s adult population is diabetic, 43% of women and 52% of men, one of the highest rates in the world. When starchy vegetables are excluded, 87% of adults ages 25-64 do not consume the daily recommended 5 servings of fruit and vegetables. Women eat an average of 1.7 fruit and 2.4 vegetable servings a day. Men usually eat 1.7 fruit and 2.4 vegetable servings daily (1). Differences in diet have a direct correlation on obesity rates when comparing American Samoa to independent Samoa. American Samoans consume more carbohydrates, protein, and fat resulting in an obesity rate of 93.5% compared to 80.4% in Samoa (2).

College Students A survey of 114 students ages 18-24 attending the American Samoa Community College showed 75% eat three full meals a day and at least 1 snack. Average college student consumption of 5 daily servings of fats/ sweets greatly exceeds food pyramid guidelines due largely to snacking on chips, cookies, cake, ice-cream, candy and soda. Higher BMI and waist circumference correlates with more soda consumption (3). College students feel the main barriers to healthy eating are both environmental and social/cultural including few nutritious foods on campus, lack of choices at home where foods are chosen by parents, and social unacceptability of refusing to eat. Students with high BMI are less likely to feel their family usually eats healthy foods and more likely to say they are ‘too busy’ to eat healthy (3). College students also rightfully perceive that healthy foods cost more. Less nutritious foods such as sweets and snacks cost $1.76 per 1,000 calories compared to $18.16 per 1,000 calories for nutrient dense foods such as fruits and vegetables (3, 4).

Youth

College Student Food Consumption Compared to USDA Food Pyramid Source: S. Samoa, 2009 USDA Recommended Daily Servings

Food Category

Average College Student Daily Servings

bread, pasta, rice

6-11

fruits

2-5

≤1

vegetables

3-5

≤1

milk

2-3

≤1

meat & eggs

2-3

fats & sweets

College Student Food Consumption Source: S. Samoa, 2009

14%

5% <3 meals 20%

25%

3 meals 3 meals 1 snack 3 meals 2 snacks 3 meals 3 snacks

36% Foods high in carbohydrates with a high glycemic index are the most commonly consumed by youth--breads, rice, sweets and soda (5, 6). Low GI foods help control appetite by delaying hunger. High GI foods cause spikes in blood sugar and insulin levels which encourages heart disease and diabetes (6). According to the 2007 Youth Risk Behavior Survey of 3,625 public high school students in grades 9-12, about three-quarters report eating fruits and vegetables weekly, but only 27% eat the recommended 5 daily servings (7). Food availability is a strong determinant of food choices in adolescents (5) but the most popular fruits and vegetables amongst this group--apples, oranges, carrots and cabbage--are all imported foods (6). More than one third of students drink at least one soda one or more times a day (7). Half of public high school students can correctly identify the most nutritious food from a choice of 3 food labels and have tried to eat foods fewer in calories or fat to keep from gaining weight in the past 30 days (6, 7). A study involving 203 students from Fagaitua High School found that milk and 100% fruit juice are more likely to be consumed at school, while soda and other sugary drinks are most popular at home. Students also have more access to cookies, candy, cake and doughnuts outside of school. Vegetable consumption is equal in school and at home. Boys consume more of all types of foods except chips, soda, sweets and canned meats which are the frequent favorites of girls. Most students understand that poor food choices can lead to obesity and other health problems but taste is what dictates their food choices The majority feels they do not get ‘enough to eat’ at the cafeteria but over half have been observed not finishing a main course or a fruit serving at school (5). Two-thirds of students say their teachers encourage nutritious eating (5), but friends are more likely than family members to encourage healthy eating habits (8).

Sources (1) American Samoa NCD Risk Factors STEPS Report. World Health Organization. March 2007. (2) Galanis, DJ, et al. Dietary Intake of Modernizing Samoans: Implications for Risk of Cardiovascular Disease. Journal of American Diet Association, 1999:184-90. (3) Samoa S. Motivations and barriers of college student healthy eating habits for a healthy weight. American Samoa Community Cancer Network Community Cancer Investigator Program presentation given May 13, 2009. American Samoa Community College. NCI # U01CA114590 (4) Vargo D. Prevalence of Overweight in American Samoan Schoolchildren, 2007/2008 School Year: Report to the Directors Department of Health and Department of Education. June 2008. (5) Stevens A. Assessing Adolescent Dietary Behaviors & access to Nutritional foods/snacks at school. Community Cancer Network Community Cancer Investigator Program presentation given May 13, 2009. American Samoa Community College. NCI # U01CA114590 (6) Vargo D. Prevalence of Overweight in American Samoan Schoolchildren, 2006/2007 School Year: Report to the Directors Department of Health and Department of Education. August 2007. (7) American Samoa Youth Risk Behavior Survey summary, 2007. Centers for Disease Control and Prevention and American Samoa Department of Education. (8) Faaiuaso G. Obesity in American Samoa’s female adolescents. Community Cancer Network Community Cancer Investigator Program presentation given May 13, 2009. American Samoa Community College. NCI # U01CA114590

American Samoa Comprehensive Cancer Control Factsheet Series 2010 Centers for Disease Control and Prevention Cooperative Agreement Grant #U58DP000777-03