Low- and moderate-income nations account for approximately 78% of the world's deaths from noncommunicable disease and 85% of noncommunicable disease prevalence (3). Noncommunicable disease occurs disproportionately among people in their most productive years of youth and middle age (4). A dramatic shift is expected to occur by 2025 when noncommunicable diseases will account for an increasing proportion of disease burden in low-income nations. Because of rapid industrialization and genetic factors, the health effects of Westernization have received much attention, primarily in South Asia and other large Asian countries and in Latin America. Less attention has been paid to the Caribbean region, despite its diverse and generally less affluent populations.

Grenada, a developing nation in the southern Caribbean, lies north of Trinidad and Tobago and is part of the chain of islands called the Grenadines (2). The nation has a population of approximately 95,500: 90,000 on Grenada, 4,600 on Carriacou, and 900 on Petite Martinque. Inhabitants are primarily of African descent. In 2005, the World Heart Federation sponsored the Grenada Heart Project (GHP) to examine effects of the epidemiologic transition on CVD risk in the nation (2). In selecting this Western Hemisphere country, the WHF considered several factors. First, Grenada's geographic isolation made it amenable to public health measures focusing on the modification of local health practices, which are highly influenced by community health leaders. These leaders could play a more active role in the dissemination of interventions than those in other countries. Second, Grenada was early in the epidemiologic transition, a stage at which interventions that mitigate the transition's negative health consequences are more likely to work. Third, its population of approximately 95,000 was a manageable number for the project.

Study participants in younger age groups tended to have less healthy diets (ie, types of food eaten and frequency) than their older counterparts (Table 2). Younger participants ate more fried meat, chicken, and duck and other types of fried food than their older counterparts. Younger women ate less fish than older women. Reported fruit and vegetable consumption did not differ by age for either sex, although garden access increased with age among women. Younger men and women were more likely to walk or bike than their older counterparts, and younger men were less likely to be sedentary than older men.

Many health indicators worsened with age for both men and women (Table 3); these indicators included systolic blood pressure, hypertension, diabetes, and heart disease. The trends of worsening health indicators were more pronounced among women than men. Smoking rates were 20% to 31% for men; women had much lower rates, 3.6% to 10.0% (data not shown). The relationships between age and hypertension, diabetes, and heart disease were consistent when stratifying by BMI for men and women combined (P < .001). The proportions of those we categorized as normal weight, overweight, and obese were approximately evenly divided (610-675 per category). Nearly all (85%) obese participants older than 65 had 1 or more diagnoses of hypertension, diabetes, and heart disease; proportions were nearly identical among men and women (84% vs 85%) compared with only 21% of participants younger than 35. Overall, 42% of women and 17% of men were obese. Participants aged 45 to 54 had the highest rate of obesity, 39%; 33% were overweight, and 28% were normal weight. More women in this age group were obese (51% vs 25% of men), and women had larger waist circumferences than men for each age group. The prevalence of metabolic syndrome was 29% for all adults, and rates were highest in those aged 65 or older (47%). The rate among all women was 36% versus 17% for men (P < .001) and among women aged 65 or older was 60% for women versus 23% for men (P < .001).

The transition to CVD risk factors is occurring in Grenada in conjunction with a tradition of very high fish consumption, which is higher among Grenadians of all ages than in the United States (12). The consumption of fish and its constituent omega-3 fatty acids, eicosapentaenoic acid, and docosahexaenoic acid, has been consistently associated with improved cardiovascular health (13). Beneficial effects of these unique fatty acids include a reduction in risk for sudden cardiac death (14-16), nonfatal acute coronary syndromes (12,17), and hospital admissions among people with congestive heart failure (18). In addition, the replacement of saturated fat with such long-chain polyunsaturated fatty acids has been associated with reduced levels of insulin resistance (19-21), the current most widely accepted risk factor for metabolic syndrome (22). Moreover, even in Japan, whose residents have a much higher level of fish consumption than those of most other countries, eicosapentaenoic acid supplementation has been associated with reduced risk of nonfatal coronary events (23). These facts may help explain the lower prevalence of CVD among Grenadians than would be expected, based on their risk factors.

Abdominal obesity and associated lifestyle factors are more prevalent among women than men in Grenada. Abdominal obesity and metabolic syndrome are more prevalent among women than among men in other developing countries and are associated with a sedentary lifestyle (24-27). Another island with a population of African origin with very high levels of fish consumption is the Republic of Seychelles. The Seychelles is experiencing rapid economic development, and obesity is common; obesity rates in the Seychelles (30%) are similar to those in Grenada (25%) (28). The age-standardized rate of obesity in adults in the Seychelles is 5 times greater among women than men (20.9 vs 4.2%) (29). Studies report that women in the Seychelles are less physically active than men, as is the case in the non-African populations of urban east India (30) and Saudi Arabia (31). Although obesity issues among women are not confined to those of African ethnicity, studies of African Americans, particularly women, indicate a lack of social pressure to be slim and a reduced stigma associated with obesity (32,33).

Emigration to Western countries has been associated with increased risk for CVD because of many factors, including transition to more urban environments, physical inactivity, a more energy-rich and atherogenic diet (3), gene-environment interactions, stress, and ethnic susceptibility (34). More sedentary lifestyles and high-fat diets have been associated with urbanization and its associated affluence and disruptions in traditional cultures. Another factor associated with urbanization is a transition to work that is devoid of physical labor. In developing rural countries, underprivileged and increasingly urban residents are predominantly lean, are engaged in physical labor, and have a very low risk of CVD. The trend in Grenada, however, is that people who have lived outside that country for more than 10 years tend to have healthier diets than those who have not lived outside Grenada or have done so for 10 years or less. This trend is particularly striking among women, who already have more worrisome dietary trends than men. Thus, migration status and fish consumption among Grenadians may be important considerations in preventing a more rapid epidemiologic transition in this poor, developing nation of ethnically African inhabitants. These trends, which may influence the health of future generations of Grenadians and residents of other Caribbean nations, warrant further study.

Our study had several strengths and limitations. Involvement of local community members on the research team enhanced trust between the community and the US investigators. The study sample was recruited using a community-based participatory research strategy that leveraged community leaders and community-based and community-driven marketing techniques. A limitation is that participants represented a self-selected convenience sample. Although this sampling technique is not optimal, we were able to recruit an estimated 57% of the residents of the islands of Petite Martinique and Carriacou. Much of the data collected were self-reported. This was a cross-sectional study; therefore, an assessment of any causal relationship of lifestyle and migration factors with CVD is not possible. Our ability to gather highly detailed dietary and other lifestyle data was limited by researchers' concerns that a long questionnaire would limit the ability to recruit an adequate study sample and local community concerns about medical research.

Robert C. Block, Department of Community and Preventive Medicine, University of Rochester. Box 644, Rochester, NY 14642, Phone: 585-275-3356, Email: robert_block/at/urmc.rochester.edu.