pacific islands obesity case study

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• Hawaii J Med Public Health
• v.77(10); 2018 Oct

Physical Activity, Nutrition, and Obesity among Pacific Islander Youth and Young Adults in Southern California: An Exploratory Study

This exploratory study aimed to assess obesity, physical activity, and nutrition among Pacific Islander youth and young adults in Southern California. A total of 129 Tongan, Samoan, and Marshallese participated in the study, including relatively similar proportions of males and females and age groups. We calculated Body Mass Index (BMI), dietary intake by a food frequency questionnaire (FFQ), and 7-day physical activity levels with accelerometers. Overall, 84% of Tongan, 76% of Samoan, and 24% of Marshallese participants were overweight or obese, with mean BMI of 31.2 and 34.3 kg/m 2 (for Tongan males and females), 32.3 and 33.4 kg/m 2 (Samoan males and females), and 25.3 and 22.1 kg/m 2 (Marshallese males and females). We found moderate- and vigorous-intensity physical activity (MVPA) fell below current guidelines at 38 min/day, with over 87% engaging in light-intensity PA and large sedentary times. Daily percent of energy from saturated fat, fiber/1,000 kcal and dairy intake were higher in Tongans compared to Samoans and Marshallese. Despite promising outcomes from this study, high prevalence of overweight, low physical activity levels, and high caloric intake put Pacific Islander youth and young adults at risk for a variety of health concerns and future efforts should focus on further research as well as community-wide prevention and amelioration efforts.

Introduction

Obesity continues to be an increasingly important risk factor for populations worldwide, yet relatively little is known about obesity prevalence to inform prevention in ethnically diverse populations, including Pacific Islanders (PIs). In 2010, there were over 1.2 million PIs (alone or in combination with one or more races) in the United States (U.S.), encompassing a wide diversity of over 20 distinct ethnic groups, each with their own culture, language, traditions, and political and migration history. 1 Compared to nearly all other ethnic groups, PIs suffer from higher prevalence of leading obesity-related health problems, including Type II diabetes, 2 , 3 hypertension, 4 , 5 and cancer. 6 For instance, a study of 80 PI adolescents found that 86% of overweight youth had at least one component of metabolic syndrome, compared to 11% of healthy-weight participants. 7 High waist circumference (> 90th percentile) and low levels of high-density lipoproteins (≤ 10th percentile) were the two most common components of metabolic syndrome in the sample. As with other groups, obese U.S. PI youth are also substantially more likely to be diagnosed with Type-II diabetes than their normal-weight peers. 18

Obese youth are more likely to become obese adults, and rates are of considerable concern for PIs. Worldwide among youth less than 20 years of age, overweight and obesity prevalence in the Federated States of Micronesia (29.7% among boys and 61.4% among girls), Samoa (42.2% and 50.0%, respectively), and Tonga (34.5% and 52.6%) were higher than in the U.S. (28.8% and 29.7%). 10 Data from the Hawai‘i School Health Survey (2015) found that 15.3% of adolescents were overweight (BMI between 85th to 94th percentile) and 12.9% were obese (BMI equal to or greater than 95th percentile), with higher proportions of overweight or obese youth who were Native Hawaiian (33.5%) and other Pacific Islander (59.3%). 9 Existing health data on PI youth in Southern California are variable. One study reported 20% of PI children as overweight in Los Angeles, 11 while another study reported disaggregated overweight prevalence of 48.6% for Samoans, 27.8% for Tahitians, 22.1% for Native Hawaiians, 17.2% for Guamanians, and 31.3% for other PIs. 12

PI cultures often view obesity as a mark of high social status, 13 and PI youth may be more likely than other ethnicities to view obesity as more culturally acceptable and even desirable. Thus, community-based, culturally appropriate research should take into consideration the norms and traditions of this diverse ethnic group. 14 Furthermore, to inform the development of intervention strategies, assessment of obesity should include measures of physical activity (PA) and nutrition, 15 as these are two of the most important modifiable risk factors for disease. This exploratory study aimed to use a community-based participatory research (CBPR) approach to estimate overweight/obesity prevalence, PA levels, and dietary intake among PI youth and young adults in Southern California.

Study Design and Team

This cross-sectional, CBPR study involved a collaborative partnership between one university and two community-based organizations. The study team included university researchers with backgrounds in behavioral science, nutritional epidemiology and kinesiology, and community leaders from the Marshallese, Samoan, Tongan communities with extensive experience in adolescent programs and/or health education. Following CBPR approaches developed in previous studies, we employed CBPR principles throughout the study period, including equal partnership of community and university researchers and shared participation in all aspects of the research design, implementation, and evaluation. 16 Quarterly CBPR meetings among the research team and community leaders occurred throughout the entire two-year study period for: planning (six months), youth recruitment (6 months), two waves of data collection (6 months), data analyses and community report-back (6 months). Community leaders and designated community members (including youth) received training on all aspects of data collection including a training manual on assessment procedures and role playing. Community and university members co-facilitated all data collection activities, with the exception of the dietary assessment spearheaded by university researchers. Please see a previous publication for a full description of the CBPR planning, recruitment and other strategies used in this study. 17 The study was approved by the California State University, Fullerton, Institutional Review Board.

Participants

Eligible participants were youth and young adults (13–24 years old) from three ethnicities (Tongan, Samoan, Marshallese) residing in Southern California. During a six-month period, we recruited participants from churches in Los Angeles, Orange and San Diego counties. Churches play a pivotal role in promoting PI culture and community in the continental U.S., taking the place of traditional PI villages (and pastors of village chiefs) from the islands. 18 Community leaders outreached to youth and young adults through multiple churches (three Tongan, three Marshallese, and five Samoan) to maximize diversity with regards to geographic location and denomination (eg, Methodist, Catholic, and the Church of Latter Day Saints). Participants received a $50 gift card for each of two waves of data collection.

Data collection occurred either at the church or a convenient community setting (eg, local community center) and in groups of 6–20 participants of the same ethnic group. Before assessment, we provided youth with parental consent forms and scheduled them to participate in two visits scheduled seven days apart. During the first visit, participants returned with signed parental consent forms, received instructions on all study procedures, signed youth assent forms and completed a demographic questionnaire. They rotated in small groups to each of three stations where they completed height and weight measures, the Food Frequency Questionnaire (FFQ), and received detailed instructions on proper wear of the accelerometers. During the second visit, participants returned the accelerometers and participated in a short debriefing interview to share their feedback on the assessments (data not reported). The remainder of this paper presents findings from the demographic, height/weight, FFQ and accelerometer data.

Physical Measures

We measured height and weight individually at each site. Height was measured to the nearest 0.1 cm using a Seca 214 portable stadiometer (Hanover, MD), and weight was measured to the nearest 0.1 kg using a stand-up Ohaus ES200L bench scale (Pine Brook, NJ). The scale was calibrated before each session. These procedures followed the guidelines provided by the National Health and Nutrition Examination Survey. 19 BMI was calculated as total body weight in kilograms divided by height in meters squared (kg/m 2 ). BMI values were compared to CDC calculations for children and teens (for only participants age less than 21 years old) to determine overweight (≥ 85th percentile to less than the 95th percentile for age and gender) or obesity (≥ 95th percentile) status. 20 Extreme obesity was calculated at BMI values > 99th percentile.

Physical Activity

We assessed physical activity levels with the ActiGraph GT1M (ActiGraph, Pensacola, FL), a uniaxial accelerometer that measures and records vertical accelerations ranging in magnitude from 0.05 to 2 g. 21 The GT1M model has been shown to produce similar results to the older 7164 model, 22 and is widely used in PA research. There is extensive evidence establishing the Actigraph as a valid and reliable instrument for assessing adolescent PA measures. 23 Validity of the Actigraph for adolescents has been reported against various criterion measures, including indirect calorimetry (r = 0.86) 24 and direct observation (r = 0.50). 25 Previous studies have reported intra-instrument reliability ranging from ICC = 0.31 for 1 day of monitoring, to ICC = 0.87 for 7 days of monitoring. 24 , 25

Participants received instructions to wear accelerometers during the waking hours for seven consecutive days. Since the accelerometers were not waterproof, the monitors had to be removed during water-based activities (eg, showering, swimming). The ActiGraph recorded activity in 10-second intervals, and we reviewed accelerometer data for valid wear times using MeterPlus v4.0 software (MeterPlus, La Jolla, CA). For this paper, data were reintegrated into 60-second intervals and presented as activity counts. A valid recorded hour was defined as having at least 30 consecutive minutes of activity counts, and a valid recorded day consisted of at least 8 valid hours of counts. Participants with at least 4 valid days of accelerometer data were included in the PA analyses. We converted activity counts to daily duration (min/day) of sedentary (activity count < 101), light- (activity count 101–1951), moderate- (activity count 1952–5724), and hard/very hard-intensity (activity count 5725–10000) activity categories. 26 We calculated average minutes per day in each category by summing daily minutes of each activity category across valid days and dividing by the number of valid days. Total daily moderate-to-vigorous physical activity (MVPA) was calculated by summing the daily totals for moderate and hard/very hard activity categories.

Dietary Assessment

We utilized the FFQ that was developed and validated by the Epidemiology Program of the University of Hawai‘i Cancer Research Center. The 150-question FFQ was administered to Native Hawaiian and multi-ethnic adults, and found relatively good agreement when compared against 24-hour recall. 27 The food composition database was derived from the U.S. Department of Agriculture, and was supplemented and updated with data from local recipes consumed by the various ethnic groups in Hawai‘i. At the first visit, participants completed the FFQ based on their “usual” dietary pattern over the previous seven days. The “usual time frame” to report participant's intake in most studies is over the last year. However, a previous report suggested that most children (8 – 13 years) better recall dietary data over the last week. 28 We also showed photographs of serving sizes and plastic food models to help participants visualize and estimate food portions.

Data Analyses

All analyses were conducted using the Statistical Package for Social Sciences (SPSS) for Windows v16.0 (IBM, Chicago, Il) and Statistical Analysis Software (SAS) v9.1 (SAS, Cary, NC). To determine categories of normal weight, overweight, obesity or extreme obesity, participants aged less than 21 years of age were classified according to CDC criteria of BMI values equaling or exceeding the 85th, 95th, or 99th percentile for age and gender. 20 Dietary data were log transformed in order to convert the data from a skewed distribution to an approximated Gaussian distribution. We calculated means and frequencies for daily micronutrients, food group intake, and PA levels, and performed independent t -tests to test for gender differences in PA levels and dietary intake within each ethnic group. Analysis of variance (ANOVA) identified differences in PA and dietary intake between ethnic groups. Bonferroni post-hoc tests were run for analyses involving more than two groups. Power calculations using G*Power (Softpedia, Dusseldorf, Germany) determined a total sample size of N = 84 necessary to detect differences of moderate effect sizes at r = .30 with P < .05 and 80% power.

A total of 129 Tongan, Samoan and Marshallese were recruited into the study, with the following completion numbers: 118 provided basic demographic data; 111 provided usable accelerometer data with 81% (n = 86) meeting the minimum criteria (at least 4 valid days with a minimum of 8 hours per day) for inclusion in PA analyses; and 129 were measured for height, weight, and provided dietary assessments. For the dietary data, we removed outliers based on recommendations from previous research. 34 We excluded the top and bottom 10% of the log transformed energy distribution, then a robust SD (RSD) was calculated. We also excluded energy intakes outside the range (mean ± 3 RSD). Subsequently, four outliers were identified and removed, resulting in analysis of 125 FFQs.

Demographic characteristics and BMI percentages by ethnic group are shown in Table 1 , with Marshallese participants presenting much lower prevalence of overweight and extreme obesity compared to Tongans or Samoans. Overall, 84% of Tongan, 76% of Samoan, and 24% of Marshallese youth were overweight (85th–94th percentile) or obese (95th percentile or greater). Average BMIs for Tongan males and females were 31.2 kg/m 2 and 34.3 kg/m 2 (respectively); 48% of males and 50% of females were extremely obese. Average BMIs for Samoan males and females were 32.3 kg/m 2 and 33.4 kg/m 2 ; 50% and 36% were extremely obese. Lastly, average BMIs for Marshallese males and females were 25.3 kg/m 2 and 22.1 kg/m 2 ; 20% of males and 0% of females were extremely obese. See Table 2 for BMI by gender and ethnicity.

Demographic Characteristics and Body Mass Index Profile by Ethnicity (n=118)

Height, Weight, and Body Mass Index Profile (Mean and Standard Deviation) by Ethnic and Age Groups (n=116)

Accelerometer data found total MVPA at 37.5 ± 27.2 min/day for the entire sample ( Table 3 ). Over 87% of daily activity was classified as light-intensity (266.5 ± 71.0 min/day) and time spent sedentary was 508.1 ± 120.5 min/day. Males had significantly higher levels of moderate-intensity PA compared to females (45.4 ± 25.9 min/day vs 24.7 ± 18.9 min/day; P < .001).

Comparison of Accelerometer Data in Minutes Per Day (Mean and Standard Deviation) by Gender (n=86)

Accelerometer data ( Table 4 ) indicated no between-group differences for total daily MVPA, although light-intensity activity was significantly higher in Samoans (308.7 ± 67.5 min/day) compared to Tongans (256.4 ± 68.1 min/day; P < .01) and Marshallese (233.9 ± 57.3 min/day; P < .001). Tongans and Marshallese also had higher minutes of non-wear time compared to Samoans ( P < .01). Compared to Samoan females, Samoan males demonstrated significantly higher minutes of moderate-intensity PA (44.9 ± 29.4 min/day vs 14.1 ± 7.0 min/day; P < .01). Marshallese males accumulated significantly higher levels of light-intensity (255.2 ± 66.3 min/day vs 208.7 ± 31.3 min/day; P < .05), moderate-intensity (57.1 ± 26.8 min/day vs 23.9 ± 14.0 min/day; P < .01), and total MVPA (58.6 ± 28.2 min/day vs 25.5 ± 14.9 min/day; P < .01), compared to Marshallese females.

Comparison of Accelerometer Data in Minutes/Day (Mean and Standard Deviation) by Ethnicity (n=86)

Marshallese males reported significantly higher ( P < .05) consumption of fiber/1,000 kcal (10 ± 4 vs 8 ± 3), vegetables (10 ± 10 vs 5 ± 5 servings), and dairy (4 ± 3 vs 2 ± 1 servings) compared to Marshallese females ( Table 5 ). Tongan males consumed a significantly higher percent of energy from protein compared with Tongan females (16 ± 3, 14 ± 3, respectively; P < .05). Between the three ethnic groups, Tongans (7865 ± 5872 calories) had significantly higher energy consumption compared to Marshallese (5503 ± 4620 calories), while both Tongans (35 ± 7%) and Samoans (35 ± 6%) had significantly higher consumption of energy from saturated fat compared to Marshallese (33 ± 7%, P < .05). Tongans (5 ± 4 servings) also had a significantly higher consumption of daily dairy servings compared to Marshallese (3 ± 3 servings, P < .05), and Tongans (9 ± 3) had significantly higher fiber/1,000 kcal intake compared to Samoans (8 ± 3, P < .05).

Comparison of Daily Macronutrient and Food Group Intakes (Mmean and Standard Deviation) (n=125)

This study aimed to use CBPR to estimate levels of obesity, PA, and dietary intake among PI youth and young adults. In this study, Marshallese participants had substantially lower prevalence of overweight (25%) than Tongan (84%) or Samoan (76%) participants, with prevalence estimates for these latter ethnicities much higher than has previously been reported. 11 , 29 , 30 In particular, we found higher prevalence of extreme obesity in the Tongan and Samoan samples than previously described international data (49% and 44%, respectively). 10 Current BMI cutoffs for Pacific Islander adults and youth may overestimate obesity based upon past studies finding higher lean mass compared to Europeans. 31 , 32 Furthermore, U.S. based Tongan and Samoan youth may be at urgently elevated risk for a variety of future medical complications, and extreme obesity may need to be addressed with more intensive treatment approaches.

CDC physical activity guidelines for youth include 60 minutes or more of activity a day. 33 The findings from this study support the literature that adolescent males are typically more active than females. Low levels of physical activity and high levels of sedentary behavior have been reported for Tongan youth overseas, 34 and findings from the present study highlight similarities for all PI groups. The overwhelming proportion (87%) of daily activity (4–5 hours/day) registered at the low end of the intensity spectrum; approximately 8–9 hours per day were recorded as sedentary. Recent studies report that high levels of sedentary behavior are associated with adverse health effects, even in individuals meeting physical activity recommendations. 35 Modest increases from light- to moderate-intensity PA could help youth reap health benefits associated with sufficient MVPA levels.

U.S. Department of Agriculture dietary guidelines recommend adequate energy intake to support growth and maintain a healthy body weight, and that calories from fat be limited to 35% of total calories. 36 Our study highlighted potentially important ethnic-specific differences between Tongan, Samoan, and Marshallese participants regarding energy, percent energy from fat, fiber and dairy intake, similar to previous calls for understanding ethnic-specific subgroup differences. 37 For instance, we found Tongan participants had higher consumption of energy and other energy-dense food groups compared to the other two groups, underscoring the importance of studies exploring the unique influences in this population. 38 Other studies have assessed dietary intake in PI adults with differing results, however our study focused on youth and thus dietary consumption via FFQ in the respective population may only lend to comparisons of dietary/nutrient intake within and between groups for our study population. 39

Limitations

There are several limitations that should be considered when interpreting the study results. First, despite attempts to identify and recruit diverse PI participants, generalizability to the larger youth population is difficult due to our non-probability, community- and church-based sampling. 17 Second, although we found high proportions of overweight and obesity in our sample, this may be an overestimation as specific BMI cutoffs for Pacific Islander youth and adults have not been established, and past research strongly suggests increased BMI thresholds due to higher lean mass compared to Europeans. 31 , 32 Third, there are several limitations associated with accelerometers. We were unable to estimate many common activities (eg, water-based activities, or activities at extreme ends of the intensity spectrum), although we hope the information in this paper still contributes to the limited literature available for this population. Although we instructed participants to wear the monitors above the right hip, many male youth wore pants much lower than waist level due to current fashion trends. 17 Newer technology that places accelerometers worn around the wrist (eg, Fitbits) could well address such limitations in the future. 40 Lastly, FFQs are considered less burdensome compared with other dietary data assessment methodology. However, FFQs generally provide data on usual intakes rather than exact point estimates of macronutrient and food groups, and therefore dietary/nutrient intake data are more appropriately interpreted via comparisons and/or rankings within group and/or between groups of the respective study population. Also, over-reporting may result in extremely high energy intakes, and therefore energy adjustment of dietary variables, as well as comparison between groups provides for a more appropriate representation of the data. Future studies should build upon this study by considering use of other robust dietary assessment methodology, such as 24-hour dietary recall or food records, and/or development of a self-reported, validated dietary assessment tool for PI adolescents.

Implications and Recommendations

Following the community report-back to share findings from the study, 17 several of the community leaders created the first-ever Native Hawaiian and Pacific Islander youth fitness day in April 2011 that has subsequently been hosted annually at the University of California, Los Angeles, by PI student and other leaders as well as community organizations. Many of these same leaders also participated in the creation of the Pacific Islander Let's Move! physical activity program for primary prevention among PIs of all ages, inspired by then first-lady Michelle Obama and launched through churches and other community organizations throughout southern California. 41 Despite these outcomes, we recommend further research particularly on appropriate BMI cutoffs for PI youth. In addition, health promotion programs aimed at decreasing caloric intake and sedentary behavior, and increasing time spent in MVPA, appear warranted for PI youth given the high levels of overweight and obesity observed in this study. Although we investigated individual-level nutrition and physical activity, public health prevention research also points to the importance of social and environmental intervention factors. Hawley and McGarvey (2015) describe a number of promising multi-level efforts across the Pacific including banning imports of fatty meats and taxing sugar-sweetened beverages, 5 although youth may present a particularly challenging age group for intervention. 42 , 43 Lastly, future research should not only confirm our local findings with other PI populations and in other areas of the U.S., but also explore the larger cultural, community and policy influences on obesity prevention, persistence, and amelioration.

Acknowledgments

The authors gratefully acknowledge the Pacific Islander Health Partnership and the Union of Pan Asian Communities, and our community leaders, including George and Greta Briand, Donny Faaliliu, Vaka Faletau, Tana Lepule, and Jane Ka‘ala Pang. Appreciation is also extended to Colleen Kvaska for her administration of the FFQs, to Kelli Cain and Erin Merz for accelerometer data processing, and to our research assistants, Jan Eichenauer and Lianne Nacpil, who coordinated all aspects of data collection and management. This research was funded by grant 1R21 HD055192 from the National Institute of Child Health and Human Development. Further support for the researchers came from WINCART: Weaving an Islander Network for Cancer Awareness, Research and Training funded by grant 1U01 CA114591 and U54CA153458 from the National Cancer Institute's Center to Reduce Cancer Health Disparities.

Conflict of Interest

None of the authors identify a conflict of interest.

Drs. Tanjasiri, Wiersma, Moy and McEligot received financial support from NIH grant 1R21 {"type":"entrez-nucleotide","attrs":{"text":"HD055192","term_id":"300424904","term_text":"HD055192"}} HD055192 . Dr. Tanjasiri also received support from NCI grant 1U01 {"type":"entrez-nucleotide","attrs":{"text":"CA114591","term_id":"34967898","term_text":"CA114591"}} CA114591 and U54CA153458.

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Childhood Obesity in the Pacific: Challenges and Opportunities

• The Obesity Epidemic: Causes and Consequences (A Cameron and K Backholer, Section Editors)
• Published: 20 October 2020
• Volume 9 , pages 462–469, ( 2020 )

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• Amerita Ravuvu 1 &
• Gade Waqa 2  

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Purpose of Review

Childhood obesity is increasing substantially in many Pacific island countries and poses an urgent and serious challenge. The Sustainable Development Goals set by the United Nations and the NCD Roadmap created at the request of the Pacific Finance and Economic Ministers identify prevention and control of noncommunicable diseases as core priorities. Among the various risk factors responsible for the development of noncommunicable diseases (NCDs), overweight and obesity are particularly of concern with the potential to negate many of the health benefits that have contributed to increased life expectancy. With the increase in childhood obesity across the region, it has become apparent that surveillance data remains a challenge; however, it is essential to inform the development of effective policies and strategies to tackle the challenge of childhood obesity in the Pacific region.

Recent Findings

The paper highlights the paucity of childhood obesity surveillance data available in the Pacific region and how the absence of a standardised tool to collect this data makes it difficult to do comparative analysis between countries.

Drawing on a global protocol and identifying the gaps that currently exist in the region, the paper aims to highlight opportunities via which childhood obesity surveillance data can be improved to monitor better childhood obesity across the Pacific region.

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Ravuvu, A., Waqa, G. Childhood Obesity in the Pacific: Challenges and Opportunities. Curr Obes Rep 9 , 462–469 (2020). https://doi.org/10.1007/s13679-020-00404-y

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How to combat obesity in The Pacific Islands through the promotion of labels

Globally, there are 1.3 billion overweight people, as opposed to 800 million who are underweight. Obesity is a global crisis. There are many factors that can be blamed for this, including: globalisation, environmental threats, economics and culture. However, the most affected geographical area are the Pacific Islands, Territories and Countries (PITCs). Figure 1 displays the 9 islands that are named in the top 10 most obese countries by the World Health Organisation (WHO). There have been several health interventions to combat the obesity rates, predominately the Pacific Obesity Prevention in Communities (OPIC). However, this essay will critically evaluate this health intervention put in place to address the serious national health-related crisis, and will argue that OPIC was ineffective in reducing obesity and would have had better outcomes had it implemented one of two labelling methods. The ‘Traffic Light Labelling’ (TLL) and ‘Country of Origin’ labels would have increased awareness and shifted the dietary culture back to traditional PITC’s diets, helping to achieve Sustainable Development Goal (SDG) 3: Good Health and Wellbeing.

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Pacific obesity crisis: 'big is beautiful' no longer the case.

RNZ's Tonga correspondent Kalafi Moala said obesity, and diseases related to it, has become "the number one killer among islanders". Photo: AFP

A recent health study which revealed that nine out of 10 countries with the most number of people obese people in the world are from the Pacific means "the notion of being big is beautiful" is no longer the case, RNZ's Tonga correspondent says.

The research published in The Lancet ranked American Samoa as the most obese nation in the world, followed by Tonga, which has the highest number of obese women.

According to the study, involving 1500 researchers worldwide, more than a billion people are living with obesity around the world, including about 880 million adults and 159 million children.

The study has found American Samoa, Samoa, Tonga, Tokelau, Tuvalu, Cook Islands, Niue, Nauru, Marshall Islands, and the Federated States of Micronesia are nations that have the highest rates of people who are overweight or obese.

RNZ's Tonga correspondent Kalafi Moala said obesity, and diseases related to it, has become "the number one killer among islanders".

Moala told First Up more than 80 percent of Tongan women over the age of 20 are living with obesity, which is up 23.3 percent from 1990.

"It's a major health threat that we're confronting here in the Pacific," he said.

"You know there was a time when the notion of being big is beautiful among Pacific islanders; it was an admirable notion," he said.

"In Tonga, for example, over 70 percent of deaths come from non communicable diseases, almost all obesity related."

"But in over three decades... obesity and diseases related to it has become the number one killer among islanders."

In the cook Islands, over 30 percent of children have obesity and official say the statistics are concerning.

Health secretary Bob Williams told Cook Islands News screening done last year for schools on Rarotonga and the Southern Group Islands mirrored the recent statistics.

Williams said sugary drinks and processed or unhealthy food were the main drivers of obesity.

Pasifika health leader and associate dean Pacific and a research director at Auckland University's medical school, Sir Collin Tukuitonga, said while the obesity figures were not new, the results for children were especially concerning, noting that "two-thirds of young Pacific girls are obese, overweight".

He said the problem is "difficult to tackle, and it's all to do with our food systems, how people are not as active as they used to be".

According to the World Obesity Federation, half of the world's population is on track to be obese or overweight in the next decade .

Copyright © 2024 , Radio New Zealand

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Study finds Pacific accounts for nine of the 10 most obese countries in the world, Cook Islands grapples with highest childhood obesity rates in the world

Study finds Pacific accounts for nine of the 10 most obese countries in the world

New analysis published in the Lancet has found that Pacific island countries account for nine out of 10 of the top countries in the world with the highest prevalence of obesity among women and men aged 20 and above.  

Looking at data from 2022, the study found that more than 1 billion people in the world are now living with obesity. Worldwide, obesity among adults has more than doubled since 1990, and has quadrupled among children and adolescents (5 to 19 years of age). The data also show that 43 percent of adults were overweight in 2022. The World Health Organisation (WHO) contributed to the data collection and analysis informing the report.  

In the Pacific, overweight, obesity and diet-related noncommunicable diseases have progressively increased in every age group over recent decades and have become a major cause of early death and disability. Being overweight or obese increases the risk of developing noncommunicable diseases such as diabetes, high blood pressure and heart disease. Not only does this threaten lives and affect quality of life, it stands in the way of economic and development goals by reducing the number of years that people can play an active part in the workforce.  

Health leaders in the Pacific have long been aware of the increasing epidemic of obesity. However, while efforts have been made, progress has not been fast enough. Part of the challenge is that many of the factors contributing to rising rates of obesity are out of the control of those working in the health sector.  

“The drivers of obesity are complex,” said Dr Mark Jacobs , WHO Representative to the South Pacific. 

“In many parts of the Pacific, unhealthy food is cheap, convenient, and pushed heavily through advertising. Healthy food, on the other hand, may be increasingly difficult to get and more expensive in the face of the droughts, floods and rising seas caused by climate change. What we eat, how much we eat, and whether we are physically active also comes down to things like the culture around us and whether there is a safe and comfortable place to exercise.”  

Recognising the need for new approaches, health leaders at the Fifteenth Pacific Health Ministers Meeting hosted by Tonga last September committed to a series of eight actions to address the complex drivers of obesity, particularly in children and young people.  

In particular, they stressed the need to engage other government ministries, particularly the ministries of environment, trade, finance, customs, agriculture, fisheries and social development.  

They also committed to empowering networks and organisations already working at the community level, such as civil society organisations, persons with lived experience, youth groups, schools, traditional leaders, local governments and faith-based organisations.  

“It’s only by working together, across the whole of government and across the whole of society, that we will be able to halt rising rates of obesity,” continued Dr Jacobs.  

WHO’s advice to people in the Pacific is to bring different parts of government together with health workers, parents, teachers, sports stars, community organisations and church leaders to:  

*Make unhealthy foods and drinks more expensive (such as via taxes on sugary drinks) or make it harder for them to be imported;  

* Make healthy food and drinks easier to access and cheaper; 

* Support healthy eating in pregnancy and ensure infants are exclusively breastfed for the first six months of life; 

*Establish healthy habits in childhood and regularly monitor children’s height and weight; 

*Change expectations around what a good meal looks like and show that we love our families and friends by serving them healthy food and drinks; and, 

*Create safe and pleasant places to exercise and show how fun it can be. 

WHO is working to support Pacific island countries and areas to promote healthier behaviours, such as through the Health Promoting Schools initiative, as well as supporting health workers to test for, monitor and treat noncommunicable diseases.  

Funding from the European Union and New Zealand makes WHO’s work on obesity and noncommunicable diseases in the Pacific possible.

Cook Islands grapples with highest childhood obesity rates in the world

Cook Islands has the highest childhood obesity rate, with over 30 percent of children having obesity, a recent study on worldwide trends in underweight and obesity reveals. 

Bob Williams, Secretary for Te Marae Ora Ministry of Health , said they are concerned with the statistics. 

Williams said the Healthy Island and Healthy School screening done last year for schools on Rarotonga and the Southern Group Islands also indicated obesity among children at around 30 per cent. 

“TMO is concerned and parents should be concerned too,” Williams said. “This is all attributed from the lifestyle that we allow ourselves and our children to have.” 

The main causes are the sugary drinks and the processed or unhealthy food that we allow our children to drink and eat, he said. 

Williams added that there is also an increase in the rate of physical inactivity among our people and children. 

“We have also discovered smoking and vaping amongst children as well,” he said. “These are key health risk factors not only affecting our children but majority of our people.” 

The study published in The Lancet medical journal last week shows that global obesity rates among adult women more than doubled between 1990 and 2022, while rates among adult men tripled. Childhood obesity rates were four times higher in 2022 compared to 1990. 

The estimates say more than a billion people are living with obesity globally, which includes about 880 million adults and 159 million children, according to 2022 data. 

The nations of Tonga and American Samoa had the highest adult female obesity rates , while Nauru and American Samoa had the rates among adult males, making up 60 per cent of each population. 

Cook Islands and Niue had the highest childhood obesity rates, where over 30 percent of kids have obesity. 

Senior researcher Professor Majid Ezzati, of Imperial College London, told the BBC: “In many of these island nations, it comes down to the availability of healthy food versus unhealthy food.” 

“In some cases, there have been aggressive marketing campaigns promoting unhealthy foods, while the cost and availability of healthier food can be more problematic.” 

Sir Collin Tukuitonga, who is an associate professor, associate dean Pacific, and a research director at Auckland University’s medical school, said the results for children were especially concerning. 

“The local data here will show that two-thirds of young Pacific girls are obese, overweight. There’s increasing trends in childhood obesity,” Tukuitonga told RNZ.  

He said obesity was a longstanding fight for Pacific nations. 

“The problem of course is that it’s so difficult to tackle, and it’s all to do with our food systems, how people are not as active as they used to be.” 

Williams said Te Marae Ora is working with the Ministry of Education to sign up schools to be “healthy schools”. 

“All schools in the Southern Group Islands have signed up with one primary school on Rarotonga in 2023,” he said. 

As a “Healthy School”, they agree to ban fizzy drinks on school grounds and designate days for healthy breakfast or lunch options. 

Williams said TMO also provides financial support for the schools to establish sustainable healthy programmes as part of the agreement. 

“We plan to sign-up some more schools on Rarotonga next month and the Northern Group Island schools this year,” Williams said. 

“TMO support the schools by supplying all students water bottles, tooth brush and tooth pastes. TMO is grateful to ADB (Asian Development Bank) for installing or improving water fountains in schools and in public places. TMO also supplies the schools with First Aid Kits sponsored by the Bank of the South Pacific.” 

Williams expressed appreciation for the support of the government and the Minister of Health, Vainetutai Rose Toki Brown, for launching the Healthy and Smoke-Free Islands initiative in February 2023. 

“This initiative is also supported by our development partners World Health Organisation (WHO) and UNICEF since the launch.” 

As of last week, Williams said the Food and Agriculture Organisation (FAO) indicated support for providing gardening equipment and resources to schools to increase the availability of nutritious food. 

“This will also be supported by an app that the Ministry of Agriculture and TMO is working with FAO to be developed to allow everyone in the Cook Islands to monitor their nutrition intake and the Cook Islands food profiles necessary to support our people in making a healthy lifestyle transformation.” 

TMO also plans to partner with all health and fitness groups and sports groups to increase physical activity levels among children and adults. Some groups have already applied healthy meal plans for their members, and TMO is grateful and willing to support them, Williams said. 

“TMO is working with WHO to finalise a dietary guideline and a physical activity guideline for the Cook Islands before TMO proposes other policy reforms.” 

The ultimate goal is for Cook Islands children to be free of non-communicable diseases and dental caries by 2030+, Williams said. 

“This also mean no more obese children by 2030+,” he said.

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• Open access
• Published: 11 July 2006

Overweight in the Pacific: links between foreign dependence, global food trade, and obesity in the Federated States of Micronesia

• Susan Cassels 1  

Globalization and Health volume  2 , Article number:  10 ( 2006 ) Cite this article

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The Federated States of Micronesia (FSM) has received considerable attention for their alarming rates of overweight and obesity. On Kosrae, one of the four districts in the FSM, 88% of adults aged 20 or older are overweight (BMI > 25), 59% are obese (BMI > 30), and 24% are extremely obese (BMI > 35). Recent genetic studies in Kosrae have shown that obesity is a highly heritable trait, and more work is underway to identify obesity genes in humans. However, less attention has been given to potential social and developmental causes of obesity in the FSM. This paper outlines the long history of foreign rule and social change over the last 100 years, and suggests that a combination of dietary change influenced by foreigners, dependence on foreign aid, and the ease of global food trade contributed to poor diet and increased rates of obesity in Micronesia. The last section of the paper highlights the Pacific tuna trade as an example of how foreign dependence and global food trade exacerbates their obesity epidemic.

1. Background

Obesity and overnutrition are becoming major global health issues. In 2000, the World Health Organization stated that overeating is the "fastest form of malnutrition", and estimates that the number of people worldwide that are overweight and malnourished equals the number of people that are underweight and malnourished, at 1.1 billion people [ 1 ]. Body Mass Index (BMI) is the most common measure of body fat; BMI equals an individual's weight in kilograms divided by their height in meters squared. Nearly one in three Americans is obese (BMI > 30) and obesity rates have risen steadily over the last 40 years, from 13.3% to 30.5%. While such growth is concerning, these rates are not the highest in the world. On the island of Kosrae, a district in the Federated States of Micronesia (FSM), 88% of adults aged 20 or older are overweight (BMI > 25), 59% are obese (BMI > 30), and 24% are extremely obese (BMI > 35) [ 2 ].

Kosrae has received international attention for their alarming rates of obesity and has become the keystone study site for trying to identify genetic causes of obesity [ 2 – 5 ]. A census of the entire adult population of Kosrae has recently been completed, which included individual DNA samples, individual-level data on height, weight, blood pressure, and glucose levels, as well as information about the identity and medical status of family members. The goal of this ongoing work is to establish the possible relationship of genetic variation to human obesity. However, these studies note that Kosraean's have not always been overweight, and hint that changes in lifestyle and environment on Kosrae were coincident with increases in obesity. Much less attention has been given to these possible factors of obesity in the FSM. Most likely, changing social and environmental context along with unlucky genes are the main causes of Micronesia's obesity epidemic. The objective of this paper is to highlight potential contextual causes of obesity in Micronesia, specifically how a combination of dietary change influenced by foreigners, dependence on foreign aid, and the ease of global food trade contributed to poor diet and increased rates of obesity in Micronesia.

Micronesia, a country comprising of more than 600 islands in the Central Western Pacific, has a long history of foreign influence and dependence. (See Figure 1 for a map of Micronesia). Spain was the first nation to colonize Micronesia; they arrived in 1886 and controlled the islands until Germany took over in 1899. The Japanese arrived 15 years later and built a thriving economy in Micronesia up until WWII. In 1945 the United States occupied the islands and soon became the "administering authority" of the U.N. Trust Territories of the Pacific Islands (i.e. Micronesia). The Federated States of Micronesia (FSM) did not become an independent nation until 1986. However, they continued to receive considerable aid from the U.S. through an agreement called the Compact of Free Association. Between 1986 and 2003, the FSM received US$1.5 billion in aid from the U.S. The Compact was renewed in 2004, and the FSM has been promised US$2.1 billion in aid and assistance over the next 20 years.

Map of the Federated States of Micronesia.

Micronesia was isolated for a long time, but then experienced significant changes in the last hundred years. Especially in the last fifty years, the population has been significantly influenced by the U.S., particularly in regards to diet. They have been and still are extraordinarily dependent on foreign nations for development and imported food. And finally, they are one of the most – if not the most – overweight populations in the world. Thus, Micronesia is an interesting place to study the links between foreign dependence, global food trade, dietary change, and obesity.

Worldwide, developing nations have experienced dietary change associated with modernization and development. The next section is a review of these links. Following that section, the focus returns to the Pacific to identify the associations between dietary change, foreign influence and trade, and obesity in Micronesia, especially over the last fifty years. The last section of the paper details the Pacific tuna trade to highlight these links between global food trade, foreign dependence, diet and obesity in Micronesia. The state of the Pacific tuna industry contributes to Micronesia's increased reliance on imported food, unhealthy diet, and population health problems.

2. Modernization and dietary change in developing countries

Many have studied the role of modernization in dietary change and obesity in the developing world [ 6 – 10 ]. These studies have suggested that rapid changes in diets resulting from modernization (i.e. improved standards of living and continued development) and market globalization have had a significant impact on the nutritional status of populations. For instance, some work has shown that modernization is associated with increased consumption of salted and processed foods and animal foods higher in saturated fat, and decreased consumption of complex carbohydrates [ 8 , 11 , 12 ]. Increased reliance on imported foods rather than traditional foods is also associated with modernization [ 7 , 13 ]. With the ease of global food trade, food preference may not be sufficient to ensure a healthy diet. The low cost and wide availability of imported foods, especially high-fat meat products, result in nutritionally detrimental decisions to consume cheaper, nutrient-poor foods rather than healthier alternatives, such as fish.

This is a relatively new development. Thirty years ago, lower incomes were associated with lower fat, lower animal protein, and higher complex carbohydrate intakes; when incomes increased, so did consumption of total and animal fat. However, this traditional correlation between income and diet has changed recently with globalization of food production and trade [ 14 ]. The global value of food trade grew from US$224 billion in 1972 to US$438 billion in 1998; food now accounts for 11% of global trade [ 15 ]. Along with the global food trade, people's preferences and increased food availability has influenced dietary patterns. Due to the widespread availability of low cost fat, even people from lower income countries consume a higher percentage of calories from fat.

Many countries, especially in the Pacific, have become dependent on trade in the global market. While global trade has brought some improvements in the standard of living and access to health care and services, for example, but has also induced many negative consequences. A significant negative consequence of global trade for countries in transition is an inappropriate, unhealthy diet high in saturated fat and low in complex carbohydrates [ 16 ], and a rise in obesity rates.

The connection between modernization, market globalization and obesity has been empirically documented. A study comparing Pima Indians living in rural Mexico (a traditional lifestyle) with genetically identical Pima Indians living near Phoenix in the U.S. (a more modernized lifestyle) showed that the American Pimas had an average BMI 10 points higher than their rural Mexican counterparts [ 6 ]. Another interesting comparative study looked at American and Western Samoans to explore the differences in dietary intake and health consequences [ 11 ]. Mean BMI for American Samoans in their study, who live a more modern lifestyle, was 35.2, compared to 30.3 for Western Samoans. Lastly, a study in Papua New Guinea demonstrated that more modern Papuans had higher mean BMI and lower levels of physical activity [ 8 ]. These studies suggest that aspects of modernity are associated with physical inactivity and increased availability of energy-dense Western food, which increases the risk of obesity.

A comparative study of Micronesians living in traditional and modern settings in 1970 also illustrates the association between modernization and dietary change [ 17 ]. The study showed the dietary difference between Micronesians living a traditional way of life in Palau and Micronesians living in a more modern economy in Guam and California, which essentially foreshadowed dietary change that accompanied modernization in the FSM since 1970. Total energy intake was greater for the traditional-lifestyle groups, but the proportion of energy coming from fat – mostly saturated fat – was much higher in the modern-lifestyle groups. The traditional-lifestyle groups relied more on energy from carbohydrates than the modern-lifestyle groups, with the predominant carbohydrate sources as follows: taro and cassava in Palau, rice and bread in Guam, and bread in California. Total protein intake did not vary drastically between the two groups, but the type of protein was different. The modern-lifestyle groups relied mostly on meat and poultry, and the traditional-lifestyle groups consumed more fish. Diets in the FSM today resemble the diets of Micronesians living in Guam and the U.S. in 1970: more simple carbohydrates, saturated fat, and imported meat.

The nutritional transition – the shift toward refined foods, meat and dairy products with high levels of saturated fats – along with reduced energy expenditure has contributed to the global rise in obesity. This has led to a shift in the global burden of disease. It is estimated that within five years, two-thirds of the global burden of disease will be attributable to non-communicable disease associated with diet [ 15 ]. This change can be seen in the ratio of underweight to obese populations in economies in transition (see Figure 2 ) [ 18 ]. In least developed and developing countries, underweight and malnourished populations surpass obese populations, but in economies in transition and developed countries, obese and malnourished populations pose more of a threat. Obesity is truly becoming a global disease burden, and one does not need to look much farther than Micronesia to see evidence.

Adult population affected by underweight and obesity by level of development (estimates for the year 2000).

3. Foreign influence and dietary change in Micronesia

In the late 1800's after sustained Western contact with explorers, traders, and missionaries, Micronesia saw almost a century of colonial rule, starting with Spain in the late 1800's and ending with the U.S. in the 1980's, that influenced local diets. Today, the U.S. and FSM still have an agreement called the Compact of Free Association. Under this agreement, the U.S. provides economic assistance and other federal benefits to the FSM, and in turn can use the Micronesian islands for defense and military operations. One externality of this agreement is continued dependence on the U.S. for aid and subsidies.

Dietary preference and food availability has changed since pre-Western contact. Traditional and local diets comprised of plant foods such as taro, breadfruit, yams, coconut, arrowroot and bananas, and animal foods were mostly freshwater, reef, and pelagic fish, crustaceans, and possibly fruitbat and birds. The Spaniards introduced maize, cassava, sweet potatoes, chickens and pigs [ 19 ], and rice became a staple after the Japanese occupation. Thus, traditional diets changed slightly with Spanish, German and Japanese influence, but there was little evidence of malnutrition until the American occupation [ 20 ].

Food consumption changed drastically in the late 1960's and 1970's, which was closely tied to the start of U.S. subsidies [ 21 ]. There was very slow growth and limited U.S. activity with or within Micronesia during the first 20 years after the war. U.S. subsidies to Micronesia started in 1962 at US$6 million a year, and increased quickly to US$130 million in 1978. With the increase of subsidies from the U.S. came salaried employment in the FSM; the per capita income rose from US$60 to US$400 in the same time frame. Concurrently, the proportion of global food production and trade increased enormously. Therefore, the new cash-based economy in Micronesia triggered a significant shift in lifestyle; one major difference was imported foods became more accessible and affordable [ 21 ].

Dietary studies since WWII in the FSM illustrate the change in diet over the last fifty years. In the 1950's, there was a strong reliance on local foods [ 22 ]. By the 1970's, less local foods were consumed and the main energy sources were from rice and imported foods. Fish was still eaten often, but "empty calorie" imported foods were becoming more common [ 23 , 24 ]. The United States Department of Agriculture (USDA) supplementary feeding program, which started in the 1960's, increased in the 1970's, and continued through the early 1990's, significantly influenced Micronesian's eating habits as well. This program provided school lunches mostly consisting of rice and tinned foods. In 1985, the school lunch program provided meals for 30% of the population every other day of the year. Many suggest that this program increased food dependency on the U.S., shifted food tastes, and contributed to local, healthy foods being replaced with rice, refined carbohydrates, and tinned foods [ 20 ]. Consumption of sugar and sweet foods also increased in the 1980's [ 25 ]. Most recently, nutritional studies have found that local and canned fish, imported chicken and turkey tails are the major protein foods [ 26 , 27 ].

Today, rice, wheat flour, sugar, refined foods, and fatty meats such as corned beef, turkey tails, and spam are commonly eaten in the FSM due to many interrelated factors such as convenience, affordability, taste and prestige. First, the FSM has suffered a great loss of food production because of inconsistent external and internal government policies and unplanned externalities from U.S. food aid programs [ 20 ]. The tuna industry, which will be described in more detail in the following section, is a telling example of how inconsistent government policies influenced local food production. Second, an overwhelming onslaught of imported foods has reached Micronesia starting in the 1960's. In 1986 food and beverages imports accounted for 40% of the total value of imports to Micronesia; these imported foods were not essential or without local substitutes, and many of the food products were nutritionally harmful [ 20 ]. Lastly, throughout Micronesia there has been an erroneous belief that imported foods were superior to local foods. American influence has changed both the preference and availability of foods over the last half of the 20 th century.

Turkey tails are a telling example of inferior imported foods replacing healthy local foods. According to the Food and Agricultural Organization (FAO), consumption of poultry meat in the Pacific has increased from an average of 19 kg per capita per year in 1980 to 34.4 kg per capita in 2002 [ 28 ]. In the U.S., the tails of turkeys are deemed inedible, but exporters found a market for them in Micronesia. Frozen imported turkey tails – simply gristle and fat – cost under $1 a pound, are commonly eaten in Micronesia, and are extremely unhealthy.

4. Obesity prevalence in Micronesia over time

Obesity is a fairly new phenomenon in Micronesia. Historically, Pacific Islanders were not overweight, as illustrated by documents from early explorers' observations. Chronicles of Magellan (1521) and Quiros (1606) refer to Pacific Islanders as "singularly tall, muscular and well-proportioned people" [ 29 ]. French explorer Louis de Bougainville said "I never saw men better made" after visiting Tahiti, and Captain James Cook (1770's) described many of the Pacific island populations as having good diets and health [ 30 ].

In Micronesia, diets may have been influenced by foreign rule since the Spanish occupation, but signs of overweight or obesity were not evident before the U.S. occupation. Documentation and photographs from the German South Seas Expedition (1909–1910) show the Micronesians as lean and healthy [ 31 ]. Additionally, the U.S. navy conducted a health survey in Micronesia after WWII (late 1940's) and noted almost a complete absence of obesity, hypertension, or diabetes [ 21 ].

The rise in obesity began at the same time as the U.S. subsidies reached Micronesia in the 1960's and 1970's. As previously mentioned, there was a complete shift in the local lifestyle with the new cash-based economy. Micronesians no longer needed to collect firewood because they could use their new propane stoves for cooking. They no longer needed to work the land for food, because with money, food could be bought at the store. These lifestyle changes, besides contributing to dietary change, also made exercise unnecessary [ 21 ]. Thus, the combination of a poor diet and less exercise resulted in a rise in obesity rates.

The first complete study of overweight and obesity in FSM was the National Nutritional Survey of the Federated States of Micronesia in 1987/1988 [ 25 ]. Comparing their results with a study of obesity conducted in 2000 on Kosrae [ 2 ], one of four states in the FSM, shows a substantial increase in overweight and obesity prevalence (Figure 3 ). Prevalence of overweight (BMI 25 – 30) increased from 25% in 1988 to 29% in 2000. The increase in obesity was even more drastic. In 1988, 35% of adult Kosraeans were obese (BMI > 30) compared to 59% in 2000. Two caveats must be noted when comparing these studies. First, the 1988 study only reports overweight and obesity prevalence for women aged 15 – 49. However, the results from the 2000 study are for men and women aged 20 – 85; the average age was 42. Average female BMI was 31.7 (+/- 5.9) in the 2000 study, slightly higher than the average male BMI at 30.1 (+/- 5.2). Therefore, the comparison over time should be viewed with caution: excluding men might overestimate overall obesity prevalence (1988 study) since women have a higher average BMI, but since obesity increases with age, the 2000 study might also overestimate obesity prevalence – compared to 15 – 49 year olds – because it uses an older sample.

Overweight and obesity prevalence in Kosrae, FSM in 1988 and 2000.

A clear rise in overweight and obesity in Pacific Island populations occurred in the second half of the 20 th century [ 32 ], which has been attributed to economic modernization and associated dietary change. The diet on Kosrae and the other states in the FSM became more Westernized during the U.S. occupation. High-fat foods imported mostly from the U.S. were being consumed in large quantities, and these dietary changes led to dramatically increased prevalence of overweight and obesity.

The following section examines the role of the tuna industry in Micronesian behavior and health. The current state of the Pacific tuna trade highlights the role of global food trade and foreign dependence in changing food production, consumption, and obesity in Micronesia.

5. The role of the tuna industry in the Micronesian obesity epidemic

Tuna fishing in the Central Western Pacific is a US$2 billion dollar a year industry. However, the FSM, which is located in the middle of these rich tuna stocks, has never been able to compete globally in the industry. Instead, Micronesia sells their fishing rights to foreign nations for a fraction of its worth. These other nations then trade tuna globally, some of which eventually returns to Micronesia. This story highlights how the FSM continues to be dependent on foreign nations due to insufficient internal development; this leads to further dependence on foreign nations for food imports.

Fish and marine resources have traditionally been an important component of the Micronesian diet. Fresh fish – usually reef fish – is still eaten when available; otherwise, it is substituted with canned fish [ 27 ]. Despite the abundance of fish off shore, fresh fish is consumed less today than it used to be [ 33 ]. Data from a 1997 household income and expenditure survey estimate that fish consumption ranges from 72 to 114 kilograms per person per year, and canned fish comprises about 25% of this consumption [ 33 ]. Imports of canned pelagic fish (mostly tuna and mackerel) have increased drastically over the last 10 years. According to the Food and Agricultural Organization (FAO), the FSM imported 242 metric tons of canned fish in 1992; by 2001 the figure increased to 1,369 metric tones [ 28 ]. Thus, much of the fish that Micronesian's eat has been processed elsewhere and imported into the country.

The FSM has jurisdiction over the fishing areas off of their shores, which includes some of the richest tuna stocks in the world. This jurisdiction came from the 1977 Law of the Sea Convention, which created a 200-mile Exclusive Economic Zone (EEZ) off of nations' shores. The FSM declared their EEZ in 1979, which covers almost 3 million square kilometers in the Central Western Pacific. The tuna stocks in the Central Western Pacific (the ocean immediately surrounding the FSM) have an estimated value of US$2 billion [ 34 ]. The vast fishery supplies about half of the world's canned tuna market, and about one third of the total tuna supply. Many foreign vessels exploit the tuna stock in this area. Japan – for long the world's largest harvester as well as consumer of tuna – harvests more than 90% of its tuna in the Pacific, and nearly 40% from the Central Western Pacific in 1995 [ 35 ]. Around 68% (US$1.3 billion) of the total tuna catch in the Central Western Pacific was taken from within Pacific Island Countries' Exclusive Economic Zones; the Pacific Island Countries include the Solomon Islands, Papua New Guinea, Vanuatu, Samoa, Fiji, Kiribati, and Tonga. However, actual Pacific Island Nations only harvested around 11% of the total catch (Figure 4 ) [ 34 ]. The FSM does not have sufficient infrastructure for a globally competitive fishing industry. Instead of fishing the tuna stocks themselves, the FSM sells their fishing rights to foreign nations.

Value of Pacific Island tuna catch by fishing nation, 1998.

The FSM commenced fishing access agreements with Japan in 1981, and began to sell their fishing rights. As previously mentioned, Japan had large stakes in the Pacific tuna industry at that time. Initially, access fees followed a lump-sum system, but soon switched to a per-vessel per-trip system. The per-vessel system was more accurate and fees could be based on actual catch. In the early 1980's, the rate of return from the access fees was set between 3 – 4% of the catch value, but in reality it was significantly lower. The low access fees were attributed to a number of factors: 1) lack of any real scarcity value – access agreements did not set a limit to the catch; 2) the small number of buyers; 3) the relatively large number of sellers; and 4) the inability to enforce compliance with agreements or monitor the value of the catch. Thus, the amount of money that the FSM receives from fishing-rights fees is much less than the potential value of the tuna, given that the FSM could harvest and sell the tuna in the global market.

Depicted in Figure 5 , the FSM did not harvest much tuna compared to Japan [ 28 ]. In 1998, the FSM harvested only 1% of the total tuna catch in the Central Western Pacific. However, the FSM collected about $170 million in fees for its tuna fishing rights from 1979 to 2000. The fees contribute to anywhere between 20 – 30% of the total domestic revenue in a given year, a significant portion [ 36 ]. Figure 6 shows the annual fees collected by the FSM for the last twenty years [ 37 – 39 ]. Note that some years are missing; the fishery access agreements and fees between individual nations and fishers are difficult to attain. In the mid 1990's, foreign commercial fishing fleets paid over US$20 million annually for the right to operate in FSM territorial waters, with Japan the largest customer. However, this figure has recently dropped to about US$13 million. In 1998, 75% of the fees were paid by Japan.

Total fishery (tunas, mackerel, billfish) production in the Central Western Pacific.

Amount of fees received by FSM for fishing rights in its EEZ.

As previously mentioned, the value of the Central Western Pacific tuna industry is near US$2 billion. Pacific Island nations, as a whole, only receive around US$70 million in fees, or 3.5% of the total value. Thus, they receive an extraordinarily small amount of income relative to the value of the industry. Micronesians do not benefit with employment either; only about 150 FSM citizens work on foreign tuna vessels at any given time [ 33 ]. Most importantly, they do not benefit by receiving fresh, local tuna.

In FSM's EEZ in 1999, 130,000 tons of tuna was harvested (down from 230,000 in 1995), and only 2% of the catch was from local Micronesian vessels. The majority of fish landed by the small locally-based longline vessels is exported to Japan via Guam. Fish exports account for more than 90% of total exports. Fish that are not export-quality, about 20%, are sold locally to processors who produce value-added products for export, or to restaurants [ 33 ]. The amount of fish that enters the domestic food supply translates to about 0.25% of the total tuna catch in the Central Western Pacific [ 34 ].

Subsistence fishers are still active in the FSM, mostly exploiting inshore resources and selling excess catches through various local outlets. However, attempts to develop and structure small scale fisheries have met limited success [ 40 ]. To date, no viable fishery operating in the FSM has reached its full potential despite more than US$70 million in investments [ 30 , 41 ]. For example, in 1995 US$6.5 million was loaned to the FSM from the Asian Development Bank for developing a fleet of locally-owned longline vessels targeting the fresh sashimi market. In 2001, the Micronesian Longline Fishing Company was founded, but has never been profitable.

Micronesians are essentially selling their own natural food resources for a fraction of the true value, and then using the revenue to import nutrient-poor food from the U.S. The FSM does not have the infrastructure to realistically compete in the global tuna market. Thus, the current structure of the Pacific tuna industry is an example of how lack of development (partly due to the U.S subsidies and U.S. dependence) has lead the FSM to continue to be dependent on foreign nations. The cash-economy stemming from the tuna industry contributes to the continued cycle of food dependence, imported-food, and poor diet, which is partly responsible for Micronesia's unhealthy, obese population.

6. Conclusion

As an economy still in transition, Micronesian's reliance on a cash-economy but lack of self-sufficiency puts them in a precarious position to depend on imported food. A typical grocery store in Micronesia today is stocked with imported nutrient-poor, canned and packaged foods. White bread, sugar, canned goods and processed foods, and canned and frozen meats such as spam, corned beef, hot dogs, and turkey tails dominate the shelves. It is estimated that the average household spends 38% of its income on imported foods [ 30 ]. Even at traditional weddings, funerals, and other cultural events, imported foods are found. Fresh fish, bananas, and coconuts used to be essential in these exchanges, now store-bought food is brought as gifts [ 42 ]. This current lifestyle is due to a long history of foreign influence and dependence, along with enhanced global food trade, and has confounded any unlucky genetic vulnerabilities of obesity in the FSM.

However, with the spotlight on Micronesia's obesity epidemic partly due to the genetic research taking place on Kosrae, Micronesian's attitudes toward obesity are slowly changing. Many health professionals in the Pacific Islands are now emphasizing eating traditional foods and encouraging residents to get back to a healthy lifestyle and to their cultural roots. With the US$2.1 billion in aid from the Compact of Free Association gone in twenty years, the FSM will have no choice but to invest in some internal development, promote self-sufficiency, and incite significant lifestyle changes.

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Acknowledgements

This work was supported by funds from the Center for Migration and Development at Princeton University. I am grateful for the advice and fruitful discussions with Sara R. Curran, Abigail Cooke, and the participants of the Trading Morsels conference at Princeton University, for which this paper was first written. This paper was greatly improved thanks to the discussants and participants of the panel on Globalization, Sustainability and Health at the 6 th Open Meeting of the Human Dimensions of Global Environmental Change Research Community in Bonn, Germany. Lastly, I would like to thank Francis X. Hezel, SJ and an anonymous reviewer for their comments and suggestions.

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Cassels, S. Overweight in the Pacific: links between foreign dependence, global food trade, and obesity in the Federated States of Micronesia. Global Health 2 , 10 (2006). https://doi.org/10.1186/1744-8603-2-10

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Poor diets damaging children’s health in the pacific, warns unicef.

SUVA, 15 October 2019 – An alarmingly high number of children are suffering the consequences of poor diets and a food system that is failing them, UNICEF warned today in a new report on children, food and nutrition.

The State of the World’s Children 2019: Children, food and nutrition finds that globally, at least one in three children under five – or over 200 million – is either undernourished or overweight.

Almost two in three children between six months and two years of age are not fed food that supports their rapidly growing bodies and brains. This puts them at risk of poor brain development, weak learning outcomes, low immunity, increased infections and, in many cases, death.

UNICEF Pacific Representative, Sheldon Yett, said, “More children and young people are surviving, but far too few are thriving. Nutritious foods are important at every stage of a child’s life. Many children in the Pacific Islands are eating inadequate amounts of healthy foods while consuming too many processed foods. We must work together to ensure that children’s diets are nutritious, safe, affordable and sustainable.”

The report provides the most comprehensive assessment yet of 21 st century child malnutrition in all its forms. It describes a triple burden of malnutrition: Undernutrition, hidden hunger caused by a lack of essential nutrients, and overweight among children, noting that:

• Several of the Pacific Island Countries have high prevalence of stunting in children under-5 years, including Nauru, the Republic of the Marshall Islands, Solomon Islands, Tuvalu and Vanuatu
• Most of the Pacific Island Countries also have high rates of  overweight and obesity  among children over five years of age and adolescents, including in the Cook Islands, Federated States of Micronesia, Fiji, Kiribati, Niue, Nauru, Palau, Republic of Marshall Islands, Samoa, Solomon Islands, Tonga, and Tuvalu
• In addition, there are high rates of anaemia among children under-5 and among 15-49 year old women in every country in the Pacific

As children begin transitioning to soft or solid foods around the six-month mark, too many are introduced to the wrong kind of diet, according to the report.

“When children start eating soft, semi-solid or solid foods at six months old, they need nutritious and safe diets with a range of nutrients to grow well. If children do not have sufficient diverse and nutritious foods, the consequences can be devastating,” said Mr. Yett.

As children grow older, their exposure to unhealthy food becomes alarming, driven largely by inappropriate marketing and advertising, the abundance of ultra-processed foods, and increasing access to fast food and highly sweetened beverages.

The greatest burden of malnutrition in all its forms is shouldered by children and adolescents from the poorest and most marginalised communities, the report notes.

The report also notes that climate-related disasters cause severe food crises. This leads to losses in agriculture, dramatically altering what food is available to children and families, as well as the quality and price of that food.

To address this growing malnutrition crisis in all its forms, UNICEF is issuing an urgent appeal to governments, the private sector, donors, parents, families and businesses to help children grow healthy by:

• Empowering families, children and young people to demand nutritious food, including by improving nutrition education and using proven legislation – such as sugar taxes – to reduce demand for unhealthy foods.
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• Open access
• Published: 10 August 2022

The tide of dietary risks for noncommunicable diseases in Pacific Islands: an analysis of population NCD surveys

• Erica Reeve 1 ,
• Prabhat Lamichhane 2 ,
• Briar McKenzie 3 ,
• Gade Waqa 4 ,
• Jacqui Webster 3 ,
• Wendy Snowdon 1 &
• Colin Bell 2  

BMC Public Health volume  22 , Article number:  1521 ( 2022 ) Cite this article

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To describe changes over time in dietary risk factor prevalence and non-communicable disease in Pacific Island Countries (PICTs).

Secondary analysis of data from 21,433 adults aged 25–69, who participated in nationally representative World Health Organization STEPs surveys in 8 Pacific Island Countries and Territories between 2002 and 2019. Outcomes of interest were changes in consumption of fruit and vegetables, hypertension, overweight and obesity, and hypercholesterolaemia over time. Also, salt intake and sugar sweetened beverage consumption for those countries that measured these.

Over time, the proportion of adults consuming less than five serves of fruit and vegetables per day decreased in five countries, notably Tonga. From the most recent surveys, average daily intake of sugary drinks was high in Kiribati (3.7 serves), Nauru (4.1) and Tokelau (4.0) and low in the Solomon Islands (0.4). Average daily salt intake was twice that recommended by WHO in Tokelau (10.1 g) and Wallis and Futuna (10.2 g). Prevalence of overweight/obesity did not change over time in most countries but increased in Fiji and Tokelau. Hypertension prevalence increased in 6 of 8 countries. The prevalence of hypercholesterolaemia decreased in the Cook Islands and Kiribati and increased in the Solomon Islands and Tokelau.

Conclusions

While some Pacific countries experienced reductions in diet related NCD risk factors over time, most did not. Most Pacific adults (88%) do not consume enough fruit and vegetables, 82% live with overweight or obesity, 33% live with hypertension and 40% live with hypercholesterolaemia. Population-wide approaches to promote fruit and vegetable consumption and reduce sugar, salt and fat intake need strengthening.

Peer Review reports

Noncommunicable diseases (NCDs), including cardiovascular disease, diabetes, cancer and respiratory disease account for over 70% of worldwide mortality [ 1 ]. The majority of this mortality burden (80%) is borne by low and middle-income countries (LMICs) [ 2 , 3 , 4 ], where NCDs have a substantial impact on individuals, households and health care systems [ 5 , 6 ]. Additionally, around 48% NCD deaths in LMICs are considered premature, affecting people under the age of 70 years [ 7 , 8 ]. The disproportional impact of NCDs on the ‘working-age’ population in LMICs compromises productivity, economic growth and development [ 9 , 10 ]. Addressing NCDs through improved prevention and treatment has been recognised as a key target in the Sustainable Development Goals.

NCDs and their risk factors are the result of a complex interplay between genes, behaviors and environment [ 11 ]. Overweight and obesity, linked primarily to an overconsumption of dietary energy, is strongly associated with an increased prevalence of diabetes, hypertension and cardiovascular disease, as well as increased NCD-related mortality [ 12 ]. Food and diet are particularly strong determinants of NCDs including type 2 diabetes [ 12 , 13 ], cardiovascular disease [ 14 , 15 ] and a number of cancers [ 12 , 15 ]. Dietary factors with the strongest correlation to mortality include high sodium intake, low intake of whole grains and low intakes of fruit and vegetables [ 16 , 17 , 18 ]. Diets that are high in sugar [ 19 ] and fat (particularly trans-fats and saturated fats) [ 20 ] also increase NCD risk. Collectively, dietary risks are the second leading risk factor attributable to global mortality for females, and the third leading risk for males [ 13 ].

Dietary risk factors in particular are of concern in Pacific Island countries, where nearly 3 of every 4 deaths are due to NCDs [ 21 ]. Pacific Island countries comprise 9 out of 10 of the most obese nations in the world, and a diabetes prevalence of 40% in adults is common among Pacific countries [ 22 ]. Studies have demonstrated a correlation between metabolic syndrome and NCDs including diabetes, cancer and cardiovascular diseases, and substantial dietary transition occurring in Pacific Island countries in recent years [ 23 , 24 , 25 , 26 ]. The dietary transition involved a displacement of diets traditionally high in fruit and vegetables and other fresh produce high in fibre, vitamins and low dietary sodium and fat [ 24 , 27 , 28 , 29 ] with processed foods high in sodium, hydrogenated fat and sugar, including edible oils, sauces and condiments, noodles, baked goods and processed meats [ 23 , 24 , 26 , 27 , 29 ]. These changes were triggered by multiple factors, including socioeconomic changes and increasing participation in globalised food systems [ 30 ]. The dietary transition has seen a 40% increase in processed food sales in Pacific countries between 2004 and 2018 [ 29 ].

Concerned about the impact of these changes on individual and community health as well as national economies [ 32 ], Pacific governments have introduced a range of population-wide initiatives for preventing diet related NCDs [ 33 , 34 , 35 ]. Pacific countries have implemented taxes on SSB [ 31 ] and/or policies to reduce sales and marketing of unhealthy food in schools [ 32 , 33 ]. Tonga, Samoa and Fiji have used import excises to reduce sales of unhealthy fats and oils [ 34 , 35 ] or fatty meat cuts [ 36 , 37 ]. Regionally, countries report against a framework for monitoring NCD prevention actions [ 38 , 39 ]. A stabilisation of diet-related NCD risk factors would be a promising sign preventive efforts are working.

However, there is a dearth of dietary intake data in the Pacific Islands [ 40 ], and the high cost of conducting national food surveys [ 43 ], together with the limited capacity for data collection and analysis [ 41 , 42 ], have made it difficult to examine the impact of policy on diet and NCDs. Also, few studies have examined changes in risk factor prevalence over time [ 43 ].

In this paper we examine how diet-related NCD risk factors have changed in 8 Pacific countries that have completed two WHO STEPs (STEPwise approach to surveillance) surveys [ 46 ].

Data source

STEPs surveys apply standardized and internationally recognized methods to collect data on a range of NCD risk factors including dietary behaviors (including sodium, sugar, fruit and vegetable intake), risk factors (hypertension, hypercholesterolemia, overweight and obesity) and health outcomes (diabetes) [ 44 ]. Since 2002, STEPs have been conducted in countries across the Pacific every 5 to 10 years. We conducted a secondary analysis using summary data from STEPS reports. The survey targets a representative sample of adults aged between 18 and 69 years and gathers data via questionnaires, physical measurements and biochemical measurements. It has been designed so that each county measures a core set of risk factors using standardized methods so that comparisons can be made over time within a country and between countries. Countries have the option of adding modules on additional risk factors or questions that capture more information on the core set of risk factors [ 43 ]. Full detail on STEPS survey methodology is described elsewhere [ 44 ]. Published STEPS reports were accessed online from WHO and/or governments websites. At the time of this analysis, no Pacific country had published more than two STEPs reports. Because we sourced publicly available data ethics approval was not sought.

Data extraction

We extracted data on modifiable dietary risk factors (fruit and vegetable intake) and specific dietary conditions (overweight and obesity, hypertension, hypercholesterolemia) that were collected in a similar manner across two time points. Most recent surveys in PICTs have added behavioral questions on intakes of sugar or sodium. Because of a growing awareness of the NCD risk associated with sugar and salt in PICTs [ 31 , 45 , 46 ] and focus in food policy [ 47 , 48 ] we also report sugar sweetened beverage (SSB) consumption and sodium intake where they were measured in the second round (these were largely absent from the first round). Data was extracted into an excel form by two different authors. Because we were interested in risk profiles by sex, data were disaggregated by sex and age strata, usually capturing samples between 25 and 64 years of age in 5 years, 10 years or twenty-year groups. We elected not to extract data on hyperglycemia given issues with blood glucose measurement in some STEPs surveys [ 49 ]. Table  1 provides definitions for the extracted risk factors and conditions.

Data analysis and reporting

We employed a direct standardization technique to calculate age standardized rates for each countries in preference to using crude age specific rates could be misleading because of the differences in underlying composition of the populations. The WHO standard population grouped in 5-year intervals [ 50 ] was used to calculate age-standardized rates for each indicator using dstdize command in Stata v17.0 [ 51 ]. A 95% confidence interval was calculated using the methods described by Breslow and Day [ 52 ]. For Tokelau, the confidence interval was not calculated as the whole target population was included in the survey. Data was only from the STEPs surveys in bands of 20 years or greater than 20 years (45–64 years / 45–69 years) and the Cook Islands and Wallis and Futuna used a non-standard age group band of 18–44 years in the second-round surveys. Hence, unstandardized rates have been presented for these countries along with confidence intervals that have been computed using exact binomial method.

We present data for individual countries and pooled prevalence between survey periods to give an indication of overall changes in risk factor prevalence for these 8 countries. The age-standardised rates were pooled using metaprop command to calculate the pooled prevalence using a fixed effect model [ 53 ]. The pooled weighted estimate was calculated using the inverse variance method after Freeman-Tukey Double Arcsine Transformation to stabilize the variances [ 53 ]. Exact binomial confidence interval was calculated for each pooled estimate. Test of proportion was conducted to examine the statistical difference between two rounds of surveys.

Eight countries, Cook Islands, Fiji, Kiribati, Nauru, Solomon Islands, Tokelau, Tonga and Wallis and Futuna, have two published NCD survey reports giving us an overall sample of 12,076 for first round survey and 9357 for second round survey (Tables  2 and 3 ). The time between surveys in each country ranged from 8 to 11 years (mean = 9.75 years).

Fruit and vegetable consumption

Figure  1 reports age-standardized prevalence of adults consuming less than 5 serves of fruits and vegetables per day. Prevalence decreased significantly in Tonga from 92.2% (95%CI: 90.4, 94.0) to 73.4% (95%CI: 71.6, 75.1) over 8 years, and in the Solomon Islands from 93.8% (95%CI: 92.6, 94.9) to 87.4% (95%CI: 85.9, 88.9) over 9 years. In both countries statistically significant reductions were observed for both women and men (see Supplementary File  1 ). In Nauru and Wallis and Futuna, prevalence decreased statistically significantly for men only, from 98.4% (95%CI: 97.6, 99.4) to 94.84% (95%CI: 92.5, 97.2) and 96.3% (95%CI: 92.3, 100.3) to 88.3 (95%CI: 83.9, 91.8) respectively. In Tokelau on the other hand, prevalence increased from 90.8 to 96.5% over the 9 years between 2006 and 2015.

Age-standardized prevalence of adults aged 25–69 years consuming less than five servings of fruits and vegetables per day by survey year and country

The pooled analysis revealed a significant decrease in the proportion of adults consuming less than 5 serves of fruit and vegetables per day, from 94% (95%CI: 93.9, 94.5) to 88% (95%CI: 87.5, 88.2), significant for both men and women.

Sugary drink consumption

Four of the countries measured sugary drink consumption in Survey 2. Adults in Kiribati, Nauru and Tokelau (across both sexes) reported consuming over 3.5 sugary drinks each per day. In contrast, Solomon Islands adults reported consuming an average of 0.4 sugary drinks per day. SSB consumption did not vary significantly between men and women (Table  4 ).

Adding salt to meals before consumption

Mechanisms for measuring salt varies significant across the included surveys. Five countries asked about ‘always or often’ adding salt before eating or when eating (Cooks, Kiribati, Tokelau, Solomon Islands, Nauru) (Table  5 ). Nauru and Cook Islands reported the per cent of participants ‘always or often’ eating processed food high in salt, and applied a likert scale querying participants on the importance of lowering dietary salt. Because of this variation we only extracted data on the percent of adults in Survey 2 ‘always or often’ adding salt to meals before eating. The proportion of adults ‘always or often’ adding salt to meals before eating ranged from 31.6% in Tokelau (higher for women than men) to 65.4% (60.5–70.3) in Nauru. Based on urinary analysis, adults in Tokelau, consumed an average of 10.1 g/day of salt, and consumption was higher for men (12.0 g/day) than women (8.6 g/day). In Wallis and Futuna salt consumption was 10.2 g/day, also higher for men (11.7 g/day) than women (8.8 g/day).

Overweight and obesity

Figure  2 reports age-standardized prevalence of adults living with overweight and obesity. There was a statistically significant increase in prevalence from 59.1% (95%CI: 57.5, 60.5) to 67.96% (95%CI: 66.1, 69.8) in Fiji largely attributable to an increase for women from 75.2% (95%CI: 74.1, 76.3) to 85.3% (95%CI: 84.4, 86.3). Prevalence also increased in Tokelau from 93.3% to 95.2%, particularly for women (94.5% to 95.4%). Women lived with a higher prevalence of overweight and obesity than men in all countries except Nauru. No significant changes in prevalence were observed for the Cook Islands, Kiribati, the Solomon Islands or Tonga. The pooled analysis revealed a significant increase from 76.9% (95%CI: 76.1, 77.7) to 82.1% (95%CI: 81.3, 82.9) in the proportion of adults living with overweight or obesity.

Age-standardized prevalence of adults aged 25–69 years living with overweight and obesity

Adults living with hypertension

Prevalence of hypertension increased in 6 countries (Fig.  3 ). In Kiribati prevalence increased from 18.4% (95%CI: 16.4, 20.4) to 42.13% (95%CI: 38.9, 45.4), in the Solomon Islands from 9.6% (95%CI: 8.1, 11.1) to 26.83% (95%CI: 23.5, 27.9), in Nauru from 29.5% (95%CI: 27.3, 31.8) to 37.6% (95%CI: 33.9, 41.2)], in Tokelau from 35.6% to 42.4%), in Tonga from 23.9% (95%CI: 21.1, 26.7) to 29.8% (95%CI: 28.1, 31.6) and in Fiji from 25.7% (95%CI: 24.6, 26.8) to 30.81% (95%CI: 29.2, 32.5) (Fig. 3 ). Increases were significant for women in all countries and for men except in Nauru and Tonga. Against this pattern, hypertension prevalence decreased from 58.6 (95%CI: 55.5, 61.8) to 47.2 (95%CI: 42.3, 52.2) in the Cook Islands driven by a large decrease for men.

Age-standardized prevalence of adults aged 25–69 years living with hypertension by survey year and country

The pooled analysis showed an overall increase in the prevalence of hypertension from 25.4% (95%CI: 24.7, 26.2) to 33.41% (95%CI: 32.5, 34.4) across the 8 countries.

Adults living with hypercholesterolemia

Six countries had comparable measures for hypercholesterolaemia (Fig.  4 ). Prevalence increased from 25.1% (95%CI: 21.1, 29.1) to 35.8% (33.2, 38.4) in the Solomon Islands and from 42.2% to 65.96% in Tokelau. Prevalence decreased from 80.0% (95%CI: 77.3, 82.8) to 58.2% (95%CI: 63.2, 52.9) in the Cook Islands, and from 27.7% (95%CI: 24.4, 30.9) to 17.8% (95%CI: 20.4, 15.2) in Kiribati. Significant reductions were observed for men and women in both countries.

Age-standardized prevalence of adults aged 25–69 years living with raised total cholesterol by survey year and country

We used nationally representative survey data from 8 Pacific Island Countries and Territories to assess changes over time in dietary risk factor prevalence. Some reductions in risk were observed, including statistically significant reductions in the proportion and adults consuming < 5 servings of fruit and vegetables per day. However, the prevalence of those living with overweight or obesity increased significantly in Fiji and Tokelau as did hypertension in 6 countries and hypercholesterolaemia in the Solomon Islands and Tokelau. Salt consumption was twice the 5 g per day recommendation of WHO in the two countries that conducted urinary analysis, and adults in Kiribati, Nauru and Tokelau were consuming up to an average of 4 serves per day of SSBs. Most Pacific adults (88%) do not consume enough fruit and vegetables, 82% live with overweight or obesity, 33% live with hypertension and 40% live with hypercholesterolaemia.

Dietary risk profile in the Pacific Islands

Our results align with literature describing a steady increase in overweight and obesity in Pacific Island countries [ 23 , 24 , 54 ]. However, in our study this increase was driven by just two countries, Fiji and Tokelau, and in particular by an increase in prevalence for women in Fiji. Fiji was one of the first Pacific countries to complete a STEPS survey, and the timing of the survey (eariery in the processed food transition) may have contributed to lower baseline prevalence compared to other countries. Our observation of increasing overweight and obesity in women compared to men in Fiji is consistent with other studies in LMICs [ 55 , 56 , 57 ]. Gender weight disparities may be a result of sociocultural factors, or because men are more often engaged in highly physical occupations compared with women, and involvement in sports is still less common in women [ 57 ]. In 6 of the 8 countries, there was no significant increase in overweight and obesity prevalence and mean BMIs were also relatively stable. This contrasts with other countries, including the US [ 58 ], where rates of obesity (BMI > 30) have accelerated faster than rates of overweight (BMI > 25) in recent years. High baseline levels of overweight and obesity in Pacific countries may have contributed to this stabilisation, noting that some Pacific populations have less fat mass at a given BMI than Caucasian populations [ 59 ]. It is also possible that preventive measures are starting to make a difference in some countries.

Pacific health and agricultural agencies have proactively promoted fruit and vegetable consumption [ 60 , 61 ] in recent years, and offered agricultural support programs for farmers [ 60 , 62 ] which may have contributed to the decrease over time in the proportion of adults consuming < 5 servings of fruit and vegetables each day. Despite this decrease, 88% of Pacific adults still report inadequate consumption. That this is consistent with the global dietary transition away from plant-based diets makes it no less concerning, and it points to the need to strengthen the efforts mentioned above. Inadequate fruit and vegetable consumption is an important but often neglected risk factor for NCDs [ 63 ], and a challenge across most regions of the world [ 64 ], particularly in LMICs [ 65 ]. A study of fruit and vegetable consumption in 28 LMICs between 2005 and 16 found that only 18% (16.6–19.4%) of adults over 15 years consumed WHO recommended amounts [ 65 ]. Consumption increased with GDP and secondary education but decreased with food pricing instability. Fiji and Tonga both relaxed import duties on fruit and vegetables, although evidence from Tonga suggest that this may have only benefited traders [ 66 ]. These findings point to the need to strengthen food systems approaches that promote production of resilient, biodiverse crops, and address post-harvest losses and market access [ 67 ].

An emerging concern for Pacific countries is high SSB consumption [ 68 ]. Adults in Nauru, Tokelau, and Kiribati consumed more than 3.5 serves of sugary beverages per day. Similarly high average daily serves have been observed in Tuvalu (3 serves/day) based on their STEPS survey. A recent study of trade data from 12 Pacific Island countries documented a 65% increase to sugary drink imports between 2000 and 2015 [ 69 ]. In this study, the Solomon Islands stood out from other countries with adults reporting consuming 0.3 average daily serves of SSBs. This may be attributable to the Solomon Islands being at an earlier stage of the global dietary transition than other Pacific countries, remoteness from markets, or the high volume of sweetened tea/coffee beverage powders consumed [ 70 ], which may not have been adequately captured by STEPS. Many Pacific Islands countries having adopted taxes on SSBs [ 31 ], but these may need to be increased in order to make meaningful shifts to consumption, and the sale of SSBs in and around educational institutions could be tightened [ 71 , 72 ]. The Solomon Islands in particular may benefit from introducing an SSB tax to keep consumption levels low [ 70 ].

The average prevalence of hypertension increased from a quarter to a third of all adults in these Pacific countries, with prevalence levels similar to Australia (34%) [ 73 ], possibly due to the high un-met needs in controlling blood pressure in Pacific countries [ 74 , 75 ]. While further surveys are needed to confirm a trend, persistently high (and potentially increasing) rates of hypertension signal a future pipeline of vascular diseases with a potentially overwhelming impact on Pacific health systems and economies [ 76 ]. Dietary sodium, saturated fats and trans fats are major dietary contributors to hypertension [ 75 ] and saturated and trans fat are major dietary contributors to hypercholesterolemia [ 77 , 78 ]. In this study, overall prevalence of hypercholesterolemia was over 40%, and in the two countries where salt intake was measured, it was over 10 g/day, more than double that recommended by WHO. These indicators support the need to disrupt current dietary patterns in the Pacific, specifically excessive consumption of fatty meat, hydrogenated vegetable oil [ 26 , 29 , 79 ], and foods high in sodium [ 28 , 80 ].

Policy response to dietary NCD risk factors

Our analysis highlights the ongoing challenge that Pacific countries face in responding to dietary causes of NCDs. Unhealthy dietary patterns are fueled by increased trade liberalization [ 81 , 82 , 83 ], the penetration of food marketing [ 84 , 85 ], and by food environments that promote affordable and convenient processed foods that are high in energy, salt, sugar and fat [ 27 ]. Additionally, policymakers have faced strong opposition from food and beverage companies trying to diminish policies [ 86 ], and pressures to minimize impacts of food policy on trade participation [ 37 ]. The multisectoral nature of food policy has made it difficult for Pacific leaders to implement and then enforce all recommended policy measures [ 87 , 88 ], leading many to favour ‘softer’ approaches (i.e. guidelines and promotional materials) over regulatory approaches. Further, Pacific Island countries have struggled to find capacity to carry out regular dietary surveys and demonstrate the potentially positive impact of food environment policies on consumption [ 40 ]. Pacific Island MANA as a component of Framework of action for revitalization of healthy islands in the Pacific has been an important step to promoting political accountability to NCD prevention [ 38 , 39 ], but countries will need to adopt a stronger cross sectoral approaches towards regulating, monitoring and enforcing food environment policies [ 33 , 39 , 89 ].

Strengthening surveillance of NCD risk factors

The purpose of STEPS is to provide a standardized method for collecting, analysing and disseminating data on key NCD risk. In the Pacific, STEPs surveys are used to inform high-level economic discussions [ 90 ], for regional monitoring and accountability strategies [ 39 ], to contribute to global monitoring, and to underpin evidence-based policymaking at the national level [ 70 , 91 ]. By gathering STEPs data from multiple countries and over two time points we identified several opportunities to strengthen NCD risk factor monitoring in Pacific countries. Firstly, standardizing age grouping between survey rounds and countries would aid interpretation of published survey reports. For instance, Nauru, Kiribati and Solomon Islands reported results in the groupings of 25–34, 35–44, 45–54 and 55–64 years in the first round while the groupings were 18–29, 30–44 and 45–69 years in the second round. Secondly, standardizing risk factor thresholds or cut points between countries and survey rounds. In Fiji for instance, 2002 fruit and vegetable consumption was reported as the percent of people reporting < 1 serve of fruit and vegetable per day, whereas in 2011, it was the percent consuming < 5 serves. Thirdly, standardized time intervals between the surveys. Fourthly reducing the lag between data collection and publication of study reports so timely action can be taken. Finally salt intake, in particular, needs to be reported consistently, perhaps in place of less useful measures such as self-reported oil intake [ 92 ].

Strengths and limitations

There are several strengths of this study. To our knowledge, this is the first paper comparing shifts in dietary risk factors over time in multiple Pacific countries. We used standardized rates rather than crude rates to make this comparison. Also, this data makes use of the reports generated by the Pacific countries for guiding and evaluating prevention efforts. We used standardized rates rather than crude rates to make this comparison. Additionally, by pooling prevalence, this paper shed light on NCD risk factor prevalence at a semi-regional level, providing critical information to guide the efforts of regional agencies, and those interested in dietary patterns of NCD risk in LMICs more broadly.

Limitations

There were limitations to the approach taken in our study, in addition to those raised above as opportunities to strengthen NCD surveillance [ 93 ]. This was a secondary analysis dependent on data summaries in published reports rather than raw data.

We did not report other NCD risk factors such as physical activity levels or tobacco and alcohol use. We were not able to report on hyperglycemia, which is a key risk factor in this Region, due to errors in that date reported previously [ 36 ]. Further, we did not present data from United States affiliated Pacific countries as many of these countries use an alternative NCD surveillance system to STEPs. Finally, two time points provide limited insight on change over time.

While some of the eight Pacific countries included in this analysis experienced reductions in diet-related NCD risk factors over time, most did not. Most Pacific adults (88%) do not consume enough fruit and vegetables, 82% live with overweight or obesity, 33% live with hypertension and 40% live with hypercholesterolaemia. Population-wide approaches to promote fruit and vegetable consumption and reduce sugar, salt and fat intake need strengthening. The value of STEPS surveys for monitoring trends in NCD risk will be fully realized when countries have conducted at least three surveys, though this requires a more consistent measurement of risk factors over time.

Availability of data and materials

This study was based on publicly available published survey reports, and the compiled dataset can be made available from the corresponding author on reasonable request.

Abbreviations

Body Mass Index

Confidence Interval

Low and middle-income countries

• Noncommunicable diseases

STEPwise approach to surveillance

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Acknowledgements

We wish to acknowledge the effort of the governments conducting these surveys and making them available for review. We would like to thank the Pacific Community and the Division of Pacific Technical Support in the Western Pacific Regional Office of the World Health Organization. We wish to thank the Global Alliance for Chronic Diseases (GACD) for their support to conduct this analysis under project.

ER, CB, BM, GW and JW are researchers on the GACD/NHMRC scaling up food policy in the Pacific project (APP1169322). This funding body had no role in study design, data collection, data analysis, data interpretation or writing the manuscript.

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ER drafted the manuscript, and ER and CB were involved in all aspects of the study. GW, WS and JW provided supervision and review to the manuscript. PL, BM and GW supported data collection and analysis and undertook technical review of the manuscript. All authors read and approved the final manuscript.

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Reeve, E., Lamichhane, P., McKenzie, B. et al. The tide of dietary risks for noncommunicable diseases in Pacific Islands: an analysis of population NCD surveys. BMC Public Health 22 , 1521 (2022). https://doi.org/10.1186/s12889-022-13808-3

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DOI : https://doi.org/10.1186/s12889-022-13808-3

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