Obesity prevention in the South Pacific
The highest rates of obesity in the world are found among the island nations of the Pacific: in Nauru, Samoa and Tonga, for example, over 75 per cent of adults are overweight or obese1. It puts a high burden on the healthcare systems of these countries given that obesity increases the risks of several diseases and conditions, including diabetes, heart disease and certain forms of cancer. Non-communicable diseases like these are the biggest causes of death in Pacific countries.
In 2004, the Wellcome Trust, in partnership with Australia’s National Health and Medical Research Council and New Zealand’s Health Research Council, funded 11 projects aimed at increasing research capacity in South-east Asia and the Pacific regions. The biggest of these International Collaborative Research Grants was to the Pacific Obesity Prevention in Communities (OPIC) project, which aimed to investigate obesity prevention strategies targeted at adolescents in Australia, New Zealand, Tonga and Fiji. It has been the largest single investment in research into non-communicable diseases in the region.
In a special supplement of the journal Obesity Reviews, published in November 2011, the OPIC investigators discuss their findings and recommendations for future research. In Australia, their approach led to reduced obesity and overweight prevalence in adolescents – the first time the success of such an approach had been shown – but they found that strong sociocultural influences prevented it having significant effects in Pacific populations. It was the first time such sociocultural influences had been studied on such a large scale: the analysis will have important implications for other ethnic groups at risk of high obesity, and is informing further research into how to influence cultural norms towards being more supportive of healthy body sizes.
From taro to turkey tails
People in countries like Tonga have seen a significant change in their diets over the past 50 years3. Traditional starchy roots such as taro and cassava have been replaced with noodles, white bread and crackers – low-fibre foods high in sugar, salt and fat. There is less local fish in a typical islander’s diet than there used to be, while fatty meats are on the rise, including cheap imported off-cuts such as ‘turkey tails’ and ‘mutton flaps’.
In many Pacific countries, a large body size has traditionally been valued as reflecting love and care; there are no vernacular terms for obesity and it has not been commonly perceived as a health risk2. As such, there were not many efforts to try to control what food was available to the islanders, so the change in food supply and diet was relatively rapid and rising obesity rates followed. Recent efforts to control, tax or ban imports of unhealthy foods have struggled to hold in the face of global trade rules – just last month, the Samoan government dropped its ban on turkey tails as a precursor to being allowed finally to join the World Trade Organisation.
Such decisions do not mean that governments are unable to introduce policies to promote healthier lifestyles, but they do need strong evidence from research in order to assess, select and commit to the best policies. The low-income countries of the Pacific do not have the same research culture and infrastructure as their more developed regional neighbours Australia and New Zealand, so international collaboration is likely to be the best way to solve the short-term challenge of rising obesity rates while also helping to increase their research capacity.
The OPIC studies
The OPIC project involved four strands of research: intervention, economic, sociocultural and policy studies. As the OPIC researchers admit, they experienced numerous challenges2 but can point to several positive outcomes and lessons for future obesity prevention research.
In each of the four participating countries, a community-based approach was used to develop relevant intervention strategies, such as promoting physical activity or changing schools’ policies to ensure the availability of healthier food. In all, 18 000 adolescents (12 to 18 years) were included in these studies. Because each community developed its own specific interventions, the findings from each site could not be combined. However, a number of general conclusions could be drawn, such as the fact that promoting food and physical activity was relatively easy compared to trying to persuade a school to change its policies around healthy food and inclusion of health promotion topics in the curriculum.
The sociocultural studies involved questionnaires and interviews with adolescents, and revealed new insights into the powerful influences related to weight gain in these communities. For example, one recommendation from the researchers is to build on the role of religious groups and their influence as determined by these studies2.
While OPIC generated “extensive evidence about the need for actions, and justification for the specific actions”, the researchers warn that this is often not sufficient to drive changes in policy that help prevent obesity3. They conclude there is a need for more strategic advocacy from those seeking to achieve such policy changes, including minimising administrative costs and working closely with partner government agencies including Health Ministries but also Ministries of Trade, Education and Finance.
OPIC has had a positive role in increasing research capacity in Fiji in particular. From a starting point of “very little existing research infrastructure”2, the Pacific Research Centre for Prevention of Obesity and Non-Communicable Diseases was established in Fiji in 2009 and has attracted funding and PhD students from the region. In addition, other projects are building on the OPIC study, extending the research base and working with government and non-government agencies to develop new, effective policies.
While only the intervention in Australia produced a significant reduction in the prevalence of overweight and obesity, this may reflect the relatively short timeframe (three years). Future intervention studies will need to be longer or more intensive to test whether they can, in fact, effectively reduce or prevent obesity.
Image credit: behang on Flickr
- Swinburn BA, Millar L, Utter J, Kremer P, Moodie M, Mavoa H, Snowdon W, McCabe MP, Malakellis M, de Courten M, Waqa G, Fotu KF, Roberts G, & Scragg R (2011). The Pacific Obesity Prevention in Communities project: project overview and methods. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 Suppl 2, 3-11 PMID: 22008554
- Schultz JT, Moodie M, Mavoa H, Utter J, Snowdon W, McCabe MP, Millar L, Kremer P, & Swinburn BA (2011). Experiences and challenges in implementing complex community-based research project: the Pacific Obesity Prevention in Communities project. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 Suppl 2, 12-9 PMID: 22008555
- Thow AM, Snowdon W, Schultz JT, Leeder S, Vivili P, & Swinburn BA (2011). The role of policy in improving diets: experiences from the Pacific Obesity Prevention in Communities food policy project. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 Suppl 2, 68-74 PMID: 22008561