"We used to get food from the garden." Understanding changing practices of local food production and consumption in small island states

Small Island Developing States: addressing the intersecting challenges of non-communicable diseases, food insecurity, and climate change

Small Island Developing States (SIDS) include 37 UN member countries sharing economic, environmental, and social vulnerabilities and intractable health challenges. In over 80% of SIDS, more than one in six adults die prematurely from a non-communicable disease (NCD), with poor diet being a major factor. Complex upstream food system determinants include marginalised local food production and reliance on low nutritional quality food imports. These drivers need to be seen against colonial and post-colonial political-economic legacies as well as the environmental and climate crises that challenge local production systems. A range of policy commitments (eg, the 2023 Bridgetown Declaration on NCDs and Mental Health) highlight these complex interdependencies and call for cross-sectoral food system policies to improve food security, food sovereignty, and nutrition, including integrating measures for climate change adaptation and mitigation. Although addressing these intersecting challenges will also depend on global efforts, the unique approach of SIDS can inform other settings.

Situating commercial determinants of health in their historical context: a qualitative study of sugar-sweetened beverages in Jamaica

BACKGROUND

Non-communicable diseases (NCDs) are the leading cause of mortality across the Caribbean and similar regions. Structural determinants include a marked increase in the dependency on food imports, and the proliferation of processed foods, including sugar-sweetened beverages (SSBs). We focused on Jamaica as a case study and the health challenge of SSBs, and situated contemporary actions, experiences and policies within their historical context to investigate underlying drivers of commercial determinants of health and attempts to counter them. We asked: how can a historical perspective of the drivers of high level SSB consumption in Jamaica contribute to an enhanced understanding of the context of public health policies aimed at reducing their intake?

METHODS

An ethnographic approach with remote data collection included online semi-structured interviews and workshops with 22 local experts and practitioners of health, agriculture and nutrition in Jamaica and attending relevant regional public webinars on SSBs and NCD action in the Caribbean. Our analysis was situated within a review of historical studies of Caribbean food economies with focus on the twentieth century. Jamaican and UK-based researchers collected and ethnographically analysed the data, and discussed findings with the wider transdisciplinary team.

RESULTS

We emphasise three key areas in which historical events have shaped contextual factors of SSB consumption. Trade privileged sugar as a cash crop over food production during Jamaica's long colonial history, and trade deregulation since the 1980s through structural adjustment opened markets to transnational companies. These changes increased Jamaican receptiveness to the mass advertisement and marketing of these companies, whilst long-standing power imbalances hampered taxation and regulation in contemporary public health actions. Civil society efforts were important for promoting structural changes to curb overconsumption of SSBs and decentring such entrenched power relations.

CONCLUSION

The contemporary challenge of SSBs in Jamaica is a poignant case study of commercial determinants of health and the important context of global market-driven economies and the involvement of private sector interests in public health policies and governance. Historically contextualising these determinants is paramount to making sense of the sugar ecology in Jamaica today and can help elucidate entrenched power dynamics and their key actors.

Exploring the link between home garden use and severe obesity: Insights from a nationwide survey in Tuvalu

Background

Obesity is prevalent and increasing but understudied across Pacific Islanders. Tuvalu is a South Pacific country with a high obesity rate and faces multiple threats of food insecurity. Home garden serves as a sustainable food source and can be a possible intervention for the obesity pandemic in Tuvalu. This study investigated Tuvaluans' home garden use and obesity, and explored factors associated with increased use of home gardens.

Methods

We conducted a nationwide, cross-sectional study in Tuvalu during 2022. Structured questionnaires were administered during the in-person interviews, and trained interviewers measured the height and weight of each participant. The association between home garden use, obesity and severe obesity were tested with univariate and multivariable logistic regression. We also applied overlapping weights to balance the distribution of baseline demographic factors.

Results

The average body mass index was 34.87 kilogrammes (kg) / square metre (m2) among the study population of 1024 adults (630 from Funafuti and 394 from other islands in Tuvalu). Overall, people having home gardens was associated lower odds for severe obesity compared to those without a home garden in overlap weighting models (odds ratio (OR) = 0.946, 95% CI = 0.897-0.997, P = 0.039) and the association was stronger in Funafuti (OR = 0.927, 95% CI = 0.866-0.991, P = 0.027) than in the outlying islands (OR = 0.967, 95% CI = 0.889-1.052, P = 0.435). Furthermore, increased age was positively associated with having a home garden in Funafuti, and smoking showed an inverse association.

Conclusions

Having a home garden is associated with lower odds of severe obesity in Tuvalu, and the association is stronger in Funafuti. Smokers are less likely to have home gardens, and increased age is positively associated with having home gardens. These findings promote more home garden utilisation and provide evidence for targeted interventions in Tuvalu.

Rapid review of factors influencing dietary behaviors in Fiji

Introduction

In Fiji, multiple burdens of malnutrition including undernutrition, overweight/obesity, and micronutrient deficiencies coexist at the individual, household, and population levels. The diets of children, adolescents, and adults are generally unhealthy. The objective of this review was to understand how the dietary behaviors of children, adolescents, and women in Fiji are influenced by individual, social, and food environment factors.

Methods

This rapid review was conducted to synthesize existing evidence, identify research gaps in the evidence base, and make recommendations for future research. The Cochrane Rapid Reviews Methods and the updated guideline for reporting systematic reviews were used. The search strategy for this rapid review was based on the Population Context Outcome [P(E)CO] framework, including search terms for population (children, adolescents, and adults), context (Fiji), and outcome (dietary behaviors). Searches were conducted in PubMed, Scopus, PsycINFO, and Google Scholar.

Results

The 22 studies included in this review identified different factors influencing dietary behaviors in Fiji. Individual preferences for processed and imported foods, especially of younger generations, and social dynamics, especially gender norms and social pressure, to serve meat and overeat appeared to be prominent in driving dietary habits. The ongoing nutrition transition has led to increasing availability and affordability of ultra-processed and fast foods, especially in urban areas. Concerns about food safety and contamination and climate change and its effect on local food production also appear to influence dietary choices.

Discussion

This review identified different dynamics influencing dietary behaviors, but also research gaps especially with regard to the food environment, calling for an integrated approach to address these factors more systemically.

Interventions in Small Island Developing States to improve diet, with a focus on the consumption of local, nutritious foods: a systematic review

Introduction

Food security in Small Island Developing States (SIDS) is an international policy priority. SIDS have high rates of nutrition-related non-communicable diseases, including obesity and type 2 diabetes, micronutrient deficiencies and, in many, persistent childhood stunting. This is associated with an increasing reliance on imported processed food of poor nutritional quality. Calls have been made for strengthening local food systems, resilient to climate change, to increase the consumption of nutritious locally produced food. We aimed to systematically review interventions intended to improve diet in SIDS, and specifically explore whether these interventions applied a local food approach.

Methods

The search strategy was applied to 11 databases, including in health, social science and agriculture. Screening of titles, abstracts and data extraction was undertaken in duplicate. Risk of bias was assessed using Cochrane tools. Narrative synthesis of the results was undertaken. The study protocol was registered (PROSPERO registration number: 2020CRD42020201274).

Results

From 26 062 records, 154 full texts were reviewed and 24 were eligible. Included studies were from the Caribbean, Pacific, Mauritius and Singapore. Five were a randomised study design, one an interrupted time series analysis, eight controlled and ten uncontrolled pre-test and post-test. Nine studies included some aspect of a local food approach. Most interventions (n=15) included nutrition education, with evidence of effectiveness largely limited to those that also included practical skills training, such as vegetable gardening or food preparation. Three studies were considered low risk of bias, with the majority (n=13) of moderate risk.

Conclusion

There is a lack of robust evidence on interventions to improve diet in SIDS. The evidence suggests that multifaceted approaches are likely to be the most effective, and local food approaches may promote effectiveness, through mechanisms of cultural and contextual relevance. Further development and evaluation of interventions is urgently required to increase the comparability of these studies, to help guide policy on improving nutrition in SIDS.

Generational issues in linking family farming production, traditional food in diet, physical activity and obesity in Pacific Islands countries and territories: the case of the Melanesian population on Lifou Island

In the Melanesian culture, traditional activities are organized around family farming, although the lifestyle transition taking place over the last several decades has led to imbalances in diet and physical activity, with both leading to obesity. The aim of this interdisciplinary study was to understand the links between family farming (produced, exchanged, sold, and consumed food), diet (focused on produced, hunted, and caught food), physical activity (sedentary, light, and moderate-to-vigorous physical activity) and obesity in Melanesian Lifou Island families (parents and children). Forty families, including 142 adults and children, completed individual food frequency questionnaires, wore tri-axial accelerometers for seven continuous days, and had weight and height measured with a bio-impedance device. A family farming questionnaire was conducted at the household level concerning family farming practices and sociodemographic variables. Multinomial regression analyses and logistic regression models were used to analyze the data. Results showed that family farming production brings a modest contribution to diet and active lifestyles for the family farmers of Lifou Island. The drivers for obesity in these tribal communities were linked to diet in the adults, whereas parental socioeconomic status and moderate-to-vigorous physical activity were the main factors associated to being overweight and obesity in children. These differences in lifestyle behaviors within families suggest a transition in cultural practices at the intergenerational level. Future directions should consider seasonality and a more in-depth analysis of diet including macro- and micro- nutrients to acquire more accurate information on the intergenerational transition in cultural practices and its consequences on health outcomes in the Pacific region.

Sociocultural Influences Contribute to Overeating and Unhealthy Eating: Creating and Maintaining an Obesogenic Social Environment in Indigenous Communities in Urban Fiji

Pacific Island countries (PICs), such as Fiji, lead the world statistics in obesity and deaths caused by non-communicable diseases. The impacts of obesity overburden the healthcare system and social services and have major impacts on the Fijian economy. This study is the first of its kind to undertake an in-depth exploration of the determinants of the obesity epidemic in PICs by exploring the sociocultural influences and situations that impact nutrient transitions, overconsumption, and unhealthy eating in an urban indigenous community. In-depth qualitative interviews were conducted with 15 indigenous Fijian women from the largest urban center in Fiji who self-identified as gatekeepers of family meal planning, preparing, and shopping for groceries, fruits, and vegetables. The women identified several cultural norms and expectations of both the individuals providing the food and the individuals consuming the food that create and maintain an obesogenic social environment. Moreover, participants also shared a misplaced value on meat, energy-dense foods, junk food, and fast foods that further contribute to unhealthy eating and overeating within this urban indigenous community. These novel findings highlight the importance of considering sociocultural influences on unhealthy eating and overeating and may be used to assist decision-makers in developing contextualized obesity prevention strategies and health messaging to target obesity in this community.

Perspectives on strengthening local food systems in Small Island Developing States

Small Island Developing States (SIDS) share high burdens of nutrition-related conditions, including non-communicable diseases, associated with an increasing reliance on imported, processed foods. Improving health through increasing the production and consumption of local, nutritious foods is a policy objective of many SIDS governments. This study aimed to understand contemporary challenges and opportunities to strengthening local food systems in two case study settings, Fiji and St. Vincent and the Grenadines. Fifty-two in-depth, semi-structured interviews were conducted with key stakeholders involved in local food production. Interviews were analysed by both country teams using thematic analysis. Local food production networks in both settings included formal governance bodies as well as more informal connections through civil society and communities. Their main function was the sharing of resources and knowledge, but levels of trust and cooperation between the stakeholders varied in a market open to intense competition from imports. Local food production was hindered by few and slow investments by local governments, dated technology, and lack of knowledge. Stakeholders believed this marginalisation was occurring against a background of rising preferences for imported foods in the population, and increasing disinterest in employment in the sector. Despite the challenges, strong narratives of resilience and opportunity were highlighted such as national pride in local produce for commercialisation and local diets. Efforts to support local food production in SIDS should focus on strengthening governance structures to prioritise local produce over corporate and import markets, assist collaboration and co-learning, and support alternative agro-food practices.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12571-022-01281-0.

Perceptions of the local food environment and fruit and vegetable intake in the Eastern Caribbean Health Outcomes research Network (ECHORN) Cohort study

INTRODUCTION

Studies conducted in the US and other high-income countries show that the local food environment influences dietary intakes that are protective for cardiovascular health.However, few studies have examined this relationship in the Caribbean. This study aimed to determine whether perceptions of the local food environment were associated with fruit and vegetable (FV) intake in the Eastern Caribbean, where daily FV intake remains below recommended levels.

METHODS

Cross-sectional analysis of Eastern Caribbean Health Outcomes Research Network Cohort Study (ECS) baseline data (2013-2016) from Barbados, Puerto Rico, Trinidad and Tobago, and US Virgin Islands was conducted in 2020. The National Cancer Institute Dietary Screener Questionnaire was adapted to measure daily servings of FV. Existing scales were used to assess participant perceptions of the food environment (availability, affordability, and quality). Chi-square tests and Poisson regression were used for analyses.

RESULTS

Participants reported eating one mean daily serving of FV. Mean daily intake was higher among those who perceived FV as usually/always affordable, available, and high quality. Multivariate results showed statistically significant associations between FV and affordability. Persons who perceived FV as affordable had 0.10 more daily servings of FV compared to those who reported FV as not always affordable (p = 0.02). Food insecurity modified the association between affordability and FV intake.

CONCLUSIONS

This study highlights the importance of affordability in consumption of FV in the Eastern Caribbean, and how this relationship may be modified by food insecurity.