Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation

Assessing Knowledge, Attitudes and Behaviours toward Salt and Sugar Consumption in the Central Division of Fiji

OBJECTIVES

This study aimed to assess salt and sugar-related knowledge, attitudes and behaviours (KAB) of adults in the Central Division of Fiji.

METHODS

A randomised stratified sample of 700 adults were selected. Questions on salt and sugar-related KABs were developed. The survey took place from March to June 2022. For analyses, population and sample weights were applied, and differences between predefined subgroups (sex, age, ethnicity and area) were compared using weighted chi-square tests.

RESULTS

534 adults participated (response rate 76%). Over 80% of participants (82% (95% CI 78.5 to 84.9%)) identified that consuming too much salt or salty sauce can lead to hypertension. More than 90% recognised that consuming too much sugar can lead to diabetes (92.3% (89.7 to 94.3%)). Approximately 80% of participants thought it was somewhat or very important to lower salt and sugar intake in their diet (79.8% (76.1 to 83.0) and 84.2% (80.8 to 87.1%), respectively). However, almost 40% reported adding salt or salty sauces when cooking (37.3% (32.7 to 42.2%)) and 65% (60.6 to 68.5%) adding sugar to drinks daily.

CONCLUSIONS

Despite having positive knowledge and attitudes, many people reported behaviours likely to contribute to excess salt and sugar intake, highlighting the need for interventions that support behaviour change and the creation of healthier food environments.

Health and Nutrition Promotion Programs in Papua New Guinea: A Scoping Review

There is a rising prevalence of non-communicable diseases (NCDs) in Papua New Guinea (PNG), adding to the disease burden from communicable infectious diseases and thus increasing the burden on the healthcare system in a low-resource setting. The aim of this review was to identify health and nutrition promotion programs conducted in PNG and the enablers and barriers to these programs. Four electronic databases and grey literature were searched. Two reviewers completed screening and data extraction. This review included 23 papers evaluating 22 health and nutrition promotion programs, which focused on the Ottawa Charter action areas of developing personal skills (12 programs), reorienting health services (12 programs) and strengthening community action (6 programs). Nineteen programs targeted communicable diseases; two addressed NCDs, and one addressed health services. Enablers of health promotion programs in PNG included community involvement, cultural appropriateness, strong leadership, and the use of mobile health technologies for the decentralisation of health services. Barriers included limited resources and funding and a lack of central leadership to drive ongoing implementation. There is an urgent need for health and nutrition promotion programs targeting NCDs and their modifiable risk factors, as well as longitudinal study designs for the evaluation of long-term impact and program sustainability.

Energy, nutrient and overall healthiness of processed packaged foods in Fiji, a comparison between 2018 and 2020

In Fiji, packaged foods are becoming increasingly available. However, it is unknown if nutrition composition of these foods has changed. This study aims to assess changes in energy, nutrient content and healthiness of packaged foods by comparing data from five major supermarkets in Fiji in 2018 and 2020. Foods were categorised into 14 groups; nutrient composition information was extracted and healthiness assessed using Health Star Rating (HSR). Descriptive statistics and a separate matched products analysis was conducted summarising differences in nutrient content and HSR. There was limited evidence of change in the nutrient content of included products however, there was a small reduction in mean saturated fat in the snack food category (-1.0 g/100 g, 95% CI -1.6 to -0.4 g/100 g). The proportion of products considered healthy based on HSR, increased in the convenience foods category (28.4%, 95% CI 8.3 to 48.5) and decreased in non-alcoholic beverages (-35.2%, 95% CI -43.6 to -26.9). The mean HSR score increased in the fruit and vegetables category (0.1 (95% CI 0.1, 0.2)) and decreased for non-alcoholic beverages (-1.1 (-1.3, -0.9)) and the sauces, dressings, spreads, and dips category (-0.3 (-0.3, -0.2)). Strengthened monitoring of the food supply is needed to improve the healthiness of foods available.

Salt and sugar intakes of adults in the central division of Fiji: findings from a nutrition survey in 2022

Background

Excess salt and sugar consumption contribute to diseases, such as diabetes and hypertension. This study aimed to estimate salt and sugar intakes and main sources, in a population of adults in the Central Division of Fiji.

Methods

One adult per household was randomly selected to participate (n = 700). Sociodemographic characteristics; blood pressure, weight, and height; a 24-h diet recall; and spot-urine samples were collected, with 24-h urine samples from a sub-sample (n = 200). Sugar intake was estimated from the 24-h diet recalls and salt intake from the spot-urines. 24-hr diet recall was used to identify main sources of salt and sugar by food groups.

Findings

534 adults (response rate 76%, 50% women, mean age 42 years) participated. Salt intake was 8.8 g/day (95% CI, 8.7-9.0), and free sugar intake was 74.1 g/day (67.5-80.7), 16.1% of total energy intake (15.0-17.1%). Main sources of salt were mixed cooked dishes (40.9% (38.2-43.5)), and bread and bakery products (28.7% (26.5-31.0)). Main sources of sugar were table sugars, honey, and related products (24.3% (21.7-26.8)), non-alcoholic beverages (21.4% (18.8-24.0)) and bread and bakery products (18.0% (16.2-19.9)).

Interpretation

Salt and sugar intakes exceeded World Health Organization recommendations in this sample of adults. Given dietary sources were foods high in salt and sugar, along with the addition to food or drinks, interventions focused on behavior along with environmental strategies to encourage healthier choices are needed.

Funding

NHMRC and GACD grant APP1169322.

Food insecurity, COVID-19 and diets in Fiji - a cross-sectional survey of over 500 adults

INTRODUCTION

Food insecurity is associated with inadequate nutrition and increased rates of chronic disease. The primary aim of this study was to assess self-reported food insecurity and the perceived impact of COVID-19 on food security, in two regional districts of Central Fiji, as part of a broader program of work on strengthening and monitoring food policy interventions. The secondary aim was to explore the relationship between food insecurity and salt, sugar and fruit and vegetable intake.

METHODS

Seven hundred adults were randomly sampled from the Deuba and Waidamudamu districts of Viti Levu, Fiji. Interview administered surveys were conducted by trained research assistants with data collected electronically. Information was collected on demographics and health status, food security, the perceived impact of COVID-19 on food security, and dietary intake. Food insecurity was assessed using nine questions adapted from Fiji's 2014/5 national nutrition survey, measuring markers of food insecurity over the last 12 months. Additional questions were added to assess the perceived effect of COVID-19 on responses. To address the secondary aim, interview administered 24-hour diet recalls were conducted using Intake24 (a computerised dietary recall system) allowing the calculation of salt, sugar and fruit and vegetable intakes for each person. Weighted linear regression models were used to determine the relationship between food insecurity and salt, sugar and fruit and vegetable intake.

RESULTS

534 people participated in the survey (response rate 76%, 50.4% female, mean age 42 years). 75% (75.3%, 95% CI, 71.4 to 78.8%) of people reported experiencing food insecurity in the 12 months prior to the survey. Around one fifth of people reported running out of foods (16.8%, 13.9 to 20.2%), having to skip meals (19.3%, 16.2 to 22.9%), limiting variety of foods (19.0%, 15.9 to 22.5%), or feeling stressed due to lack of ability to meet food needs (19.5%, 16.4 to 23.0%). 67% (66.9%, 62.9 to 70.7%) reported becoming more food insecure and changing what they ate due to COVID-19. However, people also reported positive changes such as making a home garden (67.8%, 63.7 to 71.6%), growing fruit and vegetables (59.5%, 55.6 to 63.8%), or trying to eat healthier (14.7%, 12.0 to 18.0%). There were no significant associations between food insecurity and intakes of salt, sugar or fruit and vegetables.

CONCLUSION

Participants reported high levels of food insecurity, exceeding recommendations for salt and sugar intake and not meeting fruit and vegetable recommendations, and becoming more food insecure due to COVID-19. Most participants reported making home gardens and/or growing fruit and vegetables in response to the pandemic. There is an opportunity for these activities to be fostered in addressing food insecurity in Fiji, with likely relevance to the Pacific region and other Small Island Developing States who face similar food insecurity challenges.

Effectiveness of NCD-Related Fiscal Policies: Evidence from the Pacific

Obesity in Pacific Island countries (PICs) has hit crisis levels, and the consequent high non-communicable disease (NCD) burden is devastating for their developing economies. Nutrition transitions from traditional, plant and seafood diets to a dependence on processed foods are at the core of the obesity and NCD epidemic in PICs. Fiscal policies are widely promoted as an effective mechanism to reduce consumption of unhealthy foods and increase consumption of fruits and vegetables. However, there are little data to evaluate the effectiveness of these policies as rates of NCDs and obesity in PICs continue to rise. This study used an online survey to recruit 4116 adults from six PICs: Fiji, Kiribati, Samoa, Solomon Islands, Tonga and Vanuatu. The study measured the consumption of and household access to sugar-sweetened beverages, ultra-processed packaged snacks, fruits and vegetables and attitudes on food prices and unhealthy eating. The study also assessed the relationship between consumption of these foods and drink and (1) household access, (2) price as a food choice motive, and (3) unhealthy eating attitudes. This study provides novel data on food-related behaviours in PICs, offers insights into the potential impact of NCD-related fiscal policies on food consumption and identifies other variables of interest.

A systematic scoping review evaluating sugar-sweetened beverage taxation from a systems perspective

Systems thinking can reveal surprising, counterintuitive or unintended reactions to population health interventions (PHIs), yet this lens has rarely been applied to sugar-sweetened beverage (SSB) taxation. Using a systematic scoping review approach, we identified 329 papers concerning SSB taxation, of which 45 considered influences and impacts of SSB taxation jointly, involving methodological approaches that may prove promising for operationalizing a systems informed approach to PHI evaluation. Influences and impacts concerning SSB taxation may be cyclically linked, and studies that consider both enable us to identify implications beyond a predicted linear effect. Only three studies explicitly used systems thinking informed methods. Finally, we developed an illustrative, feedback-oriented conceptual framework, emphasizing the processes that could result in an SSB tax being increased, maintained, eroded or repealed over time. Such a framework could be used to synthesize evidence from non-systems informed evaluations, leading to novel research questions and further policy development.

Opportunities to Strengthen Fish Supply Chain Policy to Improve External Food Environments for Nutrition in the Solomon Islands

Malnutrition and food insecurity have significant social and economic impacts in small island developing states, such as the Solomon Islands. Enhancing the domestic supply of fish, the main source of local protein, can contribute to improved nutrition and food security. This research aimed to improve understanding of the policy interface between the fisheries and health sectors and identify opportunities to strengthen fish supply chain policy to improve domestic (particularly urban) access to fish in the Solomon Islands. The study design drew on theories of policy learning and policy change and analysed policies using a consumption-oriented supply chain approach. Interviews were conducted with 12 key informants in the Solomon Islands, and 15 policy documents were analysed. Analysis of policy documents and interview data indicated that there were strengths as well as opportunities in the existing policy context. In particular, community-based fisheries management approaches and explicit recognition of the links between fisheries and nutrition were key strengths. Challenges included gaps in implementation, variations in capacities across government actors and communities, and limited attention to domestic monitoring and enforcement. Improving the effectiveness of resource management efforts may result in sustainable outcomes for both livelihoods and health, which will accomplish priorities at the national and sub-national levels and support the achievement of the Solomon Islands' commitments to the Sustainable Development Goals.

Research protocol for impact assessment of a project to scale up food policies in the Pacific

BACKGROUND

One of the challenges for countries implementing food policy measures has been the difficulty in demonstrating impact and retaining stakeholder support. Consequently, research funded to help countries overcome these challenges should assess impact and translation into practice, particularly in low-resource settings. However, there are still few attempts to prospectively, and comprehensively, assess research impact. This protocol describes a study co-created with project implementers, collaborative investigators and key stakeholders to optimize and monitor the impact of a research project on scaling up food policies in Fiji.

METHODS

To develop this protocol, our team of researchers prospectively applied the Framework to Assess the Impact from Translational health research (FAIT). Activities included (i) developing a logic model to map the pathway to impact and establish domains of benefit; (ii) identifying process and impact indicators for each of these domains; (iii) identifying relevant data for impact indicators and a cost-consequence analysis; and (iv) establishing a process for collecting quantitative and qualitative data to measure progress. Impact assessment data will be collected between September 2022 and December 2024, through reports, routine monitoring activities, group discussions and semi-structured interviews with key implementers and stakeholders. The prospective application of the protocol, and interim and final research impact assessments of each project stream and the project as a whole, will optimize and enable robust measurement of research impact.

DISCUSSION

By applying this protocol, we aim to increase understanding of pathways to impact and processes that need to be put in place to achieve this. This impact evaluation will inform future projects with a similar scope and will identify transferable and/or translatable lessons for other Pacific Island states and low- and middle-income countries.

Strengthening implementation of diet-related non-communicable disease prevention strategies in Fiji: a qualitative policy landscape analysis

Background

Noncommunicable diseases (NCDs) are the leading cause of death globally, and the World Health Organization (WHO) has recommended a comprehensive policy package for their prevention and control. However, implementing robust, best-practice policies remains a global challenge. In Fiji, despite political commitment to reducing the health and economic costs of NCDs, prevalence of diabetes and cardiovascular disease remain the highest in the region. The objective of this study was to describe the political and policy context for preventing diet-related NCDs in Fiji and policy alignment with WHO recommendations and global targets. We used a case study methodology and conducted (1) semi-structured key informant interviews with stakeholders relevant to diet-related NCD policy in Fiji (n = 18), (2) documentary policy analysis using policy theoretical frameworks (n = 11), (3) documentary stakeholder analysis (n = 7), and (4) corporate political activity analysis of Fiji’s food and beverage industry (n = 12). Data were sourced through publicly available documents on government websites, internet searches and via in-country colleagues and analysed thematically.

Results

Opportunities to strengthen and scale-up NCD policies in Fiji in line with WHO recommendations included (1) strengthening multisectoral policy engagement, (2) ensuring a nutrition- and health-in-all policy approach, (3) using a whole-of-society approach to tighten political action across sectors, and (4) identifying and countering food industry influence.

Conclusion

Diet-related NCD policy in Fiji will be strengthened with clearly defined partner roles, responsibilities and accountability mechanisms, clear budget allocation and strong institutional governance structures that can support and counter industry influence. Such initiatives will be needed to reduce the NCD burden in Fiji.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00859-9.

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

OBJECTIVE

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

METHODS

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.

RESULTS

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.