Traditional food for health

pohnpei bananasThis is another essay I wrote for uni; I really wanted to write on health promotion with Aboriginal food but there weren’t any published evaluation studies. Funny that. Instead, I found an intervention based in the Pacific Islands; the more I delved into the subject the more fascinating it became…


The “Traditional food for health”1 intervention based in Ponhpei—an island in the Federated States of Micronesia (FSM)—was required to address the health of a nation undergoing dietary and social transition. It was embraced with enthusiasm yet was unable to produce the desired health outcome. A more comprehensive design, policies and rigorous evaluation may hold the key to future success.

The problem
Micronesians were once a model of health with minimal obesity2 and little evidence of diabetes or malnutrition.3 Despite a history of foreign influence, they maintained a traditional diet4 of locally grown food—starchy staples like taro, breadfruit, bananas, yams, along with coconut, fish and seafood and some fruits and vegetables—rich in vitamins, minerals and fibre.

Significant diet and lifestyle changes occurred after World War II when the country’s administration was passed to the United States. A supplementary feeding program—largely consisting of white rice and tinned meat—may have influenced a change in taste. Subsidies saw salaried employment rise. The new cash economy shifted them from traditional food crop production and manual household activities towards sedentary office work, mechanized household equipment, motorized vehicles and shopping for food.5

Simultaneously there was an increase in global food production and trade. Imported food—processed, energy-dense, high in saturated fat and low in complex carbohydrates—became accessible, inexpensive, convenient and prestigious.6 Local food staples were priced higher than imported food.7 Fresh fish, coconuts and bananas once exchanged as gifts at weddings, funerals and cultural events, were being replaced by store-bought, imported food.8

Obesity, heart disease, type 2 diabetes meliitus and vitamin A deficiency were now major health concerns.9 44% of Micronesian adults aged 25 to 64 were obese and 33 percent were diabetic, as diagnosed by high blood sugar;10 64 percent reported low levels of physical activity.11 Adult females derived only 27 percent of energy from local food.12

Yet there was more than population health at stake. There was the potential loss of biodiversity and traditional knowledge of food.13 There was a need to increase food security in case of global instability. Off-island referrals for diabetic care and reliance on curative systems were costly. In response, the Island Food Community of Pohnpei (ISFC) was formed to promote locally grown food.

Similar concerns about the integrity of their traditional food systems were expressed worldwide. The Centre for Indigenous Peoples’ Nutrition and Environment (CINE), based at McGill University in Canada, launched “Traditional Food for Health”. The objective was to use indigenous food to encourage, educate and build capacity for improving dietary quality; make local food resources sources of community pride, pleasure and responsibility, thereby ensuring local determination and sustainability of the intervention effort. For areas with obesity and diabetes, the aim was to also increase physical activity, reduce the consumption of poor-quality imported food and improve knowledge, access to and use of local food.14

In 2005, ISFC was invited to join. The Mand community in Madolenihmw, Ponhpei was selected as the target population.

Intervention and implementation
The Mand Community Working Group (MCWP) began by documenting the local food system using an ethnographic, multi-methods approach. The food of the community was determined, the cultural context15 understood and twenty micronutrient-rich foods were prioritised for promotion. A literature review revealed a variety of food-based projects with varying degrees of success and the strategies and approaches that helped or hindered.16

Research, planning and implementation were participatory to increase acceptance and adherence. Community leaders and inter-sectorial agencies were involved in the design and implementation17 of the baseline survey. Interviewers fluent with the language and familiar with customs were trained on research methods. The community participated in regular activity planning. Activities were implemented through the IFCP, the MCWG and agricultural, education, health and other agencies.18

The strategy was to improve attitudes, knowledge, access and use of local food through education, training and social marketing. Primordial and primary activities included: health, gardening and agriculture training, recipe presentations and cooking classes, schoolroom and youth drama club activities, a breastfeeding support group, charcoal oven development, competitions and social marketing.19 The slogans “Let’s Go Local” and “Go Yellow” were repeated using media, interpersonal communication and a plethora of marketing materials. “Go Yellow” communicated yellow-fleshed local food were nutrient-rich and contained pro- vitamin A carotenoids, a fact discovered during early IFCP nutritional research.

Whilst the intervention and its implementation were participatory and culturally appropriate, its design could have been more comprehensive; more could have been done to overcome barriers to physical exercise and to promote it. Furthermore, the evaluation did not measure the level of intensity, duration or frequency of exercise.

With energy-dense, imported food being a major part of the problem, little was done to inhibit its consumption. When the convenience of imported food was stressed as the most important20, there was little done to increase the convenience of local food.

Evaluation
A single-group before-after design was used; an unexposed comparison group was not feasible as the intervention was being conducted island-wide. No data was collected to measure external factors that may have impacted food consumption patterns, for example, agricultural crop production, food prices, availability and accessibility. Additionally, the intervention period may not have been sufficiently long enough to measure health impact nor some agricultural effects, as some planting materials required a longer cultivation period. No conclusions can be made about the causal effect of the intervention; it can only estimate the likely effect of the intervention.

An informal census saw 71 households counted; 47 of these were randomly selected and diet interviews were conducted with the adult female. The sample was reduced in size through under-reporting, lactation and loss to follow-up. Although the adult female was most knowledgeable about food—as the primary household cook and shopper—she was not representative of the entire population. A larger sample size would have improved the detection of significant changes and a more representative one would mean the results could be extrapolated to the whole population.

The 2007 process evaluation questionnaire examined the exposure, participation and opinion of the intervention activities and materials with additional questions relating to growing plants, food consumption and food spending. Many of the intervention activities could have been assessed during the intervention to reduce recall bias. Doing so would also mean that iterative changes could be made to improve the activity.

Impact evaluation was measured by the change in diet from baseline to follow-up. The Seven-day Food Frequency Questionnaire (FFQ) determined the frequency of consumption of selected foods over a seven-day period to assess the diversity of food, species and cultivars consumed. Two 24-hour recalls were administered on non-consecutive days to estimate daily nutrient intake.

Several measures21 were used to minimise confounding and bias. Under reporting of energy intake was managed with participant exclusion using the Goldberg cutoff method.22 A mean measure reduced variability of the 24-hour recall. Visual aids—actual portions of foods and utensils—were used to reduce measurement bias. The same seasonal period, method and techniques for both surveys reduced confounding. Alternation of interviewer for repeat 24-hour recalls was used to reduce interviewer bias.

The outcome evaluation was measured through changes from baseline to follow-up in health status. The BMI, waist circumference, fasting plasma glucose and blood pressure23 of men, women and children of the 47 randomly selected households were measured.

A high level of exposure and awareness of intervention activities24 was determined. Micronutrient intake increased, consumption frequency of key food had changed and diets grew more diverse. Increased local food consumption contributed to these changes. This may provide evidence on changing food habits and behavior change influenced by the intervention. Despite this, there was no significant change detected in the health status of the Mand community.

Room for improvement
The food intervention indicates some positive changes occurred yet imported food was still the principle source of energy, protein, fat and carbohydrate in the Mand community. In addition, the consumption of imported drinks with sugar, including soft drinks, significantly increased. The food intervention is a base that advocacy and policy could build upon by strengthening local food consumption, hindering the consumption of imported food and promoting more active lifestyles.

Personal
Local leaders could share their personal policy to limit imported food consumption with stories, evidence from research and tips. They could raise the prestige of local food and overcome the stigma associated with selling and purchasing it.25 Lending their support to exercise interventions could be invaluable and a major factor for success.26 Their messages could be communicated from person-to-person and through the media.27

Community
Local leaders and organisations could facilitate actions the community as a whole could take. The Mand community—once presented with the evidence of soft drink consumption and obesity—unanimously voted to ban the drinks at community events.28 With exposure through media, two more communities followed. Community actions like these could scale in time to only local food being served at all community locations like church, school and work sites. Walking to and from school and work could be a community initiative.

Government
Similarly, a local food policy could be enacted at government events and sites. A significant import tax on imported food—beginning with soft drinks—could be introduced; such taxation strategies have been shown to reduce consumption29 and could also fund further health prevention programs. Energy-dense food with little nutritional qualities like turkey tails and mutton flaps could be banned. Agricultural policies could cultivate the quality, variety and consistency of supply of local food production and increase marketing opportunities. A value- added food industry could be stimulated with investment in infrastructure and training to increase the convenience of local food with minimal processing.

Replication
The “Traditional food for health” intervention could be reproduced in similar indigenous settings where micronutrient-rich traditional food is available yet not commonly consumed. It would need to be tailored for cultural acceptance with a similar inter-agency and community approach as even within the Pacific Islands, different groups may appear similar, yet their differences are important to them.30

However, it would need to be augmented and re-evaluated where an impact on obesity and diabetes is the primary concern. Additionally, it would need to run for a longer period for any health benefits to be detected.

In 2010, the United States Affiliated Pacific Islands—of which FSM is included—declared a Regional State of Health Emergency for non-communicable diseases. With rising health costs, food prices and the eventual withdrawal of US$2.1 billion31 aid, FSM has little choice but to work on a comprehensive solution to cultivate local food, lifestyle changes and self-sufficiency.

Photo from the Island Food Community of Pohnpei

Endnotes
1 Kaufer L, Englberger L, Cue R, Lorens A, Albert K, Pedrus P, Kuhnlein H.V 2010, ‘Evaluation of a “Traditional Food for Health” Intervention in Pohnpei, Federated States of Micronesia’, Pacific Health Dialog, vol.16, No.1, pp:61-74.
2 Corsi A, Englberger L, Flores R, Lorens A, Fitzgerald MH 2008, ‘A participatory assessment of dietary patterns and food behavior in Pohnpei, Federated States of Micronesia’, Asia Pacific Journal Clinical Nutrition, vol.17, no.2, pp:309-16.
3 Department of State, 1969, ‘Trust Territory of the Pacific Islands’, Washington, D.C.: Department of State, viewed June 2012, http://hdl.handle.net/2027/uc1.b5065025?urlappend=%3Bseq=126.
4 Murai M 1954, ‘Nutrition study in Micronesia’, Atoll Research Bulletin no. 27, Washington, D.C.: The Pacific Science Board.
5 Englberger L, Lorens A, Pretrick M, Raynor B, Currie J, Corsi A, Kaufer L, Naik R.I., Spegal R., Kuhnlein H, Ed. Thompson B, Amoroso L 2011, ‘Approaches and lessons learned for promoting dietary improvement in Pohnpei, Micronesia’, Combating Micronutrient Deficiencies: Food-Based Approaches, Rome: CAB International and Food and Agriculture Organization Of The United Nations, Ch 13.
6 Englberger L, Marks G.M., Fitzgerald M.H. 2002, ‘Insights on food and nutrition in the Federated States of Micronesia: a review of the literature’, Public Health Nutrition, vol.6, no.1, pp:5-17.
7 Englberger L, Lorens A, Levendusky A, Hagilmai W, Pedrus P, Kiped A, Paul Y, Nelber D, Moses P, Shaeffer S, Gallen M 2009, ‘Documentation Of The Traditional Food System Of Pohnpei’, Indigenous Peoples’ Food Systems: The many dimensions Of culture, diversity, and environment for nutrition and health, Rome: Organization Of The United Nations and Centre For Indigenous Peoples’ Nutrition And Environment, Ch 6.
8 Hezel FX 2001, ‘The New Shape of Old Island Cultures: A half century of social change in Micronesia’, Honolulu: University of Hawaii Press.
9 Ibid 6.
10 World Health Organization (WHO) 2008, ‘Federated States of Micronesia (Pohnpei) NCD Rick Factors STEPS Report’, Suva, Fiji: WHO Western Pacific Region.
11 Ibid 10.
12 Ibid 7.
13 Lee R.A., Balick M.J., Ling D.L., Sohl F, Brosi B.J., Raynor W 2001, ‘Cultural dynamism and change—An example from the Federated states of Micronesia’, Economic Botany, vol.55, no.1, pp:9-13.
14 Kuhnlein H, Erasmus B, Creed-Kanashiro H, Englberger L, Okeke C, Turner N, Allen L, Bhattacharjee L 2006, ‘Indigenous peoples’ food systems for health: finding interventions that work’, Public Health Nutrition, vol.9, no.8 pp:1013-9.
15 Englberger L, Marks G.C., Fitzgerald M.H. 2004, ‘Factors to consider in Micronesian food- based interventions: a case study of preventing vitamin A deficiency’, Public Health Nutrition, vol.7, no.3, pp:423-31.
16 Kaufer L, Englberger L, Cue R, Lorens A, Albert K, Pedrus P, Kuhnlein H.V. 2010, ‘Evaluation of a “traditional food for health” intervention in Pohnpei, Federated States of Micronesia’, Pacific Health Dialogue, vol.16, no.1, pp:61-73.
17 Ibid 1.
18 Englberger L, Kuhnlein H.V., Lorens A, Pedrus P, Albert K, Currie J, Pretrick M, Jim R, Kaufer L 2010, ‘FSM case study in a global health project documents its local food resources and successfully promotes local food for health’, Pacific Health Dialogue, vol.16, no.1, pp:129-36.
19 Ibid.
20 Ibid 2.
21 Kaufer L, Englbenger L, Cue R, Lorens A, Albert K, Pedrus P, Kuhnlein H.V. 2010, ‘Evaluation of a “Traditional Food for Health” Intervention in Pohnpei, Federated States of Micronesia’, Pacific health dialogue, vol.16, no.1, pp:62-73.
22 Goldberg, G. R., Black, A. E., Jebb, S. A., Cole, T. J., Murgatroyd, P. R., Coward, W. A. & Prentice, A. M. 1991, ‘Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under- recording’, European Journal of Clinical Nutrition, vol.55, pp:569-581.
23 Kaufer L 2009, ‘Evaluation of a Traditional Food for Health Intervention in Pohnpei, Federated States of Micronesia’, McGill University Canada.
24 Ibid.
25 Ibid 14.
26 Englberger L, Halavatau V, Yasuda Y, Yamakazi R 1999, ‘The Tonga Healthy Weight Loss Program 1995-1997’, Asia Pacific Journal of Clinical Nutrition, vol. 8, no.2, pp:142-148.
27 Englberger L, Lorens A, Pretrick M, Tara M, Johnson E 2011, ‘Local Food Policies Can Help Promote Local Foods and Improve Health: A Case Study from the Federated States of Micronesia’, Hawaii Medical Journal, vol.11, no. 2, pp:31–34.
28 Ibid.
29 Thow A, Jan S, Leederc S, Swinburn B 2010, ‘The effect of fiscal policy on diet, obesity and chronic disease: a systematic review’, Bull World Health Organisation, vol. 88, no.8, pp:609– 614.
30 Curtis M 2004, ‘The Obesity Epidemic in the Pacific Islands’, Journal of Development and Social Transformation, vol.1, no.1, pp:37-42.
31 Cassels, S 2006, ‘Overweight in the Pacific: links between foreign dependence, global food trade, and obesity in the Federated States of Micronesia’, Globalization and Health, vol.2, no.10, viewed June 2012, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1533815/?tool=pubmed

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