Modeling thiamine fortification: a case study from Kuria atoll, Republic of Kiribati.

In 2014, there was an outbreak of beriberi on Kuria, a remote atoll in Kiribati, a small Pacific Island nation. A thiamine-poor diet consisting mainly of rice, sugar, and small amounts of fortified flour was likely to blame. We aimed to design a food fortification strategy to improve thiamine intakes in Kuria. We surveyed all 104 households on Kuria with a pregnant woman or a child 0-59 months. Repeat 24-h dietary recalls were collected from 90 men, 17 pregnant, 44 lactating, and 41 other women of reproductive age. The prevalence of inadequate thiamine intakes was >30% in all groups. Dietary modeling predicted that rice or sugar fortified at a rate of 0.3 and 1.4 mg per 100 g, respectively, would reduce the prevalence of inadequate thiamine intakes to <2.5% in all groups. Fortification is challenging because Kiribati imports food from several countries, depending on price and availability. One exception is flour, which is imported from Fiji. Although resulting in less coverage than rice or sugar, fortifying wheat flour with an additional 3.7 mg per 100 g would reduce the prevalence of inadequacy to under 10%. Kiribati is small and has limited resources; thus, a regional approach to thiamine fortification is needed.

Lessons from the Field: The Traditional Monarch of Kitti in Pohnpei Addresses the High Rates of Non-Communicable Diseases through Local Policy.

Almost a quarter of Pohnpei's population is overweight or obese, a major factor influencing a 2010 non-communicable diseases (NCD) emergency declaration. The Racial and Ethnic Approaches to Community Health (REACH) project in Pohnpei is implementing a culturally tailored policy, systems, and environmental (PSE) intervention to reduce NCDs through healthy nutrition projects. Through collaboration with traditional leaders and using traditional protocols, REACH succeeded in soliciting formal approval from a Traditional Monarch to serve only healthy beverages during events at all traditional houses in the municipality. The Governor, in turn, also supported this initiative. This project cultivated relationships with traditional and government leaders to implement a culturally appropriate healthy nutrition PSE change intervention.

Lessons from the Field: Lessons from Yap - Changing Government and Cultural Practice Through Public Health Policy.

The heavy burden of non-communicable diseases (NCD) in Yap State, Federated States of Micronesia overwhelms the resources of this small population. Traditional cultural practices strongly influence all aspects of life, especially in the remote outer islands. The traditional Chiefs must grant permission to perform any type of health outreach or services for about one-third of the population. One key cultural practice promotes tobacco and alcohol use. The Yap Comprehensive Cancer Control Program, in collaboration with other entities in public health, systematically engaged the traditional Chiefs, resulting in a landmark policy that paved the way for other system and environmental interventions to reduce the risks of developing NCD.

Formative Research to Inform Nutrition Interventions in Chuuk and the US Pacific.

The type 2 diabetes epidemic is a global health issue, and it is especially severe in the US Pacific. Although there are nutrition interventions in Hawaii and the Pacific, success is limited, in part, because of the lack of tailoring for the Pacific context. The Pacific context is inclusive of environment, political, and economic situation; historical (precontact, colonial, and post colonial) background; cultural practices; and spiritual orientation. This study used Grounded Theory and Community-Based Participatory Research processes to identify influences that hinder or facilitate adherence to nutrition recommendations. Data were gathered through key informant interviews (faith leaders and health care providers) and focus-group discussions (individual with diabetes and care takers). Results showed barriers to nutrition recommendations adherence that were similar to other minority populations in the United States, such as cost of healthy foods, taste preference, low availability of healthy food choices, lack of ideas for healthy meals/cooking, and lack of culturally appropriate options for dietary modification. It also elucidated behaviors that influence adherence to nutrition recommendations, such as preparing and consuming meals for and with extended family and church members; patient and group motivation; and access to healthy, affordable, and palatable foods. Participants expressed the need for interventions that are tailored to the local culture and context and a holistic view of health, with a focus on motivation (spiritual and emotional support). These findings could be used to develop culturally and contextually appropriate programs. For example, adapting motivational interviewing techniques and materials by adding family members to motivational interviewing sessions vs patients only, as Pacific Islanders have a collectivistic culture and family members play an important role in adherence; conducting motivational interviewing in the community in addition to the clinical setting; utilizing church leaders as motivational interviewing counselors in addition to health care providers; and changing motivational interviewing narratives and tools (eg, a confidence scale of 1 to 10 will be unfamiliar to many Pacific Islanders); therefore, counselors need to develop another method to indicate levels of confidence, such as the color of the lagoon/ocean that goes from turquoise (the color of shallow water) to navy blue (the color of deep water).

Dietary intake in infants and young children in the Marshall Islands.

Changes in traditional foodways associated with increasing modernization have affected the feeding patterns of infants and young children. Declines in the duration of exclusive breastfeeding have been associated with poor nutritional status and increased morbidity from infectious diseases. We conducted a cross-sectional survey of dietary intake in children under six in four settings in the Republic of the Marshall Islands in Micronesia. The mean duration of breastfeeding in the sample was 11 months, however only 16% of subjects were exclusively breastfed for the first six months, which is recommended by the WHO, UNICEF and other policymakers. Among non-exclusively breastfed infants, supplemental foods were introduced as early as 2 months. Mean intakes for total energy, protein, carbohydrates, fat and iron were calculated for subjects providing recalls. Intake levels for energy, protein, carbohydrates and iron varied by location. Recommendations for future research and program intervention are outlined.

An NGO approach for addressing the nutrition dilemma: Pohnpei focuses on awareness, food analysis, conservation, and food processing.

The establishment of the Island Food Community of Pohnpei, a non-governmental organization (NGO) based in Pohnpei, Federated States of Micronesia, presents a new approach for promoting Pacific Island food for its health and many other benefits. Its vision is holistic, stressing the importance of island food for sustainable development, economic benefits, self-reliance, improved health, cultural preservation, and human dignity, at the same time protecting the natural resources. A major reason for the establishment of this NGO is the emergence of an epidemic of nutrition-related health problems, including diabetes, heart disease, cancer, vitamin A deficiency, and anemia. Although health is at the cornerstone of the establishment of this NGO and health officers are integrally involved, the project is closely associated with the agriculture sector. The Island Food Community of Pohnpei works via an ethnographic participatory inter-agency approach, and its activities include the identification and promotion of nutrient-rich varieties of the traditional staple foods, incorporating the 'Yellow Varieties Message'. There are also activities to conserve rare varieties and to develop small-scale food processing.

Risk factors for vitamin A deficiency among preschool aged children in Pohnpei, Federated States of Micronesia.

In 1993, the Department of Health of the Federated States of Micronesia (FSM) conducted a population-based stratified random survey among 355 children aged 24-48 months in Pohnpei, one of the four FSM States. The objective was to determine the prevalence, and explore risk factors for vitamin A deficiency (VAD). Trained field workers collected data from a range of demographic, dietary and socioeconomic variables related to the children. The serum retinol concentration was 19.4 +/- 7.5 microg/dl (mean +/- SD), and the VAD prevalence (serum retinol <20 microg/dl) 53.1 per cent. The significant independent risk factors, determined by logistic regression, were: mother's work at home, sibling <2 years older, rural household located on the main island, early weaning, and child anemia, controlling for pipe water and electricity in the household. If compared with a reference of apparently healthy children of similar age in the USA, the distribution of serum retinol among young Pohnpei children was shifted entirely to low levels. We conclude that eliminating the pervasive VAD problem in Pohnpei would require a multi-pronged tactical approach that combines dietary improvement strategies with the ongoing supplementation effort.

An Outbreak of Vibrio cholerae O1 infections on Ebeye Island, Republic of the Marshall Islands, associated with use of an adequately chlorinated water source.

In December 2000, physicians in the Republic of the Marshall Islands reported the first known outbreak of Vibrio cholerae O1 infection (biotype El Tor, serotype Ogawa) from this country. In a matched case-control study on Ebeye Island, patients with cholera (n=53) had greater odds than persons without cholera (n=104) to have drunk adequately chlorinated water collected from a US military installation on neighboring Kwajalein Island and transported back to Ebeye (matched odds ratio [MOR], 8.0; P=.01). Transporting or storing drinking water in a water cooler with a spout and a tight-fitting lid was associated with reduced odds of illness (MOR, 0.24; P<.01), as was drinking bottled water (MOR, 0.08; P<.01), boiled water (MOR, 0.47; P=.02), or water flavored with powdered drink mixes (MOR, 0.18; P<.01). No cases of cholera were reported among Kwajalein residents. This outbreak highlights the critical importance of handling and storing drinking water safely, especially during outbreaks of gastrointestinal illness.

Epidemiology of cancer in the Republic of Kiribati.

Little is known about cancer epidemiology in Kiribati. Between November 1998 and December 1999, trained medical record abstractors visited 8 Micronesian jurisdictions including the Republic of Kiribati to review all available medical records in order to describe the epidemiology of cancer in Micronesia and to better understand the cancer data and control systems in each entity. The Republic of Kiribati has identified many prevalent preventable cancers. The lack of a robust cancer data tracking and surveillance system, as well as the lack of resources to institute a technologically and medically sustainable cancer control system was apparent. The implementation or existence of a national comprehensive cancer control strategic plan would facilitate greater identification, prevention, and treatment of cancer patients. The health sector and Government of Kiribati are working towards this end.

Epidemiology of cancer in the Republic of Nauru.

Between November 1998 and December 1999, the Republic of Nauru was one of 8 Micronesian jurisdictions visited by trained medical record abstractors to review all available medical records in order to describe the epidemiology of cancer in Micronesia and to better understand the cancer data and control systems in each entity. There is likely incomplete ascertainment of cancer cases in the Republic of Nauru because of historical events, and the lack of a robust cancer registry and a systematic cancer surveillance system. A national comprehensive cancer control strategic plan and the implementation of that plan would facilitate greater prevention, treatment and control of cancer. The government of Nauru is working towards this end.

Formative research to inform intervention development for diabetes prevention in the Republic of the Marshall Islands.

Formative research was conducted in the Republic of the Marshall Islands to help develop a diabetes prevention intervention. Methods included in-depth interviews, semistructured interviews, and direct observation of household behaviors in urban and remote settings. Foods were classified into two main conceptual spheres: foods from the islands/Marshallese foods and imported/American foods. Diabetes (nanimij in tonal) is a highly salient illness and is believed to be caused by foods high in fat and sugar, consumption of imported/American foods, family background, and the atomic bomb testing. Physical activity and eating a traditional diet were viewed as important for preventing diabetes. The traditional belief system links a large body with health, and a thin body with illness; however, perceptions are changing with increased acculturation and education about the health risks of obesity. These findings were used to develop a diabetes prevention home visit intervention currently being implemented and evaluated in Marshallese households.

Vitamin A deficiency among children--Federated States of Micronesia, 2000.

Vitamin A, a fat-soluble, heat-stable nutrient (retinol) derived from animal sources and certain fruits and vegetables, forms the basic component of retinal pigments and plays a vital role in optimal health, growth, and development. Vitamin A deficiency (VAD) (serum retinol < or = 20 microg/dL [< or = 0.7 micromol/L] for subclinical VAD) can substantially increase the risk for childhood mortality from infectious and noninfectious causes. VAD impairs the mobilization and transport of iron and is usually associated with anemia and reduced growth. VAD is a major public health problem in parts of Africa, Asia, Latin America, and the Western Pacific. In Chuuk and Pohnpei, two of the four Federated States of Micronesia (FSM) (2000 population: 107,008), nutrition surveys during the early 1990s documented VAD prevalences among the highest in the world (CDC, unpublished data, 1991; U.S. Public Health Service, unpublished data, 1994). In response to these findings, FSM health authorities, with support of the United Nations Children's Fund (UNICEF), began distributing vitamin A supplements in 1993 and 1998 in Chuuk and Pohnpei, respectively. In November 1999, FSM requested assistance from CDC in VAD assessment surveys of children in Kosrae and Yap, the other two FSM states. This report summarizes levels of serum retinol and prevalence of VAD and other indicators of nutritional status among children aged 24-59 months in Kosrae and Yap. The findings indicated low serum retinol levels and high VAD prevalences but no substantial stunting or wasting. A comprehensive, long-term national strategy is needed in FSM to promote sustained improvement in vitamin A status.