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Undernutrition in Pacific Island Countries: an issue requiring further attention Heather Grieve, Jennifer Busch-Hallen, Kate MellorMenzies School of Health Research, Australia

Many Pacific Island countries (PICs) are affected by a 'double burden' of high rates of undernutrition coupled with very high rates of overweighta and obesityb in adults. The burden of adult overweight and obesity, and associated non communicable diseases (NCDs) is widely acknowledged and at least 17 PICs have current national NCD plans or strategies in place.1 While addressing overweight and obesity should continue to be a priority, in many PICs undernutrition requires comparable attention. While a few PICs, including Fiji, the Solomon Islands and Tuvalu, have current national nutrition plans; several PICs, including the Cook Islands, Papua New Guinea (PNG), Kiribati, the Republic of the Marshall Islands and Tonga have no nutrition plans, out of date plans or plans that have never been endorsed.The prevalence of adult overweight in some PICs is among the highest in the world. Over 80% of adults are overweight in the Cook Islands, Kiribati, the Republic of the Marshall Islands, Nauru, Tokelau, Tonga and Western Samoa.2-4 Adult obesity is also highly prevalent: the Cook Islands and Tonga have rates at or above 60%, while Kiribati, the Republic of the Marshall Islands and Western Samoa have rates above 45%.2 While data on the prevalence of childhood overweight and obesity is limited, at the other end of the scale, chronic undernutrition (stuntingc or a low height for age) is a public health problem in many PICs, with 'very high' rates (above 40%) according to WHO classifications5 in PNG and 'high' rates (30% - 39%) in the Solomon Islands.6-7 Similarly, the prevalence of anaemia in children aged 6-59 monthsd exceeds 40%5 in PNG, Fiji, Nauru, the Solomon Islands and Tuvalu, indicating a severe public health problem.7-11 (Refer to Figure 1.) The prevalence of anaemia in pregnant womend

indicates a 'severe' public health problem (above 40%) in the Solomon Islands, Fiji, Nauru and Western Samoa.7,9,10,12

MAY 2013POLICY BRIEF

Key messages• Globally there is a recognised urgency to address

both under and over nutrition.• Many PICs are affected by the 'double burden'

of high rates of undernutrition, coupled with high rates of adult overweight and obesity.

• Undernutrition requires further attention in PICs.• Many PICs do not have current national nutrition

plans.• Limited capacity to address nutrition issues in

PICs is compounded and perpetuated by a lack of nutrition training opportunities.

Overweight and obesityAdult overweight and obesity are direct risk factors for NCDs, such as diabetes and heart disease. Overweight women who become pregnant are at greater risk of complications during pregnancy (including preeclampsia and gestational diabetes) and birth, and their babies are more likely to be born with macrosomia (high birth weight ≥4000g) having insulin resistance and developing diabetes and obesity later in life.

Credit: Graham Crumb 2013

a: Body mass index >25 kg/m2

b: Body mass index >30kg/m2

c: A child (0–59 months) below minus two standard deviations from median height-for-age of the WHO Child Growth Standards.

d: Haemoglobin <110g/l

POLICY BRIEF

While data on the prevalence of vitamin A deficiency is limited, the most recent data (from the late eighties, nineties and early 2000's) indicates that vitamin A deficiency in children is a public health issue in several PICs, including PNG, Kiribati and the Federated States of Micronesia.13 The importance of improving nutrition, particularly during the period from pre-conception until a child’s second birthday, is globally recognised. Investment in nutrition during this period can prevent the irreversible effects of under and over nutrition and have lifelong impacts on adult and reproductive health, educational attainment, and labour and earning capacity. Acknowledging this 'critical window of opportunity’, the World Health Assembly endorsed the 2012 Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition, which sets out the post-Millennium Development Goal nutrition agenda and outlines six global targets to be achieved by 2025:14

• Reducing stunting in children under five years by 40%; • Reducing anaemia in women of reproductive age by

50%; • Reducing low birth weight by 30%;• Maintaining no increase in childhood obesity; • Increasing exclusive breastfeeding rates in the first six

months by at least 50%; and • Reducing and maintaining childhood wasting to less

than 5%.Given the double burden faced by many PICs, there is an urgent need to develop nutrition plans to effectively mobilise resources and direct activities to progress towards the global targets in PICs.

StuntingStunting is difficult to reverse after two years of age and associated with an increased risk of developmental delay, illness and infection. Women of short stature (<145cm) are more likely to have complicated births, die during pregnancy and childbirth and give birth to a preterm or low birth-weight baby (<2500g), perpetuating the intergenerational cycle of undernutrition.

TuvaluFijiNauruVanuatuSolomon Islands

Papua New Guinea

40% ‘Very high’ stunting and ‘severe’ anaemia prevalence cut-off values for public health significance

Stunting (<-2HAZ) in children < 5 years of age Anaemia (Hb <110g/l) in children 6-59 months

Figure 1: Prevalence of stunting and anaemia in children < 5 years of age in Pacific Island countries

Prev

alen

ce (%

)

100

50

75

25

6, 8 717 10 9 11

5

Country profile: Papua New Guinea• Population: 6.5 million.18

• Prevalence of overweight in adults: 48%.2

• Prevalence of stunting in children under five years is 'very high': 48%.6

• Prevalence of anaemia in non-pregnant women of child bearing age is 'high': 36%.8

• Prevalence of anaemia in children aged 6-59 months is 'very high': 48%.8

• Four nutrition staff are employed at the central level, two with tertiary training in nutrition and dietetics, one trained in food technology and one with no tertiary nutrition training.19

• Limited nutrition staff and designated nutrition positions in the 22 provinces.19

• Outdated National Nutrition Policy (1995).• The PNG National Health Plan 2012-2020 includes

only one nutrition-specific objective: 'to reduce malnutrition (moderate to high) in children under the age of five years.'18

• No tertiary nutrition training opportunities.20

• Limited in-service nutrition training opportunities.20

POLICY BRIEF

Country profile: Solomon Islands• Population: 597,248.21 • Prevalence of overweight in adults: 68%.2

• Prevalence of stunting in children under five years is 'high': 33%.7

• Prevalence of anaemia in non-pregnant women is 'very high': 44%.7

• Prevelance of anaemia in children aged 6-59 months is 'very high': 48%.7

• Five nutrition staff are currently employed at the central level including one nutritionist, two dietitians, one diet aide and one nutrition aide.15

• High staff turnover as a result of low pay, poor conditions, lack of leadership and staff accepting scholarships and other employment opportunities limits the capacity of the nutrition unit.15

• Current national Food Security, Food Safety and Nutrition Policy (2009).

• No tertiary nutrition training opportunities.• Regular in-service nutrition training is limited to

courses on infant and young child feeding and the Baby Friendly Hospital Initiative which is delivered to health workers across the provinces. Resource and capacity limitations proclude full coverage of these trainings, as well as the delivery of broader trainings.15

In addition to the lack of current nutrition plans, limited nutrition capacity compromises the ability of many PIC governments to effectively plan, prioritise and implement nutrition initiatives. Several PICs, including Tokelau and Tuvalu do not currently have dedicated nutrition positions and in other PICs, including Kiribati and Vanuatu, the qualified nutritionists are employed in roles that are not specific to nutrition.15

Compounding and perpetuating the lack of capacity in nutrition is an absence of nutrition training, with Fiji the only PIC offering specialised nutrition training at the tertiary level. For most PICs, tertiary nutrition training is therefore expensive and time-consuming often requiring travel to Fiji, Australia or New Zealand and leaving the few nutrition positions vacant for considerable lengths of time. For example, the three nutrition positions in the Solomon Islands were all vacant for approximately 18 months when the three qualified nutritionists undertook further nutrition training abroad.15 Anecdotal evidence also suggests that workforce attrition rates of internationally-trained national nutritionists are high.15

In-service training opportunities are similarly limited, with training often delivered regionally, making attendance time consuming and costly. Although e-learning in-service opportunities are available, these courses are not always contextually appropriate and rarely provide learning support.Positioning PICs to reduce the burden of undernutrition will require targeted investment in appropriate nutrition training and the development of realistic nutrition plans. Without this investment, PICs are at risk of stalling efforts to address the double burden and failing to optimally progress towards the global targets of the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition.

POLICY BRIEF

This research has been funded by AusAID. The views represented are not necessarily those of AusAID or the Australian Government

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References1. WPRO, Noncommunicable diseases in the Western Pacific

Region: a profile. Manila: World Health Organization Regional Office for the Western Pacific; 2012.

2. WHO, World health statistics 2011. Geneva: World Health Organization; 2012.

3. UNICEF, State of the world’s children 2012: children in an urban world. New York: United Nations Children’s Fund; 2012.

4. WPRO, Tokelau NCD risk factors: STEPS report. Suva: World Health Organization Regional Office for the Western Pacific, Fiji School of Medicine and Tokelau Department of Health; 2007.

5. WHO. Nutrition Landscape Information System: country profile indicators interpretation guide. Geneva: World Health Organization; 2010.

6. Papua New Guinea National Statistics Office, Papua New Guinea household income and expenditure survey 2009-10. Port Moresby: Papua New Guinea National Statistics Office; n.d.

7. Solomon Islands National Statistics Office (SINSO), Ministry of Health (Solomon Islands), Secretariat of the Pacific Community (SPC), Macro International, Inc. Solomon Islands Demographic and Health Survey 2006-2007. Noumea, New Caledonia, France: Secretariat of the Pacific Community (SPC).

8. National Department of Health of Papua New Guinea, UNICEF Papua New Guinea, University of Papua New Guinea, US Centers of Disease Control and Prevention, Papua New Guinea national micronutrient survey 2005: final report. Port Moresby, Papua New Guinea, 2009.

9. National Food and Nutrition Centre, Fiji, Fiji national nutrition survey 2004, Main Report. Suva: National Food and Nutrition Centre; 2007.

10. Nauru Bureau of Statistics, Secretariat of the Pacific Community (SPC), Macro International, Inc., Nauru Demographic and Health Survey 2007. Noumea, New Caledonia, France: Secretariat of the Pacific Community (SPC).

11. Central Statistics Division (TCSD), SPC and Macro International Inc. Tuvalu Demographic and Health Survey 2007. Noumea: SPC, 2009.

12. Mackerras D, Kiernan DM. Samoa national nutrition survey 1999, Part 1. Anemia survey. Technical Report. Ministry of Health of Samoa. Available at: http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf

13. WHO. Global prevalence of vitamin A deficiency in populations at risk 1995–2005. WHO Global Database on Vitamin A Deficiency. Geneva: World Health Organization; 2009.

14. WHO. Sixty-fifth World Health Assembly Geneva, 21–26 May 2012 Resolutions and decisions: Annexes. Geneva: World Health Organization; 2012. Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA65-REC1/A65_REC1-en.pdf

15. Personal communication with Erica Reeve, World Health Organization, Solomon Islands.

16. Palafox, R. et al. Vitamin A deficiency, iron deficiency, and anemia, among preschool children in the Republic of the Marshall Islands, Nutrition 19:405– 408, 2003.

17. UNICEF, Vanuatu nutrition survey. Suva: United Nations Children’s Fund; 2007.

18. GoPNG. National health plan 2011-2020. Port Moresby; Government of Papua New Guinea; 2010.

19. Personal communication with PNG National Department of Health Technical Advisor, Nutrition and Dietetics.

20. Saweri- van Hulzen, W. Training in human nutrition and dietetics (in PNG), a Discussion Paper. Unpublished.

21. CIA. World fact book: Solomon Islands. Washignton: US Central Intelligence Agency; 2013. Available at: https://www.cia.gov/library/publications/the-world-factbook/geos/bp.html

For further information contact: Heather Grieve heather.grieve@menzies.edu.au