- Research article
- Open Access
Fish, food security and health in Pacific Island countries and territories: a systematic literature review
BMC Public Health volume 16, Article number: 285 (2016)
Pacific Island countries and territories (PICTs) face a double burden of disease, with a high prevalence of household food insecurity and childhood micronutrient deficiencies, accompanied by a burgeoning increase in adult obesity, diabetes and heart disease.
A systematic literature review was undertaken to assess whether increased availability of, and access to, fish improves a) household food security and b) individual nutritional status.
A total of 29 studies were reviewed. Fourteen studies identified fish as the primary food source for Pacific Islanders and five studies reported fish/seafood as the primary source of dietary protein. Fish consumption varied by cultural sub-region and Pacific Island countries and territories. Fish consumption and nutritional status was addressed in nine studies, reporting moderate iodine deficiency in Vanuatu where only 30 % of participants consumed mostly fresh fish. Similarly, the degree to which Pacific Islanders depended on fishing for household income and livelihood varied between and within PICTs. For more economically developed countries, household income was derived increasingly from salaried work and dependency on fishing activities has been declining.
Fishing remains a major contributor to food security in PICTs, through subsistence production and income generation. However, there is a paucity of research aimed at assessing how maintaining and/or improving fish consumption benefits the diets and health of Pacific Islanders as they contend with the ongoing nutrition transition that is characterised by an increasing demand for packaged imported foods, such as canned meats, instant noodles, cereals, rice, and sugar-sweetened beverages, with subsequent decreased consumption of locally-produced plants and animals.
The Pacific Island region comprises 22 countries and territories which are diverse in geography, population size, culture and economy. Melanesian island countries (Table 1) are typically large and mountainous with fertile soils, whereas the smaller Polynesian and Micronesian islands (Table 1) are either volcanic areas or low lying coral atolls . Population sizes vary from as little as 1,200 in Tokelau, the smallest Pacific Island territory to 7.4 million in Papua New Guinea, the largest Pacific Island country . GDP per capita is low in most Pacific Island countries and territories (PICTs), ranging from US$1,651 in Kiribati to US$36,405 in New Caledonia  with five PICTs (Kiribati, Samoa, Solomon Islands, Tuvalu and Vanuatu) currently classified as Least Developed Countries [1, 4].
The nutrition transition  is well underway in PICTs. Dietary patterns have shifted since the 1970–80s from reliance on traditional low fat diets, typically based on complex carbohydrates, fresh fish and meat and leafy greens, to increasingly modern diets, based on refined starch, oils, processed meats and confectionary [6–10]. This relatively rapid transition in the Pacific Island region has resulted in an increasing demand for packaged imported foods, such as canned meats, instant noodles, cereals, rice, and sugar-sweetened beverages, with subsequent decreased consumption of locally-produced plants and animals, leading to high vulnerability to food insecurity . Moreover, such diets have been identified as a major contributor to the double burden of communicable and non communicable diseases (NCDs) in the region [6, 12]. NCDs now account for between 60 and 80 % of all deaths in the region [13, 14] and the prevalence of diabetes and obesity are among the highest in the world . At the same time, the incidence of malnutrition and vitamin and mineral deficiencies continue to be major public health concerns [16, 17]. Iron-deficiency anaemia, which is associated with impaired cognitive and motor development, low birth weight and prematurity [18, 19], affects up to 57 % of the population in some PICTs (mostly children and women) . As has been reported in other low-income countries [21–26], it is not uncommon to find both malnourished children and overweight/obese adults co-residing in the same household .
Food security, defined as the physical, social and economic ability to access sufficient, safe and nutritious food, is already identified as under threat in many PICTs due to the dietary shifts caused by changes in population growth, urbanisation and climate [1, 27]. It is evident that significant economic, environmental and population health reforms will be required to ensure that Pacific Island populations have reliable sources of affordable and nutritious food in the future .
Across the globe, fish and fisheries have been identified as being a crucial element in achieving food security, particularly in less-developed countries [29, 30]. In the Pacific Island region, the major contribution of fisheries to livelihoods, revenue and development is undisputed. Fish contribute substantially to both the subsistence and market-based economies of PICTs, and national rates of fish consumption are among the highest in the world . It is acknowledged that increased fish supplies are needed to meet growing food security demands . However, there is a lack of information regarding the contribution of fish consumption to overall nutritional adequacy and health status in PICT populations.
Here, we report the findings of a systematic literature review undertaken to explore how availability of fresh fish affects the nutritional status of Pacific Island populations. The review considered both direct benefits of fish consumption to nutritional status, as well as indirect benefits to nutritional status and food security resulting from improvements in livelihoods related to fishing.
The following PICO (participants, interventions, comparisons and outcomes) question formed the basis for the systematic literature review: Among Pacific Islanders, does increased availability of and/or access to fish, compared to reduced availability or access, improve a) household food security and b) individual nutritional status? Depending on individual study designs, relative availability or access to fish was compared between communities or provinces within a single country, or between countries and/or the three Pacific sub-regions. In the case of studies conducted over different time periods, this was also analysed as change over time. For the purpose of this review, household food security is used in the context of either an individual within a household or a household comprising more than a single person. In relation to nutritional status, the influence of fish consumption on both under and over-nutrition was considered. Pacific Islanders were defined as individuals residing in the following PICTs: Commonwealth of the Northern Mariana Islands, Cook Islands, Federated States of Micronesia, Fiji, French Polynesia, Guam, Kiribati, Marshall Islands, Nauru, New Caledonia, Niue, Palau, Papua New Guinea, Pitcairn Island, Samoa, American Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu, Vanuatu and Wallis and Futuna.
In December 2014, systematic searches were conducted using three major online academic literature databases. The Scopus database was searched using varying combinations of keywords, as listed in Table 2. Seven separate searches were conducted, with no new relevant articles being identified after search four. Additional searches were conducted in Web of Science and Medline databases using the same search strategy.
Articles from the peer-reviewed literature in English published between 2004 and December 2014 were eligible for inclusion if they addressed either fish consumption amongst Pacific Islanders and/or the contribution of fishing activities to the livelihoods of Pacific Island people. Fish consumption could include either fresh or canned fish. Fishing activities could relate to both commercial and subsistence practices. Exclusion criteria were: review articles, studies focused on historical fish consumption in PICT communities, studies of institutionalised individuals, studies focused on the contribution of the fishing industry to a country’s national revenue or gross domestic product and studies describing fishing and fisheries, such as annual fish catch, that did not relate the activity to income generation or provision of subsistence.
As a broad range of search terms were needed to identify articles relevant to both nutrition and food security, the initial database search returned a large number of records. To remove subject areas irrelevant to the review, exclusions were made using database functions (Table 3). Records were exported to EndNote version X7 and duplicates removed. A title and abstract search was carried out to screen records against the inclusion and exclusion criteria. Eligibility of any remaining articles was determined through a full text assessment. Where there were aspects of doubt over a study’s eligibility, the investigator conducting the search (EG) sought a second and third opinion from other members of the research team. The review followed the PRISMA guidelines  for reporting systematic literature reviews.
Online resources, including the websites of the Food and Agricultural Organisation (FAO), the World Health Organisation (WHO), the World Bank, WorldFish, the Secretariat of the Pacific Community and the United Nations International Children’s Emergency Fund were also searched using the same approach to identify relevant grey literature.
Additionally, one country from each of the three cultural sub-regions within the Pacific Islands was examined in more detail to identify economic, demographic and health differences among sub-regions. These islands were Vanuatu in Melanesia, Kiribati in Micronesia and Tonga in Polynesia.
A total of 31 articles were identified for inclusion in the final review (Fig. 1). In two instances, two articles described results from the same study [33–36], and all four articles were included in this review. The findings are summarised, by country, according to two themes, fish consumption (shown in Table 4) (33–55, 57–59), and contribution of fishing to household income (shown in Table 5) (37, 42, 43, 45, 60-64). In addition, the three sub-regional case studies are described in Tables 6, 7 and 8. Only relevant papers identified using the defined search strategy are cited in the tables whereas additional sources of information are included in the Discussion.
Fish intake in Pacific Islanders
Fish was identified as a primary food source for Pacific Islanders in 15 studies [36–50] although the amount and type of fish consumed varied based on factors such as geographical location and socio-economic status. The following section describes the patterns in Pacific Island fish intake reported in these studies.
A study of subsistence fishing practices in two outer islands of American Samoa found that 89 % of the fish harvest was consumed locally, with the remainder being sent to family members on other islands. Interviews with local elders suggested that fishing activities had not changed much over their lifetime and that there were ample fish resources still available .
Federated States of Micronesia
In Pohnpei, an island in the Federated States of Micronesia (FSM), 79 % of adults reported frequent consumption of fresh fish and/or seafood with locally-caught fresh fish and/or seafood consumed 4.8 days/week compared to 2.4 days/week for imported fish and/or seafood, including canned fish . This contrasts to results from the Health Behaviour and Lifestyle of Pacific Youth study (HBLPY), which reported that fresh fish was consumed by only 42 % of 15-year-old students at seven schools in Pohnpei, whereas there was high consumption of processed foods such as canned meat and carbonated beverages .
Fish intake in Fiji was assessed by Kuster et al. and Turner et al. . In a comparison of subsistence fishing patterns between 1982 and 2002 on Ono-i-Lau Island, Kuster et al. found that fresh fish remained the main source of dietary protein (finfish 261 g ± 90/person/day in 1982 and 269 g ±100/person/day in 2002) for villagers over a 20 year time span. Consumption of tinned fish doubled from 9 g per person per day to 19 g per person per day over the same period. In the remote Lau islands, local fishers and senior heads of households reported the frequency of consuming fresh fish had declined over the previous 10 years to an average current consumption level of three days per week. The decline in frequency of fish consumption was associated with higher household income. In Naikeleyaga, the Lau island village with the highest annual household income, participants reported the frequency of fish consumption declined from four to 1.5 days per week. Reasons identified for declining fish consumption were a dependence on other family members to catch fish, or a need to purchase rather than catch their own fish (possibly due to more time spent on income-generating activities ), as well as increased consumption of other purchased foods.
Two separate studies assessed fish intake in French Polynesia. In a cross sectional study of pregnant women participants, there was a mean consumption of 33 meals/month of reef and pelagic fish, however, data on actual grams per day were not collected . In a case–control study of thyroid cancer patients, an average of 71 g/day and 83 g/day of fresh fish and/or shellfish was consumed by cases and controls, respectively .
In contrast to other Pacific Islands, Pobocik et al.  reported that in adults from Guam, fish contributed only 3.5 % of foods eaten but was the third most commonly consumed meat, after chicken and beef. Of the fish that was consumed, only 47 % was fresh and the remaining canned or dried .
Three studies assessed fish intake in New Caledonia. In the Northern Province, 85 % of adults participating in a study of subsistence fishing practices reported consuming fresh fish one or more times a week, with 45 % consuming fresh fish 2–3 times/week and 11 % 1–2 times/day . Of annual fish consumption, 92 % was classified as subsistence and 8 % was purchased . Subsistence production was also the main fish supply for two-thirds of households on Ouvéa Island, New Caledonia, with annual intake of fish considerably higher than reported in the Northern Province . In a small study of 146 local fishers from the northwest coast, approximately 18 kg of fish per capita per annum was consumed, however, only reef fish intake was considered, not pelagic species nor imported fish .
On Lofanga Island, Tonga, the entire community reported eating fresh fish, with 93 % also consuming other seafood and 78 % of the community consuming canned fish. However, a decline in fresh fish consumption was attributed to increased income resources . In a cluster random sample of schools in Tonga, approximately a third (27.2 to 38.6 %) of 13- and 15-year-old girls and boys who completed the HBLPY study reported consuming canned fish on a daily basis and half the students consumed canned mutton daily . However, it is not known how many students consumed fresh fish as those data were not collected.
In Vanuatu, fish consumption varied between islands but, overall, fresh fish consumption was lower than for Solomon Islands and Tonga. The percentage of adults consuming fresh fish during the previous 24 h ranged from 10 to 50 %, depending on the island. No data were available on the amount of fish consumed . On Aneityum, considered to be a rural island with tourism, children were more likely to consume tinned fish than adults. These findings were similar to those of Phongsavan et al.  who reported that 40 % of students in the HBLPY survey reported consuming canned fish on a daily basis. On the rural island of Tanna, 39 % of primary school children consumed fish at least weekly, with the majority (70 %) consuming mainly canned fish. Fish consumption differed among the four study sites in Vanuatu, with more fish consumed in coastal villages than in urban centres .
Contribution of fish consumption to energy and/or protein intake
Fish/seafood was also identified as the primary source of dietary protein in five of the six small-scale studies that addressed contribution of fish consumption to protein intake [41, 45, 52–54]. Consumption differed across PICTs, ranging from 20 % of total protein intake in the Kolovai village in Tonga  to 37.4 % in Verata, Fiji .
Federated States of Micronesia
In Kosrae, a cross-sectional survey of children and their caretakers reported that local fish was the second most commonly consumed source of protein, after cooked chicken . Mean intake of protein, both for children and adults, was above the average requirements, as defined by Latham .
In one rural village in Fiji, the second and third sources of protein intake after fish and shellfish (37 %) were cereals (29.2 %) and meat (13 %). Higher marine food consumption was associated with lower cereal intake .
Papua New Guinea
Fish consumption in the Sepik-Ramu catchment area in Papua New Guinea differed between the four villages surveyed (two high altitude, one middle and one low) . In the low altitude village, fish was the most important source of protein for residents and comprised 41 % of all food from animal sources. Conversely, in high and middle altitude villages, animal protein comprised mostly purchased sources such as canned fish and lamb flaps .
In Solomon Islands, a cross sectional study of adults from five villages in Roviana Lagoon found that most households consumed fish as the primary source of protein but did not give details of alternative protein sources . Mertz et al.  also reported fish as the primary source of protein among residents of Tikopia, a remote area in Solomon Islands. Just over half of households interviewed owned chickens, but meat from livestock was rarely eaten. Other sources of protein included canned fish and canned meat but these were rarely available.
In Tonga, protein intake from fish was highest (20 %), followed by imported chicken (12 %) and mutton (11 %) .
Fish consumption and nutritional outcomes
Iodine status was reported in three studies [36, 38, 39]. In a case–control study of French Polynesians, inadequate iodine intake (<150 ug/day) was observed in 60 % of participants, with optimal iodine intake (150–299 ug/day) reported in only 30 % of participants. Subjects with thyroid cancer were 2.5 times more likely to have intakes of <75 µg/day compared to control subjects . The iodine concentration of umbilical cord blood of newborn babies also suggested that iodine intake was adequate in French Polynesian mothers . Fish intake of the women was assessed during pregnancy, with mean fish consumption reported as 33 meals per month (21.3 meals per month from reef fish and 11.5 meals per month from pelagic fish); fish intake varied little between women from different archipelagos. This suggests that fish was consumed daily, however, data on actual grams consumed per day were not collected . Mean blood concentration of iodine varied between newborn babies from different archipelagos, with the highest mean concentration in the Iles Sous Le Vent (2.6 μmol/L) and the lowest in the Australes (0.46 μmol/L) .
Li et al.  assessed the iodine status of children on the Island of Tanna, Vanuatu, by measuring the level of urinary iodine excretion (UIE), and reported moderate population-level iodine deficiency (median UIE = 49 μg/l). Only 30 % of participants reported consuming mostly fresh fish, with the remainder eating mainly canned fish.
In Kosrae, Micronesia, Englberger et al.  reported that the mean daily intake of total vitamin A for all infants was less than half of the requirements estimated by the WHO and the FAO . Yet both protein and fat intakes were above the estimated requirements and results were similar for infants’ caretakers. Highest intakes of total vitamin A and retinol were found in Malem, one of four Kosrae municipalities. Informants in the ethnographic analysis suggested that a wider range of seafood was consumed in Malem, including whole small fish consumed with the liver which is a rich source of vitamin A .
Assessing whole-of-diet against health outcomes was the approach used in five studies. A ‘traditional’ Polynesian dietary pattern, compared to a ‘modern’ dietary pattern, was shown to be associated with decreased risk of thyroid cancer in French Polynesia but the findings were no longer significant after accounting for several confounding variables including family history of thyroid cancer . In Samoa, the ‘modern’ dietary pattern, characterised by high intakes of processed foods, was significantly associated with an increased prevalence of metabolic syndrome .
In Port Moresby, Papua New Guinea, two predominant dietary patterns were identified amongst a Naasioi migrant population . Neither dietary pattern included high intakes of fresh fish but the ‘traditional’ dietary pattern was inversely associated with consumption of canned fish, rice and soft drinks . Dietary patterns were not associated with body mass index (BMI) nor blood pressure . A study of three villages in Vanuatu reported that both consumption of canned fish and multiple fish/meat dishes per day were risk factors for obesity, defined by both BMI and percentage body fat. Canned fish could lead to obesity because it is most commonly packaged with oil or sauce providing a higher fat content than fresh fish. Again, fresh fish intake was not considered in the analysis .
Contribution of fishing activities to subsistence and/or cash income amongst Pacific Islanders
The degree to which individuals and households depended upon fishing for livelihood varied between and within PICTs. Four of the studies reviewed were conducted in Fiji, one of the more economically developed countries in the region [42, 45, 60, 61].
Federated States of Micronesia
Fishing as the primary source of income or food has been described in many PICTs however, this is not the case for all PICTs. Pohnpei, in the Federated States of Micronesia (FSM), is considered to be one of the urban centres currently experiencing the nutrition transition. It was found that 65 % of participants surveyed reported that one or more members of their household held a salaried position. Of the monthly household income, 77 % participants reported that household food expenditure made up half or more of the budget. In contrast, farming and fishing was the primary source of income in 8 % of participants and only 6 % relied on fishing alone .
In the Navakavu fishing grounds in the south eastern area of Fiji, 88 % of households were involved in fishing activities. However, salaried work provided the most income and food for 32 % of households, while 27 % of households reported fishing as their most important resource . On the island of Vitu Levu, two contrasting villages were studied; firstly, Ucunivanua, where fishing is the primary income activity for 75 % of households. In Namatakula, the primary income source was provided from employment in local international hotels (fishing being primary income for only 10 % of households) . Despite primary sources of income differing between the two villages, there was no significant difference in total monthly income.
Key informants, local fisherman and senior heads of households, from four islands in the Lau Province of Fiji identified a decreasing dependency on fishing activities for livelihood over the past decade. Current fishing activities continued primarily for subsistence purposes, with the exception of fishing activities on Yaroi where fish was more commonly sold. Only 7 % of households ranked fishing as the primary household occupation although almost all households remained engaged in fishing practices . In the most southerly Fijian Island group of Ono-i-Lau, also part of the Lau province, the economy was again predominantly subsistence and this had not changed between the two study periods of 1982 and 2002 . While it was reported that time spent fishing had not significantly changed in the past 10 years, engagement in other forms of livelihood activities had increased including formal employment and animal husbandry . Fishing and gardens were the primary source of subsistence products but the key income-generating activities were sale of copra, seaweed farming and handicraft making. Income from these sources doubled between 1982 and 2002, but income remained insufficient at both time points to purchase sources of protein other than fish on a regular basis .
In Moorea, French Polynesia, a subsistence economy of small-scale agriculture and fishing existed until about 1962 . In a small sample of adults interviewed in 2002, over half reported dependence on lagoon fishing for at least half of their food and/or income . However, there has been an influx of tourism, and agricultural production for export markets, which have largely replaced local food production, including fishing.
Papua New Guinea
On the island of Ahus, Cinner et al.  found that more than 76 % of participants ranked fishing as their primary occupation. Participants reported that the remoteness of the island meant that there were few opportunities to engage in other economic sectors such as agriculture. Maintenance of marine tenure rights was important to create a demand for fish from the mainland .
The introduction of nearshore fishing aggregating devices (FADs) improved catch in four villages in Solomon Islands. These FADs contributed 31–45 % to the total annual catch and 26–58 % of the fish consumed annually [62, 64, 65]. The perceived benefits of FADs included provision of income through the sale of catch and improvements to diet through increased fish consumption .
The Island of Lofanga is a traditional Tongan community in which the cash economy remains limited. On this island, fisheries, ranked higher than agriculture and handicrafts for importance to income generation, and were considered vital to secure subsistence and fulfil social obligations. However, in 45 % of households studied, income was also received as financial remittances from relatives on other islands or overseas .
Country case studies
To highlight the heterogeneous nature of Pacific Islands, three PICTs, one from each of the cultural sub-regions, were examined in further detail. Demographic, nutritional and fish indicators from Vanuatu, Kiribati and Tonga (Tables 6, 7, and 8) demonstrate that fish consumption, as a percentage of total protein intake, varies considerably across the three cultural sub-regions. Fish consumption is much lower in Vanuatu, than in Kiribati and Tonga. This is presumably due to the relatively large population of Vanuatu and the limited area of coral reef capable of supporting coastal fisheries, resulting in low availability of fish per capita. The availability of beef cattle on some islands in Vanuatu, and the great importance of yams in the traditional diet, presumably also affect the role of fish in the nation’s food system.
Nevertheless, the patterns of fish consumption evident from the case studies summarised in Tables 6, 7 and 8 are representative of differences among the three sub-regions in general, with average national fish consumption in Micronesia and Polynesia, being much greater than in Melanesia . The case studies support the data presented in the numerous individual country studies identified in this review and are used to present a succinct summary overview of factors influencing fish consumption patterns, food security and health status between the sub-regions.
This review confirms that fish is an important staple food in most Pacific Island countries and territories, and that subsistence and commercial fishing activities make essential contributions to both household and individual food security, particularly in rural areas. Estimates of per capita annual fish consumption ranged from 18 to 63 kg. The wide range of fish consumption can be attributed to variables such as geographical location (rural coastal villages versus urban centres), availability of alternative animal food sources (from both agriculture and imported foods) and whether the community has a subsistence or cash-based economy. These differences are highlighted in the three country case studies, showing higher fish consumption in Kiribati, one of the least developed PICTs.
Given the central contribution of fish to both dietary intakes and livelihoods in PICTs, it is noteworthy that our review identified only 29 relevant studies from 22 countries. Nationally representative data is sparse, and whole provinces and/or cultural groups are missing from the Melanesian countries. In a broader study, Bell et al.  used data from household income and expenditure surveys to quantify average national, rural and urban fish consumption per capita for 16 PICTs. Average national fish consumption ranged from 55 kg to 110 kg per person per year in eight PICTs, 3–6 times the average global consumption of ~18 kg per person per year . Importantly, fish provided 50–90 % of dietary animal protein in rural areas across a wide range of PICTs.
With ongoing population growth, coastal fisheries based on coral reef ecosystems are not expected to yield sufficient fish to maintain per capita fish consumption in several PICTs . The rich tuna resources of the region will need to play a greater role in maintaining the food security of Pacific Island people . However, as urbanisation increases and urban centres become more focused on cash economies, the risk is that greater availability of imported, energy-dense, nutrient-poor foods will exacerbate the dual burden of malnutrition that includes micronutrient deficiencies and infectious diseases, accompanied by non-communicable diseases. Food security involves not only access to sufficient food, but also to nutritious food. Therefore, easy and affordable access to fish will be essential in order to provide growing PICT populations with healthy sources of food.
It has been estimated that for optimal nutrition, Pacific Islanders need to consume approximately 34–37 kg of fish per annum (based on WHO recommendation of 0.7 g protein/kg body weight/day and an assumption that fish will need to supply 50 % of required protein) . Dependence on fish for protein is particularly high in rural areas where there is limited access to other sources of protein, such as imported meats, and in areas where animal grazing and husbandry is not viable [27, 67]. Our review suggests that the majority of PICT communities for which data is presented consume sufficient protein to meet their nutritional requirements, however, a number of communities, particularly inland PNG, suffer from high rates of protein-energy malnutrition [68, 69]. For these communities, an increase in the availability of fish has particular potential to contribute to improved nutritional outcomes. However, the remote nature of communities in PNG poses many challenges to increasing access to fish [27, 31]. To sustain recommended levels of fish consumption across the region as populations grow, new strategies are required to assist communities to obtain fish [27, 31]. A recent paper published after completion of this review reported that fishing remained the most important livelihood for households in the Langalanga region of the Solomon Islands but that households were involved in a range of different livelihoods in order to produce food and/or generate income. The authors suggested that households in this region had the ability to adapt to changing circumstances but that fisheries management involving local stakeholders was needed in order to ensure that fisheries continue to be a major source of food and income.
This review did not identify any reported interventions designed to test the hypothesis that increased availability of fish improves nutritional outcomes. Thus, our PICO question could not be answered directly. However, it is evident that fish is a highly nutritious food and that it provides a lean source of high biological value dietary protein as well as many essential fatty acids and micronutrients. In particular, the high iodine levels in fish and other seafood mean that improved access to increased fish availability may help prevent iodine deficiency, which remains highly prevalent in PICTs such as Fiji , PNG  and Vanuatu . Improving iodine nutrition status through higher fish consumption may also contribute to the prevention of iodine-related diseases including goitre  and thyroid cancer [33, 36, 73]. In addition, the review suggests that some species of small fish that are eaten whole are important for the prevention of Vitamin A deficiency , which is highly prevalent in several PICTs including FSM , Kiribati , Marshall Islands , and PNG .
Sources of oily fish provide docosahexanoeic acid, and consumption of these fish by Pacific Islanders  may be making an important contribution to cognitive development in utero (through maternal fish intake), as well as in young children . In other developing countries, such as Cambodia and Bangladesh, fish is an important source of calcium, iron and zinc , but data on the contribution of these nutrients from fish in PICTs are not available. Overall, further research is required to determine the extent of other micronutrient deficiencies that may exist in PICTs, such as iron or calcium and how fish consumption may contribute to reducing the risk of such deficiencies.
Prevention and management of NCDs
Non-communicable diseases have been declared a crisis in the Pacific, and there are national response plans in place to address risk factors, particularly with regard to strategies to reduce population-level salt intake. Dietary survey work in Fiji identified the main sources of salt in the diet as salt (and MSG) added during cooking and at the table, as well as processed foods such as tinned fish and meat, biscuits, soy sauce, noodles, salty crisps and snacks, tinned fruit and vegetables, butter and bread . Country consultations and Food Frequency Questionnaires (FFQ) carried out in Fiji, Samoa, Kiribati and Cook Islands, have confirmed this . Locally salted, preserved fish and meat, and meals eaten in and out of the home, such as Chinese dishes, soups and curries are also a common part of the diet in the region.
An increase in the availability of fresh fish offers an alternative to foods with a high salt content. Increasing access to fresh fish also offers an alternative to imported meats, many of which are energy-dense and high in saturated fat (e.g., frozen chicken, canned mutton, turkey tails and sausages). These energy-dense foods have been associated with the prevalence of chronic diseases and over-nutrition in PICTs, and their inclusion in emerging dietary patterns confirms this, as identified by studies identified in the current review.
‘Modern’ dietary patterns, characterised by high consumption of foods such as potato chips, cake, rice, instant noodles, soup, and low intakes of local foods, have been shown to be associated with an increased prevalence of metabolic syndrome . In contrast, ‘traditional’ Pacific Island dietary patterns high in fresh fish and seafood, as well as other local foods, such as coconut-based dishes, taro and papaya, have been associated with reduced prevalence of metabolic syndrome, increased HDL cholesterol and reduced waist circumference . Heavy reliance on poor-quality imported foods  is exacerbating the genetic predisposition of people in FSM to obesity .
Whether fish is consumed fresh or canned needs to be considered. Findings have been inconsistent as to whether consumption of canned fish per se is a risk factor for obesity in PICTs. Data collected between 2001 and 2002 from rural Tongan communities reported that neither fresh fish nor canned fish were related to obesity . However, the more recent finding of Dancause et al.  that consumption of canned fish was a risk factor for obesity in Vanuatu warrants further consideration, in the context of the nutrition transition . Methodological limitations to dietary assessment should be noted; Dancause et al. used a single 24 h recall, which may not be appropriate to determine usual intake. Further, a higher consumption of tinned fish may simply be a proxy measure for a greater reliance on processed foods in place of fresh fish, as populations become more urbanized and adopt more westernised eating patterns. Both the nutrient content and the preparation methods of tinned fish may also contribute to its association with obesity. Tinned fish canned in oil or sauce has higher fat content than most types of fresh fish  and will often be served with instant noodles and rice . Packaged instant noodles are popular in Vanuatu  and across most PICTs, and their inclusion in the diet has been shown to be associated with increased risk of obesity. In comparison, fresh fish and meat more often accompany dishes prepared with traditional root crops and vegetables, which are less energy-dense. A heavy reliance on tinned fish in urban areas was reported during the first nutrition survey conducted in Vanuatu as long ago as 1951  and has since been observed in many other PICTs [83, 85, 86]. The Vanuatu Ministry of Health NCD survey in 1998 reported associations among obesity and daily consumption of non-traditional fat sources (OR = 2.19), including oil, margarine/butter, milk, fresh meat, poultry, tinned meat, and tinned fish .
In short, it appears that any association of canned fish with obesity and NCDs may well be related to the foods eaten with canned fish, as well as the added oil or sauce used to preserve fish when canned . On its own, canned fish is a valuable alternative source of protein, when fresh fish is in short supply due to unfavourable fishing conditions. While fresh fish remains a major part of the diet in Vanuatu, it is not available in all areas and only seasonally in others as shown in Table 6. It has been proposed, somewhat controversially, by Dancause et al.  that fresh meat might be a better dietary option than tinned fish in some PICTs, at least from the point of view of preventing NCDs. This requires further investigation with well designed intervention studies, but is considered impractical due to the limited scope for grazing cattle in most PICTs, as well as lack of refrigeration for storage. Animal husbandry (chickens and pigs) is already practiced widely but may have limited potential for further expansion due to the high costs of imported feeds.
The challenge is to encourage Pacific Islanders to maintain traditional dietary patterns in the face of urbanisation accompanied by the nutrition transition. To date, there have been surprisingly few publications on interventions in this regard. In FSM, a health promotion programme that encouraged the consumption of local foods, including banana, taro and breadfruit, demonstrated increased dietary diversity through higher consumption of local foods and a decrease in consumption of imported foods (such as rice) . Such efforts could be used to promote the consumption of fresh fish in areas where intake of imported meats has become increasing prevalent.
Fishing is critical to household food security in PICTs through subsistence production and income generation (which allows food purchases) especially for communities that have limited opportunity to engage in other agricultural or economic sectors to produce food and/or income [63, 88]. For example, although Fiji is one of the more developed PICTs, both subsistence and commercial fisheries remain an important source of food and livelihoods .
In 2010, at the Pacific Food Summit, a Framework for Action on Food Security in the Pacific was developed with four goals aligned to the WHO’s four pillars for food security. The first goal, availability of food, has been addressed to some extent in the literature, with predictions that the majority of PICTs will have sufficient fish for local consumption and commercial activities, as long as Pacific Island governments provide greater access to regional tuna resources and the bycatch from industrial fishing operations for local consumption . Even so, inter-annual variation in where bycatch is landed by fishing fleets could cause temporary shortfalls in fish supply in some urban centres .
Strategies such as increasing nearshore FADs have shown promise in terms of how increased availability of tuna and other large pelagic fish can help provide the protein that communities need for food security and nutrition , however appropriate monitoring and management is required. Strategies based on facilitating the supply of locally-canned tuna to the large inland population of PNG have yet to be developed in any detail but are much needed [27, 31].
The overview study by Bell et al.  showed that ~50–90 % of fish consumed in rural areas of PICTs was obtained through subsistence fishing. Other research done by the Coastal Fisheries Programme at the Secretariat of the Pacific Community  shows that an average of ~50 % of surveyed coastal households in 17 PICTs derived their first or second source of income from catching or selling fish.
However, there is limited research relating to two of the other goals, namely access to food and food utilisation. These goals are concerned with households’ ability to grow or buy foods to meet dietary requirements for good health . The fourth goal, relating to stability of food systems, is beyond the scope of this literature review.
When planning policies and interventions to increase availability of fish, ease of access to fish, and utilization of fish in PICTs, it is important to consider other factors that may affect food intake. A lack of nutrition education and a decrease in knowledge of traditional food sources in several PICTs also means that many Pacific Islanders do not have the knowledge or skills to make food choices that will benefit their health [55, 59, 91, 92]. This is increasingly problematic as more imported unhealthy foods become readily available. Qualitative evidence suggests imported, foods such as canned meats may be increasingly preferred by Pacific Islanders over local foods, such as fresh fish, because they are associated with wealth and status . The ability to purchase imported foods is increasing for at least two reasons. First, more PICT communities are moving away from a subsistence to a cash-based economy. Second, increased migration to urban centres reduces opportunities for people to grow their own food, or have access to fish when it is difficult to transport them from remote areas to urban markets.
One of the limitations of this review is that the reported findings of detailed studies on consumption of fish are based on only a few of the PICTs, and primarily in coastal areas. Evidence from many PICTs has been limited to information derived from household income and expenditure surveys , with little data on the factors determining access to fish and use of fish at a local level. In addition, the majority of articles included in this review were cross-sectional, with only one longitudinal study and one case–control study. Comparison of fish consumption was also limited because measurement of fish consumption differed between studies in terms of daily frequency, meals per month and daily amount. No intervention studies were found assessing the effect of fish consumption on improved dietary intakes or health outcomes.
Finally, a lack of co-ordinated approaches between fisheries and health ministries has been acknowledged by the Secretariat of Pacific Communities (SPC) . This has hindered the development of integrated policies designed to achieve food security through improved management and sustainability of coastal fisheries, while at the same time preventing NCDs. Such approaches are a priority for the region and will require inter-sectoral dialogue and partnership.
Recent literature confirms assumptions that fishing remains a major contribution to food security in Pacific Island countries and territories, through subsistence production and income generation (which allows food purchases). However, there is a paucity of research on how maintaining and/or improving fish consumption benefits the nutritional quality of the diets and health status of Pacific Islanders as they contend with the ongoing nutrition transition resulting from the influx of foods that are high in fat, sugar and salt. Given the significance of fish to food security and livelihoods, it is time for the region to develop a more integrated and coordinated approach to fisheries, health and food policy that identifies research priorities within national development challenges. A research and policy framework is required that addresses looming food security and public health crises caused by declining fisheries productivity, coastal fisheries management, increasing populations, and rising NCDs.
body mass index
non communicable diseases
population, intervention, comparator, outcome
Pacific Island countries and territories
Barnett J. Dangerous climate change in the Pacific Islands: food production and food security. Reg Environ Chang. 2011;11 Suppl 1:229–37.
Secretariat of the Pacific Community Statistics for Development Division. Population and Demographic Indicators Update. 2013. 9 Feb 2015]; Available from: http://www.spc.int/sdd/.
Secretariat of the Pacific Community, Pocket Statistical Summary 2013. Noumea, New Caledonia: SPC; 2013.
United Nations Conference on Trade and Development. United Nations list of least developed countries. 2013. [cited 2015 20 April]; Available from: http://unctad.org/en/Pages/ALDC/Least%20Developed%20Countries/UN-list-of-Least-Developed-Countries.aspx.
Popkin BM. Global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases. Am J Clin Nutr. 2006;84(2):289–98.
Snowdon W et al. Processed foods available in the Pacific Islands. Glob Health. 2013;9:1.
Estime MS, Lutz B, Strobel F. Trade as a structural driver of dietary risk factors for noncommunicable diseases in the Pacific: an analysis of household income and expenditure survey data. Glob Health. 2014;10:48.
Thow AM et al. Trade and the nutrition transition: strengthening policy for health in the pacific. Ecol Food Nutr. 2011;50(1):18–42.
Taylor R et al. Dietary intake, exercise, obesity and noncommunicable disease in rural and urban populations of three Pacific Island countries. J Am Coll Nutr. 1992;11(3):283–93.
Hodge AM, Dowse GK, Toelupe P. Dramatic increase in the prevalence of obesity in western Samoa over the 13 year period 1978–1991. Int J Obes Relat Metab Disord. 1994;18(6):419–28.
Hughes RG, Lawrence MA. Globalisation, food and health in Pacific Island countries. Asia Pac J Clin Nutr. 2005;14(4):298–306.
Prentice AM. The emerging epidemic of obesity in developing countries. Int J Epidemiol. 2006;35(1):93–9.
Finucane MM et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9 · 1 million participants. Lancet. 2011;377:557–67.
World Health Organisation (WHO). Noncommunicable diseases country profiles 2011. France: WHO global report; 2011.
World Health Organisation Representative Office in the South Pacific. Noncommunicable diseases South Pacific situation summary. 2015. [cited 2015 4 June]; Available from: http://www.wpro.who.int/southpacific/programmes/healthy_communities/noncommunicable_diseases/page/en/.
Coyne T. Lifestyle diseases in Pacific communities. Noumea: Secretariat of the Pacific Community; 2000.
Knowles J. Review of the nutrition situation in fourteen Pacific Island countries: constraints and opportunities. Bangkok: United Nations Children’s Fund East Asia and Pacific Office; 2005.
Allen L. Anemia and iron deficiency: effects on pregnancy outcome. Am J Clin Nutr. 2000;71:1280S–4S.
Sachdev HP, Gera T, Nestel P. Effect of iron supplementation on mental and motor development in children: systematic review of randomised controlled trials. Public Health Nutr. 2005;8(2):117–32.
Hughes R. The Feasibility of micronutrient (iron) food fortification in Pacific Island countries. Philippines: World Health Organisation Western Pacific Regional Office; 2006.
Bosu, W.K., An overview of the nutrition transition in West Africa: implications for non-communicable diseases. Proceedings of the Nutrition Society; 2014
Conde WL, Monteiro CA. Nutrition transition and double burden of undernutrition and excess of weight in Brazil. Am J Clin Nutr. 2014;100(6):1617S–22S.
Rivera JA et al. Nutrition transition in Mexico and in other Latin American countries. Nutr Rev. 2004;62(7 II):S149–57.
Tzioumis E, Adair LS. Childhood dual burden of under- and over-nutrition in low- and middle-income countries: a critical review. Food Nutr Bull. 2014;35(2):230–43.
Winichagoon P. Transition of maternal and child nutrition in Asia: implications for public health. Curr Opin Clin Nutr Metab Care. 2015;18(3):312–7.
Oddo V et al. Predictors of maternal and child double burden of malnutrition in rural Indonesia and Bangladesh. Am J Clin Nutr. 2012;95(4):951–8.
Bell JD et al. Planning the use of fish for food security in the Pacific. Mar Policy. 2009;33(1):64–76.
Béné C et al. Feeding 9 billion by 2050 – putting fish back on the menu. Food Security. 2015;7(2):261–74.
Kawarazuka N, Bene C. The potential role of small fish species in improving micronutrient deficiencies in developing countries: building evidence. Public Health Nutr. 2011;14(1):1927–38.
Kawarazuka N. The contribution of fish intake, aquaculture, and small-scale fisheries to improving nutrition: a literature review, in The WorldFish center working paper No.2106. Malaysia: The World Fish Center; 2010.
Bell JD et al. Diversifying the use of tuna to improve food security and public health in Pacific Island countries and territories. Mar Policy. 2015;51:584–91.
Moher D et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9. w64.
Clero E et al. Dietary patterns, goitrogenic food, and thyroid cancer: a case–control study in French Polynesia. Nutr Cancer. 2012;64(7):929–36.
Vengiau G et al. Associations of socioeconomic status with diet and physical activity in migrant Bougainvilleans in Port Moresby, Papua New Guinea. Ecol Food Nutr. 2014;53(5):471–83.
Vengiau G et al. Diet and physical activity among migrant Bougainvilleans in Port Moresby, Papua New Guinea: association with anthropometric measures and blood pressure. Am J Hum Biol. 2012;24(5):716–8.
Clero E et al. Dietary iodine and thyroid cancer risk in French Polynesia: a case–control study. Thyroid. 2012;22(4):422–9.
Corsi A et al. A participatory assessment of dietary patterns and food behavior in Pohnpei, Federated States of Micronesia. Asia Pac J Clin Nutr. 2008;17(2):309–16.
Dewailly E et al. High fish consumption in French Polynesia and prenatal exposure to metals and nutrients. Asia Pac J Clin Nutr. 2008;17(3):461–70.
Li M et al. Iodine nutritional status of children on the island of Tanna, Republic of Vanuatu. Public Health Nutr. 2009;12(9):1512–8.
Phongsavan P et al. Health behaviour and lifestyle of Pacific youth surveys: a resource for capacity building. Health Promot Int. 2005;20(3):238–48.
Mertz O et al. Sustainable land use in Tikopia: food production and consumption in an isolated agricultural system. Singap J Trop Geogr. 2010;31(1):10–26.
Turner RA et al. Declining reliance on marine resources in remote South Pacific societies: ecological versus socio-economic drivers. Coral Reefs. 2007;26(4):997–1008.
Kronen M, Bender A. Assessing marine resource exploitation in Lofanga, Tonga: one case study - two approaches. Hum Ecol. 2007;35(2):195–207.
Guillemot N et al. Characterization and management of informal fisheries confronted with socio-economic changes in New Caledonia (South Pacific). Fish Res. 2009;98(1–3):51–61.
Kuster C, Vuki VC, Zann LP. Long-term trends in subsistence fishing patterns and coral reef fisheries yield from a remote Fijian island. Fish Res. 2005;76(2):221–8.
Dancause KN et al. Behavioral changes associated with economic development in the South Pacific: health transition in Vanuatu. Am J Hum Biol. 2011;23(3):366–76.
Craig P, Green A, Tuilagi F. Subsistence harvest of coral reef resources in the outer islands of American Samoa: modern, historic and prehistoric catches. Fish Res. 2008;89(3):230–40.
Léopold M, Ferraris J, Labrosse P. Assessment of the reliability of fish consumption as an indicator of reef fish catches in small Pacific Islands: the example of Ouvea Island in New Caledonia. Aquat Living Resour. 2004;17(2):119–27.
Smith BJ et al. Body mass index, physical activity and dietary behaviours among adolescents in the Kingdom of Tonga. Public Health Nutr. 2007;10(2):137–44.
Labrosse P, Ferraris J, Letourneur Y. Assessing the sustainability of subsistence fisheries in the Pacific: the use of data on fish consumption. Ocean Coast Manag. 2006;49(3–4):203–21.
Pobocik RS, Trager A, Monson LM. Dietary patterns and food choices of a population sample of adults on Guam. Asia Pac J Clin Nutr. 2008;17(1):94–100.
Aswani S, Furusawa T. Do marine protected areas affect human nutrition and health? A comparison between villages in Roviana, Solomon Islands. Coast Manag. 2007;35(5):545–65.
Konishi S et al. Energy and nutrient intake of Tongan adults estimated by 24-hour recall: the importance of local food items. Ecol Food Nutr. 2011;50(4):337–50.
Hedges R, Rush E, Aalbersberg W. Correspondence between human diet, body composition and stable isotopic composition of hair and breath in Fijian villagers. Isot Environ Health Stud. 2009;45(1):1–17.
Englberger L et al. Vitamin A intake and factors influencing it amongst children and caretakers in Kosrae, Micronesia. Ecol Food Nutr. 2005;44(4):307–38.
Latham MC. Human nutrition in the developing world. Rome: Food and Agriculture Organisation of the United Nations; 1997.
Van der Heijden P. Sources of animal protein in meals of the population of the Sepik-Ramu catchment. Sci New Guinea. 2006;28(1–3):3–8.
DiBello JR et al. Dietary patterns are associated with metabolic syndrome in adult Samoans. J Nutr. 2009;139(10):1933–43.
Dancause KN et al. Behavioral risk factors for obesity during health transition in Vanuatu, south pacific. Obesity. 2013;21(1):e98–e104.
O’Garra T. Economic valuation of a traditional fishing ground on the coral coast in Fiji. Ocean Coast Manag. 2012;56:44–55.
Middlebrook R, Williamson JE. Social attitudes towards marine resource management in two Fijian villages. Ecol Manag Restor. 2006;7(2):144–7.
Walker BLE, Robinson MA. Economic development, marine protected areas and gendered access to fishing resources in a Polynesian lagoon. Gender, Place Cult. 2009;16(4):467–84.
Cinner JE, Marnane MJ, McClanahan TR. Conservation and community benefits from traditional coral reef management at Ahus Island, Papua New Guinea. Conserv Biol. 2005;19(6):1714–23.
Albert JA et al. The contribution of nearshore fish aggregating devices (FADs) to food security and livelihoods in Solomon Islands. PLoS One. 2014;9(12):e115386.
Albert S et al. Indicators of coral reef ecosystem recovery following reduction in logging and implementation of community-based management schemes in the Solomon Islands. Pac Conserv Biol. 2014;20(1):75–85.
FAO Fisheries and Aquaculture Department. The state of world fisheries and aquaculture 2012. Rome: Food and Agriculutre Organization of the United Nations; 2012.
Cinner J. Socioeconomic factors influencing customary marine tenure in the Indo-Pacific. Ecol Soc. 2005;10:1.
Keeble R, Keeble J. Nutritional study of the 1–4 year old population of the Lower Jimi Valley, Western Highlands Province, Papua New Guinea. P N G Med J. 2006;49(3–4):156–61.
Aipit S, Aipit J, Laman M. Malnutrition: a neglected but leading cause of child deaths in Papua New Guinea. Lancet Global Health. 2014;2(10):e568.
Sulu RJ et al. Livelihoods and fisheries governance in a contemporary Pacific Island setting. PLoS One. 2015;10(11):e0143516.
Food and Agricultural Organisation of the United Nations. Nutrition country profiles - Fiji. Rome: Food and Agricultural Organisation of the United Nations; 2003.
Food and Agricultural Organisation of the United Nations. Nutrition country profiles - Papua New Guinea. Rome: Food and Agricultural Organisation of the United Nations; 2003. Available at: ftp://ftp.fao.org/es/esn/nutrition/ncp/pngmap.pdf. Accessed 17 Mar 2016.
Wook JC, Jeongseon K. Factors and the risk of thyroid cancer: a review. Clin Nutr Res. 2014;3(2):75–88.
Englberger L et al. Vitamin a deficiency among children ---federated States of Micronesia, 2000. MMWR Weekly. 2001;50(24):509–12.
Government of Kiribati and United Nations Children's Fund. Kiribati - a situation analysis of children, women and youth. Fiji: United Nations Children's Fund Pacific Office; 2005.
Palafox NA et al. Relationship of vitamin a deficiency, iron deficiency, and inflammation to anemia among preschool children in the Republic of the Marshall Islands. Eur J Clin Nutr. 2004;58(10):1396–401.
Christoforou A et al. Progress on salt reduction in the Pacific Islands: from strategies to action. Heart Lung Circ. 2015;24(5):503–9.
Webster J et al. Costeffectiveness of reducing salt intake in the Pacific Islands: protocol for a before and after intervention study. BMC Public Health. 2014;14:107–14.
Keighley ED, McGarvey ST, Quested C, McCuddin C, Viali S, Maga U. Nutrition and health in modernizing Samoans: temporal trends and adaptive perspectives. In: Ohtsuka R, Ulijaszek SJ, editors. Health change in the Asia-Pacific: biocultural and epidemiological approaches. Cambridge (UK): Cambridge University Press; 2007. p. 147–91.
Cassels S. Overweight in the pacific: links between foreign dependence, global food trade, and obesity in the federated States of Micronesia. Glob Health. 2006;2:10.
Kronen M. Fishing for fortunes? A socio-economic assessment of Tonga’s artisanal fisheries. Fish Res. 2004;70(1):121–34.
Dignan C et al. The Pacific Islands food composition tables. 2nd ed. Rome: Food and Agricultural Organisation of the United Nations; 2004.
Thaman RR. Deterioration of traditional food systems, increasing malnutrition and food dependency in the Pacific Islands. J Food Nutri. 1982;39(3):109–21.
Malcolm S. Nutrition investigations in the New Hebrides. Noumea, New Caledonia: Report On Research Conducted In the New Hebrides During 1951 Under Commission Project H.2-H.5; 1952. p. 55.
Coyne T, Badcock J, Taylor R. The effect of urbanisation and western diet on the health of Pacific Island populations. Suva, Fiji: South Pacific Commission; 1984.
World Health Organisation. Diet, food supply and obesity in the Pacific. Geneva: World Health Organization Regional Office for the Western Pacific; 2003.
Carlot-Tary M. 1998 Vanuatu non-communicable disease survey report. Noumea: Secretariat of the Pacific Community; 2000.
Kronen M et al. Socio-economic drivers and indicators for artisanal coastal fisheries in Pacific Island countries and territories and their use for fisheries management strategies. Mar Policy. 2010;34(6):1135–43.
Pinca, S., et al., Regional assessment report: profiles and results from survey work at 63 sites across 17 Pacific Island Countries and Territories. Noumea, New Caledonia: Pacific Regional Oceanic and Coastal Fisheries Development Programme (PROCFish/C/CoFish). 2010.
Food Secure Pacific Working Group & Pacific Food Summit, Towards a food secure Pacific. Framework for action on food security in the Pacific. Vanuatu: SPC; 2010.
Englberger L et al. Pohnpei, Federated States of Micronesia case study in a global health project documents its local food resources and successfully promotes local food for health. Pac Health Dialog. 2010;16(1):129–36.
Food and Agriculture Organisation of the United Nations (FAO). Nutrition education for the public. Discussion papers of the FAO expert consultation. United Nations. FAO Food Nutr Pap. 1997;62:1–212.
Anon A. new song for coastal fisheries – pathways to change: The Noumea strategy. SPC Fisheries Newsletter. 2015;146:37–46.
Vanuatu National Statistics Office. 2015. Feb 23 2015]; Available from: http://www.vnso.gov.vu.
United Nations Department of Economic Affairs. World Population Prospects: The 2012 revision. 2013. [cited 2015 10 Feb]; Available from: http://esa.un.org/wpp/Excel-Data/population.htm.
Vanuatu National Statistics Office and Secretariat of the Pacific Community, Vanuatu Demographic and Health Survey 2013. Noumea: SPC; 2014.
Vanuatu National Statistics Office, Main Report on the Household Income and Expenditure Survey 2006. Port Vila: Vanuatu National Statistics Office; 2006.
World Health Organisation. Global prevalence of vitamin A deficiency in populations at risk 1995–2005. WHO Global Database on Vitamin A Deficiency. Geneva: World Health Organisation; 2009.
World Health Organisation, Global Health Observatory Data Repository: Raised Blood Pressure. Geneva, Switzerland: World Health Organisation; 2008.
World Health Organisation, Global Health Observatory Data Repository: Raised Fasting Blood Glucose. Geneva, Switzerland: World Health Organisation; 2014.
World Health Organisation, Global Health Observatory Data Repository: Raised Total Cholesterol. Geneva, Switzerland: World Health Organisation: 2008.
FAOSTAT. Vanuatu Country Profile. 2011. [cited 2015 9 Feb]; Available from: http://faostat.fao.org/site/368/default.aspx#ancor.
Food and Agriculture Organisation of the United Nations. Country Profile: Food Security Indicators. Rome: FAO; 2009. Available from: http://www.fao.org/fileadmin/templates/ess/documents/food_security_statistics/country_profiles/eng/Vanuatu_E.pdf. Accessed 17 Mar 2016.
Gillett R, Lightfoot C. The Contribution of Fisheries to the Economies of Pacific Island Countries. Manila: Asian Development Bank; 2002.
Vanuatu National Statistics Office, 2009 National Population and Housing Census. Port Vila: Vanuatu National Statistics Office; 2009.
World Health Organisation Western Pacific Region, Western Pacific Country Health Information Profiles. Geneva Switzerland: World Health Organization; 2009. p. 102–7.
UN Inter-agency Group for Child Mortality Estimation (IGME). Country Specific Under-Five Mortality Rate. 2014. [cited 2015 10 Feb]; Available from: http://data.unicef.org./child-mortality/under-five.
Kiribati National Statistics Office and the Secretariat of the Pacific Community (SPC), Kiribati Demographic and Health Survey 2009. Noumea: SPC; 2010.
Kiribati National Statistics Office, Analytical Report on the 2006 Kiribati Household Income and Expenditure Survey. Kiribati: Kiribati National Statistics Office; 2006.
World Health Organisation, Global Health Observatory Data Repository: Overweight/Obesity. Geneva, Switzerland: World Health Organisation; 2014.
FAOSTAT. Kiritbati Country Profile. 2011. [cited 2015 9 Feb]; Available from: http://faostat.fao.org/site/368/default.aspx#ancor.
World Health Organization Nutrition Landscape Information System (NLiS). Iodized Salt Consumption.1998. [cited 2015 11 Feb]; Available from: http://apps.who.int/nutrition/landscape/report.aspx?iso=kir&print=1.
Kiribati National Statistics Office, Report on the Kiribati 2010 Census of Population and Housing. Kiribati: Kiribati National Statistics Office; 2010.
Tonga Department of Statistics and the Secretariat of the Pacific Community, Tonga 2011 Census of Population and Housing, Volume 2: Analytical Report. Noumea: SPC; 2014.
Tonga Department of Statistics. Health Statistics. 2014. [cited 2015 Feb 10]; Available from: http://www.spc.int/prism/tonga/index.php?option=com_content&view=article&id=27&Itemid=31
Tonga Department of Statistics Tonga Ministry of Health Secretariat of the Pacific Community and United Nations Population Fund, Tonga Demographic and Health Survey, 2012. Noumea: SPC; 2013.
Kingdom of Tonga Department of Statistics, Household Income and Expendicture Survey 2009. Nuku’alofa: Kingdom of Tonga Statistics Department; 2010.
Food and Agriculture Organisation of the United Nations. Fishery and aquaculture statistics: food balance sheets. Rome: FAO Yearbook of Fishery and Aquaculture Statistics; 2009. p. 55–68.
Ministry of Agriculture and Forestry and Statistics Department, Tonga Agricultural Census. Nuku’alofa: Department of Statistics; 2002.
Tonga Department of Statistics, Report on the Tonga Labour Force Survey 2003. Nuku ’alofa: Government of Tonga; 2004.
This study was supported by a research grant from the Global Challenges programme at the University of Wollongong.
The authors declare that they have no competing interests.
KC, QH and JR conceptualised the review, designed the PICO question and developed the search strategy. EG and JR conducted the literature search and summarised the review articles. EG prepared the first draft of the article. All authors contributed to synthesis of the results and editing of the final manuscript. All authors read and approved the final manuscript.
About this article
Cite this article
Charlton, K.E., Russell, J., Gorman, E. et al. Fish, food security and health in Pacific Island countries and territories: a systematic literature review. BMC Public Health 16, 285 (2016). https://doi.org/10.1186/s12889-016-2953-9
- Pacific Islands
- Food security
- Systematic review
- Non communicable diseases