Pacific approach to Diabetes – A Fijian perspective

Behind the tropical scenes of crystal-clear waters, swaying palm trees, and white sandy beaches, looms a significant health issue which has become a huge burden on the people of the Pacific Islands: Type 2 Diabetes Mellitus (T2DM). Recently, the International Diabetes Federation published information comparing the World T2DM prevalence, and it is worrying to see that five of ten countries with the highest prevalence of the disease are from the Pacific Islands (Ong et al., 2023; Ministry of Health, 2023; GBD 2021 Diabetes Collaborators, 2023).

Fiji, for example, a developing country with a population just shy of one million, has a diabetes prevalence of 15.6%. However, this estimate is likely to be higher because Fiji’s underdiagnosis prevalence is 75% (Morgan, 2015; Tukuitonga, 2016).  As countries like Fiji grapple with this crippling problem, there is concern that as people migrate, they take with them their cultural and social norms, and traditional carbohydrate-rich diet, which are factors that contribute significantly to high risks of diabetes (Dearie et al., 2019).

Signs of this are evident in New Zealand which hosts about 381,000 Pacific peoples, or 8% of the country’s population of 5.2 million. Data shows that the prevalence of diabetes among Pacific peoples in New Zealand are comparable to the results seen back home, with Pacific peoples having the highest prevalence of diabetes in the country. Prevalence is highest in the Tongan and Fijian communities (Figure 1), with 15% and 14% of their populations, respectively, having diabetes (Ministry of Health. 2023). The stark disproportionate difference in the prevalence of diabetes in Pacific peoples underscores the need for a targeted approach that focuses on disease prevention by addressing modifiable risk factors, weight, diet, and exercise or physical activity.

Figure 1: Diabetes prevalence in selected countries (type 1 and 2 combined) – Ages 20 to 79: (Ministry of Health. 2023).

Diabetes Risk Assessment

Using a valid risk assessment tool is crucial in assessing and preventing the rising prevalence of T2DM. In New Zealand, that tool uses a clinical parameter to determine the risk: obesity, level of physical activity, food high in fat and sugar, history of diabetes in the family, Māori or Pacific descent, history of gestation diabetes, age group between 35 and 64, and over 65 years of age. A score of six or more means a high risk of T2DM, and a score of less than six indicates a low risk. Risk assessment is crucial for empowering people to understand their risk status and then being able to take proactive steps to prevent the onset of the disease. The New Zealand risk assessment tool is an easy-to-use guide for assessing diabetes risk. It was adopted from the American Diabetes Association and validated by the Centre for Disease Control. It has a Pre-diabetes Risk Test sensitivity of 78.9 and a specificity of 82 (Aldayel et al., 2021).

In disease prevention, understanding the risk of the priority population is crucial in being able to gauge the depth of the problem, create policies, and direct intervention where it is needed the most.

In 2023, a survey was conducted to assess the risk of T2DM among the iTaukei (Indigenous Fijians) in New Zealand. The study explored mitigating strategies derived from Talanoa (open discussions) with community leaders and volunteers.  According to data from the New Zealand Diabetes Risk Assessment tool, of the 110 iTaukei participants, 94% of the over-18 years who took part had a high risk of the disease (Devnet, 2024). After informing the community of their diabetes risk, 63% agreed to live a more active lifestyle to reduce their risk of diabetes (Devnet, 2024). This subjective response to behavioural changes following a disease-risk assessment, aligns with the principles of the health belief model.

There are many ways of promoting health and managing the high prevalence of diabetes among the iTaukei in New Zealand.  Data from the risk-assessment activity show that perceived susceptibility and severity can lead to behavioural change. The study revealed that 63% of the participants were willing to adopt a more active lifestyle through regular physical activity, a healthy diet, and a standard Body Mass Index.

Culture-Based Response:

Collectivism has always been a strength of Pacific people, including the Fijian diaspora. While evidence shows a high prevalence of diabetes among Fijians and Tongans in New Zealand, disease mitigation, particularly within the Fijian community, can be achieved through cultural and practical means. One such method is the culture of Solesolevaki, or communal work, which a community Talanoa identified as a possible response against the scourge of diabetes.

Solesolevaki, a Fijian traditional practice, offers a platform for community members to work towards goals set by the village chief (Vunibola & Scheyvens, 2019). In New Zealand in 2022, the Kadavu Canterbury Club Incorporated used Solesolevaki to develop an initiative that led to the construction of 20 raised garden beds in Christchurch that club members used to grow vegetables. Apart from its primary goal of promoting healthy eating for members, the garden also became a catalyst for social wellbeing, cultural reconnection, mental and physical health, and economic stability. The importance of the vegetable garden was underscored by a club member’s comment that it was “too expensive to live a healthy lifestyle in New Zealand”.  Solesolevaki, therefore, proved that it could provide a cost-effective approach to achieving optimal community health (Vunibola & Scheyvens, 2019). In this example, Solesolevaki encouraged high-intensity physical activities in a friendly and sociable manner.  It not only facilitated the achievement of the primary goals, it also provided a platform for social interaction, the sharing of community news, and quality family time. For good health, the World Health Organisation (WHO) recommends 150 minutes of moderate-intensity physical activity per week. By engaging in community gardening through Solesolevaki, all the participants can collectively meet this recommendation, and attain both physical health and community cohesion (DevNet, 2024).

We live in a time where some children spend long hours watching television or playing video games. While television and computers can be educational, too much screen time has been shown to affect academic performance, social and emotional growth, and cause obesity and mental health problems. In response, Solesolevaki encourages children to work outside to minimise their screen time, breathe fresh air and talk to other people. (Muppalla et al., 2023).

Sometimes, promoting health and wellbeing needs a bottom-up, community-based approach, as shown through the Solesolevaki method. This approach can empower the community to lead cultural programmes that foster personal growth, better relationships, autonomy, and competence – elements that are crucial for building self-determination and community resilience (DevNet, 2024).

Figure 2: Kadavu Canterbury Club Incorporated members practicing Solesolevaki in Christchurch. A Fijian cultural approach to health and wellbeing in the community.

Reference:

1. Aldayel, F. A., Belal, M. A., & Alsheikh, A. M. (2021). The Validity of the American Diabetes Association’s Diabetes Risk Test in a Saudi Arabian Population. Cureus, 13(9), e18018. https://doi.org/10.7759/cureus.18018
2. Ministry of Health. 2023. Te Mana Ola: The Pacific Health Strategy. Wellington: Ministry of Health. https://healthierlives.co.nz/wp-content/uploads/Economic-and-Social-Cost-of-Type-2-Diabetes-EXEC-SUMMARY-ONLY.pdf
3. Hallberg, S. J., Gershuni, V. M., Hazbun, T. L., & Athinarayanan, S. J. (2019). Reversing Type 2 Diabetes: A Narrative Review of the Evidence. Nutrients, 11(4), 766. https://doi.org/10.3390/nu11040766https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520897/
4. DevNet Development Field Research Awardee- Esala Vakamacawai, University of Canterbury. (2024, February 20). Devnet: The Aotearoa New Zealand International Development Studies Network; DevNet. https://devnet.org.nz/esala-vakamacawai-university-of-canterbury/
5. Vunibola S, Scheyvens R. Revitalising rural development in the Pacific: An iTaukei (indigenous Fijian) approach. Development Bulletin. 2019; 81, 62–66. https://mro.massey.ac.nz/items/df303c1a-175e-41d5-87e2-51f3b0aa0cf3
6. Dearie, C., Dubois, S., Simmons, D., MacMillan, F., & McBride, K. A. (2019). A qualitative exploration of Fijian perceptions of diabetes: identifying opportunities for prevention and management. International journal of environmental research and public health, 16(7), 1100.
7. GBD 2021 Diabetes Collaborators (2023). Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet (London, England), 402(10397), 203–234. https://doi.org/10.1016/S0140-6736(23)01301-6
8. Muppalla, S. K., Vuppalapati, S., Reddy Pulliahgaru, A., & Sreenivasulu, H. (2023). Effects of Excessive Screen Time on Child Development: An Updated Review and Strategies for Management. Cureus, 15(6), e40608. https://doi.org/10.7759/cureus.40608