Vitamin A deficiency (VAD) is a serious problem in the Federated States of Micronesia (FSM) and some other Pacific Island countries. VAD apparently emerged, along with certain chronic diseases, after great dietary and lifestyle changes in the 1970s. Rice, sugar, flour, refined food, fatty meats, and tinned fish, have increasingly replaced local island foods (starchy staples and seafood) in the diet, due to cost, convenience, status, government policies, food aid, and the shift from a subsistence to market economy. Programs to address the VAD problem focused on the promotion of dark green leafy vegetables (DGLV) and other local foods, including ripe papaya, known to be vitamin A (VA)-rich, but these foods were not well accepted and the programs had limited success. It was not clear as to what foods protected the FSM population in the past, as apparently DGLV and papaya were previously not commonly eaten. Little was known about the nutrient content of the different cultivars of the major food staples, banana, breadfruit, giant swamp tare, and pandanus, as few had been analysed.
Thus, a study was carried out to gain insight into factors affecting production, acquisition, consumption, and acceptability of the VA-rich foods in FSM and to identify potential local foods that may be effectively promoted in a sustainable food-based VAD prevention strategy.
A rigorous, comprehensive, multiple methodology study was designed with three parts including a nutrient analysis study, an ethnographic study using participant observation and key informant interviews, and a cross-sectional food habits study on a randomly selected population of preschool children and caretakers using trained interviewers, a 7-day food frequency questionnaire, three 24-hour recalls, and other questionnaires. Data were collected mainly in Kosrae, one of the four FSM states, from August 2000 to February 2002.
The nutrient analyses revealed that a number of the FSM staple foods contained high levels of carotenoids, including twelve banana, ten giant swamp tare, one seeded breadfruit, and three pandanus cultivars. A literature review revealed that some of these cultivars (now rare) had been very commonly eaten in the past (as documented in the early 1800s by early visitors to the islands) and were also a part of the legends. This indicates that it is likely that they contributed importantly to VA status in the past.
There were great differences in carotenoid content of the cultivars (β-carotene content of the 17 ripe banana cultivars analysed ranged from 30 to 6360 µg/100 g edible portion). The β-carotene content of one banana cultivar was 250 times the β-carotene content of the common Cavendish cultivar. Yellow/orange colouration of banana, pandanus, and to some degree, giant swamp tare, was closely related to carotenoid content. The results of two laboratories showed excellent consistency in the carotenoid results. Three fish livers were identified with high VA levels.
The food habits study showed that VA intake was very low. The mean intake was approximately half of the estimated requirements for children and female caretakers. Protein intake was high, and 50% of the VA consumed was of animal origin. The main dietary components included imported rice, flour, sugar, chicken, meats, and tinned fish and local breadfruit, banana, tare, and fish, with few fruits and vegetables. Female caretakers consumed significantly more local staple food, fish, and liver, than children, but levels of consumption of these were still low. VA intake was significantly greater in one location, indicating intracommunity cultural differences of food availability and acceptability. There were no clear trends relating gender, caretaker education, caretaker occupation, and socio-economic status with VA intake of children and caretakers, indicating that a broad-based intervention over all segments of the population is needed to change dietary behaviour.
Important implications were identified that would be relevant to a food-based intervention to alleviate VAD and chronic disease in FSM. Cultivar aspects are critical in determining VA intake and status and should be considered in establishing food policy and community dietary guidelines. Colouration of edible portion of banana, giant swamp taro, and pandanus may be used to estimate carotenoid content. Banana (commonly eaten cooked or raw), in particular the karat and taiwang cultivars, appeared to have the most potential for effective promotion. However, giant swamp taro, seeded breadfruit, and pandanus are also important to many islands and are among the only foods that can grow on some atoll islands. Due to different agriculture conditions and cultural factors, a VAD-prevention strategy would need fine-tuning in each FSM state to suit local conditions. Important strategies include raising status of local food and promoting food production for local consumption in national development programs and policies. As carotenoid-rich foods may protect against chronic disease, these foods should be promoted for the health benefits for both VAD and chronic disease. Exclusive breastfeeding in the first six months and greater breastfeeding duration; dietary improvement in pregnancy and lactation for contributing to infant VA stores, producing a VA-rich breast milk, and maternal health; and a greater parental control of young child feeding are other areas for increasing VA status in FSM.
Furthermore, it is suggested that many of the findings of this study are relevant to other countries in Micronesia and may be also relevant to other countries with similar agricultural resources. It is also maintained that this study with its multiple methodology approach offers a model for other nutrition-related studies, particularly those directed toward developing food-based health promotion programs.