Charlton et al. BMC Public Health (2016) 16:285
DOI 10.1186/s12889-016-2953-9

RESEARCH ARTICLE

Open AccessFish, food security and health in PacificIsland countries and territories: a systematic
literature review
Karen E. Charlton1*, Joanna Russell2, Emma Gorman2, Quentin Hanich3, Aurélie Delisle3, Brooke Campbell3
and Johann Bell3,4

Abstract
Background: Pacific Island countries and territories (PICTs) face a double burden of disease, with a high prevalenceof household food insecurity and childhood micronutrient deficiencies, accompanied by a burgeoning increase in
adult obesity, diabetes and heart disease.
Methods: 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.
Results: A total of 29 studies were reviewed. Fourteen studies identified fish as the primary food source for PacificIslanders 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 wasaddressed 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 householdincome and livelihood varied between and within PICTs. For more economically developed countries, householdincome was derived increasingly from salaried work and dependency on fishing activities has been declining.
Conclusions: Fishing remains a major contributor to food security in PICTs, through subsistence production andincome generation. However, there is a paucity of research aimed at assessing how maintaining and/or improving fishconsumption 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 andanimals.
Keywords: Pacific Islands, Food security, Fish, Systematic review, Non communicable diseases

Background
The Pacific Island region comprises 22 countries andterritories 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 Micronesianislands (Table 1) are either volcanic areas or low lying
coral atolls [1]. Population sizes vary from as little as1,200 in Tokelau, the smallest Pacific Island territory to* Correspondence: karenc@uow.edu.au
1
School of Medicine, University of Wollongong, Wollongong, NSW 2522,
Australia
Full list of author information is available at the end of the article

7.4 million in Papua New Guinea, the largest PacificIsland country [2]. GDP per capita is low in most PacificIsland countries and territories (PICTs), ranging from
US$1,651 in Kiribati to US$36,405 in New Caledonia [3]with five PICTs (Kiribati, Samoa, Solomon Islands,
Tuvalu and Vanuatu) currently classified as Least Developed Countries [1, 4].
The nutrition transition [5] is well underway in PICTs.
Dietary patterns have shifted since the 1970–80s fromreliance on traditional low fat diets, typically based oncomplex carbohydrates, fresh fish and meat and leafy
greens, to increasingly modern diets, based on refined
starch, oils, processed meats and confectionary [6–10].

© 2016 Charlton et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Charlton et al. BMC Public Health (2016) 16:285

Table 1 Pacific Island countries and territories
Melanesian

PolynesianFiji

American Samoa

Federated States of Micronesia

New Caledonia

Cook Islands

Guam

Papua New Guinea

French Polynesia

Kiribati

Solomon Islands

Niue

Marshall Islands

Vanuatu

Micronesian

Pitcairn Island

Nauru

Samoa

Northern Marianas Islands

Tonga

Palau

Tokelau
TuvaluWallis and Futuna

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[11]. Moreover, such diets have been identified as a major
contributor to the double burden of communicable andnon communicable diseases (NCDs) in the region [6, 12].
NCDs now account for between 60 and 80 % of all deathsin the region [13, 14] and the prevalence of diabetes andobesity are among the highest in the world [15]. At thesame time, the incidence of malnutrition and vitamin andmineral deficiencies continue to be major public healthconcerns [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) [20]. As has been reported in otherlow-income countries [21–26], it is not uncommon to findboth malnourished children and overweight/obese adults
co-residing in the same household [12].
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 andnutritious food in the future [28].
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

Page 2 of 26

world [27]. It is acknowledged that increased fish supplies are needed to meet growing food security
demands [31]. 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 offish consumption to nutritional status, as well as indirect
benefits to nutritional status and food security resulting
from improvements in livelihoods related to fishing.

Methods
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 toreduced availability or access, improve a) household foodsecurity and b) individual nutritional status? Depending
on individual study designs, relative availability or accessto fish was compared between communities or provinces
within a single country, or between countries and/or thethree Pacific sub-regions. In the case of studies conducted
over different time periods, this was also analysed aschange 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 comprisingmore than a single person. In relation to nutritional status,
the influence of fish consumption on both under andover-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 andMedline 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Charlton et al. BMC Public Health (2016) 16:285

Page 3 of 26

Table 2 Search terms used to identify articles for review
Keywords“Pacific Island*” OR Kiribati OR Tuvalu OR Micronesia OR “Papua New Guinea” OR Nauru OR Palau OR “Solomon Island*” OR “MarshallIsland*” OR Samoa OR “American Samoa” OR “Cook Island*” OR Fiji OR “New Caledonia” OR Tokelau OR “French Polynesia” OR Niue OR
Tonga OR Guam OR Vanuatu OR “Pitcairn Island” OR “Wallis and Futuna” OR “Northern Mariana Island*”
AND

Fish*

OR

“Food securit*” OR “food insecurit*” OR “food suppl*”

OR

Nutrition OR “nutrition* status” OR “nutrition* outcomes” OR malnutrition OR “under nutrition” OR diet OR wasting OR stunting OR
underweight*denotes that any word preceded by this term could be included as a search term

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 productand 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 ofrecords. To remove subject areas irrelevant to thereview, 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 andexclusion criteria. Eligibility of any remaining articles
was determined through a full text assessment. Where
there were aspects of doubt over a study’s eligibility, theTable 3 Subject areas excluded using database functions
ScopusWeb of Science

MedlineNeuroscience

Parasitology

Psychology

Toxicology

Function notavailable

Computer science

Infectious diseases
Pharmacology andpharmacy

Dentistry
Chemical engineering

Nuclear science
technology

Engineering

Clinical neurology
Neurosciences

Mathematics
Material sciences

Surgery

Medicine researchPhysics and astronomy
Pharmacology, toxicology experimental
and pharmaceutics
Engineering chemical
Virology
Computer scienceinterdisciplinary applications
Radiology nuclear medicine
medical imaging
Operations research
management science

investigator conducting the search (EG) sought a second
and third opinion from other members of the researchteam. The review followed the PRISMA guidelines [32]for reporting systematic literature reviews.
Online resources, including the websites of the Foodand Agricultural Organisation (FAO), the World HealthOrganisation (WHO), the World Bank, WorldFish, theSecretariat of the Pacific Community and the United
Nations International Children’s Emergency Fund werealso 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 examinedin more detail to identify economic, demographic andhealth differences among sub-regions. These islands were
Vanuatu in Melanesia, Kiribati in Micronesia and Tonga
in Polynesia.

Results
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 inTables 6, 7 and 8. Only relevant papers identified using
the defined search strategy are cited in the tables
whereas additional sources of information are includedin the Discussion.
Fish consumption
Fish intake in Pacific Islanders

Fish was identified as a primary food source for PacificIslanders in 15 studies [36–50] although the amount andtype 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.

Page 4 of 26

Search one: Scopus
Total results: 1892

Screening

Identification

Charlton et al. BMC Public Health (2016) 16:285

Search two: Medline
Total results: 631

Number of records after duplicates removed: 3110

Number of records screened: 3110

Number of full-text articles

Eligibility

assessed for eligibility: 122

Included

Search three: Web of Science
Total results: 1631

Number of records excluded: 2988

Number of full-text articles
excluded:
Review (29)Book chapter (1)Non free-living individuals (1)Focuses on contribution offisheries to national revenue(7)
Fish consumption in ancient
Pacific Island communities (2)Dietary intake/nutritional
status with no link to fishconsumption (21)
Describes fishing activity withno link to income generationor subsistence production (8)Total number of studies
included: 31

Fig. 1 PRISMA flowchart of search process [32]American Samoa

A study of subsistence fishing practices in two outerislands 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 withlocal elders suggested that fishing activities had notchanged much over their lifetime and that there were
ample fish resources still available [47].

Federated States of Micronesia

In Pohnpei, an island in the Federated States ofMicronesia (FSM), 79 % of adults reported frequent consumption of fresh fish and/or seafood with locallycaught 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 [37]. This contrasts toresults from the Health Behaviour and Lifestyle ofPacific 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 highconsumption of processed foods such as canned meatand carbonated beverages [40].
FijiFish intake in Fiji was assessed by Kuster et al.[45] andTurner et al. [42]. In a comparison of subsistence fishingpatterns between 1982 and 2002 on Ono-i-Lau Island,
Kuster et al.[45] 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 overthe previous 10 years to an average current consumption
level of three days per week. The decline in frequency offish consumption was associated with higher householdincome. In Naikeleyaga, the Lau island village with thehighest annual household income, participants reported
the frequency of fish consumption declined from four toPopulation

Designb

Outcome measuresb

Key findingsb

Hedges et al.
[54]

20 non-pregnant
non nursing females
in Verata

Cross sectional study :a) Food records - foodand beverages consumed
over two x weekly periods,
3 weeks apart

Energy derived fromprotein, fat and carbohydrate(CHO), intake of protein andsources of protein intake

Mean energy from protein/carbohydrate/
fat over the 2 weeks was 13 %/66 %/21 %respectively.Mean intake of energy was
9080 KJ/day.
Mean intake of protein was 70.6 g.
Primary sources of protein were cereals(3.7 % of protein energy) followed byfish (3.4 %), meat (1.7 %) and shellfish (1.5 %). Higher consumption ofmarine foods was associated withlower cereal intake (−0.54).

Kuster et al. [45]Ono-i-Lau Island30
senior heads ofhouseholds in
198259 households
in 2002

Cross sectional

Mean weekly household income
and fish yield per capital.
Daily fish intake per capita (g)and contribution of marine
sources to protein intake.

Total annual landings of finfish
decreased by 27 % from 1982
to 2002
No significant change in yieldof finfish per capita of population(96.9 kg per capita/year in 1982
to 93.7 kg capita/year in 2002)
Seafood remained the main
source of protein between
1982 and 2002.
Consumption of canned
fish increased from 9g/man/day to 19 g/man/day

Turner et al. [42]

Lau Province, 25
experienced local
fishers53 seniorheads of households

Cross sectional
Semi structured
face-to-face interviews

Time spent fishing, importanceof fishing for income generation,
patterns of fish consumption andawareness of ecological change
within the local qoliqoli(fishing ground)No significant change in overall timespent fishing in the past 6–10
years.Income-generating activities had
increased in importance over previous10
years relative to fishing activities Consumptionof fresh fish was significantly lower comparedto estimates of past consumption (Z = −3.774,
p < 0.001).
Greatest decline in fish consumption was
associated with highest mean householdincome.Of the 80–100 % of households
that engaged in fishing, only 7 % ofhouseholds ranked fishing as the primaryhousehold occupation.

146 local fishers on
the North west coast

Cross sectional study:
Face-to-facequestionnaire

Average number of fishingtrips per year, average catch
per fishing trip (kg) and annual
reef fish consumption per capita

Total catches of reef fish estimated at
169 t/year.7720 fishing trips made/year.
Mean catch per fishing trip per boat was
23 kg.Annual reef fish consumption
estimated at 18 kg/person/year

Reference
Melanesia
FijiCharlton et al. BMC Public Health (2016) 16:285

Table 4 Characteristics and main findings of studies assessing fish consumptiona

New Caledonia

Labrosse et al. [50]Page 5 of 26

Guillemot et al.
[44]646 individuals aged
over 7 years, in the
Northern Province

Cross sectional study:
Face-to-face 13-item
questionnaire

Weekly and annual fish
intake, quantity of fish
per meal (g), subsistence
versus purchased fish
intakeOnly 1.3 % of the participants reported
never eating fish. 85 % of participants
ate fish 1 or more times a week, with
45 % of these eating fish 2–3 times/week
and 11 % consuming fish 1–2/day.Average
weekly consumption of fish was 4.8
meals ± 0.7.
Average quantity of fish consumed ata meal was 233 g ± 16 g.92 % percent
of annual fish consumption was classified
as subsistence with only 8 % purchased.

38 households on
Ouvea Island

Cross sectional study:
Face-to-face household
questionnaire

Annual fish consumption
per household and per
consumption unit (CU)

Annual fish consumption per household
was a mean 289 kg.Mean fish consumption
per CU was 63 kg ± 9.7 kg (SD).Subsistence
production was the main source of supplyof fish for two thirds of households, followedby gifts and purchases from the market.

Aswani & Furusawa[52]

Five villages in the Roviana
Lagoon,106 adult males andfemales 574 males and females
aged ≥15 years 437 males andfemales ≥18 years(231 in 2001
and 206 in 2005)

Cross sectional
Face-to-face semi-structured
interviews, 24 h dietary recall
Anthropometric assessment
and 1 h dietary recall questionnaire

Contribution of marine
resources to protein intakeEnergy (MJ)
and protein (g) intake

64 – 100 % of all participants identified
fish as the main source of protein
consumed by their householdMales
and females consumed a sufficient amountof protein according to the FAO/WHO/UNU
reference values 1985.Between 2001 and2005 mean energy intake in both males(P < 0.01) and females (P < 0.0001) increased.
There were no statistically significant changes
in BMI for either males or females between
2001 and 2005.

Mertz et al.
[41]

46 heads of households
in Tikopia

Cross sectional
Face-to-face household
questionnaire

Fish and meat intake;

Fish consumed daily by 72 % of households.
Main source of dietary protein was fish
Imported canned fish and meat were eaten
when available, but was rarely available.

van der Heijden[57]

609 individuals residing inhigh, middle and low altitude
villages in the Ramu catchment
and 204 fishers from the Yonki
Reservoir (high altitude)

Cross sectional study:
Structured face-to-faceinterviews

Contribution of fishto intake of animal
based foods

Fish and other aquatic animals caught innearby waters contributed 7.7 % of foodfrom animal sources for high and middle
altitude participants.Fish was the mostimportant source of animal protein for low
altitude respondents (41 % of all food fromanimal sources) and the second mostimportant source for respondents at
Yonki Reservoir (25 % of all food from animal
sources).Canned fish and lamb flaps were themost commonly purchased animal foods

Vengiau et al. [34]70 adult Naasioi migrants
residing in Port Moresby
aged 18–65 years

Cross sectional study:Face-to-face
39-item FFQ (foods were classified
as ‘traditional foods’ or ‘store foods’)

Association between
socio-economic status
and food intake type“Socio-economic index” was positively
correlated with greater consumption of“traditional foods” e.g., bananas, tubers,

Leopold et al.
[48]

Charlton et al. BMC Public Health (2016) 16:285

Table 4 Characteristics and main findings of studies assessing fish consumptiona (Continued)

Solomon Islands

Papua New Guinea

Page 6 of 26

Assessment of household socio-economic
status determined by fortnightly income,educational level, house type and numberof household possessions

fruits and vegetables compared to“store foods” e.g., rice, noodles, canned
fish and soft drink (P = 0.04)

70 adult Naasioi
migrants residing
in Port Moresby
aged 18–65 years

Cross sectional study:
Face-to-face 39-item FFQ
to establish key dietary patterns
Anthropometric assessment
including height (cm), weight(kg), and blood pressure (BP)Identification of key dietary
patternsAssociation between
dietary pattern and BMI (kg/m2)
and blood pressure (mm Hg)

Two dietary patterns emerged. ‘Traditional diet’- which was correlated with consumptionof bananas, tubers, other sweet potato,pawpaw and leafy greens and negatively
correlated with consumption of rice, canned fishand soft drinks. The second dietary
pattern was correlated with consumption of
store bought foods e.g., rice, noodles, canned
fish and soft drinksMedian BMI was 27 infemales and 29 in males. 38 % of females
and 23 % of males classified as obese (BMI ≥ 30).
Systolic BP was > than 140 mm Hg in 8 % offemales and 19 % of malesDiastolic BP was >than 90 mm Hg in 10 % of females and 13 %of males.No association was found between
cardiovascular risk factors (BMI and BP) anddietary patterns

Dancause et al.
[46]

425 children and 559 adults
on three islands varying ineconomic development(Ambae, Aneityum and Efate)

Cross sectional study:
Face-to-face behavioural
questionnaire24 h dietary
recallBehavourial changes
within and among islands
associated with economic
development

Hypertension or CVD among family members
was reported by 19.7 % of participants in
Ambae, by 35.3 % in Aneityum and 45.1 % in
Efate.
Overweight and obesity amongst family
members was reported by 24.8 % ofparticipants in Ambae, 48.0 % in Aneityum
and 39.6 % in Efate.
Fresh fish intake ranged from approximately
10 % in Ambae to 50 % in Aneityum. Meat
and/or fish intake was highest in Efate,
followed by Aneityum then Ambae (P < 0.001).
Tinned meat was consumed only monthly or
yearly by the majority of participants in Ambaeand Aneityum, compared to consumption
daily or weekly for 80 % of participants in
Efate.
Children in Efate reported taking more
processed foods to school compared
to children from Aneityum and Ambae whoreported taking more local foods to school.

Dancause et al.[59]534 males and females
aged ≥18 years on threeislands: Ambae, Aneityum
and Efate

Cross sectional study:
Face-to-face behavioural
questionnaire24 h dietary
recall questionnaire
Anthropometric assessment
including height, weight (kg),

Association between fishand meat intake andanthropometric measures

For males and females means of anthropometricmeasures were lowest in Ambae (rural),intermediate in Aneityum (ruralwith tourism) and highest in Efate (suburban).
Risk factors for obesity included
consuming canned fish (OR 2.91,

Vengiau et al. [35]Charlton et al. BMC Public Health (2016) 16:285

Table 4 Characteristics and main findings of studies assessing fish consumptiona (Continued)

Republic of Vanuatu

Page 7 of 26

95 % CI; P = 0.020) and consuming multiple
fish/meat dishes (OR 3.24, 95 % CI; P = 0.010)
153 school children
aged 8–10 years fromfour locations on theisland of Tanna

Cross sectional study:
Face-to-face dietary
surveySpot urine sample
Thyroid volume

Intake of fish and typeof fish consumed
Median urinary iodine
excretion (UIE), iodine
sufficiency and association
between fish consumption
iodine sufficiencyAssociation
between thyroid volume
and UIE

39 % of children reported eating fishon at least a weekly basis and 44 % on
a monthly basis. Canned fish consumption
was reported by 70 % of participants.
Eating fish at least monthly was associatedwith urinary iodine sufficiency (UIE > 100 ug/L,
P = 0.011; P = 0.045 after adjusting for location,
age and sex).Children were moderately iodine
deficient and had much larger thyroid
glands compared to international reference values.
A statistical significant inverse correlation
between thyroid volume and UIE for boys(r = −0.444, P = 0.001; n 77) and girls (r = −0.319,
P = 0.005; n 76)

229 cases :203 women and
26 men diagnosed with thyroid
cancer from 1979 to 2004371
controls: matched to cases bysex and age

Case–control study:
66-item FFQ

Energy intake (kcal),iodine nutrition status
and risk of thyroid
cancerCases consumed a mean 71 g/day of fish and shellfish
compared to 83 g/day in controls.Iodine nutrition
deficiency (<150 ug/day) was observedin 60 % of cases and controls. 30 % had optimal iodine
nutrition (150–299 ug/day).Risk of thyroid cancer
decreased significantly with increasing
consumption of fish (P = 0.008) and shellfish(P = 0.002). Subjects with a severe or moderate iodine
nutrition deficiency had a 2.6 times
increased risk of thyroid cancer (95 % CI: 1.12,
5.93) compared to subjects with optimal iodine
nutrition status.

Clero et al.[33]229 cases :203 womenand 26 men diagnosed
with thyroid cancer from1979 to 2004371 controls:
matched to cases bysex and age

Case–control study:
66-item FFQ

Association between
dietary pattern andthyroid cancer risk

2 major dietary patterns were identified:Western and traditional Polynesian.
The traditional Polynesian pattern was
inversely associated with risk of thyroid cancer.
After adjustment for total energy intake,a 42 % reduced risk of thyroid cancer was
found for the highest vs. the lowest tertile:(OR −0.58; 95 % CI: 0.35, 0.95; P = 0.02).
The decreased risk was attenuated after
multivariate adjustment (p = 0.2)

Dewailly et al.[38]214 pregnant women
who gave birth between
October 2005 and February
2006 and their neonates

Cross sectional study:
Face-to-face survey
Blood sample takenfrom the umbilicalcord of neonates

Monthly fish intake(meals/month) including
type of fishIodine (I),selenium (Se) and omega 3
polyunsaturated fatty acid(n-3 PUFA) concentrations

In pregnant women, mean fishconsumption was 33 meals/monthof which 21.3 and 11.5 meals/
months were from reef and pelagic
fish respectively. Tuna (75 %) was
the most common pelagic fish
species consumed.Mean umbilicaliodine cord blood concentrations

Li et al. [39]Charlton et al. BMC Public Health (2016) 16:285

Table 4 Characteristics and main findings of studies assessing fish consumptiona (Continued)

Polynesia
French Polynesia
Clero et al. [36]Page 8 of 26

varied between different archipelagos.
Highest mean concentration of iodine
was 2.60 umol/L and the lowest was
0.46 umol/L. Mean cord blood
selenium concentration was 2.0
umol/L. Mean concentration of
n-3 PUFAs in red cell membrane
phospholipids was 3.52 %.
Eicosapentanoic acid (EPA) anddocosahexanoic acid (DHA)
represented 87 % of all n-3 PUFAs
Kingdom of Tonga
19 females (aged 40–59 years)
and their spouses (15) from
Kolovai village

Cross sectional study:
Face-to-face 24 h dietary
recall administered over 7
consecutive days during
two different seasons
Anthropometric assessmentof weight and height

Protein intake (g) andcontribution of local fish
and imported meats tonutrient intakeWeight (kg),height (cm) and BMI (kg/m2)

Daily protein intake was 112 g and 97 g
for men and women respectively.
97 % of participants were considered
to have adequate protein intake.Fishcontributed 20 % toward total protein intake
compared to the sum of the two major
imported meats mutton and chicken(23 % of total protein intake). Mutton(23 %) and chicken (10 %) were the highest
sources of fat in the diet.Mean BMI was
32.3 kg/m2 ± 4.4 kg/m2 and 36.3 kg/m2 ± 5.4 kg/m2
for men and women respectively

Kronen & Bender [43]Lofanga Island
Individual adults(>15 years), households,
key informants, 41 local
fisherman

Mixed methods
Households andindividuals: structured
questionnaires.
Key informant interviews
Fishermen: Semi-structured
interviews

Fishing practices
including contributionof fish to livelihood andweekly fish consumption
throughFisheries, agricultural production
and handicrafts all contributed
to income generation. Fisheriesranked higher than agriculture
and handicrafts.Fisheries filled
three main objectives: to securesubsistence, fulfil social obligations
and contribute to the cash
economy.
Fisha was consumed by entire community.
93 % of village also consume other seafood
and 78 % consume canned fish.

Smith et al. [49]443 school students
aged 11–16 years from
Tongatapu, Vava’uand Hapa’ai.

Cross sectional study:
Self-administered healthbehaviour survey
Anthropometricassessment includingheight (cms) andweight (kgs)

Intake of canned fish,
mutton and beef
Prevalence ofoverweight and obesity

35 % of participants reported consuming
canned fish once or more a day compared to
57 % who reported consuming canned mutton
or beef once or more a dayThe prevalence ofoverweight and obesity was 36 % amongst
boys and 54 % amongst girls using international
cut-off points for BMI.

Cross sectionalObservationof fishing activities andsemi-structured interviews

Annual fish consumption

Per capita fish catch was 71 kg.63 kg of catch
was consumed per capita per annum.Remaining
catch was either sold locally (60 % of fishers

Samoa and American Samoa
Craig et al. [47]594 fishermen and 20 males
aged 43–72 years from Ofu,

Page 9 of 26

Konishi et al.
[53]

Charlton et al. BMC Public Health (2016) 16:285

Table 4 Characteristics and main findings of studies assessing fish consumptiona (Continued)

DiBello et al. [58]Olosega and Sili villages in
American Samoa

with fishermenFree-form
interviews of 20 males

sold catch at least occasionally) or sent
to family members on Tutuila Island.

723 American Samoans
and 785 Samoans aged
≥18 years

Cross sectional study:
Anthropometric assessment(weight (kg), height (cm) andwaist circumference). Fastingblood samples and bloodpressure were measured.FFQ (42-item American Samoa
and 55-item Samoa)

Prevalence of metabolic
syndromeAssociation
between dietary pattern
and metabolic syndrome

The prevalence of metabolic syndrome
was 49.4 % and 30.6 % in American Samoan
and Samoan samples respectively‘Neo
traditional’ and ‘modern’ dietary patterns
derived.
The ‘neo-traditional’ pattern was characterisedby high intake of crab and lobster, fish,coconut cream dishes, papaya soup, coconut
milk, papaya.
Significant increasing prevalenceof metabolic syndrome across increasing
quintiles of the ‘modern’ dietary pattern
in Samoa (P = 0.05).
The ‘neo-traditional’ dietary pattern was
associated with an increase in HDL cholesterolin America Samoa (P = 0.02) and decreased
waist circumference in both communities(P = 0.03).

Cross sectional study:
27-item, 7-day FFQ
Knowledge, attitudes
and practices questionnaire

Fish and meat
consumption
Cash expenditure
on food; factors
affecting food intake

79 % of participants reported frequentconsumption of local fish/seafood.
Local fish/seafood was consumed twice
as frequently (4.8 days/week) compared toimported fish/seafood (2.4 days/week).
Imported meats such as turkey tail wereconsumed more frequently 1.9 days/week)
than local meats (1.3 days/week).8 % ofparticipants reported their household reliedon farming and fishing for their primary
income 6 % relied on fishing alone.
Household food expenditure for 77 % ofparticipants was half or more of their monthly income
52 % of participants purchased local foodfor half or more thanhalf of a month.Consuming imported food
was regarded as a sign of wealth and status
by participants

Cross sectional study:
34-item 7-day FFQ
Three non-consecutive
24 h dietary recall
questionnaires

Intake of total Vitamin A,
retinol and protein (g).
Sources of vitamin A

Main dietary components included imported productsof rice, flour, chicken, other meats
and tinned fish and local productsof breadfruit, banana, taro, fish and otherseafood.
The most frequently consumed protein
food was imported frozen chicken,
followed by local fish.

Charlton et al. BMC Public Health (2016) 16:285

Table 4 Characteristics and main findings of studies assessing fish consumptiona (Continued)

Micronesia
Federated States of Micronesia
293 females aged
15–64 years locatedin Ponhpei

Englberger et al.
[55]

Kosrae267 children aged
24–59 months and theircaretakers 65 children aged
24–59 months and theircaretakers

Page 10 of 26

Corsi et al. [37]Mean intake of protein (54 g ± 10 g),
well above the estimated requirements.
Mean daily intake of total vitamin A
for all children was less than half ofthe requirements estimated by WHO
and the FAO#.
Animal sources provided 52-53 %of vitamin A intake for both children
and caretakers.
Guam
Pobocik et al.
[51]

211 males and 189 females

Cross sectional study:
Multiple-pass telephone
24 h dietary recall
Self reported weight(kg) and height (m)Fish and other meat intake
BMI (kg/m2)

Most commonly reported meats
consumed were chicken(reported 159 times), beef (148),
fish (141), eggs (75), sausage/bacon/hot
dogs (65), pork/ham (60) and cannedmeat (42).Canned and processed meats
accounted for 21 % of all reported meatintake.
When fish was consumed 47 % was freshand the remaining was canned or dried.
Mean BMI was 25.7 kg/m2 ± 5.8 kg/m2 withsignificant differences in BMI by ethnicity(P < 0.05)

Canned fish andmutton intake

In Vanuatu, canned fish was consumed
on a daily basis by 40 % of students andcanned mutton 17 % of students.
In Tonga 32 % of students consumed
canned fish on a daily basis and 52 %of students consumed canned mutton daily.
In Pohnpei students were asked about
consumption of fresh fish - 42 % reporting
consuming fresh fish on a daily basis and
46 % consumed canned mutton dailyCharlton et al. BMC Public Health (2016) 16:285

Table 4 Characteristics and main findings of studies assessing fish consumptiona (Continued)

Multiple PICTs
Phongsavan et al. [40] 4885 school children aged
13–15 years from Republic of Vanuatu,
Kingdom of Tonga
and Federated Statesof Micronesia

Cross sectional study:
Self-administered HealthBehaviour and Lifestyleof Pacific Youth (HBLPY)
survey.

a
Fish: Refers to fresh fish unless otherwise specified. b Note: When describing the design, outcome measures and findings of each study only details relevant to this systematic literature review were included in thesummary table. BMI body Mass Index, FFQ Food Frequency Questionnaire, WHO World Health Organisation, FAO Food and Agricultural Organisation of the United Nations

Page 11 of 26

Study Designa

Outcome measuresa

Key findingsa

Kuster et al. [45]Ono-i-Lau Island
30 senior heads ofhouseholds in 198259
households in 2002

Cross sectional

Mean weekly householdincome and fish yield per
capital.Daily fish intake
per capita (g) andcontribution of marine
sources to protein intake.

Total annual landings of finfish
decreased by 27 % from 1982
to 2002No significant change
in yield of finfish per capita
of population (96.9 kg per
capita/year in 1982 to 93.7 kg
capita/year in 2002)
Seafood remained the main sourceof protein between 1982 and 2002.
Consumption of canned fish
increased from 9 g/man/day to
19 g/man/day

Middlebrook &Williamson [61]Ucunivanua andNamatakula, Islandof Viti Levu40 headsof households

Cross sectionalSelf
administered household
questionnaires

Household income,source of income andhousehold fishing activity

Ucunivanua: Mean monthly
household income of FJ$
411.75 ± 73.51 (SD).
Income generated throughfishing activities (75 %), with
20 % from farming and 5 %from wage-paid jobs.
Namatakula: Mean monthly
household income of FJ$
432.25 ± 54.65 (SD) a month.
Income generated throughwage-paid work (80 %),with 10 % from fishing and
10 % from personal business.

O’Garra [60]

Navakavu fishinggrounds, Rewa,118
heads of households
86 adult individuals(aged >21 years)

Cross sectional
household andindividualquestionnaires

Socio-demographic
characteristics ofhousehold, household
livelihood activities andhousehold fishing activities

Mean annual household income
was FJ$ 2921.88.1 % of households
engaged in fishing, 76.3 % in growing
crops and/or gleaning.
The livelihood that generated themost cash and food overall
was salaried work in Suva (32 %households) followed by fishing(27 %) and gleaning (20 %).

Turner et al. [42]

Lau Province,
25 experienced
local fishers
53 senior headsof households

Cross sectional
Semi structured
face-to-faceinterviews

Time spent fishing,importance of fishingfor income generation,
patterns of fishconsumption andawareness of ecologicalchange within the local
qoliqoli (fishing ground)No significant change in overall
time spent fishing in the past
6–10 years.Income-generating
activities had increased inimportance over previous10
years relative to fishing activities
Consumption of fresh fish wassignificantly lower compared toestimates of past consumption(Z = −3.774, p < 0.001).Greatest
decline in fish consumption was

Melanesia
FijiPage 12 of 26

Study Population

ReferenceCharlton et al. BMC Public Health (2016) 16:285

Table 5 Characteristics and main findings of studies assessing the contribution of fishing to Pacific Islander livelihoods

associated with highest mean
household income.Of the
80–100 % of households
that engaged in fishing,
only 7 % of households
ranked fishing as the primaryhousehold occupation.
Solomon Islands
Albert et al. [64]Western Provinceand Guadalcanal
Province
Households in four
villages with Fishing
Aggregating devices(FADs)

Cross sectional
monitoring offishing activitieskey
informant interviews

Annual fish catch andcontribution of FAD
to fish catchBenefits
and negative aspectsof the FAD at thehousehold andcommunity level

Near shore FADs contributed
31–45 % of the total annual
catch (mean 7500kgs).Perceived
benefits from the FADs included:
provided a source of family income,
improved nutrition, more fish
available for community events.
The negative aspect of FADs wasa reduced contribution of fishers
to household activities due toincreased time spent fishing

Ahus Island
51 households
representatives

Cross sectional
Face-to-faceinterviews

Percent of households
engaged in fishing andimportance of fishing
relative to other livelihood
activities>96 % of households were
engaged in fishing and >76 %ranked fishing as their primaryoccupation. Due to the remotenessof the Island participants reported
few opportunities to engage
in other economic sectors.

Moorea70 females
and males (aged
18–84 years)

Cross sectional
interviews with
open-ended,semi-structured andstructured questions

Fishing activities
including subsistence
and commercial activities

60 % of participants fished on
average 2 days per week; 10 %did not fish at all.56 % of participants
reported dependence on lagoon
fishing for at least half of their foodand/or cash income. 19 % ofparticipants consideredthemselves commercial fishers and
41 % subsistence fishers

Lofanga Island
Individual adults(>15 years), households,
key informants, 41 local
fisherman

Mixed methods
Households andindividuals: structured
questionnaires.Key informant
interviewsFishermen:
Semi-structured interviewsa) Fishing practices
including contributionof fish to livelihood
and weekly fishconsumption throughFisheries, agricultural production andhandicrafts all contributed to income
generation. Fisheries ranked higher
than agriculture and handicrafts.
Fisheries filled three main objectives:to secure subsistence, fulfil social
obligations and contribute to
the cash economy. Fishbwas

Charlton et al. BMC Public Health (2016) 16:285

Table 5 Characteristics and main findings of studies assessing the contribution of fishing to Pacific Islander livelihoods (Continued)

Papua New Guinea
Cinner et al. [63]Polynesia
French Polynesia
Walker &Robinson [62]Kingdom of Tonga
Kronen & Bender [43]Page 13 of 26

consumed by entire community.
93 % of village also consume other seafood
and 78 % consume canned fish.
Micronesia
Federated States of Micronesia
Corsi et al. [37]293 females aged
15–64 years locatedin Ponhpei

Cross sectional study:27-item,
7-day FFQKnowledge, attitudes
and practices questionnaire

Fish and meat consumption
Cash expenditure on food;factors affecting food intake

79 % of participants reported
frequent consumption of local
fish/seafood. Local fish/seafood
was consumed twice as frequently(4.8 days/week) compared toimported fish/seafood (2.4 days/week).
Imported meats such as turkey tailwere consumed more frequently 1.9
days/week) than local meats (1.3 days/week).
8 % of participants reported their household
relied on farming and fishing for theirprimary income 6 % relied on fishing alone.
Household food expenditure for 77 %of participants was half or more of their monthly
income52 % of participants purchased
local food for half or more than half of a month.
Consuming imported food was regarded
as a sign of wealth and status
by participantsCharlton et al. BMC Public Health (2016) 16:285

Table 5 Characteristics and main findings of studies assessing the contribution of fishing to Pacific Islander livelihoods (Continued)aNote: When describing the design, outcome measures and findings of each study only details relevant to this systematic literature review were included in the summary table bFish: Refers to fresh fish unlessotherwise specified

Page 14 of 26

Charlton et al. BMC Public Health (2016) 16:285

Page 15 of 26

Table 6 Vanuatu case study: demographic, nutrition and fish data
Indicator
Population

Life expectancy at birth

ResultRef

All

276, 579[94]<5 years

35 000[95]

Male

70 years[96]

Female73 years

Births per year
Mortality/1000

InfantUnder 5

7911

[2]

28

[96]

31

Household expenditure on food49.8 %

[97]

16 %

[98]

Stunting

28.5 %[96]

Wasting

4.4 %Nutrition
Vitamin A deficiency in pre-school aged children
Nutritional status among children <5 years:

Underweight
Nutritional status among adults

10.7 %

overweight or obese:

aged 15–49 years

Women

49.5 %

Men

35.8 %

Raised blood pressure:47.2 %[99]

Raised blood glucose:

19 %

[100]

Raised blood cholesterol:

37.6 %

[101]

2820

[102]

60 %

[103]

Energy (kcal) available per capita
Diet composition of population:

Infant feeding practices:

Carbohydrate
Fat

31 %

Total protein

9%Children < 5 years are ever breastfed

94.9 %

Infants exclusively breastfeed to 5 months

72.6 %

Households consuming adequate iodised salt:
Fish and fisheries

50.7 %
National Urban

Rural

CoastalAnnual per capita fish consumption (kg)

20.3

19.3

20.6

29.9

Subsistence fishing

51 %

17 %

60 %

-

Purchased

49 %

83 %

40 %

-

Consumption of fresh fish

60 %

38 %

65 %

72 %

Fish as % of total protein consumption

Forecasts of fish required for food (tonnes)

Total protein

14.9 %
35.8 %

2010

8200

2020

10 7002030

13 600Marine fishing activities

Fresh water fishing activities

[96]

[96]
[27, 97]

Animal protein

Rural households engaged in fishing activities
Dependence on fisheries for income :

[96]

[102]

[27]

72 %

[104]

Urban

11 %

[105]

Rural

39 %

Urban

4%

Rural

21 %

Official fishing contribution to GDP

0.8 %

[104]

Contribution of fish access fees to national revenue

1.2 %

[104]

Charlton et al. BMC Public Health (2016) 16:285

Page 16 of 26

Table 7 Kiribati case study: demographic, nutrition and fish indicators
Indicator
Population

Life expectancy at birth

ResultRef

All

101,000[95]<5 years

11 000[95]

Male

65 years[106]

Female70 years
2000

[107]

Infant

25.6

[108]

Under 560

Births per year
Mortality/1000

Household expenditure on food

46 %

[109]

22 %

[98]

Nutrition
Vitamin A deficiency in pre-school aged children
Nutritional status among children <5 years:

Stunting–

Wasting–

Underweight
Nutritional status among adults

overweight or obese:

aged 15–49 years

14.9 %

[108]

Women

78.9 %[110]

Men

67.4 %

Raised blood pressure:37.4 %[99]

Raised blood glucose:

21.4 %[100]

Raised blood cholesterol:

35.5 %[101]

Energy (kcal) available per capita
Diet composition of population:

Infant feeding practices:

3022

[111]

Carbohydrate

58.6 %

[103]

Fat

31 %

Total protein

10.5 %

Children < 5 years are ever breastfed

83 %Infants exclusively breastfeed to 5 months

69 %Households consuming adequate iodised salt:
Fish and fisheries

5%
National

Urban

Rural

CoastalAnnual per capita fish consumption (kg)

62.2

67.3

58

115.3

Subsistence fishing

63 %

46 %

79 %

-

Purchased

37 %

54 %

21 %

-

Consumption of fresh fish

92 %

91 %

93 %

95 %

Fish as % of total protein consumption

Forecasts of fish required for food (tonnes)

Dependence on fisheries for income :Total protein

28.8 %
55.9 %

2010

7730

2020

9050

2030

10 230

[29]

[27]

60 %

[113]
[113]

Sales of fish and agricultural

Urban

26 %

crops for cash income:

Rural

34 %

Paid workers in the ‘agriculture

[112]
[27]

Animal protein

Rural households engaged in fishing activities[108]

19.5 %[113]

Official fishing contribution to GDP

0.8 %

[104]

Contribution of fish access fees to national revenue

42 %

[104]

And fisheries’ sector

Charlton et al. BMC Public Health (2016) 16:285

Page 17 of 26

Table 8 Tonga case study: demographic, nutrition and fish indicators
Indicator
Population

Life expectancy at birth

Result103,252[114]<5 years

14,000

[95]
[115]

Male

65 years

Female69 years
2,896

[114]

Infant7[116]

Births per year
Mortality/1000

Ref

All

Under 518

[116]

50.6 %

[117]

17 %

[98]

Stunting

8.1 %

[116]

Wasting

5.2 %Household expenditure on foodNutrition
Vitamin A deficiency in pre-school aged children
Nutritional status among children <5 years:

Underweight
Nutritional status among adults

1.8 %overweight or obese:

Women

aged 15–49 years

79.6 %

Men

69.9 %

Raised blood pressure:

41 %

[99]

Raised blood glucose:

18 %

[100]

Raised blood cholesterol:

50 %

[101]

–

Energy (kcal) available per capita
Diet composition of population:

Infant feeding practices:

Carbohydrate

–

Fat

–

Total protein–Children < 5 years are ever breastfed

91 %Infants exclusively breastfeed to 5 months

52.2 %

National

Urban

Rural

CoastalAnnual per capita fish consumption (kg)

20.3

–

–

84.6

Subsistence fishing

37 %

—

–

-

Purchased

63 %

–

–

-

Consumption of fresh fish

80 %

–

–

87 %

Fish as % of total protein consumption

Forecasts of fish required for food (tonnes)[27, 117]

Total protein

13.5 %

Animal protein

23.4 %

2010

3,490

2020

3,690

2030

[118]

[27]

3,900

Households engaged in fishing activities
Dependence on fisheries for income :

[116]

–

Households consuming adequate iodised salt:
Fish and fisheries

[110]

33 %
Workforce employed in fishing industry

[119]

3%

[120]

Official fishing contribution to GDP

4.1 %

[104]

Contribution of fish access fees to national revenue

0.2 %

[104]

1.5 days per week. Reasons identified for declining fishconsumption were a dependence on other family members to catch fish, or a need to purchase rather thancatch their own fish (possibly due to more time spent on
income-generating activities [42]), as well as increased
consumption of other purchased foods.

Charlton et al. BMC Public Health (2016) 16:285

Page 18 of 26

French Polynesia

Vanuatu

Two separate studies assessed fish intake in French
Polynesia. In a cross sectional study of pregnant womenparticipants, there was a mean consumption of 33
meals/month of reef and pelagic fish, however, data on
actual grams per day were not collected [38]. 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 wasconsumed by cases and controls, respectively [36].

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 wereavailable on the amount of fish consumed [46]. On
Aneityum, considered to be a rural island with tourism,
children were more likely to consume tinned fish thanadults. These findings were similar to those of Phongsavan et al. [40] who reported that 40 % of students in the
HBLPY survey reported consuming canned fish on adaily basis. On the rural island of Tanna, 39 % of primary school children consumed fish at least weekly, withthe majority (70 %) consuming mainly canned fish. Fishconsumption differed among the four study sites in
Vanuatu, with more fish consumed in coastal villages
than in urban centres [39].

Guam

In contrast to other Pacific Islands, Pobocik et al. [51]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 thatwas consumed, only 47 % was fresh and the remaining
canned or dried [51].
New Caledonia

Three studies assessed fish intake in New Caledonia. In
the Northern Province, 85 % of adults participating in astudy 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 [50].
Of annual fish consumption, 92 % was classified as subsistence and 8 % was purchased [50]. Subsistence production was also the main fish supply for two-thirds ofhouseholds on Ouvéa Island, New Caledonia, with annual
intake of fish considerably higher than reported in the
Northern Province [48]. 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 reeffish intake was considered, not pelagic species nor
imported fish [44].
Solomon Islands

In Tikopia, an isolated island in Solomon Islands, Mertz
et al. [41] reported that 72 % of households consumed
fresh fish daily, whereas canned fish was eaten only
when rarely available [41].
Tonga

On Lofanga Island, Tonga, the entire community reported eating fresh fish, with 93 % also consuming otherseafood and 78 % of the community consuming canned
fish. However, a decline in fresh fish consumption was
attributed to increased income resources [43]. In a cluster random sample of schools in Tonga, approximately athird (27.2 to 38.6 %) of 13- and 15-year-old girls andboys who completed the HBLPY study reported consuming canned fish on a daily basis and half the students
consumed canned mutton daily [40]. However, it is notknown how many students consumed fresh fish as thosedata were not collected.

Contribution of fish consumption to energy and/or protein
intakeFish/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 [53] to 37.4 % in Verata, Fiji [54].
Federated States of Micronesia

In Kosrae, a cross-sectional survey of children and theircaretakers reported that local fish was the second mostcommonly consumed source of protein, after cookedchicken [55]. Mean intake of protein, both for children
and adults, was above the average requirements, as defined by Latham [56].
Fiji

In one rural village in Fiji, the second and third sourcesof protein intake after fish and shellfish (37 %) were cereals (29.2 %) and meat (13 %). Higher marine food consumption was associated with lower cereal intake [54].
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)[57]. In the low altitude village, fish was the mostimportant source of protein for residents and comprised
41 % of all food from animal sources. Conversely, in highand middle altitude villages, animal protein comprised
mostly purchased sources such as canned fish and lambflaps [57].

Charlton et al. BMC Public Health (2016) 16:285

Solomon Islands

In Solomon Islands, a cross sectional study of adults
from five villages in Roviana Lagoon found that mosthouseholds consumed fish as the primary source of protein but did not give details of alternative protein
sources [52]. Mertz et al. [41] also reported fish as theprimary source of protein among residents of Tikopia, aremote 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 wererarely available.
Tonga

In Tonga, protein intake from fish was highest (20 %),followed by imported chicken (12 %) and mutton(11 %) [53].
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 observedin 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 [36]. The iodine concentration ofumbilical cord blood of newborn babies also suggested that iodine intake was adequate in French
Polynesian mothers [38]. 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 monthfrom pelagic fish); fish intake varied little between
women from different archipelagos. This suggests thatfish was consumed daily, however, data on actual
grams consumed per day were not collected [38].
Mean blood concentration of iodine varied between
newborn babies from different archipelagos, with thehighest mean concentration in the Iles Sous Le Vent
(2.6 μmol/L) and the lowest in the Australes(0.46 μmol/L) [38].
Li et al. [39] assessed the iodine status of children on
the Island of Tanna, Vanuatu, by measuring the level ofurinary 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. [55] 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 [55]. Yet both protein and fat intakes were above the estimated requirements and results
were similar for infants’ caretakers. Highest intakes of total

Page 19 of 26

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 [55].
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 [33].
In Samoa, the ‘modern’ dietary pattern, characterised byhigh intakes of processed foods, was significantly associated with an increased prevalence of metabolic syndrome[58].
In Port Moresby, Papua New Guinea, two predominant dietary patterns were identified amongst a Naasioi
migrant population [35]. Neither dietary pattern included high intakes of fresh fish but the ‘traditional’ dietary pattern was inversely associated with consumptionof canned fish, rice and soft drinks [35]. Dietary patterns
were not associated with body mass index (BMI) nor
blood pressure [35]. 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 mostcommonly packaged with oil or sauce providing a higher
fat content than fresh fish. Again, fresh fish intake was
not considered in the analysis [59].
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 andwithin 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 thecase for all PICTs. Pohnpei, in the Federated States ofMicronesia (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 % ofparticipants and only 6 % relied on fishing alone [37].

Charlton et al. BMC Public Health (2016) 16:285

Fiji

In the Navakavu fishing grounds in the south easternarea of Fiji, 88 % of households were involved in fishingactivities. However, salaried work provided the most income and food for 32 % of households, while 27 % ofhouseholds reported fishing as their most important resource [60]. On the island of Vitu Levu, two contrastingvillages were studied; firstly, Ucunivanua, where fishingis 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) [61].
Despite primary sources of income differing between thetwo villages, there was no significant difference in totalmonthly income.
Key informants, local fisherman and senior heads ofhouseholds, from four islands in the Lau Province of Fijiidentified 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 wherefish was more commonly sold. Only 7 % of households
ranked fishing as the primary household occupation although almost all households remained engaged in fishing practices [42]. In the most southerly Fijian Islandgroup of Ono-i-Lau, also part of the Lau province, theeconomy was again predominantly subsistence and thishad not changed between the two study periods of 1982
and 2002 [45]. While it was reported that time spentfishing had not significantly changed in the past 10 years,
engagement in other forms of livelihood activities had
increased including formal employment and animal husbandry [42]. Fishing and gardens were the primarysource of subsistence products but the key incomegenerating activities were sale of copra, seaweed farmingand handicraft making. Income from these sources doubled between 1982 and 2002, but income remained insufficient at both time points to purchase sources ofprotein other than fish on a regular basis [45].
French Polynesia

In Moorea, French Polynesia, a subsistence economy ofsmall-scale agriculture and fishing existed until about
1962 [62]. In a small sample of adults interviewed in
2002, over half reported dependence on lagoon fishingfor at least half of their food and/or income [62]. 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. [63] found that morethan 76 % of participants ranked fishing as their primaryoccupation. Participants reported that the remoteness ofPage 20 of 26

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 ademand for fish from the mainland [63].
Solomon Islands

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 [64].
Tonga

The Island of Lofanga is a traditional Tongan community in which the cash economy remains limited. On thisisland, fisheries, ranked higher than agriculture andhandicrafts for importance to income generation, andwere considered vital to secure subsistence and fulfilsocial obligations. However, in 45 % of households studied, income was also received as financial remittancesfrom relatives on other islands or overseas [43].
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 andTonga (Tables 6, 7, and 8) demonstrate that fish consumption, as a percentage of total protein intake, varies
considerably across the three cultural sub-regions. Fishconsumption 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 subregions in general, with average national fish consumption in Micronesia and Polynesia, being much greaterthan in Melanesia [27]. The case studies support thedata presented in the numerous individual country studies identified in this review and are used to present a
succinct summary overview of factors influencing fishconsumption patterns, food security and health status
between the sub-regions.

Charlton et al. BMC Public Health (2016) 16:285

Discussion
This review confirms that fish is an important staple foodin most Pacific Island countries and territories, and thatsubsistence and commercial fishing activities make essential contributions to both household and individual foodsecurity, 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 cashbased economy. These differences are highlighted in thethree country case studies, showing higher fish consumption in Kiribati, one of the least developed PICTs.
Given the central contribution of fish to both dietaryintakes and livelihoods in PICTs, it is noteworthy that
our review identified only 29 relevant studies from 22
countries. Nationally representative data is sparse, andwhole provinces and/or cultural groups are missing from
the Melanesian countries. In a broader study, Bell et al.
[27] used data from household income and expenditure
surveys to quantify average national, rural and urban fishconsumption per capita for 16 PICTs. Average nationalfish 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 [66].
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 inseveral PICTs [27]. The rich tuna resources of the region
will need to play a greater role in maintaining the foodsecurity of Pacific Island people [31]. 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, butalso 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, PacificIslanders 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) [27]. 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 animalgrazing and husbandry is not viable [27, 67]. Our review

Page 21 of 26

suggests that the majority of PICT communities for whichdata is presented consume sufficient protein to meet theirnutritional requirements, however, a number of communities, particularly inland PNG, suffer from high rates ofprotein-energy malnutrition [68, 69]. For these communities, an increase in the availability of fish has particularpotential 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 theSolomon Islands but that households were involved in arange of different livelihoods in order to produce foodand/or generate income. The authors suggested thathouseholds in this region had the ability to adapt to changing circumstances but that fisheries management involving local stakeholders was needed in order to ensure thatfisheries continue to be a major source of food andincome[70].
This review did not identify any reported interventions
designed to test the hypothesis that increased availabilityof fish improves nutritional outcomes. Thus, our PICO
question could not be answered directly. However, it isevident that fish is a highly nutritious food and that itprovides 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 andother seafood mean that improved access to increasedfish availability may help prevent iodine deficiency,
which remains highly prevalent in PICTs such as Fiji[71], PNG [72] and Vanuatu [39]. Improving iodine
nutrition status through higher fish consumption may
also contribute to the prevention of iodine-related diseases including goitre [39] and thyroid cancer [33, 36,73]. In addition, the review suggests that some species ofsmall fish that are eaten whole are important for the prevention of Vitamin A deficiency [30], which is highly
prevalent in several PICTs including FSM [74], Kiribati[75], Marshall Islands [76], and PNG [72].
Sources of oily fish provide docosahexanoeic acid, andconsumption of these fish by Pacific Islanders [38] may
be making an important contribution to cognitive development in utero (through maternal fish intake), as wellas in young children [30]. In other developing countries,
such as Cambodia and Bangladesh, fish is an importantsource of calcium, iron and zinc [30], but data on thecontribution of these nutrients from fish in PICTs are
not available. Overall, further research is required todetermine the extent of other micronutrient deficiencies
that may exist in PICTs, such as iron or calcium andCharlton et al. BMC Public Health (2016) 16:285

how fish consumption may contribute to reducing therisk of such deficiencies.
Prevention and management of NCDs

Non-communicable diseases have been declared a crisis in the Pacific, and there are national responseplans in place to address risk factors, particularly withregard 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, soysauce, noodles, salty crisps and snacks, tinned fruitand vegetables, butter and bread [77]. Country consultations and Food Frequency Questionnaires (FFQ)
carried out in Fiji, Samoa, Kiribati and Cook Islands,
have confirmed this [78]. Locally salted, preserved fishand meat, and meals eaten in and out of the home,such as Chinese dishes, soups and curries are also acommon part of the diet in the region.
An increase in the availability of fresh fish offers analternative 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 andover-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 [58]. 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 [58]. Heavy reliance on poor-quality imported
foods [79] is exacerbating the genetic predisposition ofpeople in FSM to obesity [80].
Whether fish is consumed fresh or canned needs to beconsidered. Findings have been inconsistent as towhether 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 thatneither fresh fish nor canned fish were related to obesity[81]. However, the more recent finding of Dancause etal. [59] that consumption of canned fish was a risk factor
for obesity in Vanuatu warrants further consideration, inthe context of the nutrition transition [5]. Methodological limitations to dietary assessment should be noted;

Page 22 of 26

Dancause et al. used a single 24 h recall, which may not
be appropriate to determine usual intake. Further, ahigher consumption of tinned fish may simply be aproxy measure for a greater reliance on processed foodsin place of fresh fish, as populations become more urbanized and adopt more westernised eating patterns.
Both the nutrient content and the preparation methodsof tinned fish may also contribute to its association withobesity. Tinned fish canned in oil or sauce has higher fat
content than most types of fresh fish [82] and will often
be served with instant noodles and rice [59]. Packaged
instant noodles are popular in Vanuatu [83] and acrossmost PICTs, and their inclusion in the diet has beenshown 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 ontinned fish in urban areas was reported during the firstnutrition survey conducted in Vanuatu as long ago as
1951 [84] 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, freshmeat, poultry, tinned meat, and tinned fish [87].
In short, it appears that any association of canned fishwith 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 [59]. 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 ofthe 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. [59]that fresh meat might be a better dietary option thantinned fish in some PICTs, at least from the point of viewof preventing NCDs. This requires further investigation
with well designed intervention studies, but is considered
impractical due to the limited scope for grazing cattle inmost 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 urbanisationaccompanied by the nutrition transition. To date, there
have been surprisingly few publications on interventionsin this regard. In FSM, a health promotion programmethat 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 asrice) [91]. Such efforts could be used to promote theCharlton et al. BMC Public Health (2016) 16:285

consumption of fresh fish in areas where intake ofimported meats has become increasing prevalent.

Food security

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 otheragricultural or economic sectors to produce food and/or
income [63, 88]. For example, although Fiji is one of themore developed PICTs, both subsistence and commercial fisheries remain an important source of food andlivelihoods [60].
In 2010, at the Pacific Food Summit, a Framework for
Action on Food Security in the Pacific was developedwith four goals aligned to the WHO’s four pillars forfood security. The first goal, availability of food, hasbeen addressed to some extent in the literature, withpredictions 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 [31]. Even so, inter-annual variation in wherebycatch is landed by fishing fleets could cause temporary shortfalls in fish supply in some urban centres [88].
Strategies such as increasing nearshore FADs haveshown promise in terms of how increased availability oftuna and other large pelagic fish can help provide theprotein that communities need for food security andnutrition [65], however appropriate monitoring andmanagement 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. [27] showed that ~50–
90 % of fish consumed in rural areas of PICTs was
obtained through subsistence fishing. Other research doneby the Coastal Fisheries Programme at the Secretariatof the Pacific Community [89] shows that an averageof ~50 % of surveyed coastal households in 17 PICTs
derived their first or second source of income fromcatching 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 forgood health [90]. The fourth goal, relating to stability offood systems, is beyond the scope of this literature
review.
When planning policies and interventions to increaseavailability of fish, ease of access to fish, and utilizationof fish in PICTs, it is important to consider other factors

Page 23 of 26

that may affect food intake. A lack of nutrition education
and a decrease in knowledge of traditional food sourcesin several PICTs also means that many Pacific Islanders
do not have the knowledge or skills to make foodchoices 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 associatedwith wealth and status [37]. The ability to purchaseimported 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 forpeople 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 offish 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 [27], with little
data on the factors determining access to fish and use
of fish at a local level. In addition, the majority ofarticles 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 healthoutcomes.
Finally, a lack of co-ordinated approaches between fisheries and health ministries has been acknowledged by the
Secretariat of Pacific Communities (SPC) [93]. This has
hindered the development of integrated policies designed
to achieve food security through improved management
and sustainability of coastal fisheries, while at the sametime preventing NCDs. Such approaches are a priority forthe region and will require inter-sectoral dialogue andpartnership.

Conclusions
Recent literature confirms assumptions that fishing remains a major contribution to food security in PacificIsland countries and territories, through subsistence production and income generation (which allows foodpurchases). However, there is a paucity of research on
how maintaining and/or improving fish consumption
benefits the nutritional quality of the diets and healthstatus of Pacific Islanders as they contend with theCharlton et al. BMC Public Health (2016) 16:285

ongoing nutrition transition resulting from the influxof foods that are high in fat, sugar and salt. Given thesignificance of fish to food security and livelihoods, it
is time for the region to develop a more integrated andcoordinated approach to fisheries, health and foodpolicy 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.
Abbreviations
BMI: body mass index; NCDs: non communicable diseases; PICO: population,intervention, comparator, outcome; PICT: Pacific Island countries andterritories.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KC, QH and JR conceptualised the review, designed the PICO question anddeveloped the search strategy. EG and JR conducted the literature searchand 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.
Acknowledgments
This study was supported by a research grant from the Global Challenges
programme at the University of Wollongong.
Author details
1
School of Medicine, University of Wollongong, Wollongong, NSW 2522,
Australia. 2School of Health and Society, University of Wollongong,
Wollongong, NSW 2522, Australia. 3Australian National Centre for Ocean
Resources and Security (ANCORS), University of Wollongong, Wollongong,
NSW 2522, Australia. 4Betty and Gordon Moore Center for Science andOceans, Conservation International, Arlington, VA 22202, USA.
Received: 6 August 2015 Accepted: 14 March 2016

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