Promoting healthy lifestyles for Pacific peoples

“Ask a Pacific person what a 'healthy lifestyle' means for them and the response will depend on who you are talking to. For young people it may mean having regular healthy meals and participating in physical activity most days of the week, not smoking or drinking and maintaining a good social life. For more mature people, it is about eating responsibly, getting enough sleep, having the ability to do enjoyable activities e.g. going to church, family occasions, meeting all social and family responsibilities and having a comfortable and clean home.

“For those who have chronic medical conditions, e.g. type 2 diabetes, cardiovascular disease, depression or arthritis, a healthy lifestyle means more than just simply exercise and healthy eating. It is about:

• Being fully informed about their condition(s) and the consequences
• Having a care plan
• Recognising the health impact of lifestyle behaviours such as smoking, excessive alcohol consumption and a sedentary lifestyle
• Having the ability to live a “normal” life as much as possible with minimal restrictions
• Being able to do things that provide a sense of enjoyment, with their families and friends
• Being able to make choices regarding lifestyle changes
• Having the whole family involved in the care plan
• Having support, e.g. from family, caregivers, general practice, secondary care and other community services/agencies.”

Siro Fuata'i

A healthy lifestyle is the basis of a successful management plan for any chronic condition. However, many Pacific peoples are unable to achieve a healthy lifestyle, resulting in disparities in care and a greater burden of disease.

What are some of the barriers to achieving a healthy lifestyle?

1. Money

• Healthy food choices are considered costly, compared to fast foods which are considered more affordable and convenient. Take-away “meal deals” are seen as value for money.
• The cost of structured exercise such as a gym membership or personal trainer is prohibitive for most Pacific peoples (although self-directed activities such as walking can be undertaken without cost)

2. Time

• Today's lifestyle means that many people are busy at work, sometimes employed at two or more jobs. This leaves little time for anything else, impacting on the ability to exercise and make healthy meals
• Lack of time makes it more convenient to buy pre-packaged or fast foods, quite often with little or no nutritional value

3. Mindset

• Social acceptance among some Pacific peoples that “big is culturally ok”
• Issues around acceptance of generic diets/weight loss programmes
• Misconception that being physically active at work or around the home is adequate
• Lifestyle changes are “too hard” and not implemented unless accepted by all family members
• Cultural and religious expectations – healthy lifestyles are not for elderly people or those who are under “God's will”

What are some potential solutions for General Practice?

• Target individuals, but involve families
• Take every opportunity to discuss healthy lifestyles including diet, exercise, smoking cessation, substance misuse and addictions
• Tailor advice to ensure lifestyle changes can be realistically applied
• Use plain language and ensure the patient and their family understands what changes they need to make and why they need to make them
• Understand the social contexts influencing individual and family choices

For Pacific peoples, health is a concept that covers spiritual, emotional, mental, physical and social aspects. It emphasises the total well-being of the person within the context of the extended family (the Fonofale framework explains this model of health).^1,2 Food is regarded as not only a source of nourishment, but a way of conveying words of thanks, condolences, apology and hospitality. It is also used to build relationships and mark celebratory events such as birthdays, weddings and graduations. Food plays a central role in the lives of Pacific peoples.³ An understanding of this concept is important when discussing and creating expectations for dietary based lifestyle changes with Pacific patients.

The types of food consumed and eating patterns of Pacific peoples is directly associated with the high rates of nutrition-related diseases such as diabetes, cardiovascular disease and obesity.⁴ However, other determinants of health such as income, employment, education and housing, are also contributory factors to the comparatively poor health status of Pacific peoples.⁵ These health determinants influence the choices, preparation, accessibility and affordability of healthy foods.

Contributing factors to poor nutrition among Pacific peoples

1. Breastfeeding rates are low

There is strong evidence of the benefits of breastfeeding infants for the first year of their life. One of the health benefits of breastfeeding is that it helps reduce the risk of obesity, and may help reduce the risk of diabetes, in the infant later in life.⁶ It is therefore important that Pacific women are encouraged and supported to breastfeed.

Breastfeeding rates in New Zealand are similar to rates in other OECD countries, but overall, significant improvement is required. Rates of breastfeeding at six weeks are lower in New Zealand, than in other countries, especially among Māori and Pacific women.⁶ In 2007, 65% of infants at six weeks were fully breastfed, 54% at three months and 26% at six months. For Pacific infants, these rates were even lower, with 53% fully breastfed at six weeks, 43% at three months and 18% at six months.⁶

A number of barriers may contribute to low rates of breastfeeding, including:⁶

• A lack of breastfeeding education and support
• Returning to paid work
• Low awareness of common breastfeeding problems and solutions
• Limited access to appropriate help for overcoming breastfeeding problems
• Pain and exhaustion resulting in the introduction of formula
• Supplementation of breastfeeding with formula for other reasons
• Negative attitudes towards breastfeeding from the general public or family members

2. Breakfast is often skipped

Breakfast is the most important meal of the day. Eating breakfast at home is a proxy measure of good nutritional intake and healthy behaviour. It is positively associated with increased intake of most vitamins and minerals, better food choices, better concentration at school and improved mental health.⁷ Children who usually eat breakfast at home have been shown to have a lower mean BMI than those who do not.⁸ It has also been reported that children who do not eat breakfast are more likely to eat unhealthy snack foods and are less likely to eat lunch.⁹

Results of the National Health Survey 2006/07 showed that after adjusting for age, Pacific children were less likely to have eaten breakfast at home every day in the previous seven days, compared to children in the total population.¹⁰

Reasons why children may not be eating breakfast include lack of parental/caregiver supervision at mealtimes, financial barriers and time.

3. Bought lunches at school

The National Children's Nutrition Survey showed that over 13% of Pacific children bought most of the food they ate at school from the canteen or tuck shop (about 25% in the 11–14 year age group). Consequently, Pacific children were less likely than European or Māori children to bring most of their food from home – European males 92%, European females 91%, Māori males 77%, Māori females 75%, Pacific males 50%, Pacific females 57%.⁸

In many instances, the nutritional value of “school lunch” food is poor and high fat, high sugar, high salt content foods are readily available for purchase. Healthy food choices are not easily accessed.

4. Carbonated soft drinks (fizzy drinks) are frequently consumed

The New Zealand Health Survey 2006-07 reported that approximately one in four Pacific children aged two to 14 years had three to four fizzy drinks in a typical week. This level of consumption was similar to Māori children but higher than European and Asian children.¹⁰

There is a strong association between fizzy drinks with a high sugar content and an increased risk of obesity and type 2 diabetes.¹⁰

Fizzy drinks can be cheaply purchased and are frequently available as the only drink option for children at social gatherings.

5. Take-away food (fast food) is popular

The New Zealand Health Survey 2006-07 reported that Pacific children were twice as likely to have eaten take-away food three or more times in the previous week, compared to children in the total population.¹⁰ Fast food usually has little nutritional value, and is associated with weight gain and obesity.

6. Meal portions are too large

Consumption of large meals/portion sizes is common within Pacific communities. A study of over 4000 people in Auckland found that Pacific peoples consumed more food per day than any other ethnic group. Pacific diets were higher in carbohydrates, starch, sucrose, protein and fats than any other group. More Pacific peoples consumed larger than standard serving sizes of chicken, fish, red meat, potato, kumara, taro and other vegetables. Pacific peoples were more likely than any other ethnic group to fry food in butter, lard or dripping.¹¹

It is usual for large amounts of food to be provided at community and church events. Increasing portion sizes supports the general Pacific cultural view that “more of something” is better than “less of something”. With regard to food, it is better to provide more food than less food because not providing enough food results in a bad reputation for the hosting church or family. Conversely, it would be considered as a slight on the host if food is returned on the plate. Reputation is important in Pacific cultures, as the population is small, and as many community members know each other, there is potential for an impact on future working relationships.

7. Vegetable and fruit consumption is less than ideal

There is strong evidence that fruit and vegetable consumption has many health benefits, including a protective effect against cardiovascular disease. The New Zealand Health Survey 2006/07 found that Pacific men and women were less likely to eat three or more servings of vegetables a day compared to men and women in the total population.¹⁰

The Children's Nutrition Survey 2006/07 found that three out of five children ate vegetables three or more times a day. Pacific children were most likely to eat taro, cooked green banana, cassava and tomatoes. Pacific children (50%) were more likely than other children in New Zealand (40%) to eat two or more portions of fruit a day.⁸

Health is often not a priority if no physical symptoms are experienced

Cardiovascular disease (CVD) risk assessment is offered in general practice clinics for Pacific men and women over the age of 35 and 45 respectively, and annual reviews are offered for all patients with diabetes. The majority of patients' assessments and health education sessions are carried out by the practice nurse, focusing on making lifestyle changes such as dietary modification and taking up exercise. Despite CVD and diabetes assessments being encouraged, uptake is often low. A possible reason for this is that many Pacific peoples do not prioritise health and generally would not seek any help unless they have physical symptoms such as pain or discomfort.

“People with high blood pressure or blood glucose levels, and those who are overweight, will still come into the practice and say “there is nothing wrong with me” because they feel well. They would have been through health education and been advised to do exercise and to eat healthy. On their GP visit, they are asked if they have followed the advice; they will politely nod their heads acknowledging the doctor but in reality they haven't made any changes.” Tua Sua

Healthy lifestyle messages are well known but not always acted upon

Key health messages, e.g., 5+Plus-A-Day, Push Play, are usually well known amongst Pacific peoples, but there seems to be a disconnection between knowing and doing.

“Social determinants of health are often more important than individual choices. For example, most Pacific adolescents purchase school food items that are tasty, affordable and easily accessible within their immediate environment, i.e., the school canteen or shops outside the perimeter of the school. Students find it difficult to practice healthy eating when surrounded by an obesogenic environment of easily accessible unhealthy foods that are also being consumed by their peers.” Tasileta Teevale

Establish relationships and gain an understanding of Pacific culture and customs

Developing strong and meaningful relationships is instrumental in engaging Pacific patients to undertake lifestyle changes. Language may sometimes be a barrier, however, this can be broken down by using simple gestures like a smile, making eye contact and a warm welcome. Taking the time to maintain an open and friendly relationship is an important investment as it “buys” compliance and respect from patients and their families. In the Pacific culture, politeness is not necessarily an indication of acceptance of services

“We routinely recommend that patients and their families note down what issues they wish to consult with their GP about, prior to their appointment. There is often a lot of anxiety and apprehension associated with visiting a GP or Practice nurse and a little preparation ahead of an appointment can facilitate better discussion.” Anna Bailey

It is important that all Practice staff are aware of appropriate protocols and customs. Reception staff are the face of the General Practice and can gain or lose patients by their attitudes and behaviours.

Family is influential in shaping attitudes and activities

For Pacific peoples, health and wellbeing begins in the family. The family carries the culture, values and practices and, therefore, is very influential in shaping healthy attitudes and activities. This is where any interventions should be targeted and the greatest gains can be made.

“Use the strengths of Pacific cultures such as 'togetherness', 'generosity' and 'deep spirituality', to encourage and improve breastfeeding rates, vegetable consumption and having breakfast, and to reduce the consumption of fizzy drinks, takeaways and large portions” Mafi Funaki-Tahifote

Ask about food

When approaching a healthy lifestyle dietary change with a Pacific patient, discuss what food means to them and their family. Ask about what celebrations are culturally important to them and what types of foods would normally be served at these functions. Ask about the types of meals usually consumed at home and how these are prepared. The aim is to find ways in which healthy food choices can be made, while not compromising the cultural importance of the occasion. Dietary changes are most successful when implemented for, and supported by, the whole family. Consider referral to a dietitian for specialised nutritional advice.

Take every opportunity to discuss the benefits of breastfeeding with pregnant women or new mothers. Ensure they know how to access any information or support that they may require.

Ask parents about the nutrition of their children and how mealtimes are organised at home. Approaching healthy lifestyles for young Pacific peoples requires the cooperation of parents or caregivers to instil simple household based lifestyle changes such as homemade meals, supervised mealtimes and designated time for physical activities.

“The key difference between the households of Pacific adolescents who are healthy weight and those who are obese is parental presence at home. Significantly more healthy weight Pacific young people have a full-time or part-time parent at home who monitors meal consumption, making sure that appropriate meals, including vegetables are eaten. Parents of healthy weight adolescents made meals at home, as opposed to buying takeaway food and instilled simple food and activity rules in their households, for example, not purchasing fizzy drinks, and limiting television watching on school nights.” Tasileta Teevale

Encourage an active lifestyle

Discuss ways in which physical activity can be incorporated into a daily routine. Exercise does not have to cost money. Simple activities such as taking the stairs at work, rather than the lift, can be accumulated in bouts of ten minutes to achieve the recommend goal of thirty minutes or more of moderate intensity exercise per day. Exercise can also be undertaken as a family activity, such as a game of touch rugby or a vigorous walk.

“Most young Pacific peoples love sports and being active, and their families want them to be active and involved in sports from a young age. Most young people participate in sports and activity because it is enjoyable. When young people enter secondary schools however, many drop out of sports and activities. This is largely because the secondary school environment promotes sports participation for achievement, rather than for enjoyment. If a teenager does not have the skills to win a place in a team, they miss out on that activity.” Tasileta Teevale

Young Pacific peoples need to be provided with environments that promote daily physical activity, which is different to providing sports only for achievement. Healthy weight young Pacific peoples are of a healthy weight because they are active and they are good at sports. The young people that want to be active, but currently are not, should be encouraged to participate in active social activities.

Consider partnerships with Pacific providers

The growth of Pacific health providers over the last 15 years in New Zealand indicates a willingness of Pacific peoples to take control of their health, wellbeing and future. General Practices are encouraged to become aware of the profile of Pacific providers in their area, as these services are still not well utilised. Pacific provider services can be used to complement and reinforce general practice messages, for example lifestyle advice, medicine administration techniques and following up delayed or missed immunisations.

In order for a successful partnership between General Practice and Pacific providers, it is essential to ensure that consistent messages are delivered. It is difficult to engage patients in their healthcare when messages are not reinforced or are inconsistent, creating confusion and mistrust.

“We encourage parents and caregivers to take their child's Well Child- Tamariki Ora Health Book for the GP or Practice Nurses to fill in. However, they are often informed that there is no need to do this as records are kept on file. What is the rationale in us doing this? We see ourselves as partners with parents and families on a journey. Part of their responsibilities is to make sure the health book is kept up to date and maintained on behalf of their child. The health book provides an effective communication tool between the child's GP, Practice nurse, Lead Maternity Carer, Well Child Provider, hospitals and other complementary services.” Anna Bailey

Engage with “champions” to reach out to Pacific communities

Forming collaborations with Pacific institutions such as churches is an ideal way to reach out to Pacific communities.

“Engage with community champions such as church leaders. They can be allies and champions of your nutrition initiatives. Having guidelines or a policy for church premises to be smokefree and a place for community exercises is one example of initiatives you can work with churches on.” Sione Tu'itahi

Wider public health strategies are also needed

Although general practice can make a difference to individual patients and their families, the solutions to many of the issues raised in this article also require societal structural changes.

Examples of possible policy changes:

• Make nutritional foods more affordable
• Increase tax on unhealthy foods and drinks
• Restrict advertising of unhealthy foods
• Make healthy lifestyles part of the school curriculum
• Restrict fat content of food in school and workplace cafeterias