Imagine children indulging in popsicles and soda for breakfast, or ramen noodles with dry Kool-Aid powder sprinkled on top. Picture families dining on white rice, meat and sweet beverages for lunch and dinner every day. What kind of meat? Spam, canned corned beef, chicken, fish, crab, octopus and variety meats such as turkey tails or pig's intestines. Where do people eat this way? While our focus here is the Marshall Islands, similar dietary patterns are emerging in impoverished nations throughout the South Pacific and around the world.
Located about 2300 miles southwest of Hawaii, the Marshall Islands are 5-7 degrees north of the equator. With twenty-nine coral atolls, including approximately 1200 hundred islands, the total land mass is a mere 70 square miles. Half of the country's 60,000 inhabitants live in the country's capital city, Majuro. An atoll of about 30 islands, Majuro is 30 miles long and has a land area of 3.7 square miles. The elevation is just above sea level.
As you can appreciate, it would be difficult to design a diet that could more efficiently induce type 2 diabetes than the diet that has been adopted by the Marshallese people. Not surprisingly, the rates of type 2 diabetes in this population are among the highest in the world. An estimated 28% of individuals over 15 years of age have type 2 diabetes. For those over 35 years, the figure is nearly 50%. Close to 75% of women and over 50% of men are overweight or obese. Approximately half of all surgeries performed on the island are amputations due to complications of diabetes. There are no facilities for renal dialysis.
Sixty years ago, diabetes was virtually unheard of in the Marshall Islands. People were slim, physically active, and lived off the land. The diet consisted of fish and other seafood, and edible plants such as coconut, breadfruit, taro, pandanas and leafy greens. Breadfruit is a starchy fruit that grows on trees and is generally roasted in an open fire. Nutritionally, it is similar to white potatoes. Pandanas is a huge, extremely fibrous fruit that is chewed and sucked on to extract the carotenoid-rich, juicy orange pulp.
Today, with considerable overpopulation in Majuro, approximately 80-90 percent of all food calories are supplied by imported foods. The most costly imported foods are fresh fruits and vegetables, and other perishables. By ship, they arrive every 28 days, and by air, every 2 weeks. In most of the outer islands, indigenous foods supply 50-75% of food calories. While health authorities promote local foods in urban centers, the supply of local plants is insufficient to sustain the entire population on these small islands. Many locals believe that when it comes to nutrition, the only thing that really matters is having a full stomach. The value of fresh fruits and vegetables is largely unappreciated.
Local food is generally more expensive per calorie than imported food and less abundant, being dependent on the season and weather conditions. The cheapest source of calories in these centers is white rice. Many health care workers believe that white rice is responsible for the diabetes epidemic in the Marshall Islands. Some suggest that if the Marshallese replaced white rice with brown rice, the diabetes epidemic would be resolved. Unfortunately, it is not that simple. It is important to recognize that some of the lowest rates of diabetes in the world occur in areas where white rice is a staple food. In populations where white rice is consumed with vegetables, tofu and/or beans, and processed foods are minimized, diabetes rates are remarkably low. On the other hand, where white rice is consumed with canned or fatty meat, salty snacks, sweet beverages and other heavily processed foods, diabetes rates are consistently high. It is rather startling to learn that the glycemic index of the most commonly consumed rice in the Marshall Islands - Calrose white rice - is 83; several points higher than white table sugar which has a glycemic index of about 68. However, it even more startling to learn that the glycemic index of Calrose brown rice is 87. While brown rice is a better source of fiber, vitamins and minerals, the glycemic index of rice depends more on the relative amounts of two main types of starch, amylose and amylopectin, than on the fiber or nutrient content. Low-amylose rice has a high glycemic index. Calrose brown rice has a slightly lower amylose content than Calrose white rice. While this does not make the white rice a more healthful choice than the brown rice, it does suggest that blood sugar control may not be favorably affected by merely exchanging Calrose white rice for Calrose brown rice. Replacing Calrose white rice with a high-amylose brown rice would seem a more promising option, although hardly a panacea.
The Diabetes Wellness Program
In 2005, Canvasback Missions Inc. (a Christian, non-profit organization, specializing in medical missions to remote South Pacific islands), was awarded a grant for a lifestyle intervention diabetes research study. This study, to be conducted in partnership with the Marshall Islands Ministry of Health and Loma Linda University, was launched in March of 2006.
The first order of business for the diabetes wellness team was to convert a TB and leprosy clinic into a fully functioning diabetes wellness center, complete with kitchen, aerobics room, strength and cardio room, lecture room, laboratory, offices and washrooms.
The second was to put in place of all the elements required for rigorous scientific research. This is a formidable task in a developing country with limited technology and a significant language barrier. English is a second language, spoken with various degrees of fluency by more educated Marshallese (the first language being Marshallese). Local personnel were recruited, interviewed, employed, motivated and mentored to become support staff. Computer systems were set up, and a massive screening of patients was initiated. Protocols were established for lab work. Research forms, handouts, recipes, menus and lectures were developed. Relationships were established with Marshallese and American dignitaries, Ministry of Health personal, community group leaders and store managers. Contact with team members living on the mainland was limited by a very costly phone service and slow, unreliable internet service.
Next was the arduous process of enrollment. Participants had to meet strict medical requirements, be available to participate in most sessions, have a means of getting to and from the facility, and be sufficiently motivated to make profound changes in lifestyle. This process is ongoing as new recruits are needed for each intervention. The first four interventions were conducted in English, while the fifth was conducted in Marshallese. For each intervention, approximately half of the qualified participants are assigned to an intervention group and half to a control group. The research involves several interventions (each with 30-60 people), with a goal of completing 2-3 interventions per year.
ntervention participants receive diet and lifestyle instruction over a 3-6 month period, while the control group receives the "usual care". The first three interventions were conducted using a 6-month model, while the last two were intensified and condensed to a 3-month model. Each intervention begins with a 2-week intensive phase, in which participants are provided with 3 meals a day, exercise sessions, health education, cooking classes and frequent blood sugar monitoring (4-5 days a week). During the first three interventions, the 2-week intensive period was followed by a month of twice weekly sessions, six weeks of once weekly sessions and three months of bi-monthly sessions. Interventions four and five were intensified and condensed. In this case, the 2-week intensive was followed two twice-weekly sessions, alternating with two intensive four-day sessions. The final six weeks included two twice-weekly sessions and four once-weekly sessions. The 5-hour evening schedule is shown in Table 1. All control group participants are guaranteed a place in the intervention group once their six-month control period is complete.
Two key elements of lifestyle intervention are diet and exercise. The primary objective of treatment is to overcome insulin resistance and restore insulin sensitivity as much as is physiologically possible. The dietary parameters for the intensive phase are as follows:
> 100% plant-based
> Minimal refined carbohydrates - both sugars and starches
> Minimal ground grains (intact grains emphasized)
> Very high fiber (40-50+ grams per day)
> High viscous fiber (flax, oats, barley, beans, guar gum, psyllium)
> Moderate fat from healthful sources (20-25% fat)
> Low saturated fat (<7% of calories)
> Zero trans fatty acids
> Sufficient omega-3 fatty acids (from plant sources and fish)
> High phytochemicals and antioxidants
> Low dietary oxidants
> Low glycemic load
> Moderate sodium (<2400 mg/day)
Subsequent to the 2-week intensive phase, boiled, steamed or grilled fish and seafood may be added, if desired. A typical intensive phase menu is provided in Table 2:
In addition to a highly therapeutic diet, participants receive daily education about nutrition and lifestyle. PowerPoint presentations, practical workshops, dine-outs, shopping tours and spouses cooking classes are all fundamental components of the intervention. To help increase access to affordable produce, participants are taught how to grow their own vegetables. Soil and gardening experts are brought in to conduct lectures and workshops, and participants are taken on agricultural field trips.
Physical activity is a vital partner to dietary intervention. During the intensive phases, participants take part in a one-hour daily exercise class, in addition to two daily walks - before breakfast and after dinner. Following the intensive phase, participants continue with exercise classes on clinic days, and are encouraged to come to the clinic for exercise during clinic hours whenever they are able. They are also advised to continue with daily walks, as well as strength and flexibility exercises at home.
While the program results have been variable during the two years of the study, they are most encouraging. During the intensive phase (first two weeks) of the program, success is remarkable. Fasting blood sugars decline an average of 50-100 mg/dL (3-6 mmol/L); cholesterol drops about 20 mg/dL (0.5 mmol/L) and triglycerides fall approximately 40 mg/dL (0.5 mmol/L). It is important to note that these changes are seen even with notable reductions in medications.
Consistently, participants report dramatic reductions or complete disappearance of pain in the legs, arms and joints. The need for nightly leg massages is eliminated for the majority of participants. Walking becomes easier and more enjoyable. Many report significant reductions in nightly trips to the bathroom. Most notice tremendous changes in their bowel habits, with greater frequency and bulk of stools. Almost everyone reports increased energy. Several participants have noticed significant improvements in mental capacity. Weight loss averages 1-3 lbs (.5-1.5 kg) per week.
Changes after 12 weeks have been more variable, with some participants making remarkable recoveries and others slowly regressing. Those who experienced regression were participants who stopped coming to sessions. Unfortunately, most of these individuals did not resume taking medications. While they generally improved their overall diet and lifestyle, without medications, lab values at 24 weeks are often similar to baseline. In an effort to avoid this outcome, the program has been adjusted to increase medical follow-up and education regarding medications. Also, attendance has improved significantly with the shorter, more intensive 3-month program, and it is fully expected that this will be reflected in long term outcomes.
Plans to publish the research in medical journals are currently underway.
Many of our participants completely transformed their lives and their health. Some have become the health crusaders of their country. Many are politically active and are doing everything they can to change national food and nutrition policy.
While personal testimonies are of questionable scientific value, they are of infinite value to the human spirit. The following selection of notes from participants provides a glimpse into their personal journeys.
My pilot's medical certificate was denied when I was diagnosed with type 2 diabetes. I am 38 years old. I was devastated as this certificate is necessary for my work as a pilot. I heard about the Diabetes Wellness Program and I became a participant. I completely changed my diet and embarked on a daily exercise program. Upon my last physical check-up, I was told that I am fully recovered and my pilot's medical certificate was approved. I no longer have diabetes. I am very thankful. I have my career and my life back.
I suffered a stroke because of my diabetes and was in a wheelchair. I could not walk. After joining the Diabetes Wellness Program for six months, I got rid of my wheelchair and am walking on my own again. I am healthier than I have been in many years. This program has given me more than I ever thought possible. It provides the people of the Marshall Islands with the greatest hope we have had.
My diabetes started in 1991 and for the past 8 years prior to the program my sugar level was between 420 and 480. It never fell below 300. My blood pressure was always at least 190/110. My blood sugar is now between 140-180, and my blood pressure is 120/70. My doctor told me to stop my medications because I don't need them anymore. I am very grateful and life feels amazing. All the problems I used to have such as rushing over to the emergency room in the middle of the night, going to the bathroom every 15 minutes, constant hunger even after meals - I no longer have these problems.
I was bedridden all the time because in my mind I considered myself dead. I was skeptical about the program and told my wife that nothing could cure me. You see, I had a stroke and half my body was paralyzed. I had been in my bed for a year. I could not walk at all. Now I am proud to say that I can walk all the way to the supermarket without any pain in my body. I thank God for His plans to bring these doctors to our small island.
I was diagnosed with diabetes 1994. I had to take pills every day. My weight kept going up, as did my blood glucose level. I tried different diets and even walked every day, but would always end up back in my old eating patterns. I joined the Diabetes Wellness Program and I feel great now. I have no more pain, no more sleepless nights, and no more cravings for unhealthy food. I had to buy new clothes because other clothes are too loose now. I get so many compliments everywhere I go. People ask me "what is your secret - you look so good? Other people are getting old but you look like you are getting younger.
I've lost weight before but never got these kinds of compliments. It is true that my complexion is so much clearer and I feel so much better and more energized. I have a whole different outlook on what I put into my body. I am so grateful to the staff at the Diabetes Wellness Program and pray it will continue until all people with diabetes feel as well as I do.
In the Marshall Islands diabetes was long viewed as a devastating, terminal disease. No one was spared that pain of seeing family members, friends and neighbors lose their vision, their limbs and their lives. To witness recovery or healing from this condition was previously unheard of.
While program participants face barriers to success, they work closely with staff in overcoming them. Medical follow up is expanding; social barriers are being investigated; store managers are bringing a greater volume and selection of healthful foods; restaurant owners are adding "Diabetes Wellness Program Approved" options to their menus; exercise opportunities are expanding; lectures and handouts are being translated, and Marshallese staff are being trained.
Program participants have overcome seemingly insurmountable mountains of Spam, donuts, ramen noodles and cola. They have managed to put together low cost, healthful meals despite the high cost and poor quality of available produce. They have managed to do it with little education and marginal English skills. They have managed to do it with few gyms, no hiking trails and limited access to fitness facilities. These pioneers are providing a powerful example of health and healing for the people of the Marshall Islands. They are providing hope amid a deep sense of hopelessness.
Many people ask if this program could work in other countries such as the United States and Canada. The answer is simple: If there is hope in the Marshall Islands, with the enormous barriers they face, there is hope at home.
Brenda Davis, RD is the lead dietitian on the Diabetes Wellness Project. She is also author of 6 books, including Defeating Diabetes (Book Publishing Company, 2003).