Background: Breastfeeding is a critical, evidence-based intervention that addresses malnutrition, improves early childhood development outcomes, and influences long-term maternal and infant health by reducing the noncommunicable disease risk. Scaling up breastfeeding is an indisputably strong action countries can take to prevent suboptimal maternal and infant health outcomes. The Becoming Breastfeeding Friendly (BBF) initiative assists countries with scaling up breastfeeding policy and programs. BBF has been successfully implemented within Latin America, Africa, Europe and SouthEast Asian regions. This study assessed its application in Samoa. Methods: In 2018, BBF was implemented in Samoa by a 20 member committee of breastfeeding experts who participated in collecting and utilizing national level data to score the degree of friendliness of Samoa's breastfeeding environment, identify gaps, and propose policy recommendations to address those gaps. This eightmonth process resulted in a public event where priority recommendations were widely disseminated to decision makers and actions agreed upon. Results: The total BBF Index score for Samoa was 1.6 out of 3.0, indicating a moderate breastfeeding friendly environment for scaling up policies and programs that protect, promote, and support breastfeeding. Gear total scores indicated that seven of the eight gears were moderately strong within Samoa, while the eighth gear, funding and resources, was weakest in strength. Six prioritized recommendations emerged: 1) development and implementation of a National Breastfeeding Policy and Strategic Action Plan; 2) strengthening monitoring and evaluation of all breastfeeding activities; 3) ratifying the International Labour Organization's Maternity Protection Convention 2000 (No 183); 4) identifying high-level advocates to champion and serve as role models for breastfeeding; 5) creation of a national budget line for breastfeeding activities; and 6) hiring of a national breastfeeding coordinator and trainer. Decision makers demonstrated commitment by signing the breastfeeding policy for hospitals ahead of the BBF dissemination meeting and electing to move forward with establishing lactation rooms within government ministries. Conclusion: Implementation of BBF in Samoa yielded important policy recommendations that will address current gaps in national level breastfeeding support. The BBF consultation process can be successfully applied to other countries within the Western Pacific region in order to strengthen their breastfeeding programs.

Background Despite global recommendations to prioritise policies that create healthy food environments within education institutions, the implementation of effective healthy school food policies has proved challenging for many countries. This study examined the experience of Samoa subsequent to the 2012 introduction of a stronger policy to improve the healthiness of school food environments. Our aim was to identify opportunities to strengthen healthy school food policy implementation in Samoa and other comparable contexts. Methods We used a qualitative case study approach, underpinned by policy science theory. In 2018, we conducted in-depth semi-structured interviews with 30 informants, coupled with analysis of relevant documents, to generate a detailed understanding of the relevant policy implementation processes in Samoa, and the perspectives and capacities of key implementation actors. Data collection and analysis were guided by the Health Policy Analysis Triangle, supplemented by other policy theories relevant to policy process. Results Samoa’s school food policy operationalizes international ‘best practice’ recommendations. We found health policymakers and leaders in Samoa to be strongly committed to improving school food environments. Despite this, there continued to be challenges in ensuring compliance with the school nutrition standards. Key issues that negatively impacted the policy’s effectiveness were the lack of priority given to school food by stakeholders outside of health, the high prevalence of unhealthy food in the areas immediately surrounding schools, vendor knowledge and capacity, and the high degree of agency exercised by actors in and around the school. We noted several opportunities for policies to be effectively implemented and sustained. Respondents identified community-level leaders as potentially pivotal stakeholders, particularly where school governance arrangements draw heavily on community representation. Conclusions Sustained and effective implementation of healthy school food policies requires continued engagement from political and community leaders, beyond initial commitment. There is potential to capitalize on political will for diet-related NCD prevention by more clearly demonstrating the institutional and operational requirements for effective and sustained implementation. Strong incentives for compliance and effective enforcement mechanisms are also likely to be crucial to success.

Further longitudinal monitoring and evaluation of early childhood growth and development are needed to understand the influences of early diet on child health in Samoa.

Background The prevalence of obesity and diabetes in Samoa, like many other Pacific Island nations, has reached epidemic proportions. Although the etiology of these conditions can be largely attributed to the rapidly changing economic and nutritional environment, a recently identified genetic variant, rs373863828 (CREB 3 regulatory factor, CREBRF: c.1370G>A p.[R457Q]) is associated with increased odds of obesity, but paradoxically, decreased odds of diabetes. Objective The overarching goal of the Soifua Manuia (Good Health) study was to precisely characterize the association of the CREBRF variant with metabolic (body composition and glucose homeostasis) and behavioral traits (dietary intake, physical activity, sleep, and weight control behaviors) that influence energy homeostasis in 500 adults. Methods A cohort of adult Samoans who participated in a genome-wide association study of adiposity in Samoa in 2010 was followed up, based on the presence or absence of the CREBRF variant, between August 2017 and March 2019. Over a period of 7-10 days, each participant completed the main study protocol, which consisted of anthropometric measurements (weight, height, circumferences, and skinfolds), body composition assessment (bioelectrical impedance and dual-energy x-ray absorptiometry), point-of-care glycated hemoglobin measurement, a fasting blood draw and oral glucose tolerance test, urine collection, blood pressure measurement, hand grip strength measurement, objective physical activity and sleep apnea monitoring, and questionnaire measures (eg, health interview, cigarette and alcohol use, food frequency questionnaire, socioeconomic position, stress, social support, food and water insecurity, sleep, body image, and dietary preferences). In January 2019, a subsample of the study participants (n=118) completed a buttock fat biopsy procedure to collect subcutaneous adipose tissue samples. Results Enrollment of 519 participants was completed in March 2019. Data analyses are ongoing, with results expected in 2020 and 2021. Conclusions While the genetic variant rs373863828, in CREBRF, has the largest known effect size of any identified common obesity gene, very little is currently understood about the mechanisms by which it confers increased odds of obesity but paradoxically lowered odds of type 2 diabetes. The results of this study will provide insights into how the gene functions on a whole-body level, which could provide novel targets to prevent or treat obesity, diabetes, and associated metabolic disorders. This study represents the human arm of a comprehensive and integrated approach involving humans as well as preclinical models that will provide novel insights into metabolic disease. International Registered Report Identifier (IRRID) RR1-10.2196/17329

Background: Intervention strategies to prevent childhood obesity in the Pacific Islands encourage eating a variety of local and traditional foods, but context-specific data to support this approach are limited. The objective was to assess the association between 2-year adherence to modern and neotraditional dietary patterns and body mass index z-scores (BMIz) among Samoan children.Methods: A convenience sample of 214 Samoan biological mother-child dyads who participated in the Ola Tuputupua'e ''Growing Up'' cohort study in 2015 and 2017 was included. At each time point, modern and neotraditional dietary patterns were identified using food frequency data and factor analysis. Children were assigned to categories based on diet pattern adherence: consistently high, high to low, low to high, and consistently low. Associations between 2-year adherence to dietary patterns, BMIz (in 2017 and 2015-2017), and weight and height z-scores were examined using linear models adjusted for potential confounders.Results: Consistently high adherence to the modern pattern was associated with a 0.36 standard deviation (SD)-adjusted change in BMIz between 2015 and 2017 (95% confidence interval [CI]: 0.04-0.69, p = 0.03). While the estimates for the individual components of BMI were imprecise, on average, children with consistently high adherence to the modern pattern had a 0.13 SD greater change in weight z-score (95% CI: -0.10 to 0.37) and 0.15 SD lower change in height z-score (95% CI: -0.43 to 0.13). The change in BMIz between 2015 and 2017 did not significantly differ by adherence to the neotraditional pattern.Conclusion: A neotraditional dietary pattern, comprising local produce, should be encouraged as a possible childhood obesity prevention strategy in Samoa.