The need to accelerate collective and concerted action to combat Non-Communicable Diseases (NCDs) and childhood obesity is particularly relevant in the Pacific context. In October 2017, the country-driven Pacific Ending Childhood Obesity Network (Pacific ECHO) was established¹, and all twenty-two Pacific Island countries and territories (PICTs) became members of the Network. Several regional and international plans and strategies have outlined key proven populations-based measures to address this epidemic including the WHO Report of the Commission on Ending Childhood Obesity (ECHO) [1], the Global Action Plan for the Prevention and Control of NCDs 2013-2020 [2], the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition 2012 [3] and the UN Decade of Action on Nutrition 2016-2025 [4].

The ambition of the network is collective action in 4 prioritized areas to bring an end to the scourge of childhood obesity plaguing the islands of the blue continent and hindering the achievement of the vision of healthy islands where ‘children are nurtured in body and mind.’ At the inaugural ECHO Network meeting in February 2019 held in Fiji, nineteen countries endorsed national nominees as Pacific ECHO representatives and drafted Pacific-level action plans for the Network’s strategic priority areas. Through the Network, countries committed to support interventions in the areas of physical activity, restriction of marketing of unhealthy foods and non-alcoholic beverages to children, fiscal measures and childhood obesity surveillance.

Commitment towards specific Network actions which support health promoting environments for children has the potential to prevent and control, and eventually end the existing burden of childhood obesity. Literature shows that overweight or obesity during childhood increases the risk of developing a range of NCDs in adulthood [5-9] with evidence suggesting that around three-quarters of children who are overweight or obese carry this status into adulthood [10]. Literature also shows that the treatment of obesity in adulthood is difficult [5,11]. These reasons highlight the need to prevent overweight and obesity at the earliest possible stages of life. The purpose of this commentary is to discuss the role of the Pacific ECHO Network in addressing the emerging concerns around childhood obesity plaguing the Pacific region, and to reflect on the challenges that the Network has faced in its efforts to contribute to eliminating the excessive burden of NCDs in the Pacific Islands.

¹ Pacific ECHO was established at a Regional Committee Event Meeting by Pacific Health Leaders in Brisbane Australia. A working group comprising of country representatives, technical agencies and a few academic institutions in the region met in 2017 to discuss further the establishment of the network, its governance structure and strategic priority areas. In April 2018, the Network was endorsed at the Pacific Heads of Health Meeting

Childhood obesity has become a global public health crisis [12]. Between 1975 and 2016, the global childhood overweight and obesity prevalence has nearly tripled with over 340 million children and adolescents being overweight or obese in 2016 [13]. For the Western Pacific region, which also includes PICTs, the rate at which childhood obesity has increased has been very alarming [14]. For PICTs, overweight and obesity are significant problems in adolescents [15] and high prevalence is particularly found in the Cook Islands (63.7% overweight; 35.5% obese) [16], Niue (56.7% overweight; 29.7% obese) [17], Samoa (58.5% overweight; 25.2% obese) [18], Tuvalu (48.3% overweight; 21.5% obese) [19] and Wallis and Futuna (62.9% overweight; 32.1% obese) [20]. The Youth Risk Behavioral Survey conducted in some of the United States Affiliated Pacific Islands (USAPI) also indicated high rates of obesity among adolescents, with about 40% in American Samoa (2011), about 25% in Guam (2015) and 25% in the Republic of the Marshall Islands (2007) [15]. Against this backdrop of global and regional concerns, the Pacific ECHO Network has mapped out where countries are at in terms of their current interventions in combatting NCDs and childhood obesity in the Network’s strategic priority areas. The Network members have also identified how their respective countries will progress their planned interventions and specific steps they would like to undertake to move forward with. Finally, they have identified the resource support available to their respective countries to progress their activities and the potential sources to access in the near future. As part of their mapping exercise, countries were also provided an overview of the status on NCD governance in their individual PICTs and where they are at in terms of developing and implementing NCD policy and legislation using the Pacific Monitoring Alliance for NCD Action (MANA) which rates PICTs progress using a traffic light system [15,21,22]. As a monitoring mechanism, a summary of the Pacific MANA dashboards for the year 2018 was presented to highlight policy and legislation gaps that countries could address under their individual country Pacific ECHO action plans and those that could be addressed regionally.

Drawing on PICTs status assessments using the MANA dashboards, countries are making some progress on the physical activity indicator and within the network, this is the only priority area that has made some progress. Pacific ECHO is working closely with PICTs to develop and implement a Pacific wide public education and awareness campaign aimed at promoting and encouraging children to engage in physical activity and be more active. To begin this process, some PICTs (French Polynesia, New Caledonia, Republic of Marshall Islands and Wallis and Futuna) have commenced with the formative research component of the regional campaign development. This involves formal consultation with relevant stakeholders including parents and children and focusses on the collection of formative data that will guide what the regional campaign will entail. Conversely, the MANA dashboard highlighted that many PICTs are struggling with the second strategic priority area i.e., policy to regulate the marketing of unhealthy foods and non-alcoholic beverages to children, and only two PICTs – French Polynesia and Kiribati, had such policies in place. Another key area identified as being a challenge is the implementation of fiscal policies to promote healthier eating, such as taxation on sugar sweetened beverages (SSB) and unhealthy foods, and tax exemptions for fruit and vegetable imports. Between 2017 and 2018, thirteen PICTs were identified as having food fiscal policies in place but only four PICTs were rated as having ‘strong’ measures in place. Another area that was identified as the Network’s fourth priority area that will require strengthening is the regular surveillance of overweight in children, particularly targeting the primary school age group as the monitoring mechanism remains varied across the region. The availability of collated data nationally and the use of data also vary, and this remains a challenge for PICTs. These considerations have stimulated some individual country efforts but collective actions as a Network have been slow.

While PICTs recognize the critical point in the obesity epidemic of the region and have made a political commitment to address Pacific ECHO’s strategic priority areas, more resources are still needed to accelerate the prioritized actions. Foremost, ECHO focal points are overwhelmed with other competing work priorities to drive the Network. The scarcity of time and effort coupled with a lack of budgetary resources to drive plans of action continue to hinder the progress of collective actions. Needless to say, continued investment into progressive social and economic policies is needed for any meaningful impact. However, interventions of this type are politically challenging and involve multiple, often opposing stakeholders. Furthermore, civil society engagement remains very limited and countries continue to struggle with multi-sectoral collaboration to drive their plans of action. Carrying out prioritized actions requires a wholeof- government approach, for example, involving ministries of education to drive initiatives in schools, ministries of finance or revenue departments for fiscal policy areas, and enforcement units for restriction of marketing. There is insufficient attention given to driving plans of action through a whole-of-government and whole-of-society approach and ECHO needs to shift to this via mobilizing civil society organizations and other sectors to progress its prioritized actions.

The Pacific ECHO Network still has a long way to go. Clearly, a comprehensive approach is required to stimulate action and more importantly, ongoing communication amongst all those who have the potential to influence population health and wellbeing is needed. These include civil society groups, church leaders, community leaders, youth groups, industry and government and it cannot be limited to the health sector. More needs to be done and PICTs need to act now to prevent childhood obesity so that we can also limit its impact on the socio-economic inequalities in health, wellbeing, and productivity. With the onset of the COVID-19 pandemic and increasing evidence showing comorbidities of COVID-19 and NCDs, greater momentum will be needed to keep up the fight against childhood obesity across the region and to keep it on the regional agenda.

.