Review

Reclaiming traditional, plant-based, climate-resilient food

systems in small islands
Abrania Marrero, Josiemer Mattei

Small island developing states face challenges in cultivating healthy food systems and are currently bearing substantial Lancet Planet Health 2022;
burdens of obesity and type 2 diabetes. Local food production—rooted in collective local and Indigenous traditions, 6: e171–79

self-sufficiency, and climate-adaptive agricultural practices—has long emphasised a fibre-rich, plant-based diet; Department of Nutrition,
Harvard TH Chan School of
however, common histories of dietary colonialism have replaced local, small-scale farming and fisheries with non-
Public Health, Boston, MA, USA
nutritive cash crops, intensive livestock operations, and high-quality food exportation. Along with declines in (A Marrero BSPH, J Mattei PhD)
traditional food availability, the resulting food import dependence has fostered a diabetogenic ecosystem composed of Correspondence to:
energy-dense cereal products, animal-based fats, and processed foods. The destabilisation of local food sectors Dr Josiemer Mattei, Department
undermines small island social and cultural systems, contributes to impoverishment and food insecurity during of Nutrition, Harvard TH Chan
School of Public Health, Boston,
natural disasters, and, ultimately, can reduce diet quality and increase type 2 diabetes risk. Despite ongoing
MA 02115, USA
marginalisation of traditional local food systems, locally produced foods such as starchy roots, legumes, fruits, and [email protected]
seafood persist as nutritious and ecologically relevant cornerstones of self-determined local economic productivity
and dietary health. Findings from community and epidemiological work suggest that local food production—
bolstered by local and Indigenous agroecological knowledge, cultural preservation, and collective agency—can aid in
reclaiming healthy and climate-resilient small island food systems.

Introduction middle-income countries due to an epidemiological

Small island developing states (SIDS)—delineated by the transition associated with obesity, physical inactivity, and
UN as low-income and middle-income countries and poor diet quality.3 At the start of the century, the average
other non-independent island territories throughout the mortality rate from diabetes in the Caribbean was five
Caribbean, the Pacific, the Atlantic, Indian Ocean, times that observed in mainland USA.4 In Oceania,
Mediterranean, and South China Sea1—bear substantial fasting plasma glucose rose by 0·22 mmol/L in men and
burdens of obesity and type 2 diabetes. Although self- 0·32 mmol/L in women per decade from 1980 to 2008,
sufficient food production in local and Indigenous which is 3·5 times the average worldwide increase during
communities once utilised climate-adaptive practices to the same period.5 Stark health disparities exist in SIDS,
support a minimally processed and plant-based diet, with Indigenous groups, such as Aboriginal and Torres
common histories of globalisation have diminished and Strait Islander people in the Pacific, having as much as a
co-opted traditional local food sectors, amplifying food 20 year reduction in life expectancy compared with the
import dependence and diet-related chronic disease. total Australian population;6 however, both Indigenous
Initially characterised as dietary colonialism in the and non-Indigenous island communities, including
Pacific, the destabilisation of local food production can Black and South Asian populations in the Caribbean,
extend to small islands around the world, amplifying have high levels of chronic disease morbidity and
poor socioeconomic conditions, contributing to periodic mortality, beckoning investigation of ubiquitous,
food insecurity during natural disasters, and under­ structural facets of food and social systems.7
valuing healthy and culturally relevant diets. In this The rapid rise in type 2 diabetes among indigenous
Review, we aim to describe the interconnection between populations in small islands has long motivated biogenetic
shifting food systems and type 2 diabetes risk in small theories of disease, including the so-called thrifty gene
islands (as systemically shaped by dietary colonialism) hypothesis,8 despite sparse anthropological evidence for
and we posit that local food production, informed by famine in regions with year-round subsistent food
climate-resilient agroecological knowledge, cultural availability.9 Other mechanisms have emphasised the
traditions, and collective self-determination, has the metabolic mismatch of early-life undernutrition and
capacity to support a more nutritious and sustainable subsequent obesity in these rapidly modernised, dual-
food supply. burden food environments.10 Despite these findings, a
prevailing emphasis on biological determinism in the
Type 2 diabetes prevalence and contributors literature often fails to recognise the extensive role that
Small islands around the world have a disproportionate past and ongoing marginalisation might have in
prevalence of diet-related chronic diseases. In 2019, eight increasing type 2 diabetes risk.11 Diabetogenic environ­
of the ten countries with the highest age-adjusted ments in SIDS have been proposed to stem from common
prevalence for diabetes were SIDS, and, in some SIDS, as histories of colonisation, through which healthy and
many as one in three adults were diagnosed with diabetes climate-adaptive local food traditions were eliminated in
(figure 1).2 Health disparities in insulin dysregulation the interests of the colonising nation.12 The coerced shift
have inten­ sified in SIDS and other low-income and away from traditional local food sources towards import

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35 Atlantic, Indian Ocean, Mediterranean, and South China Sea

Pacific
Caribbean

30
Age-adjusted diabetes prevalence in adults (%)

25

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Figure 1: Age-adjusted diabetes prevalence in adults (20–79 years) in small island developing states in 2019
The dashed line indicates the worldwide age-adjusted diabetes prevalence in adults. Data from the International Diabetes Federation.2

dependence might offer insights into contemporary type 2 industrialisation and international mono­ polisation of
diabetes risk in island food environments. local agricultural production. Instead of reinforcing
As an important driver of diet quality and chronic genetic determinism and weight stigmati­sation, efforts
disease risk, the term dietary colonialism captures the to promote nutritional health should recognise and
processes by which colonial and neocolonial powers grapple with long-standing structural barriers to cultural,
have exerted undue influence in small islands that, in economic, political, and communal food agencies.16
turn, have destabilised local food and agricultural
production, marginalised traditional food cultures, and Traditional local food production
created external food dependency.13 The inequitable Evidence from early cultures documents a diverse range
integration of island political economies into the global of nutrient-dense fruits and vegetables available in island
market­place by colonising nations—and, increasingly, ecosystems, many of which continue to shape current
by trans­ national corporations and regional trade dietary preferences (table).17–30 Indigenous communities
policies—drives shifts in the food system of SIDS that subsisted on a fibre-rich and carbohydrate-rich diet,
diminish human health and agroecological climate gathering seasonal fruits, legumes, nuts, and seeds and
resilience. Originating in the historical displacement of cultivating endemic root species, plantains, and other
biodiverse subsistence farming and fishing communities farinaceous crops in home-based farms.19,23,31 Among
for non-nutritive plantations and forced labour, dietary Indigenous Caribbean tribes, archaeological evidence
colonialism continues to shape island food supplies via suggests a strong reliance on starchy plants such as
inexpensive meat and processed food importation,14 the cassava, yautía, and maize, eventually intensifying
erosion of cooperative social values and small-scale towards root crop horticulture and gardening.18,19 Oceania,
networks of food exchange,15 and the continued Polynesia, Micronesia, and Melanesia people subsisted

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Traditional local foods Indigenous food production practices* Colonial cash crops and modern food
imports
Caribbean17–20 Starchy plants: cassava, sweet potato, Subsistence: home gardening, gathering, and Cash crops: sugarcane, cocoa, coffee,
marunguey, taro, arrowroot, yautía, maize, net-based and trap-based fishing; tobacco, spices, and rice; and food imports:
plantains; nuts and legumes: jack-bean, intensification: terracing, ditch irrigation rice, beans, wheat, maize products, sugar,
common bean, wild legumes, systems, and conucos (ie, fertilised mounds); vegetable oils, poultry, and processed meat
and groundnuts; fruits: peppers, pineapple, and processing: cassava breadmaking and fish
papaya, canistel, avocado, sapodilla, passion
fruit, coconut, mango, and banana; and lean
protein: rodents, pigeon, reef fish,
land crabs, and mollusks
Pacific islands20–27 Starchy plants: taro, yams, sago, cassava, Subsistence: gathering of wild plants and Cash crops: sugarcane, tobacco, coffee,
breadfruit, plantains, and sweet potato; insects, inland hunting, fishing, home coconut (copra), pineapple, maize, citrus
fruits: banana, coconut, and mango; gardening; intensification: slash-and-burn trees; and food imports: rice, wheat,
and lean protein: reef fish, mollusks, techniques, shifting cultivation, vegetable oils, poultry, noodles, snack
land crabs, octopus, sea urchins, edible multicropping, animal husbandry, terracing, foods, desserts, processed meats and fish,
insects, domesticated pigs, small animals agroforestry; and processing: pounding, canned vegetables, juices, alcoholic
drying, paste and pudding making, beverages
leaf-wrapped mixtures, flour, fermentation
West African Grains: maize, millet, sorghum, rice, fonio; Subsistence: gathering of wild starchy plants; Cash crops: sugarcane, rice, cotton, barley,
coast17,28–30 starchy plants: yams, kaffir potato, intensification: small-scale farming; potatoes, beans, groundnuts, coffee,
African breadfruit, cassava, sweet potato; and processing: pudding and sauce making, banana, coconut; and food imports: rice,
and legumes: cowpeas, Bambara groundnut, pounding, frying, flour wheat, animal fats, sugar, beverages,
geocarpa bean, African yam bean poultry, maize
*Subsistence refers to practices that supply food for personal and local consumption (typically small in scale and with little to no surplus for market) and intensification refers
to practices used to increase agricultural productivity (typically for commercial sale and using advanced technologies).

Table: Historical shift from local food production toward cash crops and food imports in small islands

on taro, yams, breadfruit, banana,21,22 and other local fruits cyclones, droughts, and forest fires. For example, in the
rich in carotenoids and rarely associated with population Caribbean, cassava bread was and continues to be
micronutrient deficiencies.24 On the west African coast, pervasively produced for its shelf life and transportability.18,19
ancient grains such as millet and sorghum shaped the In small Pacific islands, drying, fermentation, and paste-
agricultural economies of early societies.28,29 Apart from making also improved long-term food storage, particularly
some seafood in coastal areas, animal protein only in areas where coralline structures and volcanic surfaces
occasionally supplemented this plant-based diet, likely limited agricultural productivity.26 Thus, place-based
due to weather and natural resource-related constraints traditional food practices ensured food and nutritional
on land-based animal husbandry.19,21,22,32 Linguistic security, despite topographical and climatic constraints,
evidence from the Hawaiian Islands suggests that small through the preservation of food and environmental
animal consumption was an ancillary luxury to more biodiversity.34
regularly consumed starchy staples.23 Robust social Local and Indigenous sociocultural customs in small
networks also enabled the exchange of foods and islands continue to highlight local foods as a means of
agroecological knowledge, fostering a collective sense of promoting health and expressing identity, social relation­
community wellbeing.19,22,29 ships, and economic wellbeing,32 with plant-based foods
Historically, traditional local food production practices serving as cornerstones of traditional cuisine. In many
might have been climate resilient and designed to Pacific islands, the current cultivation and consumption
withstand highly variant ecological and climatic of remnant cultigens, such as the giant taro and
conditions. Networks of numerous small farmers offered breadfruit, serve as evidence for the historical gathering
localised food sources, particularly among inland or of their wild counterparts.21 Foods from forests, including
remote communities.22,29 A dietary reliance on starchy yams, wild ferns, fruits, and nuts, are also a major
roots also reflected the need for an energy-dense food with contributor to food security in the region.24 In the
a short growing season and underground protection from Caribbean, locally produced plantains, melons, cassava,
natural disasters.24,33 Archaeological evidence suggests that and other starchy crops continue to be widely used in
agricultural practices, such as terracing, agroforestry, and traditional cooking.17,19,35 The largest proportion of daily
multicropping, preserved biodiversity, minimised erosion, available energy per person in SIDS continues to come
and improved soil nutrient status, protecting the quality of from plant-based foods, including starchy roots, fruits,
sparse arable land.17,19,26 Traditional food trees in vegetables, nuts, and legumes, especially when compared
agroforestry and home gardens additionally enhanced with the greater proportion of energy from animal
food access and dietary diversity, particularly among rural sources and vegetable oils consumed in larger economies
and resource-constrained families.34 Culinary traditions (figure 2).20 Aquatic food consumption also remains high
also reduced the severity of food shortages during in SIDS, accounting for as much as 90% of animal

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period, has also put strains on sparse pasture and
increased dependence on imported animal feed.4,39
90
Proportion of energy available in food supply

Industrial land-based agriculture in islands has been

80 linked to extensive forest clearance, soil erosion, and
70 local species threats; in marine ecosystems, export
(per day per person; %)

Vegetable oils
60 Animal fats commercial production has also marginalised sub­
Alcoholic beverages sistence fisheries and led to the overexploitation of fish
50 Nuts and legumes
Fruits and vegetables stocks.40 In the Pacific, modern monoculture of cash
40
Milk and eggs crops also de-emphasises tree planting within agri­
30 (excluding butter)
Seafood cultural systems, resulting in agrodeforestation and loss
20 Meat of agrobiodiversity.41 The decoupling of crop production
Starchy roots from local ecogeographical conditions has also
10 Sugars and sweeteners
0 Cereals contributed to the genetic erosion of traditional food
SIDS USA crops, destabilising local economic development.42
Declines in traditional food production have also contri­
Figure 2: Proportion of energy available from various food groups in SIDS
and the USA buted to adverse socioeconomic conditions. Although
Data from the Food and Agriculture Organization of the UN,20 2013. Cereals historically sustained by the work of Indigenous people
include wheat, rice, barley, maize, rye, oats, millet, and sorghum products; and displaced African slaves, agricultural operations
sugars and sweeteners include sugar, honey, and other sweeteners; starchy roots
dispossessed land ownership away from small farmers,
include cassava, potatoes, sweet potatoes, and yam products. Meat includes
bovine, mutton, poultry, and pork products; seafood includes crustaceans, leading to radical impoverishment and disenfranchisement.
cephalopods, molluscs, and freshwater, demersal, and pelagic fish; fruits and Inequities in land tenure also threaten the sustainability of
vegetables include tomatoes, onions, citrus, grapefruit, bananas, plantains, domestic food production.26,29,31 20th century geopolitical
apples, pineapples, dates, and grapes; nuts and legumes include beans, peas,
pressures encouraging the abandonment of small-scale
other pulses, and nut products; animal fats include raw animal fats, butter,
cream, and fish oil; and vegetable oils include soybean, groundnut, sunflower farming in favour of urbanisation, industrialisation, and
seed, rapeseed, cottonseed, palm, coconut, sesame seed, olive, and maize oils. tourism—postcolonial, neoliberal policies pressed on
SIDS=small island developing states. SIDS to assimilate into the so-called developed global
political economy of food43—also exacerbated rural
protein intake, mostly from coastal subsistence fisheries unemployment, agricultural labour shortages, food pricing
in the Pacific, and continuing to contribute to traditional instability, and heavy food import dependence.17,26,29
and transitioning dietary patterns in the Caribbean, such Additionally, declines in local food production reinforce
as in Guadeloupe and Martinique.36,37 structural susceptibility to food insecurity, particularly in
imported food distribution systems that are vulnerable to
The history and impact of colonisation the climate.17 Coastal flooding, droughts, hurricanes, and
The colonisation of many island communities, beginning other extreme weather events also devastate fragile natural
during the 1500s and extending into the 1900s, radically and built resources, highlighting the need for more
reconfigured local food systems. Colonising nations localised, climate-resilient, and ecologically relevant
often reoriented local agriculture away from traditional, mitigation strategies.44
small-scale production and towards intensive plantation
economies (table). In the Caribbean, early Spanish Dietary colonialism, food import dependence,
colonisers introduced plantations for cash crops such as and type 2 diabetes
coffee, sugarcane, and tobacco for transatlantic export Histories of dietary colonialism (eg, intensive plantation
markets,17,31 and large-scale sugarcane and coconut economies, urbanised food centres, underutilised
industries similarly replaced the cultivation of root crops, subsistence fisheries, and diminished agroecological
fruits, and seafood in the Pacific.32 In Guinea-Bissau, knowledge) in small island food systems forecast a
agricultural colonisation also displaced ancient grains continued trajectory towards modern food depen­
and, among the urban poor, led to deficiencies in the dence.13,45 The replacement of traditional food farming
intake of plant-based protein, thiamine, calcium, and with non-nutritive cash crops—many of which are still
iron.28,29 Reduced availability of traditional roots, tubers, cultivated today—has driven nutritional deficiencies and
and maize have also been associated with low fibre necessitated the importation of inexpensive, energy-
intake.4 dense foods such as polished enriched rice.46 In some
Along with nutritional deficits, agricultural intensifi­ islands, processed food consumption has also been
cation in some SIDS has amplified environmental reinforced via foreign governmental aid, including the
deterioration, including inequitable land management, US supplemental nutrition assistance programme, and
diminished freshwater resources, use of agricultural overseas remittances.31 Urbanisation and industriali­
chemicals, and increased pollution.38 The introduction sation pressures to abandon labour-intensive agriculture
of large-scale animal husbandries such as poultry farms augment poor diet quality, sedentary behaviour, and
and cattle grazing, which has roots in the colonial weight gain.47 With roots in the plantation economy,

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these and other shifts in the socioeconomic fabric of 10 Cereals

island populations—including racialised class stratifi­ Total meat
cation, concentrated political power, and land mono­ 9 Animal and vegetable oils
Legumes, bananas and plantains, and cassava
polisation—have also restructured value systems away
8
from mutual aid and towards the marketplace, perpe­

Import quantity in SIDS (million Mg)

tuating persistent poverty and income inequality.48 7
Globalised international trade continues to exploit local
6
diets and marginalise traditional local food production.49
Countries such as Australia and the USA are increasingly 5
criticised for so-called dumping high-fat processed food
into island food supplies,46 practices that are often coupled 4
with the exportation of high-quality foods that are locally
3
produced, such as groundnuts and reef fish.12,13,46 In some
Pacific islands, the sale of local fishing rights to high- 2
income countries has been associated with declines in
1
local tuna consumption and increased canned fish
intake.50 In the Caribbean, former sugar plantations are 0
now used to grow export commodities, such as coconut
60

80

90

00
65

85

95

05
70

10
75

15
17
20
20
19

20
19

20
19

19

19

20
19

19

19
and coffee, outcompeting the domestic availability of root Year
crops, vegetables, and fruit.4 In Seychelles, attempts to
Figure 3: Import quantities of various food groups in SIDS from 1961 to 2017
renew traditional plant-based crops are impeded by high
Data available from the Food and Agriculture Organization of the UN.20 Cereals include barley, buckwheat, canary
labour costs on farms and, consequently, are increasingly seed, flour, fonio, maize, millet, oats, quinoa, rice, rye, sorghum, and wheat; total meat includes pork, beef, poultry,
replaced by eggs, poultry, and pork for the tourism and mutton products; animal and vegetable oils include beeswax, raw animal fats, coconut, castor bean,
sector.30 With diminished local foods, dietary colonialism cottonseed, groundnut, linseed, maize, olive, palm, rapeseed, safflower, sesame, soybean, and sunflower oil;
legumes, bananas and plantains, and cassava includes Bambara beans, broad beans, chickpeas, lentils peas,
in SIDS is currently driven by the importation of cereal
bananas, plantains, cassava, and cassava flour. SIDS=small island developing states.
products such as rice, which has more than quadrupled
in the past half century, and imported meats and animal
and vegetable oils (figure 3).20 consumed imported margarine, butter, and processed
The dependence on food imports in small islands meat were 2·2 times more likely to be classified as having
facilitates a nutrition transition towards colonial diets obesity and 2·4 times more likely to have diabetes than
implicated in obesity and type 2 diabetes, augmenting those whose dietary fat came from traditional food
the total dietary energy available in the food supply, sources.58 Among adult Samoans, a so-called modern
particularly from animal-based fats, refined cereals, and dietary pattern composed of rice, potato chips, and
other processed foods.4,51 In the Caribbean, increased refined grains has also been associated with metabolic
total energy intake during the 20th century—largely syndrome.59 Sugar-sweetened beverages and other highly
attributable to fat from beef, pork, milk, and butter—was processed foods are also salient examples of the role that
correlated with age-adjusted diabetes mortality.4 Excess these globalised food supplies have in poor diet quality,
consumption of white bread, sugar, and sugar-sweetened with their heavily advertised convenience and low costs
beverages (high glycaemic foods implicated in obesity driving con­sumption, particularly in low-income com­
and type 2 diabetes risk52–54) also increased, whereas that munities and areas with low access to safe water.47,60
of fruit, vegetables, roots, and legumes declined.4 In Importantly, with rice and other colonial and capitalist
Puerto Rico, where as much as 85% of the food supply is foods now considered staples and often cultivated locally
imported, sugary beverages, sweets, dairy, and processed in invariably globalised island food supplies, rigid
meats are major contributors to total energy intake,55 a distinctions between local, traditional, and imported
reliance on energy-dense foods that, along with low foods can become ineffectual;61 instead, efforts to
intake of fruits, vegetables, and fibre, has been associated relocalise food systems emphasise food sovereignty as a
with adiposity in this population.56 In contrast, inten­ place-based strategy for equitable, relational, and
tionally purchasing local foods on the island has been ecologically sustainable food and agri­ cultural self-
linked to a higher diet quality, including increased intake determination.62
of fibre, plant-based protein, and healthy fats.57
An imported diet higher in animal fats, processed Local foods and cardiometabolic health
foods, and lower in dietary fibre has also been consistently Despite increasingly imported diets, robust evidence
observed throughout the Pacific.32,50,51 Declines in starchy suggests plausible mechanisms relating local food
root crops, fruit, coconut, and seafood intake have been consumption to diet quality and metabolic health.
accompanied by a heavy reliance on rice, canned meats, Although excess dietary sugar and refined cereals can
and sugar, contributing to malnutrition and adiposity.32,51 contribute to hyperglycaemia and subsequent insulin
A survey in Vanuatu found that individuals who dysregulation, high-carbohydrate diets alone do not

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100 Caribbean
that are minimally processed and nutrient-dense can serve
Pacific as an alternative to imported meats and have been
35 Atlantic, Indian Ocean, Mediterranean, and South China Sea associated with lower type 2 diabetes risk, are high in fibre,
and have a healthier fat profile.77–79 Lean animal protein
Age-adjusted diabetes prevalence in adults (20–79 years; %)

30 such as seafood, poultry, and eggs might also have dietary

advantages in prevention of type 2 diabetes80,81 and can be
locally procured by integrating equitable, sustainable, and
25
climate-adaptive management. White and oily fish
consumption has been associated with reduced type 2
20 diabetes incidence, probably due to the beneficial effects of
polyunsaturated fatty acids on insulin sensitivity, and can
15 be rich sources of fat-soluble vitamins A and D.80 Beyond
nutrient intake, home-based and community-based food
production methods (eg, small-scale farms, home gardens,
10
and ponds) serve as the stage on which familial, spiritual,
cultural, economic, and ecological relationships are
5 fortified82 and might contribute to a more holistic approach
to wellbeing and cardiometabolic health.
0
0 25 100 175 250 Self-determined and climate-resilient island
10 year net food production index food systems
Figure 4: Association between age-adjusted diabetes prevalence and 10 year food production index in SIDS Despite entrenched histories of colonisation and food
Data available from the International Diabetes Federation and the Food and Agriculture Organization of the UN.2,20 import dependence, island communities have looked
Estimates for age-adjusted diabetes prevalence are from 2019 and only include adults aged 20 to 79 years. towards food sovereignty—with roots in protecting the
The 10 year food production index estimates are from 2016 and use 2004–06 as the base period, in which the base
rights and livelihoods of smallholder farmers and
period index score is 100 (values below 100 indicate a decline in local food production from the base period and
values above 100 indicate an increase). The index includes food crops and livestock products originating in each fisherfolk, reprioritising local agriculture to feed local
country that are considered edible and that contain nutrients; coffee and tea are excluded because they have no people, and preserving communal and agroecological
nutritive value. The grey line indicates the correlation between age-adjusted diabetes prevalence and 10 year net food cultures83—and the revitalisation of local food
food production index across all SIDS (r= –0·203). SIDS=small island developing states.
production in attempts to build healthy, self-sufficient,
and climate-resilient food systems. Based on current data
necessarily predict type 2 diabetes risk.52 The con­ from the Food and Agriculture Organization of the UN, a
sumption of traditional, fibre-rich foods might be an 10 year net increase in local food production among
important protective factor against weight gain, insulin SIDS has been correlated with lower age-adjusted
resistance, and type 2 diabetes.63–65 In an intervention diabetes prevalence (r= –0·203; figure 4).2,20 Although this
study, a low-fat, high-carbohydrate traditional Hawaiian evidence is only observational, the health benefits
diet rich in dietary fibre led to significant decreases in associated with local food production and traditional
weight, blood pressure, fasting blood glucose, and lipid diets are plausible. For example, Papua New Guinea
concentrations.66 Resistant starch, a viscous, ferment­ currently has among the lowest adult prevalence of
able fibre most commonly found naturally in legumes, obesity (6·8%) and diabetes (14·4%) among Pacific
green bananas, and roots,67 might also confer benefits, Islands47 and has long prioritised the preservation of self-
improving insulin sensitivity in metabolic syndrome, sustainable communities based on farming and
reducing unrestricted energy intake, decreasing traditional social networks.84 Local and Indigenous food
systemic inflammation, and stimulating gut-mediated practices, grounded in shared knowledge and biodiverse
glucagon-like peptide-1 release.68–72 Among individuals ecosystem resources, have also been increasingly
with diabetes, a 12 week low glycaemic index diet rich reclaimed for health promotion.82,85 Small-scale sub­
in legumes showed greater reductions in glycosylated sistence farming in Jamaica, a cornerstone of household
haemoglobin than a whole wheat fibre diet.73 Traditional and national food security, has sought to leverage inter­
root and tuber crops, such as cassava, also confer a generational expertise, traditional food crops, and
lower glucose response than cereal grains74 and have agroecology in combatting food import dependence.86 In
remained varied genetically relative to non-traditional Pohnpei’s Go Local island food network, community-
crops, serving as dietarily diverse sources of vitamins based production of banana, taro, and breadfruit through
and minerals such as calcium, iron, and magnesium.75 home gardening, collective seedbanks, and small-scale
Local food production also contributes plant-based food processing, was shown to successfully increase
proteins to the diet, including tropical legumes such as carotenoid intake and decrease rice consumption.82
cowpeas and groundnuts, which are mostly consumed Adherence to a neotraditional diet high in plant-based
where they are produced and constitute an estimated fibre, lean protein, and Indigenous fruits and vegetables
80% of traditional protein intake.76 Plant-based proteins has also been associated with lower adiposity.59

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Reclaiming local food production and traditional plant-

based diets, and, in a neotraditional approach, developing Search strategy and selection criteria
synergies between Indigenous and modern sustainable This Review was based on evidence documented in both the academic and grey literature,
production technologies,87 could also promote food aiming to provide a comprehensive overview of findings from peer-reviewed articles,
security and climate resilience in small islands (where international organisations, books, and community-based research approaches,
imported food supplies can otherwise break down during particularly in typically under-resourced settings. We searched Google Scholar with the
natural disasters).17 Improving local food distribution terms “small island developing states,” “Pacific islands,” “Caribbean,” “diabetes,” “obesity,”
systems, refrigeration, and traditional value-added “insulin resistance,” “Indigenous foods,” “traditional diets,” “local food production,”
products such as cassava flour33 might help small farmers “subsistence fisheries,” “agricultural decline,” “agroecology,” “sustainable development,”
move their agricultural product to local markets effectively. “climate change,” “climate resilience,” “food security,” “food import dependence,”
Ethnobiological knowledge—with expertise in adapting to “globalization,” “colonization,” “nutrition transition,” “diet quality,” “plant-based diets,”
highly variable environments and unpredictable weather “dietary fiber,” “resistant starch,” “informal economy,” “social support networks,”
disturbances—can also be used to develop resilient and “Indigenous knowledge” for references published at any publication date. Articles
resource management and miti­ gation strategies, while were screened by title and abstract to identify relevant full-text reports. Evidence from a
collectivist agricultural traditions can overcome natural diverse range of disciplines was incorporated to provide a balanced summary of the
resource constraints by amassing physical, social, and literature and included nutrition, epidemiology, archaeology, ecology, and the medical
economic assets.88 Indigenous farming practices, such as sciences. Publicly available datasets from the International Diabetes Federation and the
shifting agro­forestry and multicropping systems, use a UN Food and Agriculture Organization served as the basis for illustrative analyses.2,20
diverse matrix of ground and tree crops, which conserves
soil nutrient status, preserves species habitats, and
produces a biodiverse range of food crops that can be diversity as assets, not obstacles, to self-determination and
more consistently cultivated throughout the year than health.
monocultures.40,89 These traditional practices can also be
combined with soil conservation strategies such as Conclusions
contour ploughing to minimise erosion and reduce the Local food production in small island communities is
risk of landslides during hurricanes or earthquakes.90 embedded in rich socioecological traditions, employing
Sustainable plant-based food production will also be local and Indigenous knowledge and ecological resources
important in mitigating climate change91 and has shown that have been mostly overlooked in shared histories of
potential in small islands. In the Caribbean, while beef dietary colonialism and dependence on food imports.
and dairy production has declined due to climate-related Reclaiming local foods could offer an opportunity to
heat stress and disease pathogens, the market values bolster a more traditional plant-based and fibre-rich
of vegetables, plantains, and fruits have increased, diet, providing nutritious and minimally processed alter­
corroborating the economic viability of these staples.35 natives to an otherwise energy-dense imported food
Subsistence fisheries, which are high-quality lean protein supply. Revitalising small-scale agriculture and subsistence
sources largely operating within informal kin networks, fisheries offers a systemic approach to improve diet quality,
have also been recognised as fundamental to food security potentially reducing the burden of type 2 diabetes and
in the Pacific and contribute to local economies at a level related chronic diseases. The need to ensure food security
equalling five times that previously assumed.92 in islands with imported supply chains that are vulnerable
Although diets are also influenced by individual tastes to climate change is becoming increasingly relevant and
and dietary preferences, reclaiming authentic food more work is needed to assess the capacity for local food
autonomy in these environments with highly colonised, production to sustain population dietary needs in a self-
imported food supplies will require acting beyond sufficient and climate-adaptive manner. Future public
interventions that fail to address, or even perpetuate, health work should integrate rigorous interdisciplinary
deeply rooted socio­ ecological inequities. For example, research within community-based action and use local
some research in the Pacific has endorsed behavioural expertise to foster a healthy, culturally relevant, and self-
change strategies to improve diet quality and physical determined local food system.
activity, but this research cites the local culture (eg, valuing Contributors
large body sizes and prioritising familial and social AM conceptualised the research question, searched the literature,
wellbeing over individual health) as barriers to health analysed and interpreted the data, and wrote the Review. JM supervised
and contributed to the Review. Both authors read and approved the final
promotion.46 Other more distal strategies, including trade manuscript.
policies such as tariffs on unhealthy food imports, might
Declaration of interests
aggravate food insecurity,93 whereas foreign aid or We declare no competing interests.
nutritional assistance programmes can perpetuate
Acknowledgments
dependence instead of local economic productivity.31 We thank Walter C Willett (Department of Nutrition, Harvard TH Chan
Revitalising small island local food production instead School of Public Health, Boston, MA, USA) for their contributions.
looks to local and community-based resources, including AM was supported by the US National Institutes of Health National
cultural traditions, social support networks, and ecological Research Service Award Training Grant in Academic Nutrition

www.thelancet.com/planetary-health Vol 6 February 2022 e177

 Review

(T32DK007703) and the Rose Fellowship at Harvard TH Chan School of 21 Arnott ML. Gastronomy: the anthropology of food and food habits.
Public Health. JM was funded by a Mentored Career Development Berlin: Walter de Gruyter, 2011.
Award to Promote Faculty Diversity in Biomedical Research from the 22 Veitayaki J. Taking advantage of indigenous knowledge: the Fiji
US National Heart, Lung, and Blood Institute (K01-HL120951) and a case. Int Soc Sci J 2002; 54: 395–402.
Robert Wood Johnson Foundation Culture of Health Leaders Award. 23 Kirch P, O’Day SJ. New archaeological insights into food and status:
a case study from pre-contact Hawaii. World Archaeol 2003;
References 34: 484–97.
1 UN. About the small island developing states. https://www.un.org/
ohrlls/content/about-small-island-developing-states (accessed 24 Durst P, Bayasgalanbat N. Promotion of underutilized indigenous
April 9, 2021). food resources for food security and nutrition in Asia and the
Pacific. Bangkok: Food and Agriculture Organization of the
2 International Diabetes Federation. Diabetes estimates (20–79 y): United Nations, 2014.
age-adjusted comparative prevalence of diabetes, %. Nov 8, 2021.
https://diabetesatlas.org/data/en/indicators/2/ (accessed 25 Pond W. Parameters of oceanic science, vol 3. In: Crowl L,
April 9, 2021). Goraghty RR, Morrison J, eds. Science of Pacific island peoples.
Fauna, flora, food and medicine. Suva: Institute of Pacific Studies,
3 Chen L, Magliano DJ, Zimmet PZ. The worldwide epidemiology of 1994: 109–23.
type 2 diabetes mellitus—present and future perspectives.
Nat Rev Endocrinol 2011; 8: 228–36. 26 Ward R. Reflections on Pacific island agriculture in the late 20th
century. J Pac Hist 1986; 21: 217–26.
4 Sinha DP. Changing patterns of food, nutrition and health in the
Caribbean. Nutr Res 1995; 15: 899–938. 27 Snowdon W, Raj A, Reeve E, et al. Processed foods available in the
Pacific Islands. Global Health 2013; 9: 53.
5 Danaei G, Finucane MM, Lu Y, et al. National, regional, and global
trends in fasting plasma glucose and diabetes prevalence since 28 Smith IF. The case for indigenous West African food culture.
1980: systematic analysis of health examination surveys and Breda: Dakar Regional Office, 1995.
epidemiological studies with 370 country-years and 2·7 million 29 Temudo MR, Abrantes MB. Changing policies, shifting livelihoods:
participants. Lancet 2011; 378: 31–40. the fate of agriculture in Guinea-Bissau. J Agrar Change 2013;
6 Anderson I, Crengle S, Kamaka ML, Chen T-H, Palafox N, 13: 571–89.
Jackson-Pulver L. Indigenous health in Australia, New Zealand, 30 Pereira D de A. The challenges of the small insular developing
and the Pacific. Lancet 2006; 367: 1775–85. states: are the Mauritius and Seychelles examples for Cape Verde?
7 Bennett NR, Francis DK, Ferguson TS, et al. Disparities in diabetes Master Thesis, Instituto Superior de Economia e Gestão, 2005.
mellitus among Caribbean populations: a scoping review. 31 Carro-Figueroa V. Agricultural decline and food import
Int J Equity Health 2015; 14: 23. dependency in Puerto Rico: a historical perspective on the
8 Neel JV. Diabetes mellitus: a “thrifty” genotype rendered outcomes of postwar farm and food policies. Caribb Stud 2002;
detrimental by “progress”? Am J Hum Genet 1962; 14: 353–62. 30: 77–107.
9 Baschetti R. Diabetes epidemic in newly westernized populations: 32 Hughes RG, Marks GC. Against the tide of change: diet and health
is it due to thrifty genes or to genetically unknown foods? in the Pacific islands. J Am Diet Assoc 2009; 109: 1700–03.
J R Soc Med 1998; 91: 622–25. 33 Lebot V. Tropical root and tuber crops, 2nd edn. Wallingford: Centre
10 Hales CN, Barker DJP. Type 2 (non-insulin-dependent) diabetes for Agriculture and Bioscience International, 2019.
mellitus: the thrifty phenotype hypothesis. Diabetologia 1992; 34 Harrison S, Karim S. Promoting sustainable agriculture and
35: 595–601. agroforestry to replace unproductive land use in Fiji and Vanuatu.
11 McDermott R. Ethics, epidemiology and the thrifty gene: biological Bruce, ACT: The Australian Centre for International Agricultural
determinism as a health hazard. Soc Sci Med 1998; 47: 1189–95. Research, 2016.
12 Dye TDV. The diabetes ecosystem and small island developing 35 USDA. 2012 Census of agriculture, Puerto Rico island and
states. April 6, 2016. https://blogs.biomedcentral.com/on- municipio data 2012. https://agcensus.library.cornell.edu/census_
health/2016/04/06/the-diabetes-ecosystem-and-small-island- parts/2012-puerto-rico/ (accessed Jan 9, 2022).
developing-states/ (accessed April 9, 2021). 36 Hanich Q, Wabnitz CCC, Ota Y, Amos M, Donato-Hunt C, Hunt A.
13 McGee TG. Dietary colonialism: or how to colonize through the Small-scale fisheries under climate change in the Pacific islands
stomach, some Pacific examples. John Ballard’s Pacific Research region. Mar Policy 2018; 88: 279–84.
Papers. 1975. https://openresearch-repository.anu.edu.au/ 37 Colombet Z, Allès B, Perignon M, et al. Caribbean nutrition
handle/1885/164988 (accessed Jan 21, 2022). transition: what can we learn from dietary patterns in the French
14 Gewertz D, Errington F. Cheap meat: flap food nations in the West Indies? Eur J Nutr 2021; 60: 1111–24.
Pacific islands. Berkeley, CA: University of California Press, 2010. 38 van der Velde M, Green SR, Vanclooster M, Clothier BE.
15 McLennan AK, Ulijaszek SJ. Obesity emergence in the Pacific Sustainable development in small island developing states:
islands: why understanding colonial history and social change is agricultural intensification, economic development, and freshwater
important. Public Health Nutr 2015; 18: 1499–505. resources management on the coral atoll of Tongatapu. Ecol Econ
2007; 61: 456–68.
16 Wilson M, McLennan A. A comparative ethnography of nutrition
interventions: structural violence and the industrialisation of 39 Work SH. Animal husbandry in the Caribbean area. J Anim Sci
agrifood systems in the Caribbean and the Pacific. Soc Sci Med 2019; 1947; 6: 195–202.
228: 172–80. 40 Thaman R. Threats to Pacific Island biodiversity and biodiversity
17 Gould WA, Fain SJ, Pares IK, McGinley K, Perry A, Steele RF. conservation in the Pacific Islands. Dev Bull (Canberra) 2002;
Caribbean regional climate sub hub assessment of climate change 58: 23–27.
vulnerability and adaptation and mitigation strategies. US 41 Thaman R. Agrodeforestation and the loss of agrobiodiversity in the
Department of Agriculture. 2015. https://www.climatehubs.usda. Pacific islands: a call for conservation. Pac Conserv Biol 2014;
gov/sites/default/files/Caribbean%20Region%20Vulnerability%20 20: 180–92.
Assessment%20Final.pdf (accessed April 9, 2021). 42 Tisdell C. Genetic erosion in traditional food crops in the Pacific
18 Mickleburgh HL, Pagán-Jiménez JR. New insights into the islands: background, socioeconomic causes and policy issues—
consumption of maize and other food plants in the pre-Columbian WP193 amended. July, 2014. https://ageconsearch.umn.edu/
Caribbean from starch grains trapped in human dental calculus. record/183260 (accessed April 9, 2021).
J Archaeol Sci 2012; 39: 2468–78. 43 Weis T. Restructuring and redundancy: the impacts and illogic of
19 Newsom LA, Wing ES. On land and sea: Native American uses of neoliberal agricultural reforms in Jamaica. J Agrar Change 2004;
biological resources in the West Indies. The University of Alabama 4: 461–91.
Press. 2004. https://pennstate.pure.elsevier.com/en/publications/ 44 Pernetta JC. Impacts of climate change and sea-level rise on small
on-land-and-sea-native-american-uses-of-biological-resources-in-t island states: national and international responses.
(accessed April 9, 2021). Glob Environ Change 1992; 2: 19–31.
20 Food and Agriculture Organisation of the UN. FAOSTAT data. 2019. 45 WHO Regional Office for the Western Pacific. Diet, food supply and
http://www.fao.org/faostat/en/#data (accessed April 9, 2021). obesity in the Pacific. Manila: World Health Organization, 2003.

e178 www.thelancet.com/planetary-health Vol 6 February 2022

 Review

46 Hughes RG, Lawrence MA. Globalization, food and health in 70 Robertson MD, Currie JM, Morgan LM, Jewell DP, Frayn KN. Prior
Pacific Island countries. Asia Pac J Clin Nutr 2005; 14: 298–306. short-term consumption of resistant starch enhances postprandial
47 Hawley NL, McGarvey ST. Obesity and diabetes in Pacific Islanders: insulin sensitivity in healthy subjects. Diabetologia 2003; 46: 659–65.
the current burden and the need for urgent action. Curr Diab Rep 71 Maki KC, Pelkman CL, Finocchiaro ET, et al. Resistant starch from
2015; 15: 29. high-amylose maize increases insulin sensitivity in overweight and
48 Beckford GL. Persistent poverty: underdevelopment in plantation obese men. J Nutr 2012; 142: 717–23.
economies of the third world. Kingston: University of the West 72 Bodinham CL, Smith L, Thomas EL, et al. Efficacy of increased
Indies Press, 1999. resistant starch consumption in human type 2 diabetes.
49 Hawkes C, Chopra M, Friel S. Globalization, trade, and the Endocr Connect 2014; 3: 75–84.
nutrition transition. In: Labonté R, Schrecker T, Packer C, 73 Jenkins DJ, Kendall CW, Augustin LS, et al. Effect of legumes as
Runnels V, eds. Globalization and health. Abingdon: Routledge, part of a low glycemic index diet on glycemic control and
2009: 257–84. cardiovascular risk factors in type 2 diabetes mellitus: a randomized
50 Cassels S. Overweight in the Pacific: links between foreign controlled trial. Arch Intern Med 2012; 172: 1653–60.
dependence, global food trade, and obesity in the Federated States 74 Ayuo PO, Ettyang GA. Glycaemic responses after ingestion of some
of Micronesia. Global Health 2006; 2: 10. local foods by non-insulin dependent diabetic subjects.
51 Seiden A, Hawley NL, Schulz D, Raifman S, McGarvey ST. Long- East Afr Med J 1996; 73: 782–85.
term trends in food availability, food prices, and obesity in Samoa. 75 Dilworth LL, Omoruyi FO, Asemota HN. In vitro availability of
Am J Hum Biol 2012; 24: 286–95. some essential minerals in commonly eaten processed and
52 Hodge AM, English DR, O’Dea K, Giles GG. Glycemic index and unprocessed Caribbean tuber crops. Biometals 2007; 20: 37–42.
dietary fiber and the risk of type 2 diabetes. Diabetes Care 2004; 76 Singh U, Singh B. Tropical grain legumes as important human
27: 2701–06. foods. Econ Bot 1992; 46: 310–21.
53 Willett W, Manson J, Liu S. Glycemic index, glycemic load, and risk 77 Rietman A, Schwarz J, Tomé D, Kok FJ, Mensink M. High dietary
of type 2 diabetes. Am J Clin Nutr 2002; 76: 274–80. protein intake, reducing or eliciting insulin resistance?
54 Malik VS, Popkin BM, Bray GA, Després J-P, Willett WC, Hu FB. Eur J Clin Nutr 2014; 68: 973–79.
Sugar-sweetened beverages and risk of metabolic syndrome and 78 Malik VS, Li Y, Tobias DK, Pan A, Hu FB. Dietary protein intake
type 2 diabetes: a meta-analysis. Diabetes Care 2010; 33: 2477–83. and risk of type 2 diabetes in US men and women. Am J Epidemiol
55 Mattei J, Tamez M, Bigornia SJ, et al. Dietary intake and its 2016; 183: 715–28.
determinants among adults living in the metropolitan area of 79 McMacken M, Shah S. A plant-based diet for the prevention and
Puerto Rico. Nutrients 2019; 11: E1598. treatment of type 2 diabetes. J Geriatr Cardiol 2017; 14: 342–54.
56 Soltero SM, Palacios C. Association between dietary patterns and 80 Patel PS, Sharp SJ, Luben RN, et al. Association between type of
body composition in a group or Puerto Rican obese adults: a pilot dietary fish and seafood intake and the risk of incident type 2
study. P R Health Sci J 2011; 30: 22–27. diabetes: the European prospective investigation of cancer (EPIC)—
57 Marrero A, Tamez M, Rodríguez-Orengo JF, Mattei J. The Norfolk cohort study. Diabetes Care 2009; 32: 1857–63.
association between purchasing locally produced food and diet 81 Tonstad S, Butler T, Yan R, Fraser GE. Type of vegetarian diet, body
quality among adults in Puerto Rico. Public Health Nutr 2020; weight, and prevalence of type 2 diabetes. Diabetes Care 2009;
24: 4177–86. 32: 791–96.
58 Carlot-Tary M. 1998 Vanuatu non-communicable disease survey 82 Englberger L, Lorens A, Pretrick ME, Spegal R, Falcam I. “Go local”
report. Noumea: Secretariat of the Pacific Community, 2000. island food network: using email networking to promote island
59 DiBello JR, McGarvey ST, Kraft P, et al. Dietary patterns are foods for their health, biodiversity, and other “CHEEF” benefits.
associated with metabolic syndrome in adult Samoans. J Nutr 2009; Pac Health Dialog 2010; 16: 41–47.
139: 1933–43. 83 Plahe JK, Hawkes S, Ponnamperuma S. The corporate food regime
60 Snowdon W. Sugar-sweetened beverages in Pacific Island countries and food sovereignty in the Pacific islands. Contemp Pac 2013;
and territories: problems and solutions? Pac Health Dialog 2014; 25: 309–38.
20: 43–46. 84 James P, Nadarajah Y, Haive K, Stead V. Sustainable communities,
61 McLennan AK, Shimonovich M, Ulijaszek SJ, Wilson M. sustainable development: other paths for Papua New Guinea.
The problem with relying on dietary surveys: sociocultural Honolulu: University of Hawaii Press, 2012.
correctives to theories of dietary change in the Pacific islands. 85 Montenegro RA, Stephens C. Indigenous health in Latin America
Ann Hum Biol 2018; 45: 272–84. and the Caribbean. Lancet 2006; 367: 1859–69.
62 Naylor L. Food sovereignty in place: Cuba and Spain. 86 Aladjadjiyan A. Food production: approaches, challenges and tasks.
Agric Human Values 2019; 36: 705–17. London: InTech, 2012.
63 Thorburn AW, Brand JC. Digestion and absorption of carbohydrate 87 Shah S, Moroca A, Bhat JA. Neo-traditional approaches for ensuring
in Australian Aboriginal, Pacific island and western foods. food security in Fiji Islands. Environ Dev 2018; 28: 83–100.
Aust Aborig Stud 1987; 45: 61. 88 McMillen HL, Ticktin T, Friedlander A, et al. Small islands, valuable
64 Yao B, Fang H, Xu W, et al. Dietary fiber intake and risk of type 2 insights: systems of customary resource use and resilience to
diabetes: a dose-response analysis of prospective studies. climate change in the Pacific. Ecol Soc 2014; 19: 44.
Eur J Epidemiol 2014; 29: 79–88. 89 Tiwari AK, Mishra DS, Kumar S, Gunathilake DC. Exploitation of
65 Ludwig DS, Pereira MA, Kroenke CH, et al. Dietary fiber, weight climate resilient minor tropical fruit crops for nutritional and
gain, and cardiovascular disease risk factors in young adults. JAMA livelihood security in Fiji Islands. Int J Curr Microbiol Appl Sci 2018;
1999; 282: 1539–46. 7: 2135–42.
66 Shintani TT, Beckham S, Brown AC, O’Connor HK. The Hawaii 90 Gumbs FA. Tillage methods and soil and water conservation
diet: ad libitum high carbohydrate, low fat multi-cultural diet for the methods in the Caribbean. Soil Tillage Res 1993; 27: 341–54.
reduction of chronic disease risk factors: obesity, hypertension, 91 Willett W, Rockström J, Loken B, et al. Food in the Anthropocene:
hypercholesterolemia, and hyperglycemia. Hawaii Med J 2001; the EAT-Lancet Commission on healthy diets from sustainable food
60: 69–73. systems. Lancet 2019; 393: 447–92.
67 Food Nutrition Board, Institute of Medicine. Dietary reference 92 Zeller D, Booth S, Pauly D. Fisheries contributions to the gross
intakes: proposed definition of dietary fiber. Washington, DC: domestic product: understanding small-scale fisheries in the
National Academy Press, 2001. Pacific. Mar Resour Econ 2006; 21: 21.
68 Johnston KLL, Thomas E, Bell JD, Frost GSD, Robertson M. 93 Thow AM, Swinburn B, Colagiuri S, et al. Trade and food policy:
Resistant starch improves insulin sensitivity in metabolic case studies from three Pacific Island countries. Food Policy 2010;
syndrome. Diabet Med 2009; 27: 391–97. 35: 556–64.
69 Bodinham CL, Frost GS, Robertson MD. Acute ingestion of
resistant starch reduces food intake in healthy adults. Br J Nutr Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an
2010; 103: 917–22. Open Access article under the CC BY-NC-ND 4.0 license.

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