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The Republic of the Marshall Islands (RMI) faces one of the world’s most difficult combinations of metabolic disease, constrained atoll agriculture, dependence on imported food, crowded urban settlements and climate risk. Majuro, Ebeye and the outer islands do not share the same food environment, but all need a system that makes water, nutritious local foods and continuing clinical care dependable.
Key takeawaysThe 2002 national STEPS survey found 62.5% of adults aged 15–64 were overweight or obese and 29.8% had raised fasting glucose or were taking glucose-lowering medication.A separate systems assessment reported diabetes prevalence of 19.6% among adults aged 15–64 using the STEPS definition then applied.Breadfruit, pandanus, coconut, taro, arrowroot, fish and seafood are central Marshallese foods and climate-resilience assets.Majuro and densely populated Ebeye require different solutions from outer atolls where transport, drought, saltwater intrusion and refrigeration are dominant constraints.
The WHO STEPS fact sheet for the nationally representative 2002 survey reported that 62.5% of adults aged 15–64 had a BMI of at least 25 kg/m² and 31.6% had a BMI of at least 30 kg/m². Raised fasting blood glucose, using the survey’s stated capillary whole-blood threshold or current medication, affected 29.8%. These figures include confidence intervals in the original fact sheet and should be interpreted with the methods and diagnostic thresholds used at the time.
A health-systems assessment drawing on the same era of surveillance reported diabetes prevalence of 19.6% among adults aged 15–64. The apparent difference illustrates why a page must name the definition, denominator and date rather than presenting one number as timeless. RMI completed another national STEPS survey in 2017–2018; its report should anchor current planning, with future surveys used to show whether the trajectory is changing.
The International Diabetes Federation continues to place RMI among the countries with the world’s highest adult diabetes prevalence. For individuals, population rank is less useful than access to screening and care: glucose, HbA1c, blood pressure, lipids, kidney function, urine albumin, serum urate, liver health and foot assessment must connect to treatment and follow-up.
Majuro concentrates government, hospital services, schools, shops and imported-food distribution. The same concentration creates an opportunity: procurement standards for hospitals, schools and public events can influence a large share of meals, while retail policy can make water and unsweetened beverages easier to choose.
Ebeye’s dense settlement, limited land and reliance on shipments sharply constrain household food production. Advice to “grow your own food” is insufficient where space, soil, water and tenure make gardening difficult. Container growing, community production elsewhere on Kwajalein Atoll, dependable transport, cold storage and healthier institutional purchasing are more realistic parts of the solution.
Outer-island communities may retain stronger access to fish, coconut, pandanus and breadfruit, yet face irregular shipping, limited refrigeration, drought and expensive transport to care. Emergency and routine food policy must protect both local production and access to shelf-stable foods with less added sugar and sodium.
Marshallese breadfruit includes culturally important cultivars of Artocarpus mariannensis, Artocarpus altilis and hybrids. Research documenting cultivar names, traditional knowledge and nutrient content is more than botanical history: it preserves planting material and knowledge needed for atoll food security.
Breadfruit can be roasted, boiled, preserved or processed into flour. Pandanus fruit, coconut, arrowroot, taro and locally caught seafood broaden the food system. Processing can extend shelf life and create income, but recipes matter. A breadfruit or pandanus product remains metabolically different from the whole food if it is dominated by refined flour and added sugar. Ingredient percentages, fiber, added sugar and serving size should be transparent.
U.S. nuclear testing and resulting displacement affected communities from Bikini, Enewetak, Rongelap and Utrik, altering relationships with land, fishing grounds, subsistence food and trust in outside institutions. This history should not be reduced to a single explanation for today’s diabetes epidemic, but it is relevant to food sovereignty, migration, research ethics and the design of respectful health programs.
Marshallese-led programs and community partnerships are essential. Research and clinical initiatives should use understandable language, informed consent, shared governance and results that return practical value to participating communities.
Sea-level rise, saltwater intrusion, drought and storm surges threaten freshwater lenses and crops on low-lying atolls. When local harvests fail or ships are delayed, packaged foods become a survival system. The long-term response must therefore combine climate adaptation with nutrition: rainwater security, protected planting material, salt-tolerant cultivation, solar-powered cold storage, resilient fisheries and nutrition standards for disaster supplies.
The goal is not to eliminate imports. It is to ensure that imported food supports health when local supply is limited—water, beans, fish, vegetables and less-refined staples—rather than making sugary drinks, instant noodles and highly processed meat the permanent default.
Sugar-sweetened beverages deliver added sugar rapidly and with little satiety. Rapid hepatic fructose phosphorylation consumes ATP; AMP degradation can increase uric-acid production, while excess substrate can promote liver fat, elevated triglycerides and insulin resistance. Genetic variation in urate transport, including SLC2A9, which encodes GLUT9, can modify susceptibility to hyperuricemia and gout.
Uric acid is relevant beyond gout. Crystals can injure joints and contribute to kidney stones and kidney injury, while high serum urate frequently accompanies reduced kidney clearance and metabolic dysfunction. In a country with a major diabetes burden, protecting kidney function requires early urine-albumin testing, blood-pressure control, glucose management and continuing access to medicines.
Related science
Fructose metabolism and uric-acid biochemistry • Why uric acid is more than a gout story • What causes high uric acid?
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